Part I (On getting pregnant in midwifery school)
Part IIa (On the discovery at 39 weeks that our little Tahini was breech!)
We arrived to the labor and delivery unit at 7am. Out of habit, I used my ID badge to swipe in and walked up to the nursing station as if I were about to put my name and pager number on the board. B looked at me and smiled. “You’re cheating,” he said.
“What?” “You’re not the student midwife now, you’re the mama. Mama’s don’t let themselves onto the unit with their ID badges. They press the call button and wait to be buzzed in, like everyone else.” He squeezed my hand affectionately.
Oh. Right. Time to take that hat off and put on the mama hat.
After getting settled in our room with labs drawn and IV placed, the third year OB resident came and chatted with us about the plan for the day. She also did another ultrasound and surprise, surprise, Tahini was still breech. Other surprise, my amniotic fluid level (AFI) was now reading 4.6, down from 7.0 yesterday. Not sure how that happened, as I didn’t have any leakage of fluid…but sometimes there can be variation in calculation of this measure. In any case, 4.6 is low, technically considered oligohydramnios (Greek for too little water). As I mentioned in the last post, the risk with oligohydramnios and a version is that the cord doesn’t have as much cushioning, so risk of cord accidents and stillbirth increase quite a bit.
I wasn’t entirely convinced they would even do a version with such a low AFI, but the resident said to sit tight and she’d go consult with the attending, who would be overseeing the version. She had been recommended to me as a skilled and compassionate OB, one who would be happy to work with us to have as calm as possible a cesarean birth if that’s what needed to happen.
We waited around a while for lab results, for the OB’s to finish morning rounds, for the resident to consult. Being an “insider,” I wasn’t alarmed in the least that B and I had over two hours to work through two Tuesday crossword puzzles from our book and for me to take a little nap, along with a visit from the anesthesiology resident who would be performing my spinal/epidural.
The resident returned around 9:30 and sheepishly apologized, noting that three other little ones decided to make an entrance that morning. “No worries,” I smiled. “I know how it is around here.”
“Oh, right,” she said. “You’re a midwifery student. You totally get it. Well, thanks anyway for your patience.”
We then chatted about the plan, which was that the attending felt ok about attempting a version in the OR under spinal, but at the slightest indication of distress, we’d move straight to a cesarean. That felt completely reasonable to me.
And so it was that a little before 10am, I was being prepped for my spinal/epidural. B and I had just a few moments to ourselves to let it sink in that October 1st was the day we’d be meeting Tahini. In just under an hour, he’d be in our arms. We both laughed a little when I asked, “Does it feel real?”
“Nope,” he said. “It won’t feel real until he’s here. And even then…” I nodded. Yup. That was exactly how I was feeling.
The placement of the spinal/epidural went smoothly. Having seen tons of them placed, I knew exactly what to expect: they first wash your back with a cold ChloraPrep solution and then inject you with lidocaine to numb the area. That was the worst part–it stings going in…but after that, all I felt was a strange tugging sensation in my spine. I tried not to think about what the anesthesiologist was doing and just focus on slowing my breath.
Almost immediately, I felt my legs go numb and become heavy. The nurse and anesthesiologist had to help me lie back down and then the team finished the rest of the prep for the version: a pulse oximeter was placed on my finger, a blood pressure cuff on my arm, a nasal cannula (which was super itchy the entire procedure and very distracting!) was placed to provide extra oxygen during the procedure. A foley catheter was placed, as I no longer had control of my bladder. I remember commenting that it felt so strange–I could tell my legs were still there, as the numbness was more tingling than complete lack of sensation…but I couldn’t move a thing.
Someone asked me what music I wanted…I was a bit flustered by the tingling sensation and nasal itching, so I said the first Pandora station I have that I could think of: Django Rheinhardt. It’s often what B and I will play on Saturday mornings while we make a slow, lazy brunch. I instantly breathed a little deeper, mindful that breathing already felt different with the anesthesia in place. I had been told that sometimes, patients have the sensation of being short of breath if the spinal anesthetic flows up the spine…but in general, I should not panic and that it’s a normal sensation. I remember slowing way down and just focusing on each breath.
Someone dimmed the lights. B and one of my midwives, Liz, came in and arranged themselves at my head. I kept my glasses on so I could see what was happening. Everyone paused to confirm we had the right patient, etc., then we got started on the version.
The first attempt lasted about two minutes. I could feel mild tugging and pressure as two residents, overseen by the attending, used their hands to try to move Tahini in a counter clockwise direction. They were able to get him to a transverse (horizontal) position before his heart rate started dropping. In medical terms, this is called a deceleration.
Normally, baseline fetal heart rate varies between 110 and 160 beats per minute. A variable decel is a random, quick drop in rate with a quick return to baseline. An “early” decel often coincides with a contraction, and is usually a sign of head compression during the pushing stage of labor. And a “late” decel is a drop in heart rate after the contraction, usually a sign of chronic placental insufficiency. A variable decel can be caused by multiple things, but usually, it’s transient cord compression. You can also have a prolonged decel, which is longer than 2 minutes but less than 10.
Tahini’s heart rate dropped down to 80 beats per minute. It wasn’t quite technically a prolonged decel, as it only last one minute, but I vaguely remember the room getting quiet as the residents focused on the screen showing the heart rate. As a student midwife, I can assure you that one minute of heart rate at 80 can feel like an eternity. B remembers the whole room was completely focused on listening to the heart rate on the monitor. It wasn’t tense, yet, just very, very focused.
At some point, the attending came over and looked into my eyes and said, “We’re just having a decel here…we’re going to give your baby about five minutes to recover before we try again.” I remember thinking, “Five minutes…that must have been some decel.” I didn’t know at the time exactly how low it had been, which was probably a good thing.
After five minutes, the attending was honest: “I’m okay attempting one more time, but your baby didn’t particularly like that first attempt…so if his heart rate dips down again, I’d like to move directly to a section.” That was fine with me. Another dip would confirm that for whatever reason, Tahini wasn’t going to tolerate further attempts, and that potentially, there was an issue with his cord that was impeding the version.
I didn’t have a strong sense of time, but it seemed like the second attempt was shorter, maybe only 30 seconds. Both residents and the attending had hands on my belly, trying to move Tahini’s head down. B says they were putting quite a bit of force into it, but Tahini wasn’t budging…and his heart rate dipped again. “Doesn’t look like he wants to move further…and he’s really not happy here.” As they spoke, apparently Tahini just slipped back into his former breech position.
The decision was clear: Tahini would be born via a cesarean section..and it was going to happen very soon.
Part IIc to follow