The arrival of Lutka Gabriel
1 year ago today I was 37 weeks + 5 days at an appointment with my midwife.....
Here is my story.
I’m now “term” and could have my baby anytime in the next month. Well, I’m early term anyhow – but within the time frame when babies are typically born and when homebirth is considered safe. Some babies arrive all on their own ‘earlier’ than they’re ‘due’ and some arrive ‘later’ than they’re ‘due’. The due date is just a guess in a month long window.
My pregnancy has been healthy and normal, but my blood pressure (bp) at this appointment is higher than expected and my fundal height measurement is smaller than expected, which has my midwife concerned that the baby may be growth restricted (IUGR) since my bp has been going up at recent appointments. My blood pressure is lower when I measure at home (I experience white coat hypertension, as do about 30% of pregnant women), and my fundal height measurements at home have been consistent, but I am VERY MUCH feeling like I need to have this baby sooner than later. I can’t imagine going all the way to 42 weeks at this point, let alone even to my due date – I know our birthing time is near. My midwife offered for me to go home and rest then she’d come re-check my blood pressure there but I knew that white coat hypertension meant the number would still be high simply because they were measuring it, so I offered to go to the hospital for an OB consult which would be the next step anyway. I was comfortable having the bloodwork for pre-eclampsia done because if it showed a problem then of course I would take the appropriate steps for a safe birth. I was reasonably confident however that the bloodwork was going to come back normal – which it did. While there I also agreed to have a non-stress test done and a basic ultrasound to take a peek at baby’s size because I knew it would help my caregivers be more comfortable moving forward and that was important too. I am not comfortable with the routine use of ultrasound technology in pregnancy and so had declined all ultrasounds up until this point. Baby passed the NST just as I expected from monitoring baby's heart rate at home using a fetal stethoscope and doing daily kick counts. The on-call OB was respectful of my discomfort with ultrasound technology and worked quickly: “Baby looks small, but fine. Placenta looks fine.” Done. I had to agree to return to the hospital the next day to have my blood pressure checked again and the OB sent me with a prescription for blood pressure medication that they wanted me to fill and start taking in the morning. I did some research when I got home and learned that while my blood pressure was higher than normal, it was not high enough that medication would be clearly beneficial so I made an informed choice to wait a day and see if I could have this baby before it was time to be officially medicated and therefore risked out of a homebirth.
Because of the increasing blood pressure and concerns about the potential small size of the baby, having a homebirth was on the line. Having worked as a doula for more than 10 years, I was averse to having a hospital birth unless there was a very clear indication that the benefits would outweigh the risks. Ontario midwives only attend homebirths where the pregnancy is deemed low risk. High blood pressure can be the first silent symptom of preeclampsia, which can lead to HELLP - a life-threatening condition that is only ‘cured’ through the birth of the baby. Untreated, HELLP results in both mother and baby dying. Preeclampsia & HELLP aren’t something to take lightly, and both require medical intervention in a hospital setting. Knowing all this, knowing my own body, and knowing that the preeclampsia bloodwork was completely normal, I remained confident that baby and I were healthy and that homebirth was still a safe choice for us. BUT the bottom line in reality was that if I wanted a homebirth, I needed to have the baby before noon the next day when it would be time for me to go back to the hospital for follow-up. I wasn’t opposed to a hospital birth IF it was truly indicated because baby or I were experiencing complications that required medical intervention. I also recognized that even under the care of midwives, giving birth in the hospital changes everything. Practically speaking, the power rests with the hospital and their policies and if the birthing woman wants something the hospital doesn’t support she has to fight for it. Just knowing that a fight may lie ahead triggers the release of adrenaline, which works in direct opposition to the oxytocin needed to allow labour to progress well. The hospital setting interferes with the optimal birth process in a myriad of ways which I personally considered to be risks so it wasn’t something I was going to choose unless absolutely necessary.
