Reflections on Sam's Birth

On the verge of my return to work, I feel compelled to reflect on what has been an incredibly transformative time in my life.  Going to medical school, giving birth to beautiful little Sam and then having 7 months to rest and tend to myself and my family has changed who I am.  Let's start with the pregnancy and birth.  I will try to limit the medical details and focus on the profound lessons I have learned.

 The day I found out I was pregnant, in a motel in Pennsylvania

 28 weeks

 34 weeks

 Picking up and wrestling nearly 40 lbs of preschooler at 35 weeks

 Homevisit at 36 weeks (with trusty 2-year-old assistant midwife)

How's that belly growing?

The Homebirth Scene

There are no homebirth midwives in the Upper Valley and, as Jeremy likes to say, none of them is Debbie.  Debbie is one of my dearest friends and midwife to Ethan and pretty much our ideal midwife.  The closest homebirth midwives here are all 1+ hours away.  I have only had a couple of friends have babies while I have lived here (contrast to the baby-factory that is my social circle in Madison) and everyone I know has had their babies at Dartmouth with the exception of my two high school friends who live close-ish but not quite in our region of NH (contrast with the fact that the first 40 births I attended in Madison were out of hospital and only a couple of my Madison friends had planned hospital births).  So, clearly, I am in a different world here than I was when Ethan was born blissfully at home four years ago.  Plus, I'm about 70% of an MD now, so I think a little differently than before.

When I got pregnant with Sam, I had no doubt that I wanted another homebirth.  So I followed my friends' recommendations for a two-midwife practice in Concord.  I also battled for insurance coverage and won.

If there is a next time for having a baby, I will live in a more homebirth-freindly area where I have more of a pick of local midwives (maybe even Debbie!) and homebirthing buddies.  I don't want to feel so isolated next time.

The Pregnancy We Were Almost Too Busy to Notice

During my pregnancy we made the long drive to East Concord for a few, infrequent prenatal visits and things ticked along with the bambino just fine.  On the sidelines, Ethan raged with insane tantrums and intellectual amazingness and awesome gymnastics moves.  Jeremy tried to keep his head above water and I came home occasionally from the hospital during what is the hardest of the four years of medical school.

Big Baby, Little Water

Towards the end of my pregnancy my fundal height (the measurement of how large the uterus has grown) was lagging behind normal.  This is usually no big deal but can indicate that there is less baby or less fluid than ideal.  I felt my midwives were not quite concerned enough about this so I requested an ultrasound.  This may be an indication that I have become medicalized by my training and I let the medical model (Always keep an eye out for the worst!  Even healthy women have bad outcomes!) color my approach to my pregnancy.  But this is also be a sign that I am like almost all women - worried about something abnormal with her pregnancy, wanting always to be safe during such a vulnerable time with so much at stake.

Midwives were happy to oblige and at 37 4/7 weeks I had a scan.  I am no ultrasonographer but I could see that there were oodles of wiggly baby in there.  Grey, grey, grey sonographic baby.  And almost no black - no fluid.  By the measurements I just qualified for oligohydramnios ("oligo", low amniotic fluid) and had a biggish baby.  I am wise enough not to trust ultrasound estimates of weight at the end of pregnancy as they are notoriously unreliable.  So I wasn't worried about too much baby.  In fact, I was relieved that my little belly wasn't due to a growth restricted baby.  But low fluid!?  That brought me to tears.  No more cruising along with the perfectly average pregnancy, just waiting for spontaneous labor and my moment of power.  Now there was a complication and decisions to be made.

