Abby 9 3am, three days before A’s due date, A sent me a text and said she thought her water broke. She moved around, and more clear fluid with specs of vernix continued coming out. A said she was having some cramping and back tightening with them. We chatted through the hour and A decided she was going to try a hot bath to see if it helped relax her or picked things up. At 5am, A text that the surges were pretty intense and she would like me to come. I arrived at A’s house shortly before 6am. I found A laying on the side of her bed, moaning through a surge, a heating pad on her back and B providing counterpressure. A said she had a major craving for tator tot’s late last night and sent B to Sonic to get her some. We joked that the tots worked better than castor oil as her stomach hurt after the tots, and soon the cramping began. I did my initial vitals assessment. A had elevated blood pressure, still normal range, the last couple weeks. Her blood pressure was elevated, which wasn’t a surprise as it appeared A seemed to be working hard. Surges seemed to be coming around every 2.5-3 minutes, lasting 30-45 seconds. I did a cervical exam and found A to be 3cm dilated, 80% effaced and baby at a 0 station. I asked if it was okay to sweep her membranes. A said yes. I swept a little, but A was uncomfortable so I did not push things. Baby appeared to be in LOA position by leopolds and internal assessment. We discussed A calling her doula. A wasn’t having much chance to catch her breath. B tried calling the doula. A moved to the toilet and did a wash with hibiclens since she was ruptured and it would help keep infection risk low. A moved to the shower to see if the warm water helped her back pain. Within a few minutes, she was leaning on her bathroom counter, B and I alternating providing counter pressure to A’s back. A then moved to the bath tub, but soon got out and moved to the toilet. A stated she was nauseous so we pulled out the peppermint oil for her to smell. Everything was looking good for a baby today! Abby 7 About 7am, I asked A if she wanted me to call her doula and she said yes. Her doula was on the way. I went into the kitchen and mixed up some magnesium powder for A to drink to help with her blood pressure. I told A we would be checking blood pressure every hour for awhile to be sure her blood pressure was okay. The next hour, A walked around bed room and bathroom, leaning over counters. Each surge, needing counter pressure. A had her diffuser going with sacred mountain and valor. A seemed to resonate well with sacred mountain and liked to keep the diffuser going with it through out the day. While A labored, I blew up the birth pool and started getting that set up and ready. A’s doula arrived at 8am. I put in a call to the birth assistant and a friend who were going to make up the birth team. A tried to lay on her side in the bed, but found that position uncomfortable. A seemed to like standing at her bed side, leaning onto the birth ball. Her doula encouraged her to shake her hips, as she provided counterpressure to her back. As 9am came, A ventured into the living room. She sat on the couch for a couple surges, then moved to the shower. Surges were now coming every 3.5 minutes, lasting 70-100 seconds and were visibly stronger. The birth assistant arrived right before 10am. A’s blood pressure was the highest reading yet.  A’s doula went and mixed up magnesium powder for her to drink to help her blood pressure, and soon we saw a drop in her blood pressure. A asked to be checked, having been 4 hours since the first check of labor. I found A to be 4-5cm dilated, 100% effaced and baby still at a 0. I swept her membranes more efficiently this time with A’s consent. Bloody show was noted on the glove and chux pad. A seemed to feel discouraged about the exam and we encouraged her about all the progress that has been made. Baby still appeared to be LOA position. A swayed her hips at her bed side. I gave A a homeopathic, Gelsemium, to see if it would help loosen her cervix. It is good for making the cervix stretchy, loosening a rigid os. A was nauseated and not having much of an appetite. She was drinking water and coconut water, but other than a couple bites of yogurt, hadn’t wanted to eat. She agreed to do a spoonful of honey to keep her energy up. Through out the 11am hour, A moved her position frequently. A laid on her left side, stood and rocked her hips, labored in the shower. I began to fill the birth pool with water. A little after 12, A’s blood pressure was much more normal. She moved around the bed room