Before leaving the hospital I asked my midwife to do a good stretch & sweep for me to encourage my body into labour sooner than later. A stretch & sweep isn’t a guarantee, and it isn’t entirely risk free, but *if the body and baby are ready* a stretch & sweep will often allow labour to begin within 48 hours and the risks associated with it are minimal. Cramping and spotting are the most common risks. It is possible that your water will break in the process but that is uncommon. It had been effective for me when I gave birth to Levi 4 years prior (in combination with evening primrose oil and homeopathics) so I was hopeful my body would respond positively again.
My midwife agreed that given the circumstances a stretch & sweep was appropriate. I was already 3-4cm with a soft stretchy cervix. The cervix is not a crystal ball and can’t predict how or when labour will progress but I was encouraged nonetheless. The plan was for me to go home and do what I could to get labour started. Before leaving the hospital I checked my cervix myself (yes, that is often possible) so that I would have an idea of what the midwife assessed as 3-4cm and I could then check again later to know what was going on if I felt that I needed that information. When I left the hospital and picked up Levi from a friend’s place, I was having mild contractions every 20 minutes. They continued as I drove home through construction traffic on the 401 and I reassured myself that these were likely just because of the stretch and sweep, but if things picked up in intensity the shoulders were wide enough for me to drive on and get to an exit. Once I was home I started thinking through what my next steps would be. Because my cervix was still thick (and because I’m not personally comfortable with it) castor oil was not an option. Black and blue cohosh are herbal tinctures I considered as they can be very effective at encouraging labour, BUT they can also influence blood pressure and that’s not something I wanted to mess with. 4 year old Levi was awake until late so sex was out of the question. I can’t stomach spicy foods at the best of times let alone on top of pregnancy heartburn. I’d done lots of walking. I’d seen a chiropractor and massage therapist to ensure my pelvis was well-aligned for birth. I was drinking herbal teas. I had laughed and cried and vented the emotions I needed to vent. I ended up taking my trusted homeopathics knowing that they would only work if my body was ready for them to work and that they wouldn’t interfere with anything. I took a long hot shower. I bounced on my ball at the computer while I chatted with friends online. I used my breast pump. And labour slowly began. I took the advice I give my clients, which is to ignore everything until your body demands your attention. I updated my doula in the early evening on the day’s events. But for the most part we just carried on as usual through our evening. Nathan mowed the lawn. Levi played. We ate supper. Contraction-expansions (because as the uterus contracts the cervix expands!) were every 7-8 minutes lasting about 45 seconds but they were mild and entirely ignorable. No one from the outside looking in would know they were happening. Around 9pm Nathan suggested that maybe his Mom – Grandma Hope - could come over and help with some last minute housework that I wanted out of the way (she had offered to help). I didn’t want to “jinx” potential labour by having people come too soon, but since Hope wasn’t coming “for the birth” I decided that was okay. She arrived around 9:30pm and brought the most delicious fresh cherries from BC as she had just returned a few hours prior from a week there. The contraction-expansions started to build in intensity and come closer together but I wasn’t timing them at that point. With encouragement from Nathan we called our doula Kim at 9:41pm. I still hesitated to call our midwife though as I didn’t want everyone hanging around the house watching me and waiting for things to happen. Like all mammals, women need a sense of safety, privacy, and warmth in order for labour to progress optimally. I didn’t want to be a watched pot, I didn’t want labour to stall, and I didn’t want to put my blood pressure up by having my caregivers there too soon. Around 10pm Nathan and Hope started suggesting more often that we should call our midwife. I decided I would check my cervix between contractions to see if I was making any progress, and based on that I would call our midwife or wait longer. Checking the cervix isn’t part of a doula’s scope of practice so it isn’t something I’m skilled at, but I could feel my baby’s head, could feel that I was a good 5cm, and could feel that the cervix was about 1cm thick. I timed a few contractions and realized they were coming every 3 minutes and lasting 90 seconds so we contacted our midwife who headed our way immediately. By now I was working HARD for each contraction-expansion. They were one on top of the other with barely a breath between them.
