A Birth In Guatemala

The Western Highlands

  A soft knock at the door, and midwife Anna Maria popped her head in.  She told me there was a birth downstairs, and I was welcome to come if I would like. Of course I would like! She then went on to say that the woman was nine centimeters dilated. My sense is that women here typically labor at home with their families until advanced labor.  I asked if this was her first baby.  Anna Maria answered no, her second.  But her first was a cesarean.

  A VBAC. How fitting that the first birth in Gautemala I observed would be a VBAC, after all the trouble I'd gone through for attending VBACs in California. I followed Anna Maria downstairs and entered the Sal de Parto, a spare room with a big,comfortable bed, a shelf of supplies and a chair for the woman's mother. The father of the baby, the woman's sisters, and her own father sat in a waiting room.

  I could tell that birth with Mayan midwives is low-fuss.  The laboring mother, at nine centers, rested silently in the bed. She smiled and politely greeted me when I entered and introduced myself.  The two midwives did not change into scrubs, but wore their "street" clothes - gorgeous hand embroidered colorful blouses and skirts. Just before the baby's arrival, Anna Maria tied a robe over her clothes to protect them. During the contractions, the woman quietly endured them, between them, she chatted with her mother. The energy reminded me of births I attended while a student at North Central Bronx Hospital, for Central and South American woman.  It is fascinating to me that the response to the sensations of labor truly is a cultural thing.  The only hint she gave that she was enduring pain, was that she asked "How much longer?"

   The midwives asked if I wanted to deliver the baby and I declined.  I was here to observe, support, and learn about their methods, not "take over".  I said would just help them, however they needed me to.

 Soon, the mother was pushing, and we could see baby's hair with the pushes. Every one was calm, quiet, and relaxed. The laboring mom kept smiling at me, for some reason she was happy I was there, murmuring in my goofy Spanish that she was doing well, just relax between the contractions, until the next one.  I noted that the unmistakable scent of human childbirth is the same, no matter where in the world you are.

  With one more contraction, the baby crowned and then came entirely out.  My first thought was, he is premature! The baby was tiny, as in 4 and a half pounds. TEENSY. He looked 34-36 weeks to me, not quite full term. He was pink, but floppy, and made no effort to breathe.  I handed  Anna Maria a towel and she dried him, and stimulated him.  He opened his eyes and stared up at us, but still did not breathe.  I handed Anna Maria the bulb syringe and she suctioned him well.  Imelda vigorously massaged his chest and I felt the base of the umbilical cord to determine the heart rate, which was normal and strong.  "Come on baby!" we cooed in our various languages, Mam, Spanish, English.  Also, we stayed calm and no one rushed or panicked.  After maybe three or four minutes, I could see that his tone was not improving, and I offered to give the baby repsirations.  The two midwives stepped aside, I tilted the baby's head and breathed into his open mouth, inflating the alveoli and initiating respirations.  I could feel his minscule lungs expanding with each breath I gave, and was very careful to keep them small, and not injure them.  After four breaths, his tone improved and he grimaced. Anna Maria cut an onion in half and placed it beside his nose. I gave a few more breaths, and then his engine began to purr  He cried, he breathed, he snuffled and snorted.  I worried, watching his skinny chest heave and ho, that he may continue to have trouble breathing, as I have seen in early babies.  But not this little guy.  He adjusted, and was fine.

  The room was cool, so after a few minutes of skin to skin with mom, the midwives dressed him.  I mean DRESSED him.  Three shirts, two pants, two hats, socks, two blankets.  The guy was so wrapped in soft knits and woolens, one had to peer down through the layers to find him in there.  I kept a close eye on him, still concerned about his size, his breathing.  But the midwives were less concerned.  They placed him in his mothers arms, and went to see another woman, who had arrived for a prenatal consultation.  I stuck around, and helped the mother to breastfeed.  i suggested that she feed him every two hours to bring her milk in quickly and get him growing.  We also talked about other methods for increasing milk supply, and Imelda told me they have herbs for that to give her. Imelda told me he was 37 weeks by dates, not premature, just small.  Most babies born at ACAM are six pounds or so.

  The baby nursed on and off for an hour, and the mother prepared to go home with her family in another hour or so. I brought them water to drink and peeked at the baby one more time.  He was warm, with rosy cheeks, red lips, and busily suckled.  I told the mother and grandmother, in my funny Spanish, that he was small, but mighty, like Napoleon.  They laughed at that, the woman took my arm and thanked me, and I went back upstairs.

