Friday, September 28, 2012

Homebirth through the eyes of an OB

Being an Obstetrician married to another birth professional, you would guess that this wouldn't be the average pregnancy and certainly wouldn't be a mainstream delivery. And if you guessed that, you'd be right. From the first text message with a picture of a positive pregnancy test, I knew that we would be doing things a bit differently.

We did our visits ourselves, together- in the comfort and intimacy of our own office or home, with the convenience of whatever time we desired. We never really settled on a midwife. I guess Tara at her core always felt like we could do this on our own. She is knowledgeable and intuitive, and trusted in our knowledge, skill, and abilities. I always held a little skepticism. Homebirth was something new for me. But, I really believed that my work with midwives over the last three years had put me in a very good place in my life and my career, to see my first homebirth.

I had read the books, witnessed raw, natural birth and watched our local midwives in action. I knew it could be done. I knew it was safe...but yet I worried. I had no rational reason to think it wouldn't go well. Tara was young and healthy and had no risk factors. She had had two previous uncomplicated births.

I wish I could describe what exactly my fears were. I guess I feared what I was least familiar with...the newborn resuscitation. I could not get it out of my head. I would fall asleep and picture our birth. The labor would be smooth and easy, the delivery would be textbook and then I would inevitably see Adria in the bed...pale, limp and lifeless. I would panic and try to logically get through the steps, walk through my NRP algorithms. How would I live with that hurt? How would I know that I had done the best that could be done, not just the best that I could do. I knew that I would do the best I could do...but our baby deserved the best. So I worried. I don't think I ever talked to Tara about my fears. I knew in my gut that they were irrational. Yes, I had read the Wax study about homebirth and ACOGs stance on homebirth and the Skeptical OB's blog trashing homebirth, but I had read countless articles that picked apart the Wax data and called into question the methods and results, showing the flaws and pointing to that homebirth truly was safe. But even beyond the published data, I pulled on what I knew to be true... Healthy women with healthy pregnancies... If not messed with, they do very well. I had traveled with Ina May and listened to her stories of birth on the Farm and the very low intervention rate and complication rate over years and years of homebirth. I had talked with Dr. Fischbein about his experience as an OB, who does homebirth. But what I knew more than all of that was my own personal experience. I have been the backup for our local midwives for nearly three years. I roughly know how many deliveries are done locally and I know certainly how many hospital transports are done. Out of that I know how few have any complications in labor. The number is very very small and there are warnings before hand. So I kept telling attention Glen, pay attention.

We had made every effort to make sure nothing would cause me to miss our birth. We had limited patients and postponed surgery. But Tuesday, September 13th I had a c-section and a hysterectomy. Our due date had passed on the 12th and I knew it could be any time, but that morning was like any other. Tara felt and looked good and was headed to a conference at the birth center.

The c-section came and went without a hitch. Then I got a text. Tara wasn't feeling well and had started throwing up and she was headed home. I was just about to start the hysterectomy. What should have been an easy surgery quickly turned more difficult that I had expected. Then another call. 'Can you hand off the surgery?' My gut told me that this was the real deal. But I couldn't leave right then. Would I make it in time? Would all this planning and care be for nothing? I was going to miss my own daughter's birth...I just knew it! I began the case and when I finally finished, she hadn't delivered yet. Thank goodness.

Hustled home to find my wife in the tub, still sick as can be. I change and get in there to help. Then my introduction to homebirth. She hands me the full puke bucket, which I promptly proceed to drop and spill. The bucket hits the floor and now I am wearing vomit! Great! I'm glad I'm a doctor usually.

Tara finally gets out of the bath, working hard with her contractions and obviously overheated. Worried doesn't quite cover it. She looks flushed and sickly. Her temperature is over 101 and the baby's heart rate is 180. (She doesn't think I can count that high, but trust me, it was that high.) Where were we going with this? Was it infection, dehydration, infection...I was very worried that our perfect plan for a homebirth was suddenly going to become a medicated, monitored hospital birth because of a fever! So we watched and worked. We started an IV fluid bolus and gave a round of Ampicillin.

Slowly, over the next few hours she started to look and feel better. The baby seemed to rotate from posterior to anterior and voila, the contractions that had been horrendously painful and in her back, dissipated. As Tara cooled off from her much too hot bath, her temperature went down and the baby's heart rate was normal. Maybe tonight wasn't the night after all. And probably a better thing it wasn't with all those problems.

We gave all our Facebook fans the news that there was not going to be a baby on this watch and to all lay down and go to sleep, because that's what we were to do.

Thursday rolls around. No work, no rounds, no patients on the horizon. This seemed to be a good day to have a baby. And what do you know... By 5pm the contractions were regular. I knew it was coming. I was excited, terrified, nervous, happy and I couldn't wait to share so everyone knew it was the real deal. But we waited to make it known.

In our every day life, Tara and I are always very close, very affectionate. Our long standing plan for labor had of course been one of closeness. We would rock together during contractions. She would stand or lay and I would rub and caress her. Regardless, I would be close and there would be physical contact through the whole process. I guess the best laid they say. However, labor wasn't anything like our ideal.

At 7pm contractions were every 2-3 minutes. Remarkably, she was still putting on her makeup for what would surely be a photo op in the near future. I suggested we call our midwife and after many repetitive refusals, ultimately Tara relented and let me text her. At 7:45 Tara got in the bath. Other than a few trips to pee, this would be the last time she was out of the tub until we delivered.

