I met Alicia when she was about 28 weeks pregnant with her fifth child. She wanted a homebirth but could not find any homebirth midwives in the Binghamton area. She had her first two children at home in Brooklyn, NY and her second two children at a birth center in Charleston, SC. She and her family had moved to Binghamton the previous year and had established care with a hospital-based practice when she discovered she was pregnant, but were still hoping for a homebirth and searching out other options. Alicia found me through my website and came up to Ithaca for a consultation in early December. We felt an instant connection, and she decided to transfer care to BirthRoot and proceed with a homebirth.
Alicia’s third trimester progressed normally for the next couple of months. In the last month or so of the pregnancy, I started to more closely palpate her abdomen at each prenatal visit to determine the baby’s position. This is done using a series of hand positions and movements around the abdomen to determine where the baby’s back and head are (see here for images showing these maneuvers). Around 37 weeks, I was unsure what position the baby was in. I thought that the baby might be lying sideways or transverse (see image of this here), but my exam was not conclusive. Not all babies settle into the pelvis head down by 37 weeks, so we decided to wait and check again the next visit. One week later I was still not sure of the baby’s position when I felt Alicia’s abdomen. We decided to do an ultrasound to make sure. Alicia went over to the hospital that same afternoon and the ultrasound confirmed that the baby was head down, which was very reassuring for all of us!
The next week and a half passed and Alicia had several episodes of contractions and bloody show. I was ready at any moment to head down to her house for the birth. However, Alicia’s baby had other ideas in mind apparently, and seemed to want to keep us on our toes! Finally, on Sunday morning March 9th Alicia woke up to a large gush of fluid. She called me and we discussed the characteristics of the fluid that are important to consider – timing, amount, color, and odor. Everything was normal – the fluid was clear and did not have a bad odor – so we stayed in contact over the course of the morning and afternoon. Contractions had not started yet, but I decided to head down to her house at about 3 pm to be there in case labor started quickly. When I arrived at the house Alicia’s husband, Scott, and the four children greeted me excitedly at the door. Everyone was in good spirits, eagerly anticipating the arrival of this new little brother (an ultrasound earlier in the pregnancy showed the baby was male). Alicia was in her bedroom, relaxing on the birth ball and rubbing her belly. I checked Alicia’s vital signs, listened to the baby, and felt her belly. I still did not definitively feel a head in her pelvis, but this appeared to be a normal finding based on the last several weeks of assessments and the recent ultrasound was head down, so I was not concerned. The baby sounded great and Alicia was feeling calm and ready for labor to start, so I settled in with a book on the couch to await the start of contractions. Throughout the rest of the afternoon, evening, and night we waited. The baby continued to do well and Alicia’s temperature and vital signs were normal, so the atmosphere was relaxed. One factor that I was aware of and alert to was Alicia’s GBS positive test a few weeks before. Read more here about what this means. She had decided to forgo antibiotics during labor unless there was a concern or some other clear reason to get them. One situation that can be a factor in babies developing respiratory infections after birth is a long time between rupture of membranes and the birth. So, this was on my mind as the hours passed and labor did not start.
Late that night, Alicia decided to drink a few tablespoons of castor oil to see if that would help contractions begin. She did this and we all decided to get some sleep. At about 6 am Scott awakened me and said that Alicia had been having contractions for a half hour or so and wanted to get into the birth tub. I went upstairs and found Alicia in the bathroom breathing through a contraction. I checked her vital signs (which were normal) and listened to the baby’s heart rate, which was fast (what we call tachycardic, anything above 160 beats per minute). I discussed this with Alicia and told her I would want to listen to the baby a little bit more frequently than usual. A tachycardic fetal heart rate can be normal for that baby, an indication of infection, or due to maternal dehydration. Normally, cooling down the mother if she’s hot or giving her fluids will help resolve this situation. I called my birth assistant, Megan, to come on down and Alicia decided to get in the birth tub. I told Alicia that she might have to get out soon if the baby’s heart rate was not slowing down. I continued checking the heart rate frequently as Alicia relaxed in the tub and drank lots of water. The baby’s heart rate did not slow down over the next 30-45 minutes, so I asked Alicia to get out of the water. She did and moved to the birth ball in her bedroom. By this time Megan had arrived and we began alternating listening to the heart rate and providing support to Alicia. Several hours passed without much of a change in either the intensity of the contractions or the baby’s heart rate. As Alicia stood up from the birth ball to head into the bathroom at one point, Megan and I noticed some dark stains on the towel she had been sitting on. Upon closer inspection, we realized this was meconium (the baby’s first bowel movement.) Normally, babies don’t pass this until