Speaking Up for Yourself

Midwife called OB back-up in Concord who recommended more testing (NST) and follow up ultrasound in a week.  A week sounded crazily long to me but I am no expert on oligo so I was open.  The testing was scheduled at Dartmouth.  Note: this is an important moment.  I had talked with just about everybody about how I wanted my back-up hospital to be the sweet little community hospital in our town.  Not Dartmouth, the conservative academic center that serves the sickest moms and babies in the region and also happens to be the hospital where I train and thus know all the docs fairly well, some of whom may be writing letters of recommendation for me shortly.  I told everybody, except it turns out, the midwife who was on call.  In this moment that is frozen in my memory, I am teary in the car driving home from the ultrasound with Jeremy and she says into the phone that she will call Dartmouth and I think "but I don't want Dartmouth" but I don't say anything.  Although I would like to think of myself as someone who is fierce and self-confident and willing always to speak truth to power, I know that I am not.  I am terrified of disappointing anyone, of getting in trouble.  I work hard to overcome this intense desire to please those around me because I know that I have important things to say that are not in the mainstream.  I try to speak up even though my voice shakes like crazy because I know that being bold and brave and honest may help protect the health and happiness and maybe even the lives of my patients some day.  But in this small way, on the last day of my pregnancy, I didn't speak up.

This moment is one of the ones in my life that has changed me.  I am emboldened now to speak up in my own care and the care of my patients.  I also now recognize that doing so will take lots of concerted effort.  This experience also helped me to realize that it is very hard to women to be their own advocates during pregnancy and labor.  Huge props to any woman that can ask for what she wants or needs when she is in the throws of the scary, intense, confusing, new experience of managing a complicated pregnancy (or even a normal pregnancy!).  What I have learned is that, as patients, we must choose providers that we trust to be wise and whose approach matches our values and who know us well so that they can advocate with us and for us and protect our safety while also respecting and understanding us as unique people.  We must also do the hard work of speaking up (have I mentioned that I struggle with this part?...).  Likewise, as providers, we must be ever so aware of our assumptions and our habit of just shuffling women through protocol without pausing to offer choices and to ask if our recommendations fit the patient's values and priorities. So, not advocating for myself was the first step in a birth experience that has taught me much about being a better patient, mother and doctor.

To Induce or Not to Induce: Obstetric Decision Making

Okay, back to the story.  We go to Dartmouth and instead of seeing us in triage, which would be the thing people do when they come in for a test, they put us in a birth room and exclaim, "You're here to have a baby!  Welcome!"  Jeremy says to me, "Um, I thought we were here for a test?"  But I know that Dartmouth recommends induction for all term babies with oligo and that coming to Dartmouth means getting swept into a powerful tide.

Testing goes great.  Rock star baby dances around in my belly for hours.  (Later I realize that he has been perfectly aligning himself for his descent into the world and I am so thankful to him.)

Repeat ultrasound shows the same picture but now we measure just above the cut-off for oligo.  There's always variability in tests so this is no surprise and regardless of the exact number the fluid is pretty low and that means that the baby is at higher risk for not doing well.  So the number doesn't matter much - except that, technically, above the magic number we don't have oligo and don't need an induction (per Dartmouth protocol) and below the number we do.  I didn't really latch on to this at the time, as I had already pretty much bought into induction somewhere in my lizard brain, but in hindsight I notice that no one stopped to say to us, "You don't actually meet criteria but you are close.  What would you like to do?  Would you like to just repeat ultrasound later or go ahead and get induced?"  Instead, we got the "Welcome!" line again.

Why did they prefer induction and assume we would as well?  Here are some ideas I've come up with:

- The evidence on increased monitoring vs. induction for oligo and near-oligo is not very clear.  In this grey area, as in all areas where medical evidence is scant or inconclusive, culture guides practice.  In high-risk obstetrics, the culture is to intervene.  To run the risk of bad things happening because you have done nothing is more abhorent than to run the risk of harm caused by the intervention.  Now that I've thought about it a bit I realize that this is not my personal culture.  I am not a big intervention gal, at least not when evidence is shakey.  I would rather risk doing nothing than doing something, all things being equal.

- Many women are so totally sick of being pregnant by 37 weeks that doctors think they are doing a favor by offering induction.  Who wouldn't want a one-way ticket out of the backaches and chub rub and fat pants?  I bet there are lots of women who agree and are excited to be induced.  But not me.  Firstly, I'd rather be uncomfortable than have potentially risky medical intervention.   Secondly, I love being pregnant (really), wasn't too uncomfortable, and wanted to savor a few more weeks with just Ethan and the profound intimacy of pregnancy with what might be my last baby.

- When you have a hammer, everything looks like a nail.  Anything odd comes up in pregnancy (and more and more "odd" things are found with increased testing) and obstetricians can't help but think Aha! I have a solution! Get the baby out!

