Postpartum Depression Screening

Postpartum depression has been called "the most common problem associated with childbirth," affecting about 13% of new mothers, or approximately 500,000 women each year (1). Postpartum depression (PPD) can have lasting effects on mothers and babies; untreated (or insufficiently treated), it can lead to bonding difficulties and developmental delays in infants (2). Women who experience PPD report the typical symptoms of situational or chronic depression: sadness; loss of energy; changes in eating habits (significantly decreased or increased apetite); emotional numbness; insomnia; loss of interest in sex; irritability and anger (sometimes intense), as well as mood swings, poor bonding, and strong feelings of shame and guilt associated with cultural disapproval of perceived weakness or selfishness of mothers who feel anything less than total bliss towards their new babies (4).

At least half of these mothers, and potentially many more, are never diagnosed, and may suffer needlessly-- a true tragedy of modern medicine, considering that screening for the disorder is simple, fast, reliable, and inexpensive. There are several tools available to screen new mothers for PPD; the most common is the tried-and-true Edinburgh Postnatal Depresson Scale (5), which was developed in the UK and has been used for over 20 years to reliably predict patients' risk of developing PPD (6,7). The format is simple: a 10-item self-administered questionnaire, which should be answered by the mother herself, that can be completed in about five minutes and reviewed immediately with care providers. The tool is available at no cost to the administering institution, and can be duplicated with attribution; it is easy to score and results are instantaneous. Each item is scored with 0, 1, 2, or 3 points, and the resulting score is compared to a standardized scale-- the higher the score (30 is the maximum), the more likely the woman is to develop PPD. A score of 12 or higher is considered to be predictive of PPD, while a score of 21-30 is considered high risk and may necessitate immediate consult with the woman's physician (8).

The EPDS has been validated as effective by many quantitative studies, although sound clinical judgment should always be used in interpreting results (10). Each individual found to be at risk should be evaluated by a medical professional not only shortly after birth, but at the initial postpartum checkup (4-6 weeks), and, ideally, at 3 and 6 months postpartum (11). Some researchers have suggested that screening should be done not only in obstretric offices, but in pediatric clinics as well, to facilitate the identification of as many cases as possible (12). Further, since most mothers who experience PPD also experienced at least one depressive episode prenatally, it has been recommended by some that obstetricians should screen their pregnancy patients at least once per trimester during routine prenatal care (13). While ACOG (the American College of Obstetricans and Gynecologists) cites inadequate evidence to recommend a standard of care, they do recognize the need for screenings, as well as treatment, follow up, and referral as required (14).






References Cited



1.  http://www.medicinenet.com/postpartum_depression/article.htm,  retrieved 10/20/2012

2. Is your new mom depressed? (Did you ask?) Schaar GL - Journal for Nurse Practitioners -  November/December 2011; 7(10); 879-880

3.  http://www.mayoclinic.com/health/postpartum-depression/DS00546/DSECTION=symptoms,  retrieved 10/20/2012

4.  http://www.postpartumprogress.com/6-surprising-symptoms-of-postpartum-depression-and-anxiety,  retrieved 10/20/2012

5.  http://www.fresno.ucsf.edu/pediatrics/downloads/edinburghscale.pdf,  retrieved 10/20/2012

6. Cox, J.L., Holden, J.M., and Sagovsky, R. 1987. Detection of postnatal depression: Development of the 10-item

Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 150:782-786.

7. Applying new techniques to an old ally: A qualitative validation study of the Edinburgh Postnatal Depression Scale

Godderis R - Women Birth - March, 2009; 22(1); 17-23

8. Schaar 2011

9. Godderis 2009

10. Mothers With Positive or Negative Depression Screens Evaluate a Maternal Resource Guide

Pascoe JM - Journal of Pediatric Health Care - November/December 2010; 24(6); 378-384

11.Screening for postpartum depression. Cole C - Journal for Nurse Practitioners - 01 January 2009; 5(6): 460-461

12. Pascoe 2010

13. Screening for perinatal depression with limited psychiatric resources. Jevitt, C., Zapata, L., Harrington, M., and Berry, E. Journal of the American Psychiatric Nurses Association, Vol. 11, No. 6

14. Screening for Depression During and After Pregnancy. Committee on Obstretic Practice, American College of Obstetricians and Gynecologists, February 2010. Retrieved from  http://www.acog.org/~/media/Committee%20Opinions/Committee%20on%20Obstetric%20Practice/co453.pdf?dmc=1&ts=20121020T1538438353,  10/20/2012

Willow's Unrest

I'm about ready to change the name of this blog: Willow's Unrest. Whatcha think? There's no rest for a birth activist/VBACtivist/lactivist/intactivist. There's no end to the stupidity, the lack of education, the lack of desire to acquire knowledge. I think that last is the worst. It's one thing to be ignorant. It's something altogether different to remain that way on purpose. You can lead a horse to water...

I know I've burbled on before about feeling burned out, ready to let it all go. I've spilled miles of ink and tapped keys till I developed callouses about why people ought to care about birth-- theirs and all women's. This is nothing new. But I find I've kept it in until I can't contain it anymore-- hence this post. Forgive me, won't you?

I wrote this several years ago. It's not great, but I still feel this way, so let me get it off my chest-- then I'll get back to my rant. It originated in an offhand comment someone tossed out-- something about "so-and-so could care less about VBAC":

I suppose I could care less. I could choose to accept the near-30% cesarean rate in the United States. That would mean accepting that wholly one-third of women in this country are unable to deliver the babies their bodies conceived and grew. That would mean buying the whole bill of goods-- doctors know best, birth is the business of surgeons-- read men, because even female OBs are conditioned to be metaphorically masculine in the operating room-- and women are just incidental to the process. Our wombs are dark, dangerous dungeons from which our babies must be cut free. Pregnancy and birth is a primitive, nasty, brutish affair that must be managed and controlled and interfered with every step of the way, from the time the stick comes up blue until the baby is released from its mother's imprisoning flesh.

I could care less about VBAC. I could accept that my cesareans were necessary, lifesaving events that were responsible for giving me healthy, whole children. I could bless the quirk of fate that made my daughter stay footling breech, the neat serendipity that gave wrapped her cord around her neck three times and made external version impossible. Thanks to that, I had a cesarean! Hurray! I was a first-time mother, and I didn't have to bother with messy, unpredictable labor. Rather, the nice medpros in blue scrubs wheeled me into a cold operating room-- one of them punctured my spinal column and anesthestised me, another cut me open and gave me my perfect baby girl. Not only that, but in that one stroke, she guaranteed that I would never have to concern myself with birth again-- in future, I need only open my datebook and choose a day that seems best to me to have my precious babies hand-delivered.

I could care less about VBAC. I didn't need to stress myself nearly to the breaking point, searching high and low for a care provider to see me through my second pregnancy. The year of hell I endured, of postpartum depression and PTSD, of being unable to bond with my son, were all entirely unnecessary. Why did I do that to myself? To him? I could have cared less about VBAC.

I could care less about VBAC. I could spend my days at the hospital where I work complimenting the cesarean moms about the roundness of their children's heads (if they were all round, which they aren't) instead of poring over their charts and trying to figure out where it all went wrong. Why couldn't they deliver? Why were they cut? Why is "failure to progress" a valid diagnosis for a *scheduled* c-section?