after the birth and passage of meconium in utero can be a sign of fetal distress. When Alicia came back from the bathroom, we discussed this new finding and decided to do a vaginal exam to see if the birth was imminent. When I checked the cervix, it was very high and posterior and I almost couldn’t feel the edge of it. I determined she was no more than a couple centimeters dilated with the baby’s presenting part too high to feel. This was concerning. Several issues were now presenting themselves that warranted closer observation and decision-making: hours of contractions without cervical dilation or fetal descent, fetal tachycardia, passage of meconium, and a GBS positive status. I discussed my concerns with Alicia, and she decided to start IV antibiotics and try some more focused movement and activity to encourage stronger contractions. I started an IV and we began infusing an antibiotic. Alicia walked all around her house, up and down the stairs, and rocked on the birth ball. Despite this, contractions began to space out until they were mild and about 10 minutes apart. The fetal heart rate remained tachycardic and was now showing some signs of minimal variability (moderate variability in the baseline fetal heart rate is normal with an amplitude range of 6-25 beats per minute; with minimal variability there are little to no fluctuations in the heart rate). At this point, the message that labor was no longer normal was loud and clear. I discussed my findings with Alicia, along with my recommendation that we transfer to the hospital. She was disappointed, but told me she trusted my judgment. Scott readied the children and we all left the house in two cars to head to Wilson Regional Medical Center.
We arrived at the hospital probably around 2:30 or 3:00 pm that afternoon. The nurses showed us into a room on the labor and delivery unit and began the process of admission and initial assessment. The nurses were calm and friendly, which we were thankful for. I provided copies of Alicia’s records and they asked some questions about the progress and details of labor up until this point. The overall atmosphere was relaxed and congenial—it was clear that the baby, although still tachycardic, was not in imminent danger. They began continuous monitoring and started an IV with fluids and the next dose of penicillin. One of the nurses checked Alicia’s cervix and found her to be six centimeters dilated. We were all very encouraged by this finding! The doctor came to the room several hours after our arrival, and his cervical check revealed eight cm dilation with a possible face or brow presentation (normally babies are born with the back of the head coming first; when the forehead or face comes first, labor can be longer and more difficult as the baby passes through the pelvis). He suggested pitocin to encourage stronger contractions (they were still 8-10 minutes apart) and would check the baby’s position again when the head had come down more. An hour or so later, Alicia felt like she wanted to push so the doctor did another cervical check. His face revealed some confusion and disorientation as he proclaimed that he was not sure what position the baby was in. The nurses brought in an ultrasound machine, and the image clearly showed a head in the top of the uterus. This baby was breech!
Preparations began for a cesarean birth, as this hospital does not perform vaginal breech deliveries. Alicia was fully dilated at this point and begging to push, but I helped her to breathe through each contraction so that she didn’t involuntarily bear down. The hospital staff quickly prepared Alicia for surgery and she was wheeled into the operating room. At 6:33 pm, Isa Immanuel was born. My assessment long before that he was in some distress turned out to be correct because he needed some initial resuscitation and spent the next several days in the NICU (neonatal intensive care unit) receiving IV fluids, antibiotics, and close observation. Alicia recovered from surgery quickly and began nursing her son the next day. She visited him frequently in the NICU and they were both discharged four days after his birth. The photo above was taken the day after they got back home. From left to right is Jahsiri, Menelek, Jahbari, Isa, Alicia, Scott, and Indigo. Alicia is so happy to be back home with her husband and children, and has expressed her appreciation for the insights and lessons that she learned from this experience. She states she has no regrets, and looks forward to sharing her birth story with others.
My personal experience with this birth was humbling and inspiring. I learned, once again, to trust my instincts and intuition. I felt a connection with this baby throughout labor, and I knew that he was trying to tell me something. I could sense that he was trying to communicate that something wasn’t right. We may never truly know exactly what factor or factors made this particular labor deviate from the norm, but it’s clear that the signs and symptoms of this happening can be trusted. I think that this timely transfer exemplifies why homebirth is safe for low-risk people. As a midwife, I am trained to carefully assess and monitor the laboring person, baby, and progress of labor. When it is clear that staying at home is no longer safe, I err on the side of caution and transfer to a hospital where medical assistance is available. I am grateful and thankful that we were received by such compassionate, respectful, and professional nurses and doctors at Wilson.
Welcome to the world Isa! Congratulations Alicia, Scott, and big brothers and sister Menelek, Jahsiri, Jahbari, and Indigo!
For more photos of Alicia and her family, check out the Photo Gallery of BirthRoot Families.