Interesting how I became primary midwife for T’s birth.  I have known T for a couple years in the birth community as a doula.   For quite some time, T had a midwife picked out for her HBAC (home birth after cesarean).  When she found out she was expecting, she asked me if I would be assistant midwife/back up midwife.  I agreed. At 35 weeks, I was talking with T’s midwife and she asked me if I could take over as primary midwife.  A few things had come up and her primary midwife was now going to be out of town most of October, which was the month we were expecting a baby. At the same time, T had begun experiencing itching of her skin that continued to increase and increase.  We monitored her liver enzymes and bile acids, and put her on dandelion root, milk thistle and chlorophyll.  Referral was sent in for the MFM (maternal fetal medicine) to have a look at baby and get an official diagnosis.  Her levels slowly increased.  We suspected cholestasis, which has some big risks for mom and baby, including still birth and hemorrhage to name a few. On October 8, T came to see me at 37.5 weeks.  We did a cervical exam and found her to be 1/50/-1, bulgy bag.  We did a membrane sweep to see if we could encourage labor.  That night my favorite acupuncturist Frank came to T’s house to work on labor encouragement.  Contractions came on about every 5-6 minutes.  They weren’t very strong, but they were regular. The next morning I met T to go with her to her MFM appointment.  She didn’t want to go alone and asked me to go with her.  Baby looked perfect, but the MFM agreed that T had cholestasis and that we needed to get baby out.  T’s first hospital choice was Texas Children’s Pavilion for Women.  The MFM said that no doctor would induce her since she was a VBAC and that every doctor would do a repeat cesarean.  The MFM agreed that Ben Taub would induce and sent a call over.  T decided that Ben Taub is where she would go. We road back to her house so that T could pack for the hospital.  Contractions remained fairly regular all morning.  I did a cervical check and found her to be 3cm!  I swept her membranes to 4cm.  Contractions remained regular as T’s doula and I helped her pack.  Soon T’s husband M arrived home and her mom arrived to pick up her toddler.  Around 4pm in the afternoon, we got T in her car and on the way to the hospital. In triage, T continued to contract about every 5 minutes.  When they assessed her, they found her to be 5cm!  That was great.  She progressed 4cm in 24 hours and it seemed she was making great change on her own. T finally got settled in her room.  We hung her prayer flags and birth affirmation posters around her room.  Anesthesia came in just to introduce and to answer any questions, and loved the birth affirmations and the flags of power as they were dubbed.  The two anesthesiologist then began to talk about placenta encapsulation and other uses of the placenta.  It was quite entertaining. The plan was to observe T for a bit and see if she made any change on her own.  No change was made so the plan was to artificially rupture T’s membranes.  She agreed to this as this was a much gentler way to augment things than just starting pitocin. Labor became serious after her membranes were ruptured.  We took turns providing counter pressure to her back.  T would try to change positions, but they were all uncomfortable.  Around 4am, T decided she wanted an epidural.  Doula D gently tried talking her out of it as was their plan they had made, but T insisted.  We left the room as her epidural was placed. Soon after, doula T had to leave to go home to figure out childcare.  We promised to keep in touch with her as labor progressed. T’s cervical exam before epidural found her to be around 6cm.  It was decided to insert an IUPC (intrauterine pressure catheter) so that they could monitor how strong the contractions were and decide if pitocin might truly be needed.  After thirty minutes it was calculated that her contractions were only measuring a 30, an ideal measurement was 200.  After weighing the pros and cons, T consented to pitocin. They gently increased the pitocin as the morning went on.  Contractions were slow to get to the intensity needed to dilate the cervix.  Around noon on October 10, they did a cervical exam, the first in hours.  Still a 6-7cm.  They encouraged her that he contractions weren’t quite strong enough and that she was not on a time table. Around 1, baby started having some variable decels on the monitor with contractions.  This continued.  The OB came in and discussed performing an amnioinfusion where they filtered back in fluid.  This helped and baby stopped having variable decels. Around 215 in the afternoon, T felt like she might be feeling a little pressure.  She had some bloody show on the chux pad.  Her contractions had been at a good intensity for a short time.  The resident came in to assess her and found her to be completely dilated!  We all cried!  T had been 6-7cm for around 12 hours, and that is the same dilation that she received her cesarean the first time.  We were overjoyed to here that she was complete. Doula T had returned, and doula D had received the news that another client was in labor.  It was a tearful departure, but T was in good hands. T labored down for about an hour before beginning to push.  Doula T and I each took a leg and gently coached T through pushing.  We joked at one point about how T didn’t want purple pushing, but since she couldn’t feel to push at the moment, we did the whole counting to ten ordeal.  Slowly, slowly T moved the baby with each push. The resident came in and assessed that baby was moving down and called her a +1.  We continued pushing with each contraction.  We tried pushing with T on her side.  Semi-sitting.  Playing tug of war.  The nurse assessed her and felt like she had made good change.  She provided T with some downward pressure to help guide where she should push.  T stated it helped and we could see a little bit of the baby’s head with pushing. The resident came back in to assess.  We were at three hours since called complete, about two hours into active pushing.  The resident stated she felt no change and that baby seemed stuck at +2.  She stated baby and mom seemed great so continue on, but explained that three hours was the recommended limit for pushing in the first vaginal birth with an epidural. After the resident left, the nurse handed me a glove and lube and asked me to check her and help her with pushing.  Pretty huge deal as midwives are not often acknowledged as equals in these situations.  I was astonished at the change and easily would have called T +3.  I continued to provide T with counter pressure to push, encouraging her with each push and letting her know when she was moving the baby’s head.  I told T that pushing was like country line dancing.  It is three steps forward, two steps back.  Each push was bringing her baby a little closer. The six o’clock hour appeared.  We were now close to the four hour mark since T had been called complete.  The OB on the floor came in and assessed T vaginally and by ultrasound to verify head position.  Dr. D determined that she thought using vacuum or forceps might be a good option at this point since baby was quite low.  Dr. D talked with T that she can’t go on forever pushing and that everything looks great, but they start getting concerned.  T asked for a few minutes to talk it over with her birth team. I talked over risks and benefits. Dr. D was about to go off, and she offered to do the forceps or vacuum since T preferred Dr. D to do it.  T decided since she was having some pain in the top of her fundus with pushing, she would push for three more contractions.  If baby did not come, she would consent to using forceps, but she wanted her epidural increased so she didn’t feel it. Dr. D was called back and agreed to be part of the forceps delivery and called anesthesia in to increase the epidural.  There was a lot of confusion and talk about the epidural.  Anesthesia came over to increase it, but did not end up increasing it.  Dr. D helped the two residents insert the forceps.  They did not cut a routine episiotomy!  With the next contraction, T pushed and the residents gently guided baby’s head out.  With the next push, T brought out her baby. Baby was brought to mom’s chest.  T looked and exclaimed, “He is a BOY!”  The cord was left to pulse for about a minute before it was cut. Baby boy stayed on mom’s chest while her second degree tear was repaired.  Soon he was ready to latch and he breastfed like a champ. Two hours after birth, they did sweet Bradyn’s weight and measurement and looked him over.  He was perfect. So blessed to have been part of T’s labor journey.  She did not have the home birth she dreamed of, but she was empowered by getting to make all the calls and had a beautiful, successful VBAC! Welcome to the world sweet baby Bradyn.  Born on October 10, 2013 at 6:22PM.  Weighing in at 6.12#, 19.25″ long.  <3