Just when you think you've seen it all, the universe sends you a new one. And this one was a whopper!

It was exactly 10 days past her due date. I wasn't worried. Baby obviously wasn't worried. Our mama wasn't worried. She knew babies come when they are ready. But boy, were the midwives worried. They had already resorted to scare tactics by telling Zala the statistics on stillbirths and post-due babies. Right, I thought. Exactly what she needs just now.

So now Zala was becoming less confident by the minute. She considered using castor oil, tried long walks, and then agreed to let the midwife she was seeing strip her membranes--twice. That is done by sweeping a finger around the baby's head inside the cervix. The water isn't broken, it is just manipulated a bit, just enough to get things rolling, usually. It often sends a signal to the uterus to begin labor. It didn't do anything in this case. Another day went by.

Then on day 12, a gorgeous Saturday morning, I got a text at 10 a.m.: "Contractions 5 minutes apart. Meet us at the birth center."

I was so excited. Even after 30-plus years I still get excited. I texted back: "On the way! Happy birth day!" I was actually ecstatic because I thought my grandson's birth had been my last-ever birth two years earlier. I had retired due to health issues; paramount was my loss of over 90 decibels of hearing. I was diagnosed with Meniere's which not only destroys hearing but also affects one's balance and equilibrium. I could no longer only not hear my clients but could fall over at any time without warning besides. Broken ribs and a fractured leg proved my point.

On the way to the birth center I got another text: "Water broke. Birth center won't be open until 12:30." Since when do birth centers have hours? Really? I couldn't believe this.

When I got there I rang the doorbell over and over again. There really won't be anyone here until 12:30? That is over an hour from now. Are you kidding me? I went from being incredulous to being angry. What the f&#@! I still could not believe it.

Finally the door opened. The lady apologized, "I am so sorry. I am just the cleaning lady." I told her she isn't just the cleaning lady. We couldn't do this without her!

She let me in and I asked if there really would not be anyone in until 12:30. She confirmed that.

I could not wrap my brain around this one. What do I do now? Well, I do what I have always done when I find myself in hot water: I brainstorm all my options and all the possible scenarios.

I decided I would go to the couple's home and catch the baby there if I needed to. But I'd retired from midwifery close to 10 years ago now. I didn't have a birth kit with me. I didn't have anything.

I told the cleaning lady that I am thinking I should "borrow" some supplies from the center and go to the couple's house and hang out there until the center opened. She agreed (I would have stolen the goods even if she had disagreed,) so I went into the first birthing room along the hallway and ransacked the drawers. I opened up my shawl and started dumping things into it: sterile instrument pack, cord clamps, gloves, bulb syringe, etc. I wrapped it up and made a bee-line for my car parked out front. It crossed my mind that I might end up in jail by the end of this day, but I didn't care. It wouldn't be the first time. And that was not for delivering a baby.

It was back during the notorious 1960s when I was hitch hiking with friends along the West Coast.

We'd made it as far as Eugene, Oregon from San Francisco when we were arrested. Literally. Hitch hiking is illegal in Oregon. Who knew? We were put in jail, literally. Although I was only 16 at the time, they didn't buy my story. They laughed when I told them I was a minor. So I spent the night in jail. I chocked the experience up to "education." The other time I was arrested was a year before the hitch hiking fiasco while protesting the Vietnam War at Washington Square Park in Greenwich Village, New York City. I was allegedly defacing city property by painting peace signs on the cobblestones, even though it was water-based acrylic paint. Yes, the '60s were an exciting time.

But back to this birth which was close to fifty years after the arrests. (I have managed to avoid prison time since then.) So I raced to the couples' house 12 minutes away from the birth center with the loot wrapped up in my scarf on the passenger seat. I ran a red light, too, which I have never done before. A 65-year-old rogue. A miscreant grandma. What had I become? The thought crossed my mind, I wonder if they have a vegetarian option in prison these days?

When I got to the house Zala was dealing well with the contractions (being called 'rushes' now,)

walking around the house, puffing away, holding up the wall when a rush built up again. I didn't think we were at transition just yet. Her breathing didn't sound like we were. You get used to that sound if you hear it enough times.

I asked if she felt 'pushy' yet, which she didn't, though I expected to hear that tell-tale sign sooner than later. I encouraged her to keep drinking juices and rest when she could.

