Friday, December 19, 2014

A Tale of Two Sons: a VBAC Story by Vanessa

I grew up surrounded by homebirth. Not only was I born at home, but so were my three sisters, two brothers, and four step siblings. I can vividly remember my parents preparing for birth, spending hours flipping through my mother’s books about labor and baby development, and I have strong memories of the births of my youngest two sisters. These experiences left me with the powerful feeling that birth is a normal part of life and nothing to fear.

When I became pregnant with my first son I was in a new city and we were in the process of buying a house. I briefly considered planning a homebirth but as an inherently lazy person I felt the process seemed too complicated. We were in the middle of a move and my pregnancy was going great ­ I felt better than ever! After a few minutes searching on Yelp, I found an OB practice and hired a doula. In my naivety I figured that the place I decided to give birth didn’t matter. Even though I hated the hospital environment where I was supposed to deliver and ended up not being happy with my Yelp­researched doctor, I was sure that I could have a natural and normal birth in any setting. I thought I knew what to expect.

I went into labor at midnight on a Friday. I remember calling my mom around 4am PST on Saturday morning and crying because of intense back pain. She suggested I get out of bed and see if the pain was coming in a pattern. Sure enough, I was having contractions. Excited, I woke my husband and we went into motion. We had just moved two weeks earlier and had yet to install our car seat or pack our hospital bag. I called my doula to let her know labor had started. She told us that she would be on standby and to call her when contractions were 5 minutes apart. Our plan was to labor at home with her as long as possible and then arrive at the hospital around 6 cm. To pass the time we distracted ourselves by watching Futurama while I labored on a birth ball. When we grew tired of that we went for a long walk in our new neighborhood and around noon I passed my mucus plug. Labor was getting more intense! My husband called our doula and she started to make the journey from Oakland to Daly City. On her way to us she encountered heavy traffic. At this time my contractions were 1­2 minutes apart so we decided to go ahead and meet at the hospital.

When we arrived the nurse checked my progress; I was only dilated 4 cm. This was enough to keep me at the hospital but I was disappointed we weren’t further along. To make matters worse, once we arrived at the hospital my labor seemed to slow to a snail’s pace. The nurses saw us settled into our room and basically left us to our own devices. Every hour or so someone would come and check me. 4.5 cm. 5 cm. 6 cm. 6.5 cm. Around four a.m. I was exhausted and asked for an epidural. It took another eight hours before I was completely dilated and ready to push. At this time I met the doctor on call. She quickly realized my son was presenting in a posterior position and before I even started pushing she mentioned that we might need a c­section. This was something I had not prepared myself for at all and was sure we wouldn’t come to. I pushed for about an hour, during which my son’s heart rate was decelerating and having difficulty recovering. I asked several times for assistance getting into another position to see if that would help the baby turn, but the doctor insisted that keeping me on my back was best. Eventually she tried to manually turn the baby. When that did not work she tried the vacuum. Both attempts at the vacuum failed. Finally, completely exhausted and confused we were rushed to the operating room where my son was delivered via c­section.

Fortunately, I recovered quickly from the surgery and had no issues with breastfeeding or bonding. My shock and confusion related to why I had a c­section was another story. At the core of my being I knew that it wasn’t necessary and I felt like I had failed. Failed to deliver my son naturally, failed to advocate for myself in the hospital, and failed to prepare properly for birth. While I worked hard to bury these feelings so they wouldn’t cloud my time as a new mom, my son wasn’t two weeks old before I started researching VBAC (Vaginal Birth after Cesarean) and HBAC (Home Birth after Cesarean). I was afraid to go to another hospital to deliver again, and I became fond of telling people that the only way I would go back was if I was being dragged by wild dogs.

Preparing for VBAC

Eighteen months after my first birth I became pregnant again. Already resolved that this birth would be different, I started reaching out to homebirth midwives in my area that had experience with VBAC. Eventually I was led to Maria. By coincidence she had also recently delivered our friends’ babies and came recommended by them. Feeling confident in Maria's 30+ years of experience, all the stress and anxiety surrounding being pregnant again dissolved. I never worried about uterine rupture or other complications from VBAC. I just knew that if I labored at home that I would be OK and so would the baby.

