Tess's Birth, by Sara Patterson

The arrival of Tess 1:06pm on Tuesday 15th July 2003; a beautiful healthy second daughter for Sara and Stuart and little sister for Faye and Ross.

I am writing this story for Tess and as I want everyone to know that even when things don't go "to plan" it can still be a positive experience.

We had been hoping and planning for a home water birth after two previous caesarian sections. The first had been an emergency caesarean after a long medicinalised labour ending in Faye being in occiput transverse position and failed forceps attempt. The second was to have been VBAC (Vaginal Birth After Caesarean) but I chickened out after having suffered non-proteineuric pregnancy hypertension at end of the pregnancy and "obstetric advice" tongue in cheek - basically not knowing then what I know now!

Note from Angela:
'Proteinuria' means protein in the urine, and together with raised blood pressure, it is one of the signs of pre-eclampsia. Pre-eclampsia can occur without protein being detected in the urine, but this is less common. Sara's 'non-proteineuric pregnancy hypertension', or high blood pressure without protein in her urine, could therefore have been a blood pressure rise due to various different factors - and opinion varies greatly as to how significant, or risky, this is.

We had spent much time reading, researching and contemplating a third child before even conceiving (two years of tears, angst, frustration, grieving, and more tears). Only having taken advice and going over and over things and looking at the medical records of the previous two pregnancies and deliveries did we decide to go ahead and have another baby.

Under the care of Laura and Jane, our two independent midwives, we enjoyed a good positive pregnancy with excellent care and support. None of the upset, confrontations and hassle of the previous attempt to VBAC under the NHS! This previous VBAC attempt had been supported in principle by the consultant but we never saw the same doctor twice and opinions of how a woman attempting VBAC would and should be "handled" varied!

During the course of this pregnancy our independent midwives did make contact with the consultant who I had been under shared care for the previous two pregnancies, and had asked for obstetric input that I think did not materialise in the way that my midwives had expected. I had been sent back in January a routine clinic appointment but in light of previous experience and much deliberation I did not attend as this was not the obstetric input required. I continued the pregnancy with the attitude that I would personally see an obstetrician should an obstetric / medical need arise; in the absence of such a need I was happy to continue with midwifery care.

At the end of April when I was about 30 weeks, I had to attend the local maternity hospital the weekend of my parents' ruby anniversary celebrations. Jane had come out to see me as I was complaining of headache, swollen feet and feeling grotty. I had proteinuria, raised blood pressure and oedema (swelling). This fortunately turned out to be a urine infection and a case of overdoing it in hot weather.

I managed to survive the experience of this hospital admission (much as I had been determined "not to go near that place again") as I was looked after by friendly, professional midwives who made no judgement of my plans to have a home birth after two sections. In fact many were curious of my plans and use of independent midwives; I think I was unusual in their experience. I did however meet with a locum obstetric registrar who did not seem to understand that my concern at that time was my purely my 'condition', i.e. raised BP etc. and not my informed choice of mode of delivery. It was my first positive experience and I surprised myself by being gently assertive with this doctor and avoiding upset. He wrote something in my notes I think about not agreeing with my choice of home birth and that I had refused examination. I did not feel at that time that an internal would have been of benefit so I had been in my rights to decline!

The consultant however, following this admission, wrote to me to invite me to meet him and "discuss the implications of my decision". I decided not to meet him but my midwives and I discussed at length (again) and documented our understanding of the risks of VBAC and home birth in general.

At about 34 weeks my kind and sensible GP signed me off work for a few weeks as I had problems with tiredness and a series of urine infections. He felt it was time I slowed down and I was close to starting my planned maternity leave anyway. I arranged the hire of a water pool to arrive for 39 weeks and started making preparations.

At about 41 weeks my diastolic blood pressure crept up to above 100mm (90mm Hg diastolic is the usual guideline for high blood pressure, ie when midwives start to keep a closer eye on you), my urine showed a trace of protein and I felt unwell. All the hot weather was not helping. So back into hospital I trundled again for obstetric review (now I was getting upset as it looked like plan for the homebirth was vaporising). As it turned out, my blood tests and fetal monitoring were all okay and my BP came down so I was allowed to go home and given appointment for monitoring / follow-up in 4 days time. I did not however see a doctor as intended. Laura and Jane were concerned about this so they spoke with a senior midwife at the hospital at length and an appointment was made for the following day (a Saturday) to go in for assessment and to see an Obstetrician. This again was a positive experience.

I was now just over 41 weeks and expected hassle but the midwife was wonderful and carried out the routine tests and discussed options at length and was very understanding and did not judge my choice. She carefully noted documented the discussions in my notes and hospital records and made sure we were all clear with what was and wasn't possible. I had now decided to write a hospital birth plan and a plan for caesarean should the need arise.