Finally we got to 12:00 p.m. without a baby appearing so we all agreed to go to the birth center, where they quickly got Zala in a room and checked on her progress. 5 centimeters. YAY!

Contractions slowed down, allowing her to rest and eat something. Then they all but petered out. The midwives started getting anxious. Walking didn't help. Nothing helped, so we waited, and waited...and waited. Finally, about supper time, they suggested that for some unknown reason, she just might need a bit of help getting things going, like with Pitocin, which they couldn't offer at the clinic but she could get at the hospital. The couple were pretty deflated by that, to say the least, but I explained that if it worked, got the rushes coming again, they could turn off the dose completely and we could proceed with a natural birth. I also told them that they could still have a midwife and we would also still honor their wishes as outlined in their birth plan. (And I had visions of a home birth only hours earlier.)

They liked that, though it was not what they had expected. I assured them that they would be respected and not be bullied into all sorts of interventions. This hospital had some great midwives that I'd worked with in the past and I told them that we all still wanted the best for them and their baby.

We got settled in and the new midwife checked Zala. 4 centimeters. What is going on here? I thought to myself. I haven't seen anything like this in a very long time. I didn't want to alarm anyone, so I tried to stay positive and very patient. A major change during labor, like moving to a different place could definitely slow things down. Except 10 hours later, she was still at 4 centimeters. We had tried everything. Walking, resting with a peanut ball between her knees, more walking, lunges which often help baby engage in the pelvis. The midwives were concerned that the baby had not properly engaged in her pelvis. She remained so high and felt like she was in an asynclitic presentation.

Below, everything you've always wanted to know about asynclitic presentation but were afraid to ask, from the Spinning Babies website, https://spinningbabies.com

Asynclitism refers to the position of a fetus in the uterus such that the head of the baby is presenting first and is tilted to the shoulder. Asynclitism means asymmetrical. It’s when a baby’s head is tipped towards one shoulder. The tipped head has a harder time passing through the narrow part of the pelvis, the ischial spines. Labor becomes longer, and sometimes baby doesn’t fit out the pelvis. Happily, we have techniques for this problem!

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The baby who is asynclitic after engagement is at a disadvantage. Soften and balance then get upright for stronger and more effective surges to bring baby down.

Early in labor, the baby’s head enters the brim of the pelvis in asynclitism, tipped, to get around the protruding base of the spine (sacral promontory). Early in labor, before 3 cm, asynclitism is normal and desired.

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Normal asynclitism helps baby engage by navigating the sacral promontory.

At 3 cm, when the nurse checks the cervix, she’ll notice that the baby’s head is closer to the mother’s front (usually). There is space between the baby’s head and the mother’s sacrum in back. We are reassured, as long as the forehead doesn’t overlap the pubic bone (in which case, we help the baby engage in labor).

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Normal posterior asynclitism – this just means baby’s head now tips below the sacral promontory.

By 4-5 cm, the head has usually filled in the space in the pelvis evenly. There will be more room in the back, but the side to side angles of the head match. The head has become symmetrical inside the pelvic canal. The head is synclitic.

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Now baby is synclitic and about to rotate on the pelvic floor (not shown) See the “seam” or suture of baby’s skull bones in the transverse diameter. First time Zala is about 5 cm now.

Asynclitism becomes a problem when the head is still tipped at, and after, 5 cm dilation.

Discovering asynclitism in labor

The nurse, doctor, or midwife may notice the asynclitism during a vaginal exam.

The cervix will be thicker on one side and thinner on the other side (NOTE: thicker in front is normal, in my experience, and I don’t worry too much about that). The baby’s head will seem a little lower and closer to the bones on the thin side. The baby’s head will seem to angle away, deeper into the pelvis and less close to the mother’s bones on the thick side. The nurse will have to think about it, so ask her to check for this before or during the vaginal exam.

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The baby’s head is asynclitic. On one side there is more head coming down, and less cervix. On the other side there is more cervix but less head. I’m not talking front to back, but rather, side-to-side.