Fast forward a month before my due date. My husband and I walked into Maria's office for what we think is a normal prenatal appointment. Instead she sat us down and told us that the previous week she attended a VBAC homebirth that ended in complications for her patient. The experience, in combination with the recent passing of stricter laws regarding homebirth in California, led to her decision to stop attending VBACs at home. Because she had already agreed to attend our birth she was willing to do so, but she encouraged us to choose another option that she offered called labor management. Under this service she would act as our doula, but also manage labor to make sure we did not go to the hospital too soon. In addition, she recommended that we deliver at UCSF which is known for its VBAC success rate and nurse­midwife / doctor practice. She was certain we could have a successful childbirth there.

Changing our birth plan from a homebirth to a hospital birth was an incredibly difficult decision. I was completely uncomfortable with the idea of going to a hospital to deliver. Planning a homebirth meant I had been able to ignore my fear of the hospital but now I was forced to face that fear head on. As I examined what was so difficult about my first son’s birth I realized that it wasn’t the c­section itself that I struggled with, but the way in which the surgery happened. The moment I chose to have an epidural the birth process was no longer something I was in control of. It became managed by the doctors and nurses and I became a patient and not a participant. This was partially due to the setting and partially because I have never been a strong advocate for myself. The result was an experience that resulted in a feeling of loss of control and disempowerment that was still painful. Knowingly putting myself into that position again was not something that I wanted to do. Planning to go to the hospital started to feel as if I was losing control over the birth process again.

After a lot of discussion with my husband and some incredible women that offered their counsel to me during this time, we finally decided to take Maria's advice and switch gears to plan a hospital birth. I made clear that my goal was an empowered birth and a healthy baby. A successful VBAC was important to me, but more important was understanding and control in the birth process. Maria agreed to be a strong advocate for me and to do what she could to help me achieve my goals. As with my first labor our goal was to remain at home as long as we could and spend as little time as possible in the hospital. In order to prepare, I made a conscious decision not to tour the hospital before labor and, unlike with my first son, I decided to take two weeks off work prior to my due date in order to "get my head in the game." I prepared our home for the baby, I walked, and I rested.

Lex’s Birth

My entire pregnancy I assumed the baby would come early like his big brother did, but this time my due date came and went. Uncomfortable and ready for labor, I did everything I could to induce labor naturally. I hiked up Bernal Hill and in Pacifica, I made cookies rumored to be “labor inducing,” and I doused my scrambled eggs in Tabasco. Nothing seemed to work. Finally, four days after my due date I woke up with bloody show. Excited, I called Maria to let her know that I thought labor was starting. My contractions were mild at this point so we planned to contact her again when things became more regular. Even though I was told repeatedly that second babies tend to come more quickly, I was preparing for a long labor.

It just so happened that I was also scheduled for a non­stress test this day. Since my contractions were stable and manageable I didn’t want to go into the hospital for the test, concerned that the moment I did so labor would slow. In order to try and speed things up, my husband and I decided to go on a walk and have breakfast at a greasy spoon diner near our home. Thinking that this could be my last meal before labor I went whole hog and ordered the largest pancake breakfast I could find on the menu. As I was finishing my pancakes I called UCSF to cancel the non­stress test. Instead of letting me cancel the nurses insisted we come in so they could perform the ultrasound, confirm labor was in progress, and check fetal positioning. We reluctantly went in for the test and, as I feared, labor stopped during the car ride to the hospital. While I was disappointed that labor had stopped, the ultrasound did give us some important information. Everything was fine but the baby was facing posterior. Knowing that I was going into labor with the same positioning that resulted in a c­section the previous time was empowering. I called Maria as I left the hospital to inform her of the position. She ensured me not to worry as many babies turn during labor.

At this point my husband and I just waited. We napped, we ate, we walked. Later that evening my contractions started again, mild, but regular. Friends called to ask if we were at the hospital yet and each time we informed them that no, we were “shopping at Home Depot” or “having sushi” or “walking.” Eventually we walked back home to get some rest. That night I slept as much as I could and periodically woke to more intense contractions.

The next morning my contractions were still coming. Around 9 am Maria suggested she come over to see how far along I was dilated. Her exam showed that I was between 3­4 cm but that my cervix was still fairly closed. We decided to go for a walk and purchase some castro oil. The plan was to take the castro oil if I wasn’t progressing later in the day. My contractions remained steady but controllable throughout the walk. In fact, I felt great. This was in sharp contrast to my previous labor when I was in extreme pain and already at the hospital at the same point. When we finished our walk Maria checked me again ­ this time I was at 5 cm and around 50% effaced. We decided to strip my membranes and see if that would speed things up at all. Since I still felt like I was in control of things and not ready to go to the hospital, Maria left to return to her office. We planned to check back in after lunch and then meet at UCSF in a few hours or when things became more intense.

