Posts Tagged ‘advanced maternal age’

Stephanie had contacted me early in her pregnancy (which was a surprise!) looking for a doula to support she and Bryan during their birth. She hoped for a natural labor and delivery. I recommended childbirth classes with Chan McDermott, which would help them both feel more prepared and confident, and she communicated to her physician, Dr. Breen her wishes. She also saw Susan Steffes, an obstetrical physical therapist, who helped release her tight ligaments to help her have a easier birth.

As her due date approached, Stephanie was closely monitored to make sure she and the baby were looking good– and they were! Dr. Breen was very patient to let her go past her due date and wait for labor to begin on it’s own. Early Sunday morning 3/2/14 they had a “scare” of some bright red blood, so spent a few hours at the hospital just to make sure all was fine. They were released later in the morning, all looking good.

Her real contractions began that night. She and Bryan worked through a whole night of irregular but strong contractions. We talked in the morning, while it still seemed like early labor, they were going in for their regular appointment with Dr. Breen, so I told them to keep me posted… Bryan called me at 9:30am to inform me Stephanie was already 5 cm dilated, 100% effaced, and -1 station! Although Stephanie reported “leakage” overnight, the test for amniotic fluid came back negative. They were headed into Seton. I was close by, so headed straight over!

It took a while to get Stephanie admitted (several attempts for an IV before calling anesthesia) but finally we were able to settle into just laboring. Stephanie liked standing, leaning over the bed the best. She was using her breathing and relaxation to cope. Bryan was super calm and steady, making a few phone calls and texts to let everyone important know what was happening!

By 11am, contractions had picked up and were a steady 2-5 minutes apart. Dr. Breen was at his office so asked if it was ok to have one of the residents check her– Stephanie declined. She was fine with just plugging away, trusting that was needing to happen was happening. Our nurse Allison was wonderfully supportive– we discovered she actually works also at a local birth center, and was completely comfortable and supportive of natural birth. What luck!

After more discussion, it was agreed that Stephanie probably did have a high leak, and her water actually was broken. As the late morning progressed, Bryan and I noticed she seemed to be working harder, although Stephanie reported they felt “the same”. Dr. Breen came in at 1pm and suggested an exam. He happily reported she was now 6-7 cm! He recommended breaking the forebag of water, to help the labor progress. Stephanie decided that was ok– we hoped it would help put her into transition and bring us a baby quickly!

Stephanie spent a while on the toilet– a great place to help bring a baby down. She asked for her “gentle baby” aromatherapy which helped her get into her “zone”. She was doing an amazing job of managing her contractions…I suggested to Bryan that he run out to get a bite to eat, knowing things would get busier later. He didn’t argue a bit.

Since Stephanie was so tired, I recommended we try a side lying position for a while, to encourage rest, and perhaps to help the baby rotate. I put a hot pack on her front, where she was feeling most of her contractions. We had a few really big contractions there, signaling we were moving into the next phase.

By 2:30pm she was acting “transition-y”… closer, more intense contractions. They were taking more of her effort now to get through them. She liked massages, and both Bryan and I being close by. Her back was hurting more now– I hoped that was a good sign the baby was moving down. Stephanie continued to work with her labor, vocalizing more, clearly working hard.

Since the baby’s baseline had increased, the nurse recommended fluids– we were drinking regularly, but with a long labor it’s easy to get dehydrated. Stephanie agreed. She continued to plug away, one at a time. Around 4pm, Stephanie had the first “inkling” of pressure– a good sign the baby had moved down. As that built up, she was sure she had to poop, so I recommended she labor on the toilet a while, that way, if she did need to poop, she could! (But I was pretty sure it was a baby coming instead.)

She spent some time on the toilet, then was back to the bed. Hands and knees felt good. She said something felt “different”… more continuous rectal pressure. Yay! By 6pm she was very gently feeling a little pushy at the peak of the contractions– Allison and I hoped it was a sign we were getting close to pushing!

Dr. Breen came in around 6:30pm to do an exam. Stephanie was 8-9 cm and the baby had come down nicely. (+1 station) I asked him about positioning and he said the baby was “ROT” which meant she was on Stephanie’s right side, transverse. Most babies need to be LOA to fit through the pelvis well– we had tried moving her all day, so I wondered if she was going to rotate ROA instead to come down… perhaps she was doing this her “own way” as Frank Sinatra so claimed. Dr. Breen was very pleased with her progress and was in no way worried that we needed to intervene in any way. Sadly tho, he was leaving (having been on call for 24 hours already) so Dr. K was taking over. We said goodbye and hoped we’d be pushing soon!

Knowing the baby still had some rotating to do (which way I did not know…) I suggested some hanging squats and some lunges, to create space. I threw a sheet over the doorway and showed Stephanie how to hang from it in a squat. Thank goodness she was so physically fit! She was game for anything. We also tried the hip squeeze while she did hands and knees, hoping to release the sacrum to allow the baby to move however she pleased. Our new nurse Rachel was easy going and supportive!

By 8pm, Stephanie hit the “wall”– contractions feeling overwhelming, almost unbearable, wondering if she could do this. Bryan and I offered words of encouragement… she had already come so far. She knew she “had to do it”… so determined. The baby was so low, the pressure was intense. She was talking to the baby, her body to open up. Rachel suggested an exam, maybe she was complete and ready to push? Rachel stated she was 9+ cm, the baby was really low, was not sure of positioning, but recommended lying on her left, as there was a little more cervix on that side. This position would help the cervix move out of the way.

Rachel reported back to Dr. K our progress. Dr. K came in, concerned that Stephanie was slowing down in progress, and worried she would become exhausted. She recommended considering getting an epidural to help her relax, and some pitocin to strengthen the contractions. (They had spaced some). Stephanie politely thanked her for her suggestions and said she’d think about it.