Labor with an asynclitic baby

If the bag of water releases suddenly with a strong contraction, there is a possibility that the baby’s head comes down to the mid-pelvis while still asynclitic. Asynclitism may be caused by a hand near the face, or if muscles are imbalanced a twist in the lower uterine segment, causing the baby to twist to fit the area. More typically, the pelvic floor is asymmetrical and so the head gets tipped as it is pressed down with strong contractions on the uneven edges of the opening to the pelvic floor.

Labor is often longer. Sometimes the labor pattern is a fast dilation to about 8 cm and then slow to get to 10 cm. Other times, when a hand is up, things may be slow throughout dilation. Pushing tends to go very slow – the baby can’t help get born in this position. The head is angled wide and the baby can’t wiggle down because the neck isn’t lined up with the spine. Zala has to do the work.

Dilation often takes longer and there can be a delay in progress at about 8-9 cm or 9 1/2 centimeters for many hours.

A mother may feel pain to one side. She may have significant pain in one hip. Hip pain may also be from one of the baby’s arms being up along the head or a spasm in the muscles within the broad ligament.

Contractions are often strong throughout, unlike the ebb and surge of a posterior labor (though that can happen, too).

Longer second stages

It not unusual for second stage to last 3-6 hours when the head is tipped. I’ve also attended first-time mothers with second stages 2 and 3 times longer than this.

The baby can develop a caput. This doesn’t necessarily mean that the baby won’t fit. Often, the baby requires the mother to change position frequently (maternal positioning) to open the pelvis. Spinning Babies pays attention to the “soft tissue” anatomy (muscles, fascia, ligaments) in the midpelvis and muscles to the pelvis.

What should I do for Asynclitism?

· Do the Pelvic Floor Release (Side lying Release)

· Follow with the lunge (the lunge will work better after the pelvic floor/sidelying release)

· Doing the Dangle should follow the Pelvic Floor Release and the lunge.

· Sometimes resting and not pushing at all through 2-5 contractions helps molding. Rest in a Rest Smart position.

· Vertical positions, such as standing and slightly bending the knees during a surge

· Stand with one foot on a stool

· Sit on the toilet with one foot on a stool and the other foot on the floor

· Pulling on a towel or rebozo during pushing contractions

· “Shake the apple tree” by shaking the mother’s buttocks in the same speed you would shake a branch to make a ripe apple fall

· Keep moving during a contraction (it’s ok to rest, but don’t “freeze” your body with tension)

Eating small amounts and drinking warm honey tea helps keep labor contractions strong enough to keep moving the baby.

Lying down in one position is not likely to allow the baby to descend further downward. Very specific and persistent techniques are often necessary.

As long as we are talking about what to do, please look into craniosacral therapy and pediatric chiropractic for baby after birth. They should know the special techniques for babies. This can be very helpful with the breastfeeding latch.

Asynclitism means asymmetrical. It’s when a baby’s head is tipped towards one shoulder. The tipped head has a harder time passing through the narrow part of the pelvis, the ischial spines. Labor becomes longer, and sometimes baby doesn’t fit out the pelvis. Happily, we have techniques for this problem!

Save

The baby who is asynclitic after engagement is at a disadvantage. Soften and balance then get upright for stronger and more effective surges to bring baby down.

Save

Normal asynclitism helps baby engage by navigating the sacral promontory.

Save

Normal posterior asynclitism – this just means baby’s head now tips below the sacral promontory.

Save

Now baby is synclitic and about to rotate on the pelvic floor (not shown) See the “seam” or suture of baby’s skull bones in the transverse diameter. First time Zala is about 5 cm now.

Asynclitism becomes a problem when the head is still tipped at, and after, 5 cm dilation.

Discovering asynclitism in labor

The nurse, doctor, or midwife may notice the asynclitism during a vaginal exam.

Save

Labor with an asynclitic baby

If the bag of water releases suddenly with a strong contraction, there is a possibility that the baby’s head comes down to the mid-pelvis while still asynclitic. Asynclitism may be caused by a hand near the face, or if muscles are imbalanced, a twist in the lower uterine segment, causing the baby to twist to fit the area. More typically, the pelvic floor is asymmetrical and so the head gets tipped as it is pressed down with strong contractions on the uneven edges of the opening to the pelvic floor.

Dilation often takes longer and there can be a delay in progress at about 8-9 cm or 9 1/2 centimeters for many hours.