In order to kill some time my husband and I decided to make a trip to see our now toddler. We sent him to stay with a friend the day before when we thought labor was starting and wanted to check in on him. After that visit we made a run to the grocery store to purchase the ingredients to make chocolate chip cookies and grab some lunch. The entire time we were in Safeway my contractions were getting strong enough that I was sure that the other shoppers were beginning to notice. Finally, I couldn’t stand it any longer and suggested to my husband that we get home to time my contractions as soon as the deli counter finished making our sandwiches.

Once home we noticed that my contractions were consistently a minute and a half apart and lasting about 40 seconds. I still wanted to make the cookies, however, because even though things were becoming more intense the pain was manageable and I felt comfortable at home. Based on Maria’s suggestion, we called the labor and delivery number at the hospital to let them know I was in labor and would be coming in some time that day. When the nurse got on the phone I explained that I was having my second child, a VBAC, 5 cm dilated and 50% effaced, had just had my membranes stripped, and positive for GBS. I told her that I didn’t feel I was ready to come in yet but that I just wanted to let them know to expect me sometime that day. Surprised, she strongly encouraged me to come in. Her exact words were something like “best of luck to you but I am recommending you get here immediately.” Not wanting to completely ignore her advice, but trusting in my assessment of where my labor was, I finished my lunch and then called Maria. We decided to meet at the hospital and take a walk around one of the courtyards until I felt like it was time to check in. The cookie ingredients were forgotten on the kitchen counter and we headed to the hospital.

After about an hour of walking around the hospital courtyard Maria recommended that we go ahead and check in to labor and delivery. Rather than going through emergency, we rode the elevator up the 15 floors to the labor ward and strolled up to the front desk. The closer we got to labor and delivery, the less intense my contractions became. I knew that I would need to get settled into my room before I could focus again. I was so calm the nurses at the front desk didn’t quite believe me when I told them I was in labor and took their time getting us into a room.

Once we were settled in our delivery room I was immediately handed a monitoring belt and a heavy monitor. This I would have to wear my entire labor to keep track of the baby’s heartrate. A heplock was inserted into my left hand and they begin administering the antibiotics for the GBS. While I was able to walk around, nothing about the hospital situation felt “natural.” Rather, the entire situation began to feel like a cascade of interventions. I remember sitting on a birth ball, looking out the window of our room over the city of San Francisco and doing everything I could to keep from crying. She must have realized I was about to lose control because at this point Maria took my hands and told me to think of each contraction as WORK. “Don’t fight them, work with them.”

Around this time the nurse midwife on duty at the hospital came to introduce herself to me and check to see how far I had progressed. While I was still at 5 cm I was now 95% effaced. Things were picking up!

While we were getting settled, several of the doctors and nurses on duty came in to wish us well and let us know that "Colleen told them to take great care of us." Colleen is a friend of ours that happens to be a resident at UCSF. After my husband texted her that the baby was coming she sent out a mass message to her colleagues at the hospital. This was all in sharp contrast to our last birth where we were basically left alone with our doula to labor. Already, my experience at UCSF was beginning to feel different and I was able to calm down. With each contraction my anxiety dissipated. I forgot about the monitor and the IV and turned my attention to the business of laboring.

We weren’t at the hospital long before my water broke. Things really started to pick up and as each contraction became more intense I continued to work with them. I labored standing up, on the toilet, on a birth ball, squatting on the bed ­ moving to any position that felt like it was working to progress labor. Eventually I could not get comfortable. I remember holding on to the back of the bed in a squatting position, moaning intensely as a doctor came in to check me. I could hear him telling the nurse that I was at 8 cm. At this point people were coming in and out of our room on a regular basis but all I could do was focus on labor. My husband and Maria moved me into the shower but I wasn’t there long before I started to feel the urge to push. I was quickly helped back to the bed and checked again. This time I was fully dilated and already pushing with each contraction. As the hospital staff worked to get ready I struggled to find a comfortable position on the bed. Everything hurt. My legs were shaking uncontrollably. My back was killing me.