I could care less about VBAC. I could throw away the list I keep of VBACs and CBACs at my hospital. I could celebrate the surgeries instead-- Goddess knows the list would be far longer. I could stop agonising about this generation of surgically delivered children. I could accept that it's "just another way to be born" and believe that there are no far-reaching consequences of arriving via "vaginal bypass surgery."

I could care less about VBAC. I could turn my back on the research that refutes the position of the OBs, whose concern lies mainly with their pocketbooks and their malpractice insurance rather than with the patients they purport to care for. I could accept that it's right and good for a new mother to be unable to breastfeed her infant because she's too drugged or in too much pain or her IV line won't reach far enough. I could accept that iatrogenic prematurity is nothing to be worried about, a few days in a NICU is a fine start to life. I could agree that not wanting to "stretch one's bottom" is an acceptable reason to choose major abdominal surgery.

I could care less about VBAC. I could take the fading ICAN sticker off my van and stop slipping cards into my patients' education folders. I could insist that homebirth-- not to mention HBAC!--  is dangerous and wrong, and all women can and should simply report to the hospital at 38 weeks on the dot to have their babies removed. I could close my eyes and mind and heart to the pain in the stories I read. I could join the hordes who insist "only a healthy baby matters" and tell my scar-sisters to "get over it." I could ignore my own lingering hurt, pretend my babies and I weren't affected by their "births."

I could care less about VBAC.

Other than the statistic-- the cesarean rate in the United States is now 32.8%, according to the CDC-- I still feel the same as I did when I wrote that, 3 or 4 years ago. Little has changed; I'm a little further out from my surgical deliveries, but I'm no less outraged. I certainly don't want another one, should I ever be blessed with another pregnancy ! And yet I'm still expected to button my lip, keep it to myself, pretend that it's only a healthy baby that matters. Say nothing that might offend. Or frighten. 

Let me back up; I've wandered off into my rant without giving any context. Sorry about that. 

I'm a nurse. I became a nurse in self-defense, after my CBAC in 2002. My experience was so horrific-- so degrading and inhumane, that I was determined never, ever to be at the mercy of medpros again. For my entire nursing career I have worked in one facility, a mid-sized urban hospital that I must decline to identify. I work primarily in mother-baby, though I sometimes go to NICU or labour & delivery. I spend the vast majority of my time caring for new mothers and infants. Education is such a huge part of my job that last year I became a Certified Childbirth Educator through CAPPA, and I'm one of my facility's instructors for the hospital-approved Prepared Childbirth Class. I teach 4-6 classes annually, to (usually) first-time parents, covering the typical "What to Expect from Your Hospital Delivery" curriculum. On the up side, I get to use the InJoy Birth/Parenting Education videos, which are well made and comprehensive-- the ones we use were filmed at the same hospital where I delivered my first child, and "my" midwife is featured, which always gives me pause for thought. On the down side, there's little room for, as Opus was wont to do, departing the text. I have 5 hours, total, over 2 weeks, to cover pregnancy, labor, birth, postpartum, and newborn information. I'm not allowed to teach breastfeeding at all-- I'm required to refer my couples to the hospital's Official Breastfeeding class. Cytotec? Can't go there. VBAC? Can't cover it. Circumcision? Nope. Other than to answer basic questions, I can't say anything "controversial." Nothing that might dissuade a mother from opting out of the culturally and medically sanctioned norm. I'm not technically allowed to provide resources-- the best I can do is say, "I strongly recommend that you look ____ up and educate yourself."

My opinion doesn't count for anything, as far as the hospital is concerned. Never mind evidence-based. Forget personal experience. Hell, don't even worry about patient advocacy-- which is, as a nurse, my highest concern! Just stick to the party line, and for Goddess's sake, don't make waves!

Deep breath. Okay. I try to toe the line. I answer questions in a manner as vanilla as I can make it. I think I usually manage... or I did. I'm due to start a new class tomorrow night-- and today the nurse-manager of our labour & delivery unit informed me that I need to "be more aware" of what I'm saying. Apparently, she received a comment from a patient who took my class last December, who was (understandably!) upset because I allegedly said that "if you have a c-section, you might as well leave the hospital in a body bag." 

First of all, I assured the manager-- as I am assuring you, now-- that I never, ever, ever said any such thing. I have never uttered the words "c-section" and "body bag" in any kind of proximity to one another. I've wracked my brain, and I can't figure out anything that might have given anyone such a notion. The manager replied that she didn't know where the patient had come up with the idea, maybe I said it, maybe I didn't, but  just be careful. I reiterated that I would, and hung up the phone.

Then I wept. 

I do teach my classes that cesareans, while sometimes necessary and lifesaving, are not the optimal way to begin motherhood. I have, when asked, elaborated on potential consequences, both in the short term and in future pregnancies. I emphasize that most of the time vaginal birth is preferable, and it's well worth it to try to avoid surgical delivery. When couples ask me about my deliveries, I try to stick to the basics: I had a primary c-section for double-footling breech, a failed induction and repeat c-section, and then a homebirth VBAC. I don't tell my stories. I don't talk about the years of postpartum depression and PTSD. I have spoken of the wound complication I had after my CBAC, because a dad asked if anyone ever had incision problems. Yes, postpartum wound infections occur. I was lucky; I "only" developed a seroma and minor infection; I didn't have a full dehiscence that required surgical treatment, debridement, packing and repacking for months, as some mothers have. 

Essentially, I'm forced to abide by a version of "Don't ask, don't tell." I'm not supposed to offer anything off menu, so to speak. But if asked, I'm not going to lie... and I'm not going to "pretty it up." I will never tell a client "I loved my c-sections!" But I certainly never have, and never will, tell an expectant mother that having a cesarean will kill her. **

True, my CBAC made me want to die. I can't pretend otherwise. I once sparked a flame war on a prominent pregnancy and birth support forum by stating that I would rather bury a child than endure a forced c-section. Was that overly shocking? Unquestionably, though in my defense I was mired in severe depression at the time, and words cannot describe the anger and bitterness that were my constant companions then. Did I truly feel that way? Yes, I did. Do I now? No... probably not. But if another woman, after a traumatic birth, chose to express herself that way... I would support her. 

I wept because I would never intentionally frighten a pregnant woman. I would never set out to horrify or hurt another mother. But somehow... I did both. I'm angry and remorseful and frustrated. Why go on? Why, if all I do is cause distress? 

Maybe I should just... care less. Stick to the text, never depart. Why, yes, inductions are always medically necessary! Of course epidurals are safe for you and your baby! Your doctor always has your best interest at heart-- he would never section you at 5 pm for "failure to progress," even though the Friedman curve is a myth and you labored nicely to 7 cm in 10 hours, just because he wants to go home and catch the newest CSI episode! Cesareans are always the safest option for "big babies!" No, c-section recovery is no big deal at all!

I guess we'll see how tomorrow night's class goes. I"ll be good; I won't scare anyone. I won't express any opinion that's even a millimeter out of lock-step with the hospital's standard operating procedure. Maybe I'll even feign ignorance if someone asks about potential complications.

No, I won't. I couldn't live with myself. I'm a nurse. I'm a mother. I'm a birth activist. There's no rest for the wicked, they say... I suppose I'm living proof.