Contractions are often strong throughout, unlike the ebb and surge of a posterior labor (though that can happen, too).

Longer second stages

It not unusual for second stage to last 3-6 hours when the head is tipped. I’ve also attended first-time mothers with second stages 2 and 3 times longer than this.

What should I do for Asynclitism?

· Do the Pelvic Floor Release (Side lying Release)

· Follow with the lunge (the lunge will work better after the pelvic floor/side lying release)

· Doing the Dangle should follow the Pelvic Floor Release and the lunge.

· Sometimes resting and not pushing at all through 2-5 contractions helps molding. Rest in a Rest Smart position.

· Vertical positions, such as standing and slightly bending the knees during a surge

· Stand with one foot on a stool

· Sit on the toilet with one foot on a stool and the other foot on the floor

· Pulling on a towel or rebozo during pushing contractions

· “Shake the apple tree” by shaking the mother’s buttocks in the same speed you would shake a branch to make a ripe apple fall

· Keep moving during a contraction (it’s ok to rest, but don’t “freeze” your body with tension)

Eating small amounts and drinking warm honey tea helps keep labor contractions strong enough to keep moving the baby.

Lying down in one position is not likely to allow the baby to descend further downward. Very specific and persistent techniques are often necessary.

Added on December 12th:

We tried many of the above maneuvers, though nothing worked for long.

Her midwife suggested an epidural at this point, her reasoning being that maybe labor wasn't progressing because Zala was so depleted. They had started an IV so they could re-hydrate her, which made Zala feel so much better, but didn't restore the rushes or encourage dilation. I suggested that the epidural be postponed which the midwife thought about for a moment and then agreed with. I suggested that perhaps a short term drug like Fentanol might give her the rest she needed without pulling out all the big guns, so to speak. After this, the midwives and nurses included me in all their conversations, asking for my advice or input along the way. As the couple's advocate I often turned to them, explaining what had been said and giving them full autonomy in the process. This was paramount to me.

One nurse in the room said that if she had known who I was she would have felt quite intimidated by me; (the midwife had actually trained under me in a birthing clinic in the city while she was still in school and knew about my book, Ma Doula: A Story Tour of Birth, and had obviously talked about it at the nurses' station.) This particular nurse however, had absolutely impressed me with her brilliant knowledge of how to correct mal-presentations. This was new to me. It was brilliant, groundbreaking stuff. I told her she should publish this.

When she said that she would have been intimidated by me, I couldn't disagree more: what she was doing in this hospital and teaching new methods of correcting a mal-presentation actually blew me away. I was genuinely in awe of this lady and I told her so. I had never seen anything like it and had a lot to learn from her. Then I quoted something Ina May Gaskin once said, "If you meet someone who knows more than you do, you just shut up and listen." Exactly! I might never have an opportunity like this again. One thing that she addressed was the shape of Zala's pelvis. 50% of African women have an Android pelvis which could be what we were dealing with here. I had heard of this and had a bit of a guess that this was possible. So many women in Africa experience the horrific complications of this (when a C-section is not available) that they not only loose the baby, but even if they themselves survive delivery, often their anatomy is compromised by a fistula and other damage and they are rendered incontinent. This becomes a permanent condition without surgery to correct it. see https://www.youtube.com/watch?v=93JdSmRqsNc

From another, reputable source:
The Android pelvis. It has a heart-shaped brim and is quite narrow in front. This type of pelvis is likely to occur in tall women with narrow hips and is also found in African women. The pelvic cavity and outlet is often narrow, straight and long. The ischial spines are prominent. Women with this shape pelvis may have babies that lie with their backs against their mothers’ backs and may experience longer labors. It is important that these women take an active role during their labor and need to squat and move around as much as possible.

The Gynaecoid or genuine female pelvis. It has an almost round brim and will permit the passage of an average-sized baby with the least amount of trauma to the mother and baby in normal circumstances. The pelvic cavity (the inside of the pelvis) is usually shallow, with straight side walls and with the ischial spines not so prominent as to cause a problem as the baby moves through.

The Anthropoid pelvis. It has an oval brim and a slightly narrow pelvic cavity. The outlet is large, although some of the other diameters may be reduced. If the baby engages in the pelvis in an anterior position, labor would be expected to be straightforward in most cases.