As the nurse and my husband helped shift me on the bed to begin pushing there was a staff change. Ingrid, the kind and gentle nurse that had been helping to coach me was replaced by Vanissa. Unlike Ingrid, Vanissa was a drill sergeant. She immediately had my legs up against the birthing bar. With each contraction she coached me to hold my breath and push. To pull forward as if in a crunch and push. To keep my legs up and PUSH. Each time she told me what to do I thought about how much I hated her advice. Couldn’t she see how hard I was trying? I could barely hold my legs up. I started crying and begging for someone to help me with my legs. My husband and Maria each took a leg for support but it didn’t seem to be working.

Suddenly the atmosphere in the birthing room changed. There seemed to be more and more people in the room and Vanissa kept mentioning that the baby’s heartrate was experiencing decelerations ­ the reason for my first c­section. I kept my eyes closed and did my best to only hear the words of encouragement that were being spoken by the people in my room. I heard my husband telling me “This is it! You’re doing great.” Maria telling me “That’s it Vanessa, we can see his head.” The doctors murmuring words of support from the direction of my feet. With each push when my son still didn’t come I started to imagine that at any moment I was going to be put to sleep and wheeled into surgery. Every push was more painful than anything I had imagined and I just wanted it to be over. Finally, I felt release and heard my husband say “You did it!” In shock, I felt my son between my legs but didn’t quite believe it was over. I could only think to mutter, “Holy shit, I did it.” Unlike my first son’s birth, no tears came this time. I just felt an immense relief. Relief that I didn’t have to have surgery and relief that it was done. All the planning, all my anxiety, all the worry was finished. We did it. I did it. My son did it. He was born in exactly the way I had hoped and face down ­ exactly like he should have been. 8 lbs and 21 inches. 

Thursday, December 11, 2014

Birth Story : Cole Alexander Monsees

On the Saturday morning of November 1, 2014, at 9:13 am, we welcomed little 7 lb. 10 oz. 19" long Cole Alexander Monsees into the world!

The previous night was Halloween, and Dave and I decided to take a longer evening walk to enjoy the Halloween festivities on 24th street in Noe Valley.  We rummaged through our box of Halloween costumes and knick-knacks to get into the spirit.  We kept it simple - Dave wore Groucho glasses, Winston our Maltese had on his plaid bowtie collar, and I safety-pinned a severed doll arm holding a pumpkin candy basket onto my then fully-blossomed belly (a recycled costume worn by a friend last Halloween when she was pregnant with her little guy).  My costume was by lengths a success amongst many kids and adults that caught sight of the baby crawling out of my tummy to go trick-or-treating.  Little did I know that this costume was to foreshadow what was to happen early the next morning!
In the early morning hours of Nov 1st, at around 3AM, I awoke, as typical, to relieve my tiny, compressed bladder.  Upon returning to bed, I began to have light cramping - similar to the discomfort of the 1st day of my period.  It was an unusual but familiar feeling (as I hadn’t felt that in 9 long months!), but I did not think much of it and tried to go back to sleep.  By 3:30AM, the cramps felt a little more intense, so I went to the restroom again and after wiping noticed pink discharge on the toilet paper.  I remember thinking - well, my mucus plug is still M.I.A., so perhaps it will show soon or this is just my body slowly preparing itself for labor in the coming weeks.  I crawled back into bed to try and close my eyes, but the cramps continued to intensify.  By about 4AM, I decided to wake up Dave and told him what I was feeling and seeing, and all the while, the cramps continued to become more and more painful.

My recollection of what comes next is a bit blurred as my body continued to turn up the intensity and my mind began to focus more and more inward, but I remember needing to move from the bed to the living room and sitting on the couch leaning my arms against the backrest.  Dave in the meantime had quickly downloaded an app on the tablet to record my contractions.  As the minutes passed, I remember it was becoming harder and harder for me to communicate through the rushes and I began out of necessity to moan through exhalations to release the tension emanating from my lower abdomen.  

According to Dave, by 5:45AM, we decided that this was in fact labor, and paged Maria -- contractions were 7 mins apart and a hard 1 min 20 sec long.  I was not in a mindset to process how long my contractions were, what that meant, or even the concept of time for that matter (!), so I recall in those moments thinking it was too early to call Maria - that I didn’t want to inconvenience her with what was probably nothing or just early labor.

