Breeching Protocol (a birth story)

Breeching Protocol

by Rebecca Kuder

(An abbreviated version of this essay was published in Midwifery Today, Issue Number 106, Summer 2013.  Following is the essay in its entirety.)  

The nurse couldn’t find my cervix.

What was I doing here, in this medical factory?  The Plan had been to have a natural birth, at a birth center, assisted by a midwife, with support from my husband and doula.  But circumstances changed the plan.

I was 41 and pregnant for the first time.  Forty-one is considered advanced maternal age (AMA) by the AMA (American Medical Association).  AMA also means “against medical advice.”  Like, for example, when someone leaves the asylum without benediction of the medicos.

Convention pushes against natural birth.  When I told my previous obstetrician I was interested in the natural birth center connected to the hospital where he worked, mentioning water birth, he laughed and said, “I don’t have waders!”  So I left him and met the birth center midwives, who were in practice with an enlightened OB, Dr. Stephen Guy, and hired a doula named Amy Chavez.

* * *

Pregnant women are fed on fear.  Browsing at Barnes and Noble, I saw more books about miscarriage and loss than about healthy, natural pregnancies and birth.  Anxious and mildly obsessive by nature, now I was pregnant with the scarlet “AMA.”  But instinct told me to avoid too many books and late-night Internet searches.  After reading a few customer reviews of What to Expect When You’re Expecting, I saw a reference to Ina May Gaskin’s books.  Spiritual Midwifery eclipsed the scary images of birth that are splattered across mainstream TV and film.

* * *

Against type, I cultivated the ability to relax, indulging in massage and prenatal yoga.  I paid attention to my thoughts, challenged my fear and negativity.  With my doula, I acknowledged terrors, dispelled some anxiety.  I wanted to prepare for anything, but knew I had to quiet my obsessions about how things could go wrong.

That year, I was taking a class called conscious living/conscious dying, which was about preparing to die, and how to live more fully.  We discussed pessimism: the way people assume something will be hard, or impossible.  Instead of approaching birth with the assumption of difficulty, the teacher suggested I consider, “how easy this will be.”  I drew a ten-centimeter circle and focused on it, visualized opening.  I read that what we believe about breastfeeding (and whether or not we can easily nourish our babies) affects milk supply.  Applying that notion to birth, I did an exercise from Birthing From Within.  I drew pictures of what I thought would happen, and what I wanted to happen.  Before thinking, I drew the picture of what I thought would happen: the baby was head-up.  A breech baby.

* * *

To each prenatal visit, I brought a list of (obsessive) questions.  “What if the baby is breech?”  I asked Dr. Guy, during my second trimester.

“Don’t worry about that now,” he said.  But because I hadn’t “proven” I could give birth, I probably wouldn’t be “allowed” to do it naturally.  I had learned to trust Dr. Guy.  I knew he supported natural birth if he thought it was safe.

When I was 33 weeks pregnant, our daughter hadn’t turned head down yet.  Only about three to four percent of babies are breech after week 37.  By week 37, she still hadn’t turned.

Breech babies’ heads comes out last–trouble if the head is too large.  There is also the risk of cord prolapse–the umbilical cord is squeezed, limiting the flow of oxygen and blood to the baby.

Dr. Guy tried to turn the baby from outside my belly.

I breathed deeply.

“You’re a good relaxer,” he said.  But she wouldn’t turn.  He smiled and said, “She’s stubborn!”

We scheduled an external version–in the hospital “just in case” I went into labor, or needed an emergency C-section.  Then Dr. Guy hurt his back.  Could I trust another doctor, relax with a stranger?  And if it worked, I would have to wear a girdle so the baby would not turn back to breech.  This sounded medieval.  If I waited to go into labor, the baby might turn at the last moment, allowing a vaginal birth.  This happens.  Or I could schedule a C-section.  In my desire to avoid surgery, I left the question to time and nature.  Caesarian sections are chillingly common nationwide, comprising about 23% of all live births in Ohio.  When necessary, medical interventions can be essential and lifesaving.  But I wanted a natural birth.

Why hadn’t the baby turned?  Perhaps there’s a good reason she’s breech, I thought.  “Trust your instincts,” I told her, “If you need to be born breech, it’s okay.”  In the meantime: inversions, moxibustion, visualization, and chiropractic.  Fetal speakers placed low on my pelvis, my husband Robert and I played the Ramones, and Elvis Costello, trying to snake-charm her to turn.