** I would never say that... but I might recommend she read the details of the surgical consent form. Unfortunately, cesareans have killed mothers. But no one wants to hear that-- and if I mention it, I'm the bad guy. Goddess help me, maybe it would be better for all concerned if I went back to my archaeological roots and found someplace that would just let me go dig in the dirt.

Just an Example

As one of my New Year's projects, I've decided to try to informally track the deliveries at my hospital and watch the trends over 2012. This is not a rigorous scientific study, by any means; it's really little more than anecdotal. I plan to record our deliveries daily, and to make note of method of delivery, primary vs repeat cesarean, indication for surgery, etc. This will only include babies who are admitted to the well baby nursery, so there will be a good chunk of missing information right there; we do have a Level IIIb NICU, and it will be difficult to obtain delivery notes on those infants admitted directly to them on days I'm not actually here. So, as I say, this is just a sort of exercise-- in observation, data recording, and preliminary analysis.

I started recording delivery stats on December 19; I have 21 consecutive days of data, as of today. Just for giggles, so to speak, I decided to glance over them-- to see what I had. Here's my data:

n= total deliveries= 68
v= vaginal deliveries= 39  (57.4% of total births)
x= c-sections= 29 (42.6% of total births)
r= repeat c/s= 11 (16.2% of c/s)
p= primary c/s= 18 (26.4% of c/s)

The cesareans were done for a small number of predictable reasons. I broke the indications down into four categories:

1. "failures"-- labeled as such by the OBs, including "FTP (failure to progress)," "FTD (failure to descend)," "failed induction," and the ever-popular, vague, and widely inclusive "NRFHT (non-reassuring fetal heart tones)"

2. primary elective for breech-- no one here will do vaginal breech deliveries on purpose, so for all intents and purposes, these are physician-elected c/s

3. primary elective for maternal reasons-- there were three of these, including one mom who was HSV+ with a current outbreak, one mom who had a history of spina bifida and attendant multiple back surgeries, and one mom who was urged to elect her c/s for that fabulously accurate diagnosis, "suspected macrosomia"

4. other-- only because I wasn't sure where else to put it; I didn't have enough history in the report I got or on the chart; it was presented as a primary nonelective, nonemergent cesarean due to oligohydramnios and "placental issues, nonspecific"

The majority of the primary c-sections fell into the first category: 10/18, or 34.5%. There were 4 breech sections-- three scheduled, one discovered in labor (when mom was ready to push!)-- so 13.8% of the total. The other 4 were also scheduled, for the reasons listed above. That nonelective, nonemergent one resulted in a completely normal newborn with no signs of distress . That allegedly ginormous baby weighed a whopping 8 lbs 4 oz. Oh, and most of those NRFHT sections (ie, for fetal distress) produced babies with APGAR scores of 8/9 and 9/9. Sigh.

So, in the past three weeks (covering Christmas and New Year's), we had a cesarean rate of almost 43%-- well above the national average. I'll be curious to see if this trend continues. I've long suspected that our facility's c/s rate was that high, but I've never been able to demonstrate it. If I can keep this up, at least I'll be on my way to documenting outcomes for one mid-size hospital in Middle America. That's the plan, anyway.

A Bright Blessed Holiday to You All!

 Bright Yule, Blessed Alban Arthan, Happy Hanukkah, Merry Christmas... Love, light, and joy be yours!

Redemption

On the occasion of my sweet son's SIXTH (!!!) birthday, I wanted to post the story of his birth-- and mine. I warn you: it is LONG! Interestingly enough, since it's been 6 years, the dates correspond to this year's calendar. 


This is the story of the birth (yes, BIRTH!) of Rowan, my third child, the first baby to whom I gave birth. It's the story of my long-fought-for and dearly wanted VBAC, my UBA2C. In a way, it's my own birth story-- because I felt that I died on the operating table when my second baby was extracted from my body after a failed induction, but I was born as Rowan emerged from my strong, resilient uterus.

I'm taking some of this straight from my journal-- I've long since succumbed to some mommy amnesia. Some of my labor and birth are already fuzzy... some parts, like the feel ofRowan's head as he was crowning, I will never forget. Never.

Sunday, 4 September 2005

My physical state is fine. No sign of impending labor. Let it be. [This Beatles song gave me my pregnancy and birth mantra.]

Emotionally... sigh. Bored, discouraged, depressed. Wish it'd just get going so I could stop worrying about it. DON'T want to go back to work on Tuesday, but no choice if no labor-- I can't afford to lose paid time off hours. BLECK!!

Monday, 5 September 2005 -- Labor Day. Ha!

Physical: fine, a few more ctx [contractions], some fairly intense.

Emotional: hate the world, wish everyone in it would bugger off and leave me alone! 

Tuesday, 6 Sept 2005

41 weeks, on the dot.

WHY AM I NOT IN LABOR???!?!?!

Am I really broken?

No. Can't be. Surely not.

It'll happen. Won't it?

Tami G. emailed me and said something profound: in a month, I'll be holding my baby. Hang onto that.

ICAN VBAC!!!!!!!

Wednesday, 7 September 2005  ~5 pm

Stopped to get gas-- reached down to pop the gas tank door-- felt another distinct POP! Water broke-- gushing, but clear. Baby obviously not engaged. Got back in the car and drove home-- lots more fluid with each ctx. Niagara Falls effect stopped when I got home and got upright for awhile-- Rowan's head settled deeper in pelvis?

Few light ctx, not regular. Trying to stay up, moving, etc, but leaking is a problem. Stood at computer and emailed ICAN, IM'd Lisa-Marie. Hard to concentrate.

6:30 pm-- kneeling on bed, rocking hips-- feels good. Ctx still seem light.

7 pm-- up and around a bit, lots of show. Loose stool. Light ctx every 2-3 minutes (trying to avoid the clock). Bored. Lying on side uncomfortable-- up to shower again.

9 pm-- ctx spaced out. Not timing. Can only focus on one thing at once during ctx. RELAX. More gushing-- not like earlier, though. Sleep soon?

10 pm-- KIDS ARE DRIVING ME INSANE!!!!!!!!!!!!!!!  Whining, fighting, carrying on-- wish I had someone to take them AWAY! Definite downside to DIY. Ctx more intense. More show. Going to sleep soon-- assuming kids will stay in bed! [NB: Rhiannon, my daughter, was 5 at this time; Gareth, my first son, whose story I posted on his birthday, was 3. They slept through everything.]

11 pm-- no sleep for me, can't lie down comfortably. Shower WONDERFUL!

_____

This is where my journal entries end-- I couldn't write anymore. The kids did stay in bed, and I sent their dad, John, to bed too. I told him to get some rest, and I'd call him when I needed him. I figured I had hours ahead of me, and he would need the sleep. Then, labor hit like a freight train!

I had been in the shower for maybe ten minutes when I got out to tell him that I needed the pool NOW. And I promptly went and got into it!

The pool was set up in my living room, and was about a quarter filled. John had started working on it as soon as I came home and informed him that my waters had released-- we never did get a hose or an attachment for the faucet, so he was filling it one bucket at a time. Luckily, we have a wonderful hot water heater-- it never failed me. And John, who was a trooper through the whole labor, boiled pot after pot of water (how stereotypical can you get?) to "hot up" my pool even more.

When the pool was about 2/3 full of blissfully hot water, John set up camp in the living room. He dragged in the mattress from Gareth's (unused) toddler bed, covered it with sheets and a comforter, then got in and tried to go back to sleep, while I labored in the pool.