Imelda, midwife and up-and-coming
 leader in her community

A Tale of Two Cords

Dear Readers,

       Over the years I have been very careful to avoid criticism of our local hospitals in my words, and in my blog.  I am grateful to have safe hospitals nearby for those times when we need them.   My intention with this post is to bring to light an issue that is important , and needs to change.  Remaining silent in order to avoid sounding critical does not actually serve mothers and babies.  
     This post is  about  the baby's umbilical cord;   when and why it is clamped and cut, and the implications of that choice for the baby.  I will briefly discuss how my own management of the cord has evolved over the years, give some links to latest research, and then illustrate some important points with a story.
     I was trained in 1995 in a busy public hospital in the Bronx.  My preceptor taught me to always check for a cord around the neck once the head was born, and then "reduce" it,  meaning pull it over the baby's head, or clamp and cut it if it was so tight that I could not.  If option B happened, then we had to hurry to deliver the rest of the baby quickly as the baby's oxygen had just been cut off.  The cord, mind you, is what delivers oxygenated blood to the baby from the placenta in utero, during the birth, and if the cord is left alone, for several minutes postpartum.  During my studies I also learned about the myriad benefits of delayed cord clamping for the baby.  For a detailed explanation of those, please read this . Then I learned that in the hospital, when a baby is born compromised, and not able to start breathing on her own, the cord is cut right away so the baby can be rushed across the room to be resuscitated on the warming bed.
       When I began attending births at home many years later, I quickly realized that home born babies have this brilliant advantage:  If the baby is born compromised and not breathing, the cord is left intact, delivering oxygen to the baby just as it did in utero. The midwives resuscitate the baby right there beside the mother.  The first time I did this, I was amazed at the difference that I saw.  In the hospital, distressed babies are blue or grey in color as they lie on the warming bed, their lifelines severed so that the nurses can work on the other side of the room.  At home, our little non-breathing baby was pink instead of blue, getting her oxygen from both the cord and our ambu-bag until she perked up and could start breathing on her own. 
     Around that time, an article was  published in the ACNM  Journal, questioning the act of even checking for a cord around the neck in the first place.  The  study interviewed midwives in the U.S. and midwives in  New Zealand, comparing  various practices.  Lo and behold, New Zealand midwives don't ever check for a cord, and U.S. midwives always do.  And guess which babies do better?  Neither;  the outcomes are the same.  
       My third year of homebirth practice, I attended a waterbirth for a VBAC (Vaginal Birth After a Cesarean) mama. The head was born in the water, I reached in and checked for the cord, and sure enough there was a very tight cord around the neck.   I realized that  I couldn't possibly clamp and cut it with her in the birthing tub like that, so I just let it be.  That baby was fine.  Better than fine.  He was born, I unwrapped the cord from around his neck, lifted him out of the water and gave his back a little rub, and placed him in his mama's arms, pink and perfect.  I have never cut a tight cord since. It was an "A-ha!" moment.  You don't have to cut a tight cord.  Soon after, I studied detailed intructions on  "The Sumersault Maneuver"  by which the baby's  body can be  sumersaulted past the head to accomodate a tight cord during birth. .  Over the years I have attended births with the cord wrapped once, twice, even four times around the neck, without it ever being a problem for the baby.   And I am always grateful for that lifeline if the baby needs extra help breathing. 
    There has been a lot of research lately to confirm what homebirth midwives already know; babies that need resuscitation do better if the cord is intact.  Read about this promising study of preemies here.  Read about this beneficial practice in the developing world here   Also, there are efforts to develop technologies (like a lightweight board that can be placed beside the mother Wow wow. We use a plastic cutting board at home.)  so that our State of the Art, first-world hospitals can cease cutting cords to rush babies across the room. Read about a pilot program for that here.

Let me quote from these articles :
"When babies aren’t breathing at birth, doctors typically have to cut their umbilical cords and whisk them away from their mothers in an urgent attempt to resuscitate them. The intervention saves lives, but it’s a trade-off. These babies lose nutrient-rich cord blood that can help prevent brain damage and other complications."