I always knew that a hospital birth or caesarean was always possible (as for any delivery) but now I faced it in a new light. This medical hiccup did me a huge favour. I was able to take control of what may happen to me and discuss with others what I needed. We saw a consultant obstetrician who naturally pointed out the "usual concerns" with a VBAC (I had to explain to him what VBAC meant!). We mutually agreed a plan of action and compromised on some points regarding monitoring and how long I would wait before further review (42 weeks rather than term plus 10 days). The consultant wanted me to consider AROM as a means of induction if nature had not taken its course although I was not keen on this at all. The idea was that he knew I wanted to have a chance at delivering 'naturally' and this could be a last attempt at this. The plan of action was to wait and see if I went into spontaneous labour and then I decided I would play it by ear!

The hospital midwife attempted a stretch (stretching and sweeping the membranes covering the cervix - a 'gentle' way of bringing on labour) which unfortunately she could not quite do (I was however encouraged as in two days I had gone from 'closed' to the external os being opened). I now felt more positive and felt that although now a home birth looked less likely, I planned to stay at home as long as possible and certainly until I was in established labour as long as the baby and I were okay. In some ways that meant nothing had changed other than I had an additional risk of BP and an increased likelihood of transfer in labour.

I went in on the Monday for follow up and fetal trace, blood tests and BP were all normal (my BP had now gone back down to 120/80). However, I had a urine infection and needed antibiotics. I asked the midwife I saw that day in hospital to make an attempt at a stretch and sweep for me but she would not do it as she felt there was no point having had an attempt Saturday. I went home feeling happy about BP but disappointed about the declined stretch.

I started to wonder if I would go into labour as I felt the stress and anxiety of the last week was not conducive to labour. Luckily for me 10 o'clock that night (when 10 days over - must be my "proper gestational age" - same as for the time when I went into labour with Faye) I had some very weird 'twinges' that I thought must be braxton hicks about 15 minutes apart. I had a slightly violent bowel movement and a show. Stuart and I decided to have an attempt at inducing labour and about 10 minutes after he had "performed" I started having contractions they were close together (about 2 - 3 minutes) but short (only about 30 seconds) and varied in strength but were mild.

The exact timings of the rest of the night I could not tell you for certain but the sequence of events I can recall! After awhile of waiting to see if the contractions continued I rang Laura to warn her that maybe something was going to happen after all. I remember being excited and telling her that they were not too painful! This was about 11:30; Laura recommended having a cool shower (it was a very hot and sticky night) go to bed as it was possible things may stop. I remember thinking good idea and also that I would not worry too much if the contractions did stop as at least then I would get some sleep and energy for the labour ahead. I think I joked about how I didn't know if anyone starting labour and it stopping and not starting again.

I did as she suggested but no such luck, as soon as I lay down to try to sleep the contractions got further apart but longer and harder! It did not seem long before they got further apart (about 4 to 5 minutes) but stronger and longer. Now I had to concentrate; I put on the music compilation I had made especially for labour and had to really breathe! At some point Stuart turned up the thermostat and put the water boiler on and we started getting the pool ready (which we had not sent back!). By about 1:30 in morning we decided it would be a good idea to get my mother in law around just in case we had to go rushing in to hospital or Faye and Ross woke up.

By about 3:00am I had to ring Laura to let her know that the contractions were now about 1 minute long and four - five minutes apart. I think I was sitting on the birth ball next to the pool when I spoke to her. Stuart was filling the pool and had a very hot moment trying to retrieve the thermometer at one point as it had fallen to the bottom (he subsequently decided it would be a good idea to get some string so he could reel it back in each time). It was getting very hot and humid in the conservatory with all that hot water and I decided that sitting was getting too uncomfortable. Laura let me know that her and Jane now would be making their way. In the end only way to get comfy was to walk and then lean against lounge door (gripping the handle with one hand) rocking and breathing. The contractions at time were very intense but varied from ouch to more ouch; every now and then I would get one where I thought I had got half way and through the worst of it and started to relax to find that it was not half way and the peak of the pain caught me unprepared. I found breathing and concentrating on my hips helped. Each inhalation / exhalation seemed to break the pain of the contraction into portions of manageable pain like a link of sausages that you ate one at a time rather than one long inedible sausage if that makes sense?!

Laura was first to arrive about 5ish and suggested we finish getting pool ready. I felt much happier once she arrived as I had been going through a period of really intense contractions before she arrived where I felt I was going to burst and had started to get back and hip pain. - She started doing my regular checks for pulse and BP and checked felt my abdomen to check the lie of the baby and the baby's heart rate. I think the pool altogether took Stuart about about 4 hours to fill and to get to the right temperature. In the end he had to remove some hot water before adding more cold; we had overestimated the temperature and amount of hot water we needed! I was using a homeopathic birth kit which worked well, for example aconite for anxiety and kali carb for back labour. Jane arrived about 6am.