It was about midnight-- I'd made John turn the clock away from me, because I didn't want to watch it all night. I knew I had a long slog ahead, and I didn't want to get discouraged. I'd seen that the contractions were coming roughly every 2 minutes, and I didn't want to know anymore.

The contractions... I'm not sure what to say about them. In the shower, I handled them best by letting the water spray on my back, down low (where I kept my fists jammed most of the night, the result being that my shoulders were killing me the next day) while I rocked my hips back and forth. I was chanting the Goddess Chant through each surge-- two versions, mine and 
Starhawk's. Sometimes I got them mixed up, but I doubt the Bright Lady cared!

Starhawk: Isis Astarte Diane Hecate Demeter Kali Inanna

Mine: Isis Athena Rhiannon Cerridwen Brighid Anath Arianrhod

Soon it changed to "Open" over and over, longer and more drawn out with each surge: "Oooooooopennnn. Oooooooooooooppppppennnnnnn." Four or five of those got me through a contraction.

In the pool, early on, I spent time on my knees, still rocking my pelvis. When a contraction came, I had to submerge-- get under it, literally. I went to my hands and knees, then into a push-up position. I hung onto the side of the pool, chanting "open" again and again-- my old trick of counting through each contraction, which I used throughout my labor with Gareth during that idiotic seventeen-hour induction, failed me this time. Nor was I able to escape the sensations and go elsewhere, the way I had last time. This was much faster, much more intense. 

I found I was better able to handle the contraction on my feet, so I stood up much of the time, knee-deep in warm water, fists thrust into the hollow of my back, toning. "Open" was now just "Ohhhhhh... ohhhhhhh" low and loud-- I couldn't control it, though I didn't want to wake John up. I stood there in the semi-darkness-- the living room lights were out, but the bathroom light shone through-- singing my birth song and trying to work with, rather than against, the expansions of my uterus.

Does anyone remember the study that said that even a "virtual doula" helps a woman get through labor-- that someone in her head, an imaginary doula to encourage her, is beneficial? Well, I can say that for me, at least, it was true. The real-life doula I had during my attempt at hospital VBAC was kind but ineffectual. The one in my head this time-- Kmom!-- was brilliant! She said everything I needed to hear: you're doing great. Keep breathing. don't forget to pee. You're doing this, you really are!

And so I labored. As before,  I had no concept of time. John tells me it was about 1 am when my vocalizing changed and he woke up fully (he'd only been dozing anyway). About 1:30 he remarked casually, "They're less than a minute apart now. You ARE progressing. They're lasting about 20 seconds."

Twenty seconds--?? I was crushed. I kept thinking, "longer, stronger, closer together." If these were only 20 seconds-- !!!

"I don't want to know that," I groaned. "Don't tell me that."

After a few minutes, Kmom told me to go to the bathroom again, so I did. I emptied my bladder-- John had placed a large mug of water and a huge plastic cup of crushed ice on a milk crate beside the pool, and I had been drinking and crunching plenty-- then got back into the shower. It wasn't as comforting as it had been, so I went back to my pool and asked John to add some more water. He tried to hold me, offering to do a supported squat, but I couldn't bear to be touched during a contraction. So he bailed some water out of the pool and replaced it with hot.

He was so supportive, even though he felt he didn't do enough, that he was "too hands-off." But that's exactly what I needed. He held the space and he kept my water hot. He sat quietly and watched me, but didn't interfere; he helped me focus when I really needed it. He was perfect, and for that, I will always be grateful.

A small piece of my mind wondered where I was, dilation-wise. I didn't want to psych myself into thinking it would be done soon, even though it felt VERY fast and intense to me. I was trying to prepare myself, physically and mentally, for another whole day of this-- longer, if necessary! Think of Eugenie, I told myself-- Eugenie, brave woman, who labored for 80-plus hours to birth her son. Yes, I argued with myself, but think...

There were clues, and I couldn't help but notice them: the way I was toning through contractions, the lowing, birthsong quality to them. Shorter, more intense contractions could mean I was in or near transition. I was starting to feel nauseated at the end of each surge. I never did throw up, but I told John repeatedly that I felt I might. I started dozing or "zoning out" between contractions, drifting into a strange, incoherent laborland. I could only endure contractions by standing and rocking my hips, then getting underwater and floating once I'd passed the peak.

I realized I was feeling very foggy. Random thoughts crossed my mind-- bizarre, dreamlike notions that seemed to make sense at the time, even though a part of me knew they didn't. The only one I remember was odd-- and please, don't anyone take this as offensive, it's just what wandered through my head: "I wonder why it is that white women named Irene often shorten their name to Reni, while non-white women just use 'Irene'?" [I have no idea if this is true, but I doubt it. Weird labor thoughts!] "And why is it 'Ear-ray-na" in England, but 'Eye-reen' here?" Transition, anyone? ;)

Then, abruptly, the fog lifted. Suddenly I was thinking clearly again-- the world came back into focus. And to my astonishment and chagrin, I realized that I was pushing at the end of each contraction!

This can't be right, I thought wildly. Something's wrong-- it's too soon--

But it didn't feel wrong; it felt right. Not good, but RIGHT. So I pushed.

I remember thinking, I want this over! I want it over and done. How much can a person be expected to take? This is silly! I did not have to do this!

I don't think I said any of this aloud (and Kmom chastised me, albeit gently, in my head!). I know I did whine, "I can't do this!" once or twice, and John came and looked me straight in the eyes, saying, "Yes, you can, you are, you're doing great." I reminded myself that I'd known what I was getting into, I'd made my choices and I had to accept them, and whinging about it wasn't going to help anything. I may as well be there, since I had to be-- it was like that old kids' game, "Going on a Bear Hunt" : "Can't go over it. Can't go under it. Have to go THROUGH it." At times I hated it-- my friend Gretchen is right, pushing SUCKS-- but I kept going through.

The urge to push was subtle. It wasn't "I GOTTA PUSH," the way it was when I was laboring with Gareth. It was like something had taken over my body and was pushing whether I liked it or not! I began to roar with each push, getting louder and stronger.

"You're progressing," John said with satisfaction.

"I think I'm pushing," I told him.

"Don't wear yourself out. Take it easy."

Easy to say, but the effort was impossible to resist. I was worried-- it still seemed too early (as far as I can make out, it was only about 2 am) to be pushing. I hadn't been laboring long enough. I was afraid that I was only 5 cm with a badly malpositioned baby, that I was making it worse with every surge, swelling my cervix and sealing my doom. I didn't know what to do, and I said so. Then, in a fit of desperation and doubt, I asked John to check me-- the first vaginal exam I'd had since I was 9 weeks along and worried about a possible miscarriage.

He went and scrubbed up-- offered to use bleach (!!!) but I convinced him that soap and water was sufficient, as long as he scrubbed for at least 20 seconds. (I think he did 2 solid minutes. ;) He came back, and we waited through another contraction. Then I tried to lay back and let him fumble around for a moment or two, as long as I could endure. He reported, "No, nothing."

I wanted to cry. In fact, I think I did cry, a little it. How much more could I bear? What should I do?