Within minutes, Stephanie reported that something felt different– less sharp pain, more pressure, and some burning. Rachel and I were delighted to hear this! We hoped it meant the baby was coming down and we were getting ready for the next phase– pushing.

At 8:40pm Rachel called in a doctor to do an exam. One of the residents (Dr. M) said she was still about 9cm/90/0 station. (stingy exam) She also assessed the baby’s size (was the baby too big to fit?) and recommended some pitocin. Stephanie’s contractions had spaced somewhat, perhaps her body was tiring out? She also offered the idea of an epidural to allow Stephanie to get some rest. Stephanie was up for the idea of some stronger/closer contractions, but asked me “can they force me to get an epidural?” and I said no way, it was totally up to her how she managed her pain.

So although Stephanie was drop dead exhausted (so was Bryan) she opted for some pitocin without an epidural– let’s see what happened. It was 10pm. Those contractions definitely got stronger and closer– she was giving it all she had to get through them. It took both me and Bryan coaching and encouraging her to keep it together, she was doing amazing!

By 11pm, Stephanie was feeling defeated– like she was doing all this work for nothing. Dr. M came in again to check her– she was “almost complete”– just had a slight lip of cervix left, which she felt she could push back. So I explained to Stephanie what she was going to do– hold back the cervix while Stephanie had a contraction. It would be pretty intense and uncomfortable, but it would get us to the next step– pushing. Once Dr. M got the cervix out of the way, she said the baby was at +1 station, and still ROT– it was time to start pushing. It was 11:30pm.

We tried to encourage Stephanie to push gently at first, to keep the cervix out of the way and help bring the baby down more. We gave her some apple juice to give her some energy to work. It had been an incredibly long day and she was pretty wiped out. Keeping Susan’s recommendations in mind, we tried a variety of pushing positions, first on her side, a few on her back, then the other side.

At 12:30 (after an hour of pushing) the doctor came in to check. She said the baby was still about +1 station and had not rotated yet. She assessed Stephanie’s pushes and did say they were very powerful. At that point she encouraged us to keep going.

By 1am something changed– we saw some progress! Perhaps the baby was finally rotating! I asked Stephanie if she had enough energy to try some hands and knees pushing– we needed all the room to get that baby down. It was more work, and exhausting for Stephanie, but she was game. As I saw Bryan fading, I sent him to bed for a power nap– it would be a while still before we had a baby, and I knew he needed to have some rest.

Rachel continued to monitor our progress, offer encouragement. She said the thought the baby was direct OP, which meant she was rotating– the long way around. By 2:15am, I saw the first peek of the baby’s head without anyone holding Stephanie’s tissues out of the way. That was really encouraging! I told her she was going to finish this! That baby was coming! Dr. A came in at 2:40am to check– she said the baby was slightly acynclitic but had definitely moved down. We switched back and forth between side lying and hands and knees to give Stephanie a chance to rest. It sure seemed like the baby was finally making her way.

At 3am (Bryan was back up now after a good 1.5 hour nap) Dr. K came back in. Her take on things was that it had been plenty of time for this baby to come– if she was coming, she felt it would have already happened. She gave Stephanie an ultimatum of 30 more minutes– if the baby hadn’t made some significant progress in that time, she was going to recommend a cesarean.

So we put the pedal to the metal. I knew Stephanie was completely wiped out but said we needed to do something different if we were going to get a baby here. I helped her get into a squat with me on one side, Bryan on the other. It was hard work, but she did it. Rachel watched her progress and was really encouraging– she felt like this was really working. In between contractions, we let Stephanie lean back and rest. She was beginning to think maybe a cesarean was going to happen… but remained determined to give it her all.

Dr. K and the residents returned at 3:30am. They seemed to bring a cloud of doom and gloom into the room. They said “Ok, let’s see what kind of progress you have made”. One exam and she said the “same”… then the next push, the baby’s head seemed to really come down. Everyone in the room was cheering! They said “Keep going, she’s coming down”. “If you keep going like that, you’ll be able to have this baby, even if we have to help”… right when we thought all was lost, we had one final hope!

Stephanie continued to push, and we saw great progress. I think that baby had finally turned and was now officially coming down. It still took another hour– another offer of a vacuum (which Stephanie declined) and an offer of an episiotomy (which Stephanie also declined) but Stephanie pushed out that baby girl all on her own, after 5 hours of pushing, with no tears… Danielle was officially here at 4:32am.

At the moment she was born, we saw large amount of meconium, which made us change gears a bit. The cord was cut quickly, and Danielle was taken to the warmer for suctioning and assessment. They called a NICU nurse in to help. I encouraged Bryan to go be with her and to talk with her– she would be fine but needed the reassuring voice of her daddy to help.

Meanwhile I stayed with Stephanie and praised her for a job well done! She had done it!! Over a day of work, but she had the natural birth she had hoped. She had been incredibly strong and determined.

Once they had given Danielle a little attention, a decision was made that she needed to be taken to the NICU for further support and assessment. She was brought to Stephanie for a quick moment, skin to skin, so her mommy could kiss and love on her…then she and Bryan headed to the NICU.

Welcome, Baby Girl Danielle, we are so glad you are finally here!

How does a doula really make a difference?
Results from different studies have all suggested that having a doula reduces the overall cesarean rate by 50%, Pitocin use by 40% and requests for epidurals by 60%. The use of a doula also showed a major reduction in the length of labor due to fewer stress hormones being produced in the laboring woman’s body.

The Doula Book © 2002; Klaus, Marshall, Klaus and Kennell.