- Induction is very common and it is so routine to the obstetric team, and usually proceeds normally, that I think it just doesn't seem like a big deal to them.  The risks are often glossed over.  But to us on the outside (and I consider myself to be half-insider, half-outsider at this point), especially those of us with a bent toward minimizing intervention, the risks seem worth considering.  Example: I was chatting with one of my surgeon friends - one who actually once told me that should would rather schedule herself a c-section than have to deal with labor - and she said, "You got induced?  Isn't that just a ticket to cesarean?"  It was so validating to be reminded that induction does indeed have risks and I was not crazy for being reluctant to induce.  (Side note: cesarean can of course be a life-saving intervention and can be considered a great outcome if it helps keep mom and baby safe.  But I think it should be avoided if possible and the induction-turned-cesarean for marginally good reason is something I'd rather avoid.)

In our real time birth story, though, I'm a deer in the obstetric headlights.  Then my super-hero-like husband steps in and does an INCREDIBLE job advocating for us.  He asks lots of smart questions about risks/benefits and what oligo even means.  Then he asks for us to have some time to talk and call our midwives.

We call our people and talk talk talk and eventually decide to induce. Why?

- To get the baby out before something bad happens.  We asked ourselves, if we don't induce and just do increased testing ("watch and wait"), what will we be waiting for?  A baby in distress?  A bad outcome on testing?  No thanks!  We wanted to get induced with a healthy baby, not a baby in trouble.  This is also the obstetricians argument for induction. 

- Little faith in my ability to go into spontaneous labor.  I had Ethan at 41 5/7 with the help of some acupuncture and I had a miscarriage that didn't pass on it's own without medication.  I think I had started to believe that I am not someone that goes into labor on her own.  This is a dangerous belief as it justifies all kinds of interventions.  While it's probably true for some women out there, it's definitely not true for as many women as are offered induction and I think is not true for me.  I did indeed go into labor with Ethan on my own, just on the later end of the spectrum at 41 weeks, and then had a 5-day-long labor/no labor/labor thing because he was not aligned well in the pelvis.  Who knows what was up with that miscarriage - it wasn't a normal pregnancy so I doubt it's appropriate to compare.  I may or may not have gone into labor on my own with Sam but I was only 37 weeks and I think (now) that it was hasty to decide that I would *need* induction.

- Convenience. We were already at the hospital.  Ethan was already sleeping over at Nana's.  Everyone at Dartmouth thought it was a good idea so it was easier to go along with them than to say "no thanks" and either broker an alternate testing plan or go to another provider.  This is not a great reason but it was nonetheless underlying my thinking and probably the thinking of many patients and providers.  I hope to be more aware of this factor in future medical decision making.  Perhaps if we can name it, then we can decide how much of a role it should play in our medical choice.

For good reasons or not, I got induced and had some mild, early labor for the next 12 hours or so.

Homebirth: More than comfort and aestetics

During my early labor, I thought about jumping ship and either letting labor continue at home and having a homebirth or letting labor fizzle out and going for the watch-and-wait approach instead.  The docs and the midwife at the hospital thought this was crazy-talk.  We had a very unpleasant conversation where the hospital midwife kept saying that I wanted my homebirth because it would be "beautiful" but it was not safe and instead they could make it home-like at the hospital.  I was a blubbering mess, literally incoherent due to my sobbing, but I did manage to say "Homebirth is not just about aestetics.  I am not sure what the best choice is here but I do not see induction as perfectly benign."  Jeremy then stepped up again and said everything I thought.  I have never felt so completely connected to that man.  After we insisted that all this talk was totally unnecessary as we had already decided to stay in the hospital, they finally left us alone.

What bothered me the most was the implication that homebirth is all about being in your pretty, cozy little house.  There is some truth to that.  The hospital is ugly and uncomfortable and they wake you up all the time and the bed is tiny and plasticky and you have a dozen different providers.  Of course I don't like that stuff.  Of course I prefer my own bed.  But there is so much more that made me choose homebirth in the first place and, in the midst of my induction, intensely mourn the loss of that option.  You can read all about the benefits of homebirth somewhere else.  What matters most to me is this: Being treated with respect and reverence.  Having providers that are not blinded by protocol and are open to doing things many different ways, whatever way is working for mom and baby.  A real appreciation that intervention may cause harm.  Being able to trust that when internvention is used, it is done so wisely, out of necessity.  Being the most important player in my own care, not some bystander that comes along for the ride.