Another surge, like a terrier shaking a rat. Lots of show, some gushing fluid, intense pressure in my rectum. Something was moving through me-- there was no escaping it. "It feels like it's right there," I kept saying. "It" was hard to describe, but it felt foreign-- not me. It seemed to move opposite to me-- if I swung my hips left, it rotated right, or else I rotated around it while it stayed still. It didn't hurt, but it was very, very uncomfortable. There was no getting away from it. It was... inexorable.

I pushed and roared and pushed, giving up my brain's worries to let my body, my primitive self, take over. "I surrender," I told the Universe. "Whatever happens..."

It went on, and on, and on. I had no clue what time it was, or how long I'd been there. I pushed standing up in my pool until my knees shook and threatened to buckle, then I went back to kneeling. I tried to push while lying on my side-- first right, then left-- but while floating on my side and back between contractions felt good, pushing in those position did NOT!

Standing was best-- kneeling was tolerable, but only just. Sitting, lying, even floating in the push-up pose I'd used earlier-- these were all completely untenable.

"Bathroom," Kmom commanded in my head, and I managed to drag myself out. I sat on the toilet and pushed there through a few surges-- that felt pretty good, but not as effective as I'd hoped, so I went back to the pool. Surge-- push-- howl like a wolf. Repeat.

After awhile, John, who was getting more excited and nervous, asked me, "Should I check you again?"

"If you want..."

More groping, then, "It feels like it's getting harder."

"The head?"

"I don't know... but I can tell you, you're really open."

Push. Roar! Breathe. Again. And again. Have I ever worked so hard in my life?

Push. Push with all my might-- I was worried that I was doing the "purple pushing" encouraged in hospitals. Shouldn't I be trying to breathe the baby out instead?

Screw it! I thought grimly. I don't care if I tear six ways from Sunday. I want this kid OUT!

Push. ROAR! Breathe.

Over and over, more than body and soul can bear. I can't do it. I can't. Not anymore. I can't.

"Yes, you can," John insisted. "You've come this far. You're not giving up now. You've told me a hundred thousand times you can do it, and I believe you. You CAN."

I reached down, trying to see if I could feel-- something, anything. "If it helps," John was saying, "your belly [meaning the bump that was Rowan] is lower." With my last push, I had felt a stinging sensation, and the phrase "ring of fire" had danced through my mind, but I had quickly dismissed it. Still-- maybe my perineum was at least bulging a bit--

And there "it" was, just under my fingers, barely inside me: a squishy soft mound, damp and warm. I froze. O my dear good Goddess--

"There's a head there," I said, shocked.

John lit up. "Yay! You're almost there!"

Another push-- the head slipped back, but only a little, and there was a definite burn now. I didn't care-- it wasn't bad, and anyway, there was a head there! Set me on fire, I don't mind, I'm BIRTHING!

The surge ended. "Want to feel?" I asked John, and he reached into the water-- I must have been kneeling at this point. I can't describe the expression on his face. "Yeah," he whispered. "Yeah..."

PUSH! I bore down hard, remembering the old saw, "Giving birth is like passing a watermelon through a hole the size of a lemon." I pressed my fingers hard into the skin around my vagina, trying to stretch the tissues. That one stung-- but in the next moment, I had a small (!) firm head in my hand! John was holding it too-- Rowan was out to his ears, maybe, and I was screaming. It HURT-- the only part of the whole labor I could truthfully call, well, excruciating.

"What now?" John wanted to know. He was stunned.

"Wait," I gasped, "for the next contraction..."

"Come on..."

It felt like forever. I tried to push without the contraction, but the baby didn't budge. For the first time all night I was praying-- pleading-- BEGGING for another contraction!

Finally it came-- and I PUSHED--

The head came out; the shoulders and body quickly followed. (So much for my fears about shoulder dystocia!) Before my brain could register was had happened, I was holding a slippery new baby in my arms!

I sat back-- the pool, which up till now had stayed remarkably clear, was now murky with fluid, blood, mucus, and fecal material-- but mine; there was no meconium. I didn't care what I was sitting in. I had done it! I BIRTHED MY BABY!!!!

I VBAC'd!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

"Hello," I crooned to my new little bug. "Oh, hello!"

He was perfect-- well, I didn't know he was a "he" yet-- snuggled up to my shoulder. He was dusky, but his face and chest were pink. He hadn't made a sound. I rubbed him, talked to him-- he opened his eyes and looked at me, but he still didn't make a peep.

"Hi, sweetie," I said. "Oh, you're so beautiful. Look at you-- oh, hello, Rowan!" 

He finally whimpered a little when I gave into John's increasingly anxious requests and turned him over to check the sex. I laughed in surprise: "Oh my God, it's Rowan Riley!"

Rowan would have been Rowan whether he was a boy or a girl, but with different middle names depending on gender. We had been expecting a girl all along, but Rowan fooled us. We laughed and Rowan finally cried, and I held him close while John got a towel to cover us.

I couldn't stop thinking, I did it! I DID it!! I DID IT!!!!!

"What time...?" I managed.

"Congratulations!!!" John shouted. "You did it-- 4:33 am!"

4:33 am?? That's ALL??! I was in complete shock-- my water broke at 5 pm, I'd only really labored since 11 pm. Five and half hours, and most of it pushing...? Early in the evening I had joked, "Wouldn't it be great if the kids could wake up and find their new sibling? And I could call my mom and tell her to stop by on her way to work?" I never thought it would happen...

John helped me out of the pool and we headed for the bedroom, marveling over our new baby boy. I found a tape measure and tried to get some stats-- I came up with 14 1/2" head circumference (molded) and 21 1/2" body length, but Rowan wasn't very cooperative, so they were largely gross estimates. He seemed smaller than his siblings-- smaller than Gareth, certainly, who had been 10 lbs 5 oz; maybe littler than Rhiannon, who'd weighed a pound less. But who cared? I had birthed him!

I put him to the breast, and he latched on and nursed for quite some time-- twenty, thirty minutes? Can't recall. I was still have irregular, intense contractions, and around 5:15, they started gearing back up, getting stronger and closer together. I told John to get the big plastic bowl I'd bought, and I got up to deliver the placenta. Push-- but only a small, palm-size piece came out. A clot? No, definitely part of the placenta. It was followed by another, larger chunk, and in a few minutes, the largest piece-- but still only a quarter to a third of the whole. This one included the cord, which was perfectly, beautifully attached, just as it should have been-- a proper, three-vessel cord with textbook insertion.

I knew that a placenta that delivers in pieces is a bad thing, and if I had been thinking straighter I would have called for transport then. But I was high on my birth, I was exhausted, and I just wanted it to be over so I could bask in the afterglow and snuggle with my little guy. In retrospect, of course, it was a bad call.

John went and called my mom and said, as I'd instructed, "Stop by the house on your way to work-- there's someone you'll want to meet." Then he came back and took the baby, and I got up and took a shower! Such a small thing, but when one's previous "birth" experiences entailed major surgery and a long period of convalescence, the ability to step into one's own shower, unassisted, is nothing short of a miracle-- and underscores yet again (as if I needed reminding!) the vast difference between a vaginal birth and cesarean surgery. The latter is most definitely NOT "just another way to have a baby"!!

At 6:30 we woke the kids up to get ready for school. John told Rhiannon, "Come in here and see-- baby Rowan came." Rhi tore into my room, saw Rowan, and stopped short, staring in awe. Then she cooed, "Oh, he's soooo cute!" Gareth came just after, amazed to find that "the baby came out of Mama's tummy!" They were just precious, both of them.