and living room, rocking through the surges coming every 2.5 minutes, lasting 90 seconds. R, A’s doula, pulled out labor ezz and did massage with that. At 1:15pm, A asked for a cervical exam. She was 6cm dilated now. I had been encouraging getting in the birth pool for a couple hours, and A said she did not want things to slow. Things were visibly regular, long and hard and I encouraged A to think about the birth pool. She got in the shower while we finished filling it. When she got out, I encouraged her to do three “Captain Morgan’s” on each leg to help baby rotate. Baby had felt acynclitic with this last exam. Close to 2pm, A got into the birth pool. Abby 2 A labored for awhile on her knees, moaning with surges. A couple took her breath away and A said she did not know if she could do this anymore. We encouraged her how amazing she was doing. Labor was hard but she did so well. I was so proud of her. Abby 3Abby 15 I suggested around 3pm for A to try laboring in a semi reclining position in the pool, using the seat of the pool for counter pressure. Surges seemed easier to manage in this position. Abby 11 About 3:20, surges were coming about every 3-3.5 minutes, lasting 90 seconds. A wanted another exam. I found her to now be 7cm dilated. Abby 1 All this time, the birth team took turns providing counter pressure. A was having pretty intense back labor, which made me check position by leopold’s a few times, but baby appeared to be LOA persistently through out labor. Abby 5 Through out the 4pm hour, A alternated positions from kneeling to semi reclining. She started stating that she was feeling an urge to push. We told her that was awesome. I encouraged A to wait until the pushing urge was unbearable. Surges were coming every 3 minutes, lasting 120 seconds. Abby 14 A had these beautiful birth affirmation cards she had made.  As she worked through surges, she asked me to speak those affirmations over her. Around 5pm, A’s doula needed a break to grab a bite so I jumped in for the counter pressure. Funny moment. A turned around and said, “Who is doing that?” When she saw it was me she said, “ That is awful strong for Shannon.” I laughed, and told her I will request an explanation later! A’s body was beginning to spontaneously bear down. A was primal, grunting through surges, letting her body do the work. At about 5:25, A agreed to an exam to see if we had any cervix remaining. She was 8cm, and baby had moved down to a +1 station. However, the cervix was swollen, particularly in the anterior lip. I felt some caput on the baby’s head. I stayed to feel how baby beared down during the next surge, and noted the cervix was not stretchy and wasn’t going over baby’s head. I told A it was really important not to bear down right now, that she needed to try to blow through some surges to let the swelling down. Since she liked being in the pool, I encouraged her to rotate laying on her right and then left side for 3 contractions (3 is my magical number! Ha!), and hands and knees as well. Close to 6pm, I found A to still be 8cm, but the cervix much more swollen. A said it was very hard to blow through the urges. I talked to A and told her if it was too hard, we might need to consider getting out of the pool and moving around, trying open knee chest to help get baby off the cervix a bit to help reduce the swelling. A moved to the shower, and then into open knee chest. I stepped out to breathe and grab a quick bite. About 6:25, I went into the room and found A struggling to blow through surges. A was so tough trying so hard to blow away an urge her body was encouraging her to do. I discussed with A about our two options. One, blowing and not pushing, or two, I could try really, really hard to go in and try to reduce her cervix with surges, but that it might not work, would be painful and we would have to work together. A moved into a hands and knees position and consented to me trying to reduce the lip. At this moment, A requested that B and the birth photographer not come into the room. I found A to be 8-9cm and that the cervix would try to reduce with surges, but would come back in between. Baby sounded perfect. After two surges trying to reduce, A breathed through two surges. I told A we might need to try laying flat on her back and see how I can reduce that way. A agreed. Cervix was definitely swollen, felt like rough flower petals in my hand. Baby was pushing down to a +2 position during surges. A invited B and the birth photographer back into the room around this time. B stood by her head, helping her with bearing down. Abby 6

