Saturday, November 6, 2010

Third Stage

I am devoting this post to the third stage of labor, also known as delivery of the placenta, because my two experiences with this stage have been uncomfortable and the most recent was just downright bad.

The first time, after they put my son on my belly, it felt awkward, and I didn't really want to be with him right away. The best antidote to this apprehension probably would have been plenty of time with him just then, but alas, it could not be. They took him away almost immediately because there had been meconium (baby poop) when they broke my water and meconium when he came out, and they needed to check him out to make sure he wasn't overly stressed out. This seemed justified to me. So naturally, with the baby out of my hands, all I had to think about was the delivery of that danged placenta. I kept asking my doctor, "When is it going to come out?" Of course he couldn't answer that question, so he just assured me that it would come out, and the only thing he could do to expedite the process would be to pull on the cord but he also added, "but you don't really want me to do that, do you?" The reason he cautioned against pulling on the cord is because doing this before the placenta has separated from the uterus may cause the uterus to invert. Pressing on the belly before the placenta is delivered can cause the placenta to separated incompletely. I think both can lead to hemorrhage, and retained placental fragments can also lead to infection. He may also have known how uncomfortable it would be without an epidural.

With my most recent birth, it was even worse. Or maybe it's just because it's fresh in my memory. In any case, it was sub-par. First of all, they took my son, whom I was delighted to meet, away before I realized what was happening. I think I thought they were going to bring him right back after a minute or two, but it was a lot longer than that. And secondly, the residents attending my delivery insisted on pulling on the cord and pressing on my belly. I asked them to stop, which they did for a while, but after 30 minutes had elapsed, they got antsy again and insisted, threatening that otherwise they would have to go up there with their hands (which I'm not sure would have been much worse) to pull it out. The other thing they were trying to do at the same time was sew up a second degree perineal tear that I had sustained.

So here's the scenario: I'm shaking uncontrollably. I'm tense, because I'm freezing cold. I can barely hold my head up much less my legs and my torso. They are tugging on the cord, every bit of which I can feel. And my legs are propped up in stirrups so they can finish as quickly as possible (which I had asked them to do because I just wanted them to quit messing with me). At some point, I felt her stitching together something that I was pretty sure didn't need to be stitched together and told her so. She told me I was wrong. And my baby is somewhere else...I think in the room, but I'm not sure where...and all I can think about is being done with this awful business. Yuck.

A couple of post-delivery observations. I'm fairly certain that a chunk of my placenta came out a few days after I got home from the hospital. Also, that part that I told her I didn't think she should be sewing together? About a week later, one or two of my perineal stitches snapped, so I'm pretty sure I wasn't wrong about that. I was horrified by both of these things at first, then I was angry, and now I am just resolved for it not to happen again.

After this, I did some reading on third stage management (in the midwifery text Heart & Hands: A Midwife's Guide to Pregnancy and Birth by Elizabeth Davis) and found out the following:

Adrenaline drops immediately after delivery, and oxytocin increases. Adrenaline and oxytocin oppose one another. Oxytocin promotes bonding with your baby, breastmilk production, and (here's the kicker) delivery of the placenta! So what's at least one effective way to promote oxytocin in mom? Keep the baby with her. But guess what else? If you are cold, adrenaline remains high, "which can disrupt placental separation by opposing oxytocin" (129). Also, "A drop in adrenaline levels moments after the birth makes it difficult for [the mother] to stay upright." These are ALL the problems I experienced during third stage: freezing cold, couldn't stay upright, and tension and anxiety because they took my baby away.

"The placenta usually delivers twenty to thirty minutes after the birth, although it may take an hour or more." Maybe my placentas just take a little bit longer to deliver than others? Given the fact that my babies seem to like to stay inside for longer than other babies, maybe my placenta has a hard time letting go, too. Completely speculative, but no one else seems to have any theories about why some placentas come flying out in 10 minutes and others take their time.

Perineal tears do not need to be repaired right away. This is one thing that could have waited. I asked them to just get it over with, but I might have been able to rest and bond with my baby if I hadn't been propped up for the repair.