My mom and sister arrived at 7:15 with a baker's dozen of Krispy Kreme doughnuts. They stayed with me and admired the baby while John took Rhi to school. My sister was especially amazed-- she had fully expected me to have to be taken to the hospital in a flight-for-life helicopter for emergency surgery. She'd had nightmares that Rowan and I would die-- the main reason I hadn't told her or my mom that I'd been in labor.

"I can't believe it," my sister kept saying. "You look great. I remember after Gareth was born-- even after Rhi. You looked so sick-- grey and little and sick. Now you're just... glowing!"

If pride and excitement were visible, I'd be lighting up the entire city. I've never felt so alive, so empowered, in my life. I could move mountains!

My mom went on to work, and my sister took Gareth. John and I rested, then got up and took Rowan to our pediatrician, when he was 6 hours old. The office staff was aghast and amazed when we told them about our unassisted homebirth. But the doctor pronounced Rowan "perfect!" and gave us the official stats: 21 1/2" long, 14 1/2" head, 10 lbs 8 oz!!!! Bigger-- just a little, but he had had a wet and dirty diaper since his birth-- than Gareth!!!

I was stunned-- I'd really thought Rowan was smaller, since I didn't get as big as I had with his brother, and he just seemed little. I'll admit I was slightly disappointed, thinking, Well, maybe I couldn't deliver a ten-pounder, but at least I can deliver an eight-pounder.... But the scale confirmed it: TEN-POINT-FIVE POUNDS, definitely a "big baby" by modern medical standards. That ten-pound stigma had caused my medwife to dump me last time-- she was terrified of Gareth's size. But I birthed the same size baby on my own with no problems-- no sticky shoulders, not a tear, not a skidmark, nothing! HA!!!!!!!!!! Take THAT, sOBs and Evil Medwives of the world!!!

Birth happens. I know it does. It happened right there in a blow-up pool in my living room. Birth happens as God/dess intended, without drugs or knives or sterile fields. Birth happens.

It wasn't perfect-- I still had the retained placenta to deal with. (I'll write a separate epilogue for that-- I've gone on long enough!) But in the end, it was all so beautifully simple. I went into labor. I dilated to complete, without anyone having to reach gloved fingers into my body to verify it. When it was time to push, my body did what it was supposed to (although I'm a little bitter that I didn't get my "rest and be thankful" moment!). I acted instinctively to assume the positions that were best to facilitate Rowan's descent. I supported my own perineum, and I did not tear. Rowan was born-- and so was I.

Capitalizing on Loss and Risk

My dear friend Shannon at BirthAction wrote this post that everyone should read. Go on, read it. I'll wait.

Capitalizing on Loss and Risk


It brings up so many good points... the main one being that, for women birthing in hospitals, the playing field is never level. True informed consent does not exist in our current system; without it, women "choose" interventions and procedures that damage them and their babies-- and sometimes kill. How can we increase awareness? How can we make women understand that they have choices? That labor starts and progresses without dangerous drugs-- that babies can be born without drips and wires and gleaming metal instruments? How can we convince women that they are strong and capable, and they do not have to lie down for the knife? Most of all, that birth is safe... interference is risky?

Benoni

"And it came to pass, when she was in hard labor, that the midwife said unto her, Fear not, thou shalt have this son also. And it came to pass, as her soul was in departing (for she died), that she called his name Benoni: but his father called him Benjamin."-- Genesis 35:17-18

I have three children, but in my mind, I've only given birth once. While I'm forever grateful for that birth, I still haven't come to terms with the delivery that preceded it. Today is the ninth anniversary of an ill-advised induction and rather sad VBAC attempt-- I look back with some bitterness and much pity on that woman, who thought she was prepared and so clearly wasn't. Gareth, my first son, will be nine tomorrow, and I will celebrate him, all the wonderful things he's brought to my life. Today is my griefday, the day I try to find some peace for myself.

Like every attempted VBAC, this story begins with a cesarean. In 1999 my dd arrived via a prudent, respectful, and not altogether horrible (though not conclusively necessary) c/s in Boulder, Colorado. She was a double footling breech with a triple nuchal cord-- I'm not convinced she was unbirthable, but in my ignorance and lack of initiative, I opted for a planned surgical delivery. My midwives and OB were very supportive; their assumption was that I would VBAC next time. The recovery wasn't bad, and I was comforted by the fact that she chose her own birthday-- I went into spontaneous labor with a dramatic water-breaking event worthy of a sitcom-- but I never once considered having a repeat section. My daughter's delivery was fairly atraumatic, but it wasn't, in my opinion, the way babies ought to come into the world. I began researching VBAC as soon as I got home from the hospital.

I might've been all right if I had stayed in Boulder, but by the time I found myself pregnant again, I was in Los Angeles-- definitely not a positive move in terms of birth options. The clinic that confirmed my pregnancy for me asked if I wanted a referral to an OB "for prenatal care or for termination?" Every OB practice I called wanted to schedule a repeat section without even taking a history. I got plenty of gasps and horror stories when I asked about VBAC: "Oh, no, we don't do that anymore! I have a friend who's a nurse, and her sister wanted a VBAC, and she went to 36 1/2 weeks without going into labor and when she did her uterus split open and she DIED and so did her baby..." It was hideous. Fortunately, I had found ICAN by then, and I knew a dead baby card when I heard one. I hired and fired two OBs, an APN, and two midwives, driving up and down the Los Angeles freeways-- Ventura to San Diego County, Simi Valley to Riverside. I got more and more frustrated; my marriage, which wasn't what one could call rock-solid to begin with, became more and more strained. Finally, at 30 weeks, I found a "famous" Hollywood birth center that would take me on and allow me to have a VBAC out of hospital. The midwife I met with, Elizabeth, was a little older than me and about 24 weeks into her own pregnancy. She was just what I was looking for: passionate about birth, excited about VBAC, supportive of me and my dreams for this birth. I only had 10 weeks (plus or minus-- dd came at 39 weeks, but I was prepared to go 42 or more), but I felt I had finally found a caregiver I could work with.

That may have turned out to be true-- I have no way to know. Three weeks later, Elizabeth broke her foot and went on medical/maternity leave. My care fell to the founder of the birth center, Nancy-- midwife to the stars, self-proclaimed pioneer of waterbirth. From my first meeting with her, I knew the game had changed-- she was much more medicalized than her colleague, much less enthusiastic about my chances of a successful VBAC. I kept going to her center, though, because I had no one else to turn to. As far as I knew, Nancy was my very last chance. 

I hired a doula around the same time. She was finishing her certification; she needed two more births, and she gave me a great deal, financially speaking. Unfortunately, I found that I got what I paid for: Michelle was sweet, but inexperienced; she was no more prepared to deal with single-minded medpros than I was. When push came to shove (literally), she did not have it in her to support a VBAC in the face of resistance from hospital staff.