Because the baby was in the frank rather than another breech position, Dr. Guy didn’t consider a vaginal birth prohibitively risky.  He learned we had great support from our doula.  He respected our commitment to natural birth.  I was lucky.  Dr. Guy was one of the only two “old school” doctors around who still supported vaginal breech birth.  Medical students don’t learn this stuff anymore.

I’d have to go to labor and delivery, not the birth center.  This was disappointing.  Labor and delivery was just a few turns down the hall, but miles away in enlightenment.

“And,” Dr. Guy said, “The best thing you can do is come to the hospital at eight centimeters dilated, and have labor progress smoothly.”

No problem.

* * *

A week after my due date, midmorning, mild cramps began.  I ate a sandwich.  Robert made final corrections to a collection of short stories and sent them to his publisher.  After lunch, I rested in bed.  The contractions strengthened.  Over the phone, Amy suggested I rest and eat, reminding me that early labor can last a while.  I called Dr. Guy.  Five minutes apart, my contractions were still pretty mild.

Around dinnertime, Dr. Guy called to check my progress.  He said to come to the hospital when my contractions were 2-3 minutes apart and I had trouble walking or talking.  About ten o’clock, Amy arrived, and gave me a massage.  Robert, always a counterbalance to my anxiety, seemed calm.  Home was a cocoon, safe, peaceful.  Though we forgot to take photos, fixed in my mind are the winter night shades of our living room, the heart of our house, dark purple sofa, woodsy trim, and my deep red nightgown.  Time was velvety, as we three steeped in this mystical stew of hushed intensity.  Wrapped in the purple-striped shawl my mother had knit, enveloped with warmth and maternal love, I was aware of this special thing happening, expectation, a quiet gem waiting, waiting.  The night was thick and dark as my pain swelled and subsided.  I moaned, trying not to wake the others as they napped.  In bed, during contractions, Robert pressed his knees into my back to relieve pressure.  Amy reminded me that each contraction, each specific moment of pain, would never return: once a contraction is over, say goodbye, let it go.

* * *

Around six a.m., everything intensified.  Was it time to go to the hospital?  Amy suggested I take a bath, then see how I felt.  She explained what to expect at the hospital–answering intake questions, being admitted to labor and delivery.  Within reason, the longer I could wait, the less chance my labor would stall.  The more chance of birthing naturally.

Amy said giving birth was the hardest thing I would ever do.

Daylight finally came, and with it, more optimism.  Robert made hash browns and a goat cheese omelet; all I could eat were small bites of toast with almond butter.  I drank a little cocoa.  I went to the bathroom and bled, tangible proof of what was happening.  Progress.

By one p.m. on Sunday, about twenty-four hours after the stronger contractions had begun, we decided to go to the hospital.  After weeks of dress rehearsal, I put on my birth bracelet, each bead given by a friend, colors spangling my wrist with love.

The nurse who couldn’t find my cervix summoned another nurse who could.  She said I was eight or nine centimeters dilated.  (As the doctor ordered!)  Although the nurse offered a wheelchair, I walked to the birthing room.  Because I was Group B Strep positive, which means there was a slight chance of passing it on to the baby, protocol necessitated IV antibiotics.  And, though the nurse knew I wanted a natural birth, she said an intravenous site was necessary just in case I wanted pain medication.

It seemed the nurse was waiting for me to break, and scream out for an epidural, like a clichéd movie scene.  I touched my birth bracelet.  The Mylar hospital wristbands clashed with the multicolored beads, juxtaposing the medical and the beautiful.

Labor was nine additional hours of breathing, working, chanting ohm…I laughed, wondering what the hospital staff thought of our hippie circle of three, almost four.  After I’d been pushing for a while, Dr. Guy broke my water to relieve the pressure.  Hooked up to IV saline and monitors, I tried lying in different positions.  Amy was benevolence embodied, contrasting the bossy coach nurse.  I focused inside, and bid good riddance to each contraction.

The nurse yelled:

“Don’t give up!”

“Push my fingers out!”

“Show us what you got!”

“Just get around that corner!”

Is there a corner somewhere inside my body that I didn’t know about?

With false sincerity, she said, “I know, I know,” but without much credibility.  Yelling, “Push!” at a laboring woman does not to help open the birth sphincter.

I wish I’d told the nurse that words have power and hers were not helping.  I formulated sentences in my head, ways to tell her, but it seemed pointless.  Her hand was inside my body and my daughter needed to be born.