I moaned. I walked. I swayed. I held onto Nathan. Hope offered to go home and have someone else come be with Levi for the birth as had been the plan but things were too intense for me to consider changing who was with us. Kim our doula arrived around 10:15pm and immediately stepped in to offer her support. With Hope caring for Levi, and the house organized, Nathan was free to labour with me which is something we missed in my labour with Levi and had really hoped for this time.
About 10:30pm our midwife arrived. She knew right away that things were progressing quickly and went straight to work setting up. Nathan was my anchor – I leaned against him constantly. Levi was hanging out with Grandma in the living room, and asked to watch Call The Midwife (an appropriate choice. lol). Of note – our house is pretty open concept and under 1000 square feet so even in the living room Levi was still very much a part of the birth. From time to time he’d have a question for me which I did my best to answer as I wanted him to feel like he was an important part of what was happening.
Soon I was feeling a bit of pressure at the peak of contraction-expansions. Our midwife asked if it was time to call the second midwife but I told her not yet. She asked if I wanted her to check my cervix to decide if it was time to call the second midwife and I agreed. Part of my plan for birth was no vaginal exams except possibly to assess whether we needed to call the second midwife. I was fully dilated so the call was made. Another contraction-expansion arrived, bringing immense pressure with it. I moved to my hands and knees and told everyone the baby was coming. My body was doing all the work – there was no need for me to actively “push”. While that may seem unusual (to not push for hours), when birth conditions are optimal Dr. Michel Odent refers to what he calls the Fetal Ejection Reflex where essentially the baby is born rapidly, with no coaching from others and with little to no added effort on the part of the mother. It simply happens. The mother is typically in an upright/bending over posture, and the placenta usually follows quickly. Elevated blood pressure can result in a very intense rapid labour too, and so can the homeopathics I used. Whatever the cause – labour was moving fast.
I breathed and cried and swore and asked how much longer till it was over. I leaned my head against Nathan while Kim our doula stood behind me, and Grandma Hope held Levi – all three watching as baby emerged. I reached my hand down to see if I could feel the baby’s head yet and felt our midwife’s hand there. She said baby’s head was out and that if I wanted to push (even though it was between contractions) I could. I added my efforts to what I was feeling and at 11:02pm our baby slid out. When I looked down I discovered that our baby had been born “in the caul” (inside the amniotic sac) which happens in less than 1 in 80,000 births (although some other sources say 1 in 1000 which is much more common though still rare) and has been considered a good omen for the child in many cultures throughout human history. (Yes, we have dehydrated and kept the cord). Our midwife removed the membranes and I could see that we had a boy. I asked Levi if he wanted to come see whether he had a brother or sister but he preferred to stay back just a while longer. As I was figuring out how to sit back without giving myself a hip cramp, at 11:05pm my placenta came out so we also had a partial lotus birth which hadn’t been planned. A partial lotus birth is when you don’t clamp and cut the cord until after the placenta has been birthed. A partial lotus birth ensures that the baby gets their optimal blood volume from the placenta. Our midwife suggested we hold the placenta up for a bit so gravity could help baby get cord blood. I was thankful she thought of that as I hadn’t anticipated the placenta arriving so quickly. Once the cord went thin, limp, and white she clamped it and Nathan cut it.
The placenta was circumvallate, which means that when it was developing the amniotic sac doubled back on itself, pulling the placenta with it so that it covers less surface area in the uterus than is typical. A circumvallate placenta occurs in roughly 1-2% of pregnancies, for unknown reasons. It is theoretically detectable by ultrasound but most of the time it is missed. Depending on the severity (ours was mild), a circumvallate placenta can bring with it an increased risk of pregnancy loss (miscarriage or stillbirth), pre-term birth, placental abruption, subchorionic hematoma, low amniotic fluid levels, and IUGR.