From our first meeting, Nancy was worrying about my baby's size. She commented on my two-year-old daughter's "chipmunk cheeks" and wondered if "she was always a Sumo baby." At her mandatory childbirth prep class she told fearmongering stories about "giant babies" and bad outcomes-- shoulder dystocias, nerve damage, a death. If I'd been in my right mind, I would've run like hell-- but I couldn't do it. Instead I swallowed it all and did what she told me, slashing my carbs, trying to stick to her recommended (and quite restrictive) diet so I wouldn't grow too big a baby. I kept a detailed food journal; my net gain for the pregnancy was 11 lbs. She accused me of lying, of not writing down every morsel I ate, of bingeing on ice cream and popcorn. She kept harping on how big this baby was going to be, "at least 10 lbs, you better hope you go into labor sooner than later!" She wanted me to have an ultrasound to get an estimate of size; I refused, knowing how inaccurate late-term scans tend to be. I concentrated on trying to go into labor, as she suggested: I ate the hottest, most cilantro-filled Mexican food I could find, I walked around the Burbank IKEA until I thought my feet would fall off, I bought the homeopathics she recommended and dutifully swallowed them every 2-3 hours, around the clock. I prodromaled from 37 weeks on, but I did not go into labor. I was losing all hope for my birth.

At 40 weeks on the dot I went to see Nancy. She checked my cervix, pronounced me "soft, squishy, almost completely effaced, maybe a fingertip dilated." Then, before I could get off the table, she brought in a sonographer and subjected me to an ultrasound I did not want and to which I had not consented. The results were predictable: "This baby is already 10 lbs. If you don't go into labor by 40 weeks, 6 days, I'm done-- I have to risk you out. I have no choice-- I can do a VBAC or I can do a big baby, but not both."

She informed me that she was scheduling an induction at California Hospital, a charity facility in downtown LA where she had privileges, and I would show up. If I went into labor before then, great. But she expected that I would end up with another cesarean. "If I'd known how big your daughter was [9 lbs 5 oz, 22 1/2"], I would never have taken you on."

I begged for an extension. It was July 12; 41 weeks would be July 19. I was moving to Arkansas July 29, driving across the country-- I told her I could not deal with a c-section.

"What you can't deal with," she answered coldly, "is a dead baby."

I went sobbing to my doula and to the wisewomen of the ICAN list. Michelle had no suggestions, beyond offering tools and tricks to deal with the induction. My ICAN friends were succinct: Get. Out. Don't go. Have a sick child, a lost cat, a flat tire. DON'T AGREE TO THE INDUCTION. Sensible advice... but I didn't listen. I asked Michelle what would happen if I waited to go into labor and showed up at another hospital-- she conceded that it was an option, but she could not in good conscience go with me, for fear of being charged with practicing medicine without a licence. I continued to prodromal, but I couldn't go into labor. I wrote a heartfelt eviction letter to my baby, pleading with him/her to come out. My sister took my daughter for a day so her father and I could engage in awkward, joyless intercourse, just for the prostaglandins. I kept taking those tiny white pills; I gulped down an entire bottle of castor oil in root beer. Nothing. And then it was Thursday night, and dh was on the phone with Michelle, arranging a time and place to meet.

At 5 am we met Michelle in the parking deck. The first thing Michelle did was apologize for not having a birth ball-- "I don't think there will be room"-- or a CD player-- "My toddler broke it." We walked into the hospital and were escorted to L&D by a security guard. Nancy arrived at 6:30, half an hour later than she'd planned. She barely looked at me as she rushed us into a small, shabby room. She handed me a faded hospital gown and pointed me to the bathroom. "Let's get this show on the road."

She had promised me I could wear my own clothes. She had assured me that I would have mobility, autonomy. "You just need a whiff of pitocin and you'll just spit that baby out." Instead, she shoved the gown into my hands and told me "get a move on." I took off my red maternity shirt-- blood-bright, it sang birthing power to me-- and pulled the thin, scratchy gown on instead. In that moment I gave away the last of my power, my self-determination. I buckled, caved. 

I climbed awkwardly onto the bed, met the offgoing nurse, Catalina, who had had two VBA2Cs and saw no reason why I shouldn't succeed too, and then the day nurse (Julie? Jeannie?), who had had a waterbirth with Nancy at her birth center a year before. I got an IV, external monitor and tocometer, blood pressure cuff. They started the pit at 7 am sharp... and Nancy disappeared. I only saw her once more-- rather, I heard her-- hours later.

Labor hit hard; my concept of time disappeared. From time to time people came in-- a resident, I think, did a vag exam and said I was closed, thick, posterior. Nancy had lied; my cervix was not ready. I'd been told I could get off the monitors and go to the bathroom; when I tried, I was informed that was not possible and handed a bedpan. I could not void; the indignity and awkwardness made it impossible. I requested a Foley catheter, adding another tether to the bed. They kept increasing the pitocin, and soon added a pulse ox monitor to my lines. I think I was only about 2 cm when they broke my water, insisting that it was necessary in order to place an internal monitor, since the EFM wasn't picking up well. The ham-handed resident did it, and got the internal fetal probe hung in my cervix. That must have really messed up the fetal heartrate tracing, because two or three nurses came running in and huddled around the machine. The resident was called back, and fixed the problem by screwing a new electrode into my baby's scalp.

The day wore on. I tailor-sat on the end of the bed and counted myself through contractions. Michelle and my husband hovered in the background, uncertain what to do. I didn't want to be touched, effleuraged, or even talked to. I pretty much ignored everything that went on around me-- until I heard Nancy in my ear, telling me it was 5 pm, I was about 5 cm, and she wasn't going to be able to make it to this birth, "but good luck." Then she had the nurse put me on my left side-- a move I resisted. I didn't want to lie down. I wasn't given an option.

At 7 pm Catalina came back. She brought a doctor with her, a man with a thick accent and an unpronounceable name embroidered on his lab coat, above the words "Reproductive Endocrinologist." He was on call for the evening, and wanted to know a) why I didn't have an epidural and b) why I was still being permitted to labor. Catalina gave him report and told him I'd been progressing slowly but without difficulty. He recommended an immediate c/s. She told him no, I was working for a VBAC. He wanted to know, "Is her pelvis adequate?" At that point I sat up and yelled, "It most certainly is!"

As far as I can recall, he never spoke directly to me. He told Catalina, my husband, and Michelle that I was still only 5-6 cm, and he would give me 2 hours to make significant progress. Also, he insisted that I accept an epidural immediately, or he would roll me to the OR and deliver me at once. Then he swept out. 

I was crushed. I had achieved a sort of "groove" with my labor, and even though the pitocin contractions were hard, unremitting, relentless-- I was coping. As soon as that doctor walked in, the atmosphere was poisoned, ruined. Michelle encouraged me to go ahead and get the epidural-- "Maybe it'll help you relax and dilate." So I agreed, and the next thing I knew, an officious and unsmiling CRNA (certified registered nurse anesthetist) arrived. She cleared the room, forcing my panicked spouse and doula to leave. She was as compassionate as an iceberg as she drove that trocar into my back three times-- three attempts to place the epidural, three misses. I'd had enough; I told her the third attempt had worked, although I still had full sensation down my right side. She taped down the catheter and left at last, allowing my support team to return. 

The RE came back around 9 pm. I was "maybe 6-7," but it was progress, and he let me continue. I labored through transition-- I left reality behind at that point; I vaguely recall reciting a cake recipe. Then, suddenly, the fog lifted-- the world came back into hard focus. Catalina checked and pronounced me complete. I'd done it, I'd labored to 10 cm. It was about 11 pm.