“There is no expense and no equipment needed. All the attendant has to do is pause, let the baby breathe and then clamp the cord,”

   I was inspired to write this post by a beautiful birth I attended this week.  Here is the Story, as promised.  Thank you Mary for allowing me to share this.

A Tale of Two Cords.

     For Mary's first birth three years ago, her plan for a home birth changed when she went post dates and we discovered low fluid levels around the baby.  We went in for an induction to her local hospital, and with a little medication she went into labor.  Mary did a tremendous job laboring all night in the shower and on her birth ball.  My assistant and I served as her doula.  In the morning she was close to delivery.  She pushed for a few hours, and fortunately the baby's heart rate sounded terrific the whole time, showing the staff that he was tolerating the labor well.  We got very close to birthing time.  The doctor came in.  The baby's head was born, and there was a cord around the neck.  The doctor clamped and cut it.  Then, everything stopped for a few minutes.  Contractions, pushing, everything.  I felt this terrible sinking feeling when the doctor cut that cord, but now nothing could be done but wait.  Several minutes went by, baby half out, oxygen cut off.   Finally the baby came, grey and limp and in poor shape.  He was rushed off to the NICU .  $64,000 and five days of pokes, pricks, IV's and oxygen masks later, the baby was discharged home, healthy.  Mary said the nurses kept reminding her how wonderful it was, that they saved her baby.  I never said a word to her about that cord, but she knew that that was why her baby had gotten so sick.  "They saved my baby from a mistake the doctor had made, and expected me to be grateful for it.  And I was, but it was really hard." 
    This week, Mary had her second baby, at home, under my care.  She went into labor just after her due date, and her labor progressed quickly.  Her water broke as she approached the final stage of birth, and once again she had scant fluid with meconium.  There wasn't time to transport for this, so we readied ourselves to help the baby at home.  Mary gave birth on soft towels on the bedroom floor.  The head was born, and the little one spit out a mouthful of meconium (which landed on my nose but you didn't need to know that).  I reached a finger in to check the shoulders and felt a tight cord around the neck.  I withdrew my finger and let it be.  Just like last time, it took a little while for the baby's body to come.  Mary got up to a kneeling lunge, and the body slowly emerged.  The baby sumersaulted himself , I unwrapped the cord, and then just watched.  The baby looked around, waved his little fingers about, and then opened his mouth a took a deep breath.  His color went from purple to cotton candy pink.  The cord pulsed away.  This all happened in that silent, timeless moment we call the first minute after birth.  It was my first home birth since my year off in India and I felt honored to witness the perfect design, the perfect physiology, that is the miracle of birth. 
   
    
   Folks, don't all our babies here in Butte County deserve this beneficial care, not just the ones born at home?  I think so.  I know so.  Perhaps we can begin bringing awareness to our medical community that it is time to update their practices.  Let's not just stand by shaking our heads.  Some ideas: 

1.  write a letter to the nurse-manager of your local hospital, including copies of these articles I have linked to.
2.  Bring copies of these referenced articles to your next visit with your OB or hospital midwife, and ask to discuss these issues with them.
3. Join the Chico Birth Network, to promote safe and gentle birth;  contact me for info.  I welcome your ideas and input.  

The First Breaths of Life

     It seems my clients like being written about on their midwife's blog.  I had no idea when I started this a couple months ago that folks would be so open to my writing about them.  Talia and Mishu are my most recent new parents and they have graciously agreed to let me tell about their story.  So here it goes...

  Talia and Mishu came to me a little less than 2 years ago, nine months pregnant.  With tears in her eyes, lovely red-headed Talia requested that I take her on in the eleventh hour.  She explained how over the nine months of pregnancy, she slowly realized she should be having a homebirth.  She had been seeing the hospital midwives and but now REALLY wanted a homebirth after all.   Mishu was a recently graduated nurse, and they were prepared to do whatever was needed for birth at home .  We went for it.   Talia rocked her first birth with twenty-four hours of early labor and then a straightforward active labor the following night.  She did great and little Livia happily came into this world.