In the name of efficiency, they took my baby away to clean him up and do their testing, and they worked on my perineal repair while they waited for the placenta to come out. In fact, though, it may have been more efficient for them to let me hold and nurse my baby, lie down, and cover me up with blankets. This would have spurred oxytocin secretion, which would have facilitated delivery of the placenta, and they could have sewed up the perineum after the placenta had been delivered and I was comfortable again.

All of these things created a toxic combination that have given a sour foot-note to an otherwise thrilling birth experience.

Part of the problem may be that hospital care providers are unfamiliar with the sensations that a lot of women experience after delivery without an epidural. With an epidural, you probably won't feel the discomfort of the contractions after pushing the baby out, and you won't feel the discomfort of the tugging on the cord on the pressing on the belly, and you won't feel if the stitches are being done in the right place.

My last note is this. In total fairness to my providers, they were trying their best to keep me comfortable. At one point, while I was wincing from a combination of cord-pulling, perineal-stitching, still-having-contractions pain, the resident said she just couldn't bear the thought that her work (stitching the perineum) was causing me pain, so she gave me an extra shot of local anaesthetic, thinking this would solve the problem. Unfortunately, she misunderstood the source of my discomfort, so it was not effective relief. And no doubt they were anxious is because I was anxious, confused, in pain, and didn't know what I wanted or needed and was making incoherent, contradictory requests. A good friend that had a similar hospital experience asserted that care providers should know what women need and want post-delivery when they are shaky, cold, and weak. Well, they didn't; but next time, I will.

Thursday, November 4, 2010

Funny Story

We are right now living with my parents. Every two weeks, two latina women come to clean their house. These two ladies were eagerly anticipating my son's birth, and last week, they had a chance to meet him. Their reaction to the circumstances surrounding his birth made me smile because of the contrast that I usually experience when I tell other (usually white) friends.

The first question: "Cut or regular?" By this, the older of the two women meant, "Did you have a c-section or a vaginal delivery?" Somehow the terms "cut" and "regular" bring into focus the reason that vaginal (regular) delivery is so important to me. Vaginal deliveries are "regular", and usually you can't beat the design God gave you. On the whole, women's bodies recover faster from vaginal delivery for that reason. Babies often recover faster, too (nursing and breathing may come more easily to vaginally-delivered infants). "Cut" also brings into focus the fact that a c-section is a major abdominal surgery, which always carries additional risks. I do not believe that c-sections and vaginal deliveries are equally good ways to get your baby out.

Don't hear what I'm not saying - c-sections are necessary for mom or baby's health somewhere between 5-10% of the time. And most women and babies that go through them do just fine. But a national c-section rate of upwards of 30% is grossly out of proportion to what is considered necessary by the WHO, and I don't think it's just because U.S. citizens are horribly unhealthy, as some doctors may claim. It's largely a product of fear, both on the part of women (fear of the pain of labor, lack of control) and their doctors (fear of being sued if they contradict ACOG protocols for individuals that don't fit the traditional mold, and lack of control).

The second question: "Libras (pounds)?" When I told them that my baby was 9 and a half pounds, they exclaimed, "Healthy! Strong!" This made me smile because what I normally hear from people is, "What a gigantic monster! That must have been horrible!" But the fact of the matter is that my baby is healthy and strong, and it's time that we stopped thinking about big babies as monstrosities. So be proud of your big babies, ladies.

The third question: "Boob?" Yes, she actually said "boob." She was asking if I breastfeed my son, which I do. When I answered in the affirmative, she said, "Oh, very good. Very healthy." And it's true. The American Academy of Pediatrics recommends breastfeeding babies for at least one year, for their health, and the American College of Obstetricians and Gynecologists recommends at least six months, for your health. It's worth the sacrifice of time, sore nipples, and other inconveniences.

The conclusion that these ladies had for me and my baby? "Very good. You will be able to have 5, 6, many more children." They hit it spot on and their conclusion was extremely gratifying to me. Because one of my intentions is and always has been preserving my ability to continue to have children until my husband and I deem it imprudent to continue. I would never want the fact that I happened to have an unnecessary c-section or the fact that a doctor is afraid the baby will be "too big to fit" when the baby fits just fine to keep me (or anyone else, for that matter) from future childbearing.