Despite all that - our tiny little Lutka Gabriel was here. Our midwife saw when doing his newborn assessment that he has a sacral dimple. A sacral dimple occurs in 1-2% of pregnancies, and about 50% of the time it is a variation on normal, while the other 50% of the time it is associated with spinal cord issues and Spina Bifida. Fortunately Lutka’s dimple is normal. He weighed in at 5lbs 1oz, which meant that he was small for his gestational age (3rd percentile). Our midwives (as the second had arrived) informed us that because of his weight their scope of practice mandated a consult with a pediatrician and Lutka would be admitted to the nursery as part of the hospital’s blood sugar protocol. Babies who are very small or have IUGR are at greater risk for a number of post-birth complications including meconium aspiration (but there was no meconium thankfully and he was born en caul so couldn’t have aspirated it anyway), infection (being born in the amniotic sac reduced the risk of infection and birthing at home meant no exposure to hospital super germs), and also hypothermia and low blood sugar. Prior to the invention of incubators one of the leading causes of newborn death was low birth weight and the accompanying complications. While incubators, IV’s of sugar water, and formula all have their place…. So does constant skin to skin with mama and breastfeeding often. Being skin to skin helps vulnerable babies regulate their body temperature, heart rate, breathing rate, and blood sugars, and helps keep them calm - - in ways that an incubator simply can’t duplicate. The official title for this sort of care is Kangaroo Mother Care. It was the middle of the night, I had colostrum stored in the freezer to supplement with as needed, I had plenty of experience breastfeeding and assisting others to breastfeed - - I was confident that the best place for Lutka was at home on my chest. We made the informed choice to decline transporting to hospital for a consult. Our midwives reviewed the warning signs of infection, hypothermia, and low blood sugar with us, as well as all the usual things to watch for in baby and I, and were very clear that what we were choosing - to stay home with our baby - was against their recommendations and protocols, and at our own risk. For the next few days we checked Lutka’s temperature regularly, kept him skin to skin at all times, breastfed hourly, and topped up with colostrum by syringe. If Lutka had shown any of the warning signs we would have of course ensured he received the medical care he needed.
Before long everything was cleaned up and cleared away. The trash and laundry were gathered. The bed was made. Our midwives and doula and Grandma Hope all headed home. And we were ready for bed. Our family was now 4 instead of 3 and we were grateful.
P.S.Lutka lost 3.5% of his birth weight in the first couple days (7-10% is common) and was back up to his birth weight by day 4 (newborns should usually be back to their birth weight by days 10 to 14). At his two week visit Lutka weighed 6lbs 2oz and by 4 weeks he was up to 7lbs 10oz. He doubled his birth weight by 2 months, which is usually expected at 6 months, and tripled it at 6 months, which is usually expected by 1 year. Today he is 1 year old, and weighs 20lbs.
Our story wasn’t necessarily typical, and some of the choices we made were outside the recommended standards of care. Many factors influence how a particular birth story unfolds and having an honest, respectful relationship with your primary healthcare provider - so that you can work together to achieve the optimal birth *for you*- is key. Every mother-baby is different. Our history, education, values, support systems, how we assess and weigh risks vs benefits etc all impact the decisions we make and ultimately what our births will look like. The choices that are best for one mother-baby aren’t necessarily the best choices for another mother-baby, even when their stories look similar on the surface.
Our choices weren’t all standard, however they were made consciously and after having explored information from a wide variety of sources. To fully embrace the idea of “informed consent/choice” you must be willing to fully OWN the choices you make - and their outcomes – whatever they may be. That includes the good outcomes, the bad outcomes, and the unexpected outcomes, and it includes recognizing that if your primary healthcare provider truly and deeply believes that your choice is too risky for them to support, s/he reserves the right to not take you on as a client, or to transfer your care to a more suitable healthcare professional. We are grateful to our midwives for walking with us even though the choices we made for our family stretched the status quo.