    For her second pregnancy, Talia came to me from the get-go.  Mishu has become a very well-respected RN at our local hospital.  (I love it when local RNs choose to birth at home!)   Right around her due date, the 1st of March, she had some bouts of contractions during the night that went away at dawn.  This happened a few nights in a row.  Then, on Wednesday, they didn't go away at dawn.  Talia had irregular mild contractions throughout the day, and in the evening they got a bit stronger, although still not strong.    I had checked her in the afternoon and  she was barely 1 cm open with the baby's head high.  That evening, my assistant Amber went over to check in on her, and she texted me updates such as "No need to rush over here, not that much going on.  Contractions, but irregular. Baby's heart tones sound great."   Well, around 9 pm a little voice deep inside me said "Go over there now".   I went.   When I was approaching her street, Amber texted me "Water broke, gush of clear fluid."  Oh yeah, it was time.
     Talia was sitting in her bathroom on the pot, cranky about how the contractions felt but still chatty and not really looking like she was deep into labor.  About fifteen minutes later she stood up to wash her hands, turned a deep red color and p*u*s*h*e*d.   "Talia, hold on there a second"  I said, running to peel off my street clothes and throw on my baby-catching clothes.  With my shirt half on, I heard Amber say "Dena, I see the head!"   Sure enough the head was crowning.   Talia was on her hands and knees in her small bathroom.  I climbed behind her, half in the shower, and Mishu and I together put our hands on the head as it was slowly born.   The little face was pink and she was making little movements.  Hello dear!   Then we waited for the next contraction.  And waited.  And waited.  It was a few minutes but it felt long.  These dang irregular contractions!  I had Mishu reach down and rub her belly.  I had Talia crawl a few feet into the bedroom to give me more space to work.

    A contraction came, Talia pushed, and the baby was born.  She was floppy like a rag doll and a mottled purple and white color.  She was not grimacing or sneezing or trying to breathe.  I quickly dried her with a warm flannel blanket and rubbed her up to stimulate her.  While doing so I placed my fingers on the skin where her  umbilical cord inserts and felt a normal heart beat.  "Good heart beat" I said.  But still no effort to breathe at all.  And limp.  Amber had the oxygen tank and ambu bag ready.   I had recently taken the neonatal resuscitation training of Karen Strange CPM, who is the pre-eminent authority on resuscitation in the home birth setting.  She talks about mouth-to-mouth breathing as an initial alternative to ambu-bag and oxygen tank.  For more info, see her website  www.newbornbreath.com 
       I lifted the baby to my face, placed my mouth firmly over her nose and open mouth, and carefully, slowly gave the baby an "inflation breath."  With mouth-to-mouth,  I can literally feel her lungs' alveoli inflate, and her lungs expand to take in oxygen.  I am so connected to the baby's life force.  A newborn baby's alveoli must inflate so she can take in oxygen through her lungs.  In the womb, the alveoli are collapsed and the lungs are filled with water.  That is why the baby's  first, big breaths are so important.  I pulled her away a bit to look at her.  She opened her eyes and looked at me.  But didn't breathe. "Okay baby, lets breathe"  I said, and gave her four more mouth-to-mouth breaths.  By the fourth, I felt her suck in on her own, she mewed, and then gave a good cry.  She turned a rosy pink from head to toe, and her arms and legs bent into normal position.  She was breathing fine.  Her heart rate was fine.  Her tone was strong.  She was a little more than a minute old.  I had been working on the baby right beside Talia, with the cord intact and pulsing away, providing oxygen to the baby even while she wasn't breathing.  In the hospital, if the baby is not breathing, they cut the cord right away and take the baby across the room to work on her.  At home we leave the cord, which is still  bringing oxygen to the baby via the placenta for several minutes,  and work on the baby beside the mother. I would like to see hospitals learn to do things that way - it is definitely to the baby's advantage.

   The baby was now warm, pink, and perfect in Talia's arms.   She was letting us know all about it.  Talia stood to get into bed and the placenta plopped into a bowl I had at the ready.  She hardly bled a drop.   Within two hours, and baby had eaten,  been cuddled skin to skin with both her Mom and Dad, Talia had been up and showered, and we were all eating blueberry birthday cake.  The baby was strong and alert and weighed in at 9 lbs!

Here she is after being checked out thoroughly by her midwives.  That is yours truly holding her lovely footprints, her first mark on the world.

   Today when I called to check in on the family, Mishu told me they have decided to name their baby Adina, partially in honor of their midwife, who provided her with her first breath of life.   I am the one deeply honored, and so grateful to all my teachers and mentors, and supportive, wonderful assistants.  Most of all, I am grateful to all the moms and babies I have served over the years, who have truly been my real teachers.