The Platypelloid pelvis. It has a kidney-shaped brim and the pelvic cavity is usually shallow and may be narrow in the antero-posterior (front to back) diameter. The outlet is usually roomy. During labor the baby may have difficulty entering the pelvis, but once in, there should be no further difficulty.

Many women are concerned that their pelvic capacity may be limited and that they will therefore have difficulty in giving birth. The true capacity of the pelvis will only be realised during labour. Only the forces created by mother and baby during birth will allow the pelvis to open to its full potential. This may take some time, but it is the only true way of exploring the “fit” between the mother and baby during birth. ~ end of quote on pelves (plural of pelvises.)

******

And then Zala's temperature started creeping up. And after that her blood pressure crept up, though ever so slowly. And the baby's heart rate soon followed suit. What was going on here? Her urine was also pink at this point, though we knew she wasn't dehydrated. No one could put their finger on what was going on here. That's when Zala mentioned that she thought the amniotic fluid that continued to drip smelled funny to her. Smart lady.

Bingo! The next thing I knew, a special team showed up to both analyze the infection, now being called sepsis, determine what kind it was, and isolate it or confine it to this room only. This hospital is on the ball, I thought to myself.

From some articles on sepsis explaining that the baby can get the infection from the mother before or during delivery: The following increase an infant's risk of early-onset bacterial sepsis: GBS colonization during pregnancy, infection of the placenta tissues and amniotic fluid; Neonatal sepsis can be caused by bacteria such as Escherichia coli (E coli), Listeria, and some strains of streptococcus. Group B streptococcus (GBS) has been a major cause of neonatal sepsis. However, this problem has become less common because women are screened during pregnancy. The herpes simplex virus (HSV) can also cause a severe infection in a newborn baby. This happens most often when the mother is newly infected. Early-onset neonatal sepsis most often appears within 24 to 48 hours of birth. The baby gets the infection from the mother before or during delivery. The following increase an infant's risk of early-onset bacterial sepsis: GBS colonization during pregnancy, preterm delivery, water breaking (rupture of membranes) longer than 18 hours before birth, infection of the placenta tissues and amniotic fluid (chorioamnionitis,) etc. ~ end of article.

Without having the luxury of an instant diagnosis--the blood work could take hours to get back--the midwives and now their consulting OB doctor laid out the options which continued to dwindle by the minute. What it all came down to was: A. we could wait for the labs to get back, but if they were positive, then baby would have to go to the NICU (neonatal intensive care unit) immediately upon delivery or, B. If baby was delivered now, s/he could stay with Zala and bond, most likely be treated in the room with Zala, and not have to be separated. The team would deal with the infection in the most appropriate way as the results of the labs came in. At this point the surgeon came in and explained all this to the couple. He did't rush and I must say I have never seen such respect from a doctor before. He could not have been kinder.

This was not a case of going to the hospital and having all the interventions domino into a C-section. This couple could not have done anything differently or better. The doctor explained that the uterus was fighting this freak infection and couldn't function normally by producing effective contractions or appropriate dilation. Now we knew what we had been dealing with all along. It dawned on me that if this couple were back in East Africa where they were born, the odds of Zala and baby surviving were not good at all. They were just as good as nil. They might have become a WHO (World Health Organization) statistic.

Her doula, Isa, and Dad were given scrubs to put on and went into surgery with her. I could have gone in, though I would have bumped her doula who I knew needed as much experience as she could get and was only at the beginning of her career. I had seen dozens of Cesareans and as much as I wanted to see their baby being born, I didn't want to take this away from Isa.

Within an hour Zala was in recovery. We all sighed a huge sigh of relief and said our prayers of thanksgiving. I got to see the new little family in recovery. Daddy had baby on his bare chest. He was on cloud 9, totally smitten with his new baby girl who was peacefully sleeping. After a couple more days they could go home and start their new lives as parents.

Zala, you are my hero and I love you so much. All that pure love and energy to birth your child. Thank you for sharing that with me.
I count my blessings.

To leave comments at this blog, please email me at: ssskimchee@gmail.com

Call the Doula!

Thursday, November 29, 2018

You are my hero!

To leave comments at this blog, please email me at: ssskimchee@gmail.com

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