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Denise Punger MD FAAFP IBCLC
David Stuart's Birth Story
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My Prenatal Care

Many birth stories focus on labor and don't share any of the anxieties women have throughout pregnancy. I am 36 weeks. My impending birth and subsequent birth story would not be complete without the details leading up to it. I became the client with needs unable to be met by birth teams, which I attribute to different cultural customs and routines taken for granted. These differences have been a major stress point in my third pregnancy.

My Birth Plan was simple: To give birth surrounded by my midwife and doula friends in the comfort of my house.

Considering my friends are in the birth field, my plan is not that complicated. I thought about birthing this way before I was pregnant. As circumstances would have it, my family moved out-of-state. It was tough to leave my friends. Even with phone and email the distance seemed enormous.

The  the new community  was vastly different from Florida. The small town culture was not expected. After all I trained in this state; I lived in yhis state longer than anywhere else, but this town  was so different than the otherl ocations that I lived-- I would have never believed it even if someone had tried to explain it.

Making contacts through the birth community was one of the first ways I attempted to make new contacts. A few weeks before the move, I searched yahoogroups and found a birth community and introduced myself. I was welcomed before I even left Florida. This gave me something to look forward to even as I grieved what I was leaving behind. Meeting on-line would eventually turn out to be different to meeting in person.

This difficult move became even more challenging when I became pregnant a few months later. I could continue the email and telephone communication, but would not have the familiar prenatal care or birth plan I hoped for. I was going to have to recreate a birth plan or find meaningful friendships quickly. As soon as I knew I was pregnant, I sent email to my doula friends in Florida. Their initial replies were exciting. I felt special. They made it so exciting for me that I wanted to tell everyone else I knew that same day. Since I had family all over, and several Internet communities of friends, email made it real easy to share the news.

I was taken back a bit by the cumulative responses in my new  birth community. First, "Congratulations. I am shocked. I dont know what to say." This is from a midwife wannabe who I knew socially and couldn't wait for me to be in her locale; she previously claimed that she was deprived of a birth network living out in Mayberry. She had claimed before that she could never tire of talking about birth and babies, yet she was speechless over my news. A few days later, I ask her for the name and number of her midwife. She says that she'll look it up and try to get back with me. She had just given birth: she had to try and look for this number? Her responses made me uncomfortable. I didn't get it. Was this a communication gap that I misunderstood? Why was she shocked? Because I just moved, because I was looking for a new practice situation, or just my overwhelming personal family issues. I felt judged and realized she wouldn't be good prenatal or labor support with the tone set. I found the midwife's number without her help before she got back to me days later.

Next I had run into a doula at my boys Martial Arts Class. I shared my great news. She didn't say much, again confusing me, but a few days later I found out she was  dreading leaving the area and wouldn't be around for my birth. I obviously knew how it felt to move and I thought I should be sensitive to her needs rather than to brag about my pregnancy, birth, and desire to have a doula with me. This was frustrating. I really wanted to share my excitement with someone in person.

My doulas in Florida are still sending me notes of enthusiasm and encouragement while I made contact with the recommended midwife. I told her she came highly advocated by several local moms  and I'd look forward to my first prenatal in a few weeks. Being in the birth community, I was thinking ahead, being courteous and letting the midwife know when I was due. Somehow this offended her. It was her policy to have a "consultation" first not an "initial prenatal." She stated that just because I wanted her, did not mean she wanted me wanted me as a client. Whoa. Low blow. Why would she not even want to meet me before coming out and saying something so humiliating? This made me really second guess myself. Where was the support in this community? I had participated whole heartily in the natural childbirth movement, supporting midwives, and she responded like I was unworthy. To keep from being depressed, I could only think that it was cultural issue. What if I did say "consultation?" Did I come across too sure of myself? This was such a let down. I thought I was a good home birth candidate. Now I wasn't so sure. After thinking about it a few days I decided I should not have to feel obligated to prove myself to her. I could find another midwife.

While I was searching for another, I also discovered the midwifery "is not legal in this state, but not prohibited either." It is legal in Florida. More adjustments! What this means is that there is no state licensure for midwives. A midwife could obtain a national license or credentials, but this is a personal choice and not recognized by the state. The midwife takes the risk. Perhaps this is why the midwife was cautious, but I did not realize her huge responsibility at the time I called. For the birthing family they can birth anywhere they want without legal consequence. It also means that midwives could not order labs and medications. This part did have an advantage. I was not contrived in to having unnecessary testing, especially amniocentesis, or coerced into taking medication I did not want. I'd have to make the effort to go to a physician if I wanted these "extras."

This part of  the state doesn't have an abundance of midwives, but I did finally find one. She was a lay midwife, without formal training, credentials, or a state or national licensure. My husband and I do value formal education and accepting this difference was also challenging. I value the initials after my name. It is another one of those things I didn't understand. Even if the state didn't recognize it, why wouldn't you want to show the world you could do it! And show the state this profession was worthy of being legal. Some people think I am just proud because it is an "M.D." after my name. I am equally proud of the IBCLC initials. I feel like it shows my patients I am committed to helping them breastfeed and differentiates me from other physicians who support breastfeeding with lip service, but don't keep up with the information. I was so uncomfortable with the no-credentials thing; I hated to ask her how she felt about it. I feared being alienated by another midwife. Not asking, however, did not help me resolve my issues. I did eventually ask other midwives in "legal, but not prohibited states." Jan Tritten, editor of Midwifery Today, explained to me how complicated this issue is and deserves its own dissertation. I may not understand it all now, but can respect the difficult situation for midwives.

On the phone initially my midwife warned me that she has a distributorship for vitamins and would highly recommend all sorts of vitamins from her company. I felt like my pregnancy was a racket for her other business. She really meant it, too. I made it clear to her by the second visit that I will eat well and I will take cheaper vitamins. I thought it was unnecessary for anyone to buy the most expensive vitamins and I wouldn't be buying hers. "Look at me. Do I look deprived of food." I rarely have taken vitamins in the past and what I am taking already is a big compromise on my side. I didn't take too many vitamins my previous two pregnancies. I had started them this time because I had lost eight pounds initially and I questioned