It is probably possible to make these things happen in the hospital.  But low lights and soft music are not enough.

"My Water Just Broke"

Bad conversation and sobbing definitely got in the way of my labor groove.  So we started pitocin and had the good fortune to get a new nurse.  She was upbeat, supportive, kind.  Jeremy and I decided to focus on the joy of having a baby, not the difficult quagmire of decision making we had been in.  So we chatted with our new best friend nurse about our kids, movies, labor, the weather, whatever.  I smiled.  Slowly, contractions picked up.

Then, my water broke and came flooding out.  Oh, the irony!  We were here for low fluid and here we could all see that I had so, so much of it.

He is Born

Super strong active labor began immediately.  I took respite in the hot tub.  We called in our homebirth midwife and a friend to attend the birth.  I could feel the bones in my pelvis shift and open as he sunk low.  I touched his head with my hand and it was one of the most tender things I've ever felt. I pushed my beautiful, perfect baby into the world in three little pushes.  It burned like hell.

I pulled him to me like we were animals in danger and I needed to protect him, now and always.  I was flooded with relief that we had survived all the real and imagined risks of our journey.  He was quiet, peaceful, so soft and tiny.

Did We Make the Right Choice?

Did we have great reasons to induce?  Was it worth the risk?  Did we make the right choice?  I am not sure.  I have questioned this decision many times over, both during my induction and in the months after Sam was born.  Initially I was very guilty and ashamed about getting caught up in a medicalized birth.  I didn't want anyone to know he wasn't born at home.  I felt most painfully that I had failed to protect Sam and myself from the harm that can come from intervention.  We didn't suffer any harm, thankfully, but I still felt like I'd moved us right into the line of fire.  I also felt like I'd allowed my medical training and my fear of authority at Dartmouth shape my birth in ways that weren't in line with my deeper values.  Like I'd lost myself.

These feelings swirled alot during the first weeks after Sam's birth and I was so very sad and guilty.  I got angry and tearful everytime I thought of everything leading up to his birth.  But slowly, with the natural return to more of a hormonal balance (thank god) at two weeks postpartum and the tincture of time, I no longer feel so emotional about it all.  Mostly, I think about what I learned and how I have grown.  Here are some of the things I think:

- Having the complication that I did and going to Dartmouth ended up meaning an induction and a hospital birth, which felt like a big deal for me - me, the wildly unusual homebirthing mama in a sea of medical students, the woman who came to medical school to back-up homebirth midwives, the one who wrote letters to my insurance carrier demanding that they pay for my homebirth. But I am not completely lacking in perspective.  I recognize that my induction was pretty much smooth sailing and I had a straightforward, awesome birth and a healthy baby.  Not all birth stories end this way.  Compared to what could have happened and what has happened to others who got caught up in a very medicalized birth (sometimes appropriately for everyone's health and safety, sometimes inappropriately), my moment of just floating along with the medical current was not such a big deal after all.

- I wish I had had a stronger sense of self and providers who could have better guided me back to my values.  I will strive for this in future medical decision making (of the baby-having variety or otherwise).    

- There are problematic assumptions underlying the recommendation for induction for oligo (and I would venture other conditions).  First, there is the assumption that something bad will happen if you wait.  In truth, our baby might have done well (and many babies do) right up until labor begins on its own.  Second, there is the assumption that there are no harms in induction or that the risk of them is much smaller than the risk of waiting.  Evidence is not strong on this.  I think we should always remember that intervention can cause harm.  If its worth the risk, go for it.  But don't ignore the risks. 

- I think we made a really safe choice for our baby.  Oligo is a real risk factor for bad things happening to babies and we knew that our baby was term and well grown.  We tried to keep him safe.

- There are no right choices.  We just do the best we can with the information we have at the time and if we are guided by the love of our children, we will do alright.