Dave continued to monitor my contractions - my uterus decided to pick up the pace and contractions quickly accelerated to 3 min 30 sec apart.  By this point, there didn’t feel like there was a moment to catch my breath.  The best I could do was pace circles around the kitchen island and fight the surges standing up - hopefully finding a surface to lean on when my surges peaked.  In my head, I was trying to remind myself to live in the moment, but in reality, I was anticipating the next surge and how much more painful the next one would be.  As the contractions got more intense with fewer breaks in between, I clearly remember thinking, if this is what it’s going to feel like for the next 36-48 hours, I don’t think I’m going to make it!  

Eventually, maybe because I could not find a comfortable position or thought of the women we saw in videos during our homebirth class that labored in the bathroom, I moved onto the toilet.  Here I stayed with pillows and towels at my feet (along with Winston and Dave) to labor.  After some strong surges, I felt something hanging out of my vagina.  I somehow verbalized this to Dave, who got a flashlight to look and thought it was some part of the baby’s body, but that it was too small to be the head.  In that moment, he nervously considered the scenario that he’d have to deliver the baby himself!

At around 7:30AM, Maria arrived - I was still laboring on the toilet at that time and had by that point given in to the urge to push (which did feel like a vomit reflex...just from the opposite end!).  Maria examined me and was amazed to see that what was hanging out of me was the amniotic sac, or balloon, as the sac had not ruptured, and also determined that I was already at 10cm!

Sue Baelen (our assisting midwife) arrived shortly thereafter, and both Maria and Sue thought I would make better progress by moving to the bed.  When it was suggested I move to the bed, I remember thinking impossible! and that was like someone asking me to climb Mt. Everest.  I somehow managed to make it onto the bed, but after an hour on hands and knees on a soft memory foam top bed (not optimal folks for hands and knees!) and little progress, I became exhausted.  Maria recommended that I try flipping over onto my back with Dave sitting behind me so that I could lean into his torso.  There, he could support me and help me hold my legs back to rotate my pelvis up while pushing.  What helped tremendously was having Maria focus my pushes towards the back of my vagina where she was applying pressure.  This worked well and and after a few more pushes, you could see Cole’s hair behind the amniotic balloon.  

During this time, Maria repeatedly told me to open my eyes - to re-focus but also to see the head starting to crown in the mirror.  I kept my eyes shut tightly - maybe because I didn’t want a visual for the pain I was experiencing, maybe because I was trying to escape.  Instead, she asked that I reach down and feel the head emerging.  I did - and I thought, wow really?  I’m already this close now?  The sensation of a baby that far in the birth canal was not what I expected - yes the surges were painful, but the fact that the baby’s head was sitting in my pelvis about ready to be born surprisingly was not intense.

Oh but the so-called Ring of Fire - yes I felt that indeed!  My encounter with the Ring of Fire was acknowledgement of it, and then damn it, just push past it!  And voila - the head was out.  The balloon finally opened and Maria reached in to unloop the cord from around Cole’s neck (my cord apparently was quite long) -- she said he came out with his eyes wide open.   By this point, the surges were becoming less intense - I wasn’t sure I was ready to push the body out, but Maria gave me one last round of encouragement and the next thing I know (after about an hour of pushing on my back), Maria tells Dave and I to reach down and catch our baby!  We reach down and pulled a crying Cole onto my chest.  He was big, pink, and full of life.  Dave admitted there were tears.  I honestly cannot recall what thoughts flooded my head at that moment, but I was certainly awe of Cole, in awe of what my body just did, in awe of Dave, in awe of Maria and Sue, all the while thinking, this is it!  

It’s humorous to note that Winston our dog sat quietly on the bed next to us - literally a foot away from all the action.  Either he knew exactly what was going on or was wondering why the hell everyone was making so much noise!

We let the cord pulse out for a few minutes, and the placenta delivered quickly thereafter.  I received stitches from Maria for a labia tear - luckily, we later learned from another midwife Ami that Maria is the best embroiderer around!  

The only other big challenge after that was peeing.  After a few tries that morning, and concern about swelling near my stitches, Maria inserted a catheter and was able to drain an incredible 2 liters of urine from my bladder - a record according to Maria!

By 12:15PM our new family was alone.  After only 6 hours of (intense) labor, and a week and a half early, it was hard to believe what just happened. To capture some of the sentiments from Dave’s own written account of the birth - having only known him for less than 36 hours, I can tell that little Cole is an amazing guy. And after watching Judy bring our baby into the world in such a brave and focused fashion, I can't imagine myself ever being prouder.

And now after 3.5 weeks of living our lives with Cole, I can also say that I can’t imagine myself ever being more proud of our new little family.