Amy, who had a great working relationship with Dr. Guy, cornered him in the hallway.  She told him I’d probably kill the nurse but that I’d be able to birth this baby naturally because I trusted him.  If he recommended a C-section, I’d believe him.  He returned, which was reassuring, though the nurse was still in the primary spot between my legs.  But having Dr. Guy there, touching my arm, smiling, helped me feel safer.  I’d come to trust his voice, his round, childlike face.  His presence soothed like sunshine.  Later, I learned this was unusual–the OB usually arrives just in time to catch the baby.

I was exhausted.

Robert joked about a contortionist who squeezed himself through the head of a tennis racket.

Robert gave me water when I was thirsty.

Amy helped me find breath.

I thought, “This would be okay if not for the heartburn!”

I only recall feeling fear once: during a very strong contraction, as I was chanting ohm, my voice wavered.  Chanting had become my buoy, bringing focus, and when that faltered, my head dipped underwater.  But somehow I knew I would be okay.  All the women who’d ever birthed helped pull me through.  I never doubted I could do it.

* * *

Somewhere in the cascade of pushing, a new nurse arrived; the first nurse’s shift was over.  Gentler, wiser, the new nurse suggested different positions.  But the first nurse stayed, wanting to see the breech birth.

Even Dr. Guy, a valiant proponent of natural birth, would have recommended a C-section after two hours of pushing, but he had to go catch another baby.

Many women describe the moment of birth as feeling split in two.  The description fits.  I pushed, pushed, pushed…I’d been pushing for four hours; strangely, it didn’t seem that long, yet each breath and each movement of muscle was eternal.  The baby must be partially out–she must be.  But she was still inside my body, and there was more work to do.

When the baby was finally ready, we moved to the operating room…protocol, “just in case.”  By then, I knew I’d push her out naturally.  Someone asked if I wanted to touch her when she was crowning, or in her case, butting.  I didn’t, I couldn’t, it scared me; I needed to focus on my work.  But a few pushes later I put my hand between my legs.  I felt her emerging.  My body had been changed for months by her body, but now here was her form, blossoming.  I felt the force of her, almost here, and I felt gravity, and I felt the world.

And then Merida was born, though we hadn’t named her yet.  Dr. Guy lay her on my belly.  She was sweet and slippery and new, and she was our baby, and writing this, and thinking about that moment makes me cry.  As memories fade or are immortalized into story by retelling, I don’t want to forget the sensation of her slick little body on mine, us, finally together, skin to skin.

They put a striped hat on her head, and a warm blanket over us.  She was fine and I was fine and it was amazing and wonderful and I was so glad to be done!

The placenta came out, and Dr. Guy said I’d torn a little and needed stitches.  I don’t recall feeling pain then: in our weary celebration, I was experiencing a metaphorical orgasm.  She was here.  We were done.

* * *

While they wheeled me back to the labor room, I told Dr. Guy how grateful I was that I’d been allowed to do this.  He’d forgotten my age.  Amy stayed for a little while but needed to go before she was too tired to drive.  The three of us had summoned this power, formed a circle of humor and love and rubber-band-bonded-glue-team: mama, papa, and doula, a family, in a way.  There was a new hole, with Amy gone.

Before we were transferred to postpartum, the new nurse asked me for a hug–she said I’d made them all look good.  I was glad people were impressed with how hard I’d worked.

As I think about enduring a breech birth without medication, with very little fear, two clashing facts seem crucial: 1) It will hurt; 2) Our bodies are made to do this.

Support from Robert and Amy, laboring at home, and the Ina May energy embodied in my birth bracelet gathered to protect me from the harshness of the hospital IV jewelry and what it represented.  Dr. Guy was experienced and comfortable–accepting breech as another normal (if rare) birth position.  A warm, caring, giant-hearted man, he wanted the birth we wanted.  I’ve since learned more about the AMA (American Medical Association, in this case) and their vast lack of support for natural birth.  Envisioning how hard it must be for Dr. Guy to work in this context, my gratitude to him is ever-deepening.  And as one of the midwives had said, they’d had several “good” breech births recently.  Unwittingly, the other woman whose baby Dr. Guy had to go catch gave me more time.

I was lucky to have these people help me birth my daughter.

I had no reason to believe I could do it.  I let go.  I trusted that I would have medical help if truly necessary.  Amy was my fierce angel.  Robert never faltered; he was completely present and real throughout the whole adventure.

As a 41-year-old first time mother, at this point in the history of birth, having my breech baby naturally felt like a victory.  My baby and I worked together: to/get/her into the air, healthy and whole.  Because I’d advocated for myself, and the birth was so powerful, I entered motherhood clearheaded and victorious.  Strong.  Like a warrior goddess.

Women’s bodies are made to birth babies, including breech babies.

My story should not be so unusual.