Such a beautiful moment between A and B.

At 6:50, I told A that I think she needed to blow through a few surges. She blew through them, the entire birth team sitting with her, encouraging through each surge. A sipped on some water and a spoonful of honey. A few minutes later, A moved to the shower to help get through surges. A moved from the shower, to leaning on her bathroom counter. Then sat on the toilet, and tried a squat. All as she blew through the roller coaster of surges. At 7:10pm, A requested for me to try to reduce her cervix again. She got into a semi reclining position. I found her cervix to be a swollen 8-9cm, and baby’s head had more molding and still felt to be a little acynclitic. I remember reaching up and feeling on A’s belly to confirm where the back was, and found baby to feel OA. At 7:19, I asked A to blow through contractions. The cervix was not going over the baby’s head now and felt more swollen. At 7:35 pm, A moved into a squat. She felt like a squat would be helpful at bearing down. A’s doula got behind her on the bed to help support her in the squat. A beared down quite effectively and the cervix seemed to really try to go around the baby’s head. The birth assistant alerted me that it was time to listen to the baby. I grabbed the Doppler and my heart sank. Baby’s heart rate was in the 80-90s. A’s doula and I quickly got A back into the bed and laying on her left side. I listened to the baby for several minutes, happy to hear baby return to baseline. I instructed A to blow through surges, and I listened to baby through a few surges, baby sounding great. Over the next 20 minutes of mostly listening to the baby and being happy that the baby sounded good, I did A’s vitals. A’s friend, helped me with the thermometer. It seemed it had to be wrong. After taking the temp three times, it was not wrong. A was running a low grade fever. Since I know she hadn’t had enough fluids yet, I pushed and encouraged fluids for A. The birth team helped her drink down water, coconut water and pineapple juice. I stepped out of the room to take a five minute breather. I was feeling emotional. Here was my dear friend in so much pain, not progressing, and all signs pointing that we would have to move to the hospital soon. It killed my heart seeing all the years of planning and preparing for this beautiful home birth blowing away. At 8:18, A stated she is feeling really exhausted and considering going to the hospital. We all struggled to encourage A, as we were all pained at watching her in pain. At 8:30, I pulled B out of the room and talked with him. We both shed a few tears. B was having a hard time knowing what the right choice was to make. He hated seeing her in pain, and knew she wanted to be at home. I discussed everything that was going on with A (swollen cervix, fever, high level of pain, not progressing) and told him I felt we would need to talk about transporting in the next 30-45 minutes if something big didn’t change with her cervix. B agreed to the plan, and went back into the room to encourage A. At 8:44, A’s temp was 99.7, so looking better. She moved into the shower to blow through surges, her doula and friend encouraging her as she moaned and blew through surges. At 9:05, A got out of the shower and moaned through a few surges. She moved back to the bed for one final exam to see where we were. I was devastated inside as I felt her poor, swollen cervix. She had swelled back to 7-8cm. Her vagina was visibly hot, a clear sign that we probably had chorioamniotis. This was not happening at home. I looked at A and told her. And told her it was time for us to transport to the hospital. A readily agreed. Exhaustion and fatigue all over her face. Abby 8

Having the transfer talk in this moment with my dear friend.  It is never an easy conversation.

I called the nearest hospital at 9:17 and spoke to the charge nurse who was quite unkind on the phone. I have always had great transports to this hospital, and the hostility from the charge nurse made me say a quick prayer that God would be gracious to us with an awesome nurse and on call doctor upon arrival. We already had the birth pool taken down. The birth team and I quickly through together all the birth supplies, while B helped A get ready for transport. At 10:15, A was taken back to triage to be assessed.  At 11pm, I was requested to come back and speak to the OB. The OB was fabulous.  OB stated hospital policy is to have an automatic NICU stay for any baby born to febrile mother.  If A consented to a cesarean, it would avoid NICU stay.  If she preferred getting an epidural and attempting a vaginal birth, baby might have a NICU stay if the temperature went over 100.4.  CBC came back at this time with WBC count of 27, double normal range.  WBC elevated with low grade fever and warm vagina are all pointing towards early stages of chorio.  OB requested I speak with A and B over choice of vaginal or cesarean birth.  The OB was very sympathetic towards A. She said she always preferred vaginal delivery, but being an IBCLC, she would hate for A to miss out on the bonding and breastfeeding in the first 48 hours. The OB stated if she wanted a cesarean she wanted to do it asap before the nurse took another temperature. I walked into the room and found A laboring next to the bed, B providing counter pressure. I talked over everything with A and B, and they quickly consented to a surgical birth. I opened the door and told the doctor, and they quickly got things rolling for preparations for the cesarean delivery. I watched the monitor and could see that cesarean birth was a good option. Baby was having a lot of variability with surges, and a visible late decal with each one. Surges were coming every 4 minutes, lasting 2 minutes at this point. Right around midnight, A was wheeled back to the OR. Sweet Rocco was born earthside at 12:19am, weighing in at 7lbs 2ozs, 21″ long.  Labor was long, hard, painful… But A was strong, ferocious, raw, determined. I am so proud of this mama’s strength in the way she handled her labor journey, and in the tough decisions she had to make in her birth.   Abby 10

A particularly emotional photo for me.  After having to talk to A about needing to transport, I

walked into the kitchen and had a good cry. 

Photos by the lovely Stephanie Shirley Photography.