Due to my previous obstetric history (c sections) I had to have BP and pulse checks every 15 minutes to watch out of early warning signs of rupture. I got into the pool at some point about 7am and did spend a lovely couple of hours in there. The warm water took the edge off the pain and I relaxed back against the side of the pool. Stuart's mum and the children appeared after awhile and I think Faye and Ross were surprised to find me sitting in a large 'paddling pool' in the conservatory but they were quite happy. I made a few phone calls whilst floating and arranged with a friend to take Faye to school. Stuart went off after eight to take Faye to her house.

By this time it was apparent that my BP was not behaving completely and although it had come down a bit it was still a bit too high for comfort but more of a concern was my pulse rate of 120 that was not going down and had in fact risen further. Stuart took Ross off to nursery for the day and Jane contacted Kettering hospital once we had discussed what we wanted to do. I talked to Jane, Laura and Stuart and decided to go into hospital and felt that there was nothing that could be done there that would benefit me and I felt that I would rather not risk intervention which may have increased risks of rupture or fetal distress. I decided that my safest option was to have a caesarean. But this time it was my informed choice and I felt was definitely the best course of action for me and the baby!

Laura with my consent carried out a one off internal more for my benefit as I wanted to know for the record how far I had got! I was pleased to find out that I was 2-3 cm but no more! I think I would have agonised more about what to do if I had been a bit been further on. Labour ward then knew I was on my way and we finished throwing the odd few items into bags like music, drink, homeopathic birth kit, etc. (I had sensibly already prepared a labour and hospital bag). For some reason I had about 45 minutes respite from the contractions and Laura said nature was being kind now I was not going to do it that way!

Unfortunately once we got into the labour ward, with no rooms available and no easy access to entonox (which I now craved) the contractions came back harder than ever. We saw another helpful midwife who let us know what was happening and it was not long before we saw the registrar. I was now on the monitor which proved very uncomfortable as I really wanted to move with the hideously strong contractions. A discussion took place about what was going to happen to me. He talked to us about how elective caesareans were scheduled for the following day and that carrying out an emergency section (ie unplanned) was 'sub-optimal'. I wanted to know if technically there was going to be any difference and it was explained to me about anaesthesia and blood testing was preferable planned ahead. It had been noted however, that I had not eaten anything other than one slice of bread 6:30am that morning. It was agreed he would discuss my status with my consultant and that a decision would be made depending on whether or not I was in established labour and asked if Laura or Jane would carry out another internal to see if I had made progress. Laura discussed with him how I had transferred in for a medical reason and that we wanted to avoid an emergency situation and that my condition / pulse etc, indicated that there was cause for concern.

I had, with horror, asked mid-contraction in agony what he proposed to do if I was to wait until the following day!! I did not quite understand the logic of this as my uterus was contracting regardless of whether I was in established or early labour! Anyway Laura carried out the internal much to my displeasure but it seemed a means to an end - I was now 4 - 5cm so officially in established labour. I was shortly revisited by the registrar, who was pleased to inform me that the anaesthetist was on her way. I would be going for my section shortly which he would perform! Hurray stress and uncertainty gone. I was prepared for theatre and our caesarean plan was discussed. I also signed a consent form which the registrar brought for me and we discussed. I was also pleased to discover that the hospital midwife who would be coming with us into theatre was the same midwife who as a student midwife had been my main carer when I had an elective caesarean for Ross.

It made such a huge difference this time knowing the people that would be with me. Jane and Laura were allowed to stay with Stuart and I and were able to speak up for us and knew the things that were important to us. Things such as Stuart being the one to discover and announce the sex of our baby, being able to have my music played (this helped me relax), having the baby with us - Stuart stripped of his scrubs top and held Tess for ages, minimal procedures carried out, etc. I also wanted to see my placenta - something I had not been able to experience before! The placenta was kept and videoed for my benefit. I was sent through to recovery with baby Tess on my chest under the sheet, skin-to-skin, which I loved and had never had the chance of before! It tickled me that when the registrar came to talk to me before I went through to recovery, he asked me what I had had, showing that he had not even looked - knowing that it was important to us that Stuart had that job!

So it didn't go all to plan A, but it was a brilliant labour and I am proud that I got all the way to 5cm plus with no pain relief at all. We had a brilliant caesarean so we got our plan C with our own music, the hospital staff very caring and supportive and, of particular importance to us, Jane and Laura were there to look after us and to share the experience too! So this time it truly was a happy experience, our informed choice and we were in control. This time no distressed mum or baby!! Tess is the most settled and content of the three babies we have had and I am sure this has something to do with my calmer pregnancy and positive birth experience.

Sara Patterson
spatterson @ hippocampus.nildram.homebirth.co.uk
Remove 'homebirth' to get the real email address.

Sara's midwives were Jane Dutton and Laura Abbott
who practise in Herts, Beds, Bucks, Cambs and North London

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