I started pushing immediately--  coached pushing, on my side, which was uncomfortable and felt unproductive to me. But I kept going, pushing with all strength, while a tech came in and set up the delivery table. Row after row of shiny instruments, green surgical towels, a bucket-- Was this really going to happen?

I kept pushing. "I can see hair!" my husband crowed. Catalina was supportive; Michelle was excited. I started to think-- maybe--

After an hour or so I was still trying to birth my baby. Catalina was watching the monitor intently. She grabbed an oxygen mask and slapped it on me, telling me to "breathe for the baby." She reached up inside me, stimulating the baby's scalp as the strip showed a significant decel. "Push now," she told me, as if I hadn't been straining for what felt like forever.

Suddenly she was screaming out into the hallway, and in a few seconds the room was buzzing with activity. The doctor appeared and studied the strip. "You must push now. This baby needs to come out." 

Catalina and another nurse got me up into that wonderful frog position, and I pushed with everything I had. They could see a silver dollar's worth of scalp, but it didn't descend. The doctor called for a crash section. Michelle leaned in and whispered, "It's time to do what the doctor says." Then the bed was rolling, I was moving down the hall, into bright lights and noise, into a cold white OR. The nurses helped me scoot over to the operating table. The doctor leaned over me. "Your baby's heart rate dropped for several minutes," he said. "It has recovered now, and there is no distress. But I cannot let you push again. We need to do a c-section now." 

I was crying now as the staff fell into the practiced choreography of surgical prep. "Will you use the same scar?" I asked the RE. "I want you to use the same scar." 

"Of course I will, no one will be able to see it," he said reassuringly. He thought I meant my external scar.

"No, on my uterus... I want a low transverse scar, the same as before..." 

He muttered something and turned away. The CRNA came to dose the epidural, and I realized I could feel what they were doing as they washed and draped my belly. "I want general," I blurted, and she glowered at me. "Please!"

"I'm going to give you a bolus. You'll be fine."

"But-- I can-- " I couldn't get the words out. I was suddenly terrified that not only was I going to end up having a cesarean, but I would feel it. I'd read some fellow ICANers stories of surgical awareness, and I was choked with fear, tears running down my face. "Please!"

She snorted in disgust and said scornfully to the RE, "She's demanding general." 

"Dose the epidural." And he kept on with his prep. I could feel pressure on my belly-- I didn't know what they were doing--

Then I heard, "Oh, shit." The CRNA held up the epidural catheter, which had apparently fallen out when they transferred me to the table. The RE said, "Put her out." A black mask came down, and everything went dark. The last thought in my head was, Oh, good, I can go now. The baby will be fine, his dad can take care of him. I honestly expected-- and wanted-- to die.

I woke up as they were wheeling me into recovery. I could hear voices, but they all seemed to be coming from the end of a long tunnel. I saw my husband in scrubs, holding a small blanket-wrapped bundle; someone said, "You had a boy." I thought groggily, Someone had a boy... that's nice... I felt something hot run down my inner thigh; I mumbled, "There's more amniotic fluid." Michelle appeared and said soothingly, "That's not amniotic fluid now, sweetie. That's blood." 

I'm told I breastfed my new son in recovery, but I don't remember it. He was big, indeed-- 10 lbs, 5 oz. I have no memory of him in the hospital at all, though I know he was there, that I held him and nursed him. We only put him in the crib when I pushed it out into the hall and forced myself to walk in the corridors. My first clear recollection of Gareth Benjamin is when I was finally discharged from the hospital on Tuesday afternoon-- he was extracted at 1:11 am on Saturday, July 20, 2002-- and his dad hadn't installed the carseat. I struggled up out of the wheelchair and put it in the car myself, then put Gareth into it. I climbed in beside him and left the nightmare behind-- I hoped.

During my stay on the postpartum unit, I was denied pain medication after the first day. Since I didn't have an epidural, there was no option for PCA pain control. For some reason, no one would prescribe pills. I was given IM shots of morphine, which did little for the pain and made me itch abominably but allowed me to leave reality behind temporarily. I had three of those, but when I begged for a fourth, I was told, "Nobody ordered any more meds for you, that order expired." They gave me 600 mg of ibuprofen-- equivalent to 3 Advil, which is what I normally took for a headache. No one helped me clean up-- I remember having to get up about 8 hours after surgery and try to pee, since they had taken the Foley out in recovery as well. Someone helped me shuffle to a shower chair, then left me on my own. If my linens were changed, it was done while I was drifting in a morphine fog. They would not let me eat-- no one advanced my diet from clear liquid to regular until lunchtime on Tuesday, just before I left. Mostly I was ignored, left alone with my baby son, since my husband had to care for our two-year-old. The brightest spot in my stay was one evening when my sister sneaked me in a milkshake.

I went home on Tuesday, July 23. Immediately I had to deal with packing up and getting ready to move across country, since we were leaving on July 29. On Friday, I got into the shower and pulled off the peripad I'd been using to shield my incision. I screamed-- the pad was soaked with blood. My incision was open on the right side-- maybe an inch, and draining what looked like watery blood. I made my husband take me to the nearest ER, where I was told that such mild dehiscence was a "normal but uncommon result of abdominal surgery." There was some talk of opening the wound and packing it, but the Er doc finally decided to leave it alone. He told me to keep a pad on it, monitor the drainage, and come back if it started to look like pus. He prescribed a 10-day course of Keflex and sent me home. On Monday we left Los Angeles and headed east on I-40. My incision stayed open and leaked serosanguinous fluid for 6 weeks.

I barely remember my son's first year. I lived-- survived-- in darkness, only getting out of bed to care for my babies. I had nightmares, cold sweats, flashbacks to the OR. Most days I wished I had died on that operating table. I poured out my grief and rage on the ICAN list, and the wonderful wisewomen there supported me as best they could. It took years before I could talk about Gareth's "birth" without weeping, and I still can't talk long without tearing up. I hated all doctors, all midwives, all doulas. They had betrayed me, stolen my baby's birth. I was broken and defeated. I was bitter. And then I was angry. I burned in that crucible, channeled my fury into nursing school-- I refused to ever be at the mercy of medpros again. I became an RN and took a job in postpartum, so I could give mothers the care I did not receive. 

I conceived again just before my last semester of nursing school; I sat my boards hugely pregnant. I had an empowering unassisted pregnancy and birth, and three years and six weeks after Gareth was surgically removed from my uterus, I gave birth to his baby brother-- in my living room, on my own terms, into my own hands. He was slightly bigger than Gareth, who was vertex but had his head cocked-- an asynclitic presentation. Rowan was positioned beautifully, in part because I had learned how much more important position is than size-- something Nancy never mentioned or, I suspect, even considered. 

So... that's my story. The CBAC from hell made my career and my triumphant UBA2C possible. And of course I got the gift of my first son, my Gareth-- my gentle, angry boy. I guess I should feel some measure of peace over it now... maybe one day I will. 

I gave him the middle name Benjamin for my grandfather. But it was fitting in another way as well. In the book of Gensis, Rachel dies giving birth to a son she names Benoni-- "son of my sorrow." His father, Jacob, renamed him Benjamin, "son of the right hand." In a very real sense-- to me, at least-- I died on that table. The woman I was, who trusted professional caregivers to do what they promised, went to sleep and never woke up. Instead there was-- me, angry and bitter and devastated-- and determined.