It soon became apparent that the only physical contact between her and I was going to be with my pinkie. During contractions she would grab my pinkie and pull it underwater with her hand. No touching, no rubbing and certainly no caressing. But that was her way of dealing with the contractions.

It also became apparent that all of us should have had a script. What do you tell someone that continuously asks you to say something nice? I didn't know. Jennifer didn't know. So I tried humor. Oops...not the best idea. It will now certainly be a long standing joke in our house, but she asked for something nice and I told her that her Escalade would be ready to be picked up tomorrow. They had called today. It WAS nice for her after more rental minivan. That would be the same minivan that I would later clean up a front console of puke before giving it back.

At times I felt that the labor was surreal...that time was standing still and there wasn't anything happening. At times I wondered what I would be doing if this were in the hospital. But, I knew... I KNEW that everything was going well and that it was in fact going to be OK. There wasn't a monitor ticking away in the background. Pandora was there instead. There wasn't the beep of the blood pressure cuff or the IV bag finishing. Cal Worthington Ford's annoying commercial was about all that wasn't calm and soothing. The bathroom lights were dim. The tub was lined with fragrant candles. It was nothing at all what my hospital experiences were like...minimal resemblance to the births I have the honor of attending. I thought this to myself and felt a fleeting wave of sadness, as that's not the way it should be.

I knew Tara had no desire to be checked in labor. She felt as if there was no need. And honestly, I never once felt the need to check her. I could hear it in her voice. I could see it in her face. I knew that she was making change. Amazing, the value of observation and intuition. Funny that she didn't trust us to pick up on it though. We all were trying to give her encouragement. You're doing great. You're almost there! “How do you know I'm almost body has checked me. I could very easily be 4!” Jennifer and I glanced at each other...8cm was our guess.

Before long her tone took on a different tenor. Lower, deeper, longer. It was coming and it was coming soon.

Pop...gush. There it was, her water had finally broken. Having been the start of her other two labors, this time it waited until the very end. Once it broke, things went quickly.

I find it amusing to watch the video at this point. I reached into the water, desperately wanting to do something, but each time pulling back my hand. I didn't NEED to do anything. I fumbled and accidentally turned on the water. I grabbed for a towel to provide support. Really? In the water? So I reached down and gave pressure on her bottom. No gloves. But even that wasn't needed. The baby's head was crowning and with a grunt her head was out.

Delivery of the shoulders. Hmmmm. I was trained to just get on and get it over. Tara wanted none of that. In fact, she had been adament about it. I had to make an absolute conscious effort to do as little as possible. I did check for a cord and then beyond that, just waited. According to the video, her head was out nearly a full minute before the rest of her was born. That seemed like an eternity to an obstetrician! But, once again, I had to pull on what I knew to be wasn't an eternity. It was just fine and everything was going the way it should. Voila...just like that, another hard push and she was out. Tara reached down and grabbed her and Adria was screaming on the way up to her chest. Relief!!!!

I turned into a dad...and Tara turned into a midwife. I kissed on Adria, rubbed her head and just listened to her. Tara asked how her bleeding was, did someone want to listen to her-there's a stethoscope in the other room, she said. How was her bleeding now. How was it NOW? Does she need to get out of the tub? She wanted to let the cord stop pulsating...but she doesn't want to bleed too much. The perked consciousness and awareness of a midwife. Meanwhile...I'm still admiring our baby daughter.

She gets out...gets to the bed...delivers the placenta, and I all of a sudden I become an obstetrician again! HOLY SHIT!!! I was mortified to say the least. The placenta! OMG, the placenta. It was the scariest looking placenta I ever remember seeing.

Velamentous insertion. The vessels of the cord start dividing in the membranes. Big, honking vessels unprotected and vulnerable. Plus, a vessel running through the membranes. Yes, anything could have happened. So what did I do? I took pictures. Loads and loads of pictures of our crazy scary placenta.

A flurry of things then happened quickly. A few stitches, a quick drive to Tesoro for Motrin and a drink...Motrin for her, drink for me. Adria got weighed in a hanging fish scale, she got her newborn exam, a few pictures with the little ones and Candice and then the best.....silence. Everyone left. At that point it was Tara, I and Adria, in our bed. It was 2am by this point and the world outside was quiet. We pulled up the covers, turned on the TV and relaxed. After about 20 minutes, we turned off the TV and went to OUR bed, in OUR house. Comfortable, relaxing and peaceful.

In the end, I'm glad we did what we did. Being the 'midwife OB doctor' and the backup to the local midwives, I would have had a hard time doing it any other way. I truly believe- as well as research shows- that home birth for low-risk women with healthy, low-risk pregnancies is safe. It's where we felt was the best and safest for US. Of course, I had my fears, my 'what ifs', my 'worst-case-scenario' moments, but they were all erased the moment I saw her and knew that we had made the right choice.

Just like we did that night, I'll pull up the covers and say 'Goodnight' or 'until next time.' I look forward to the day that our experience is what is the norm for birth in our society. I look forward to being a doctor and instrument of change as a doctor who sees and acknowledges that we are not treating birth in the manner that it needs and deserves to be treated. I look forward to giving mothers, babies and families births they deserve. And of course, I look forward to doing this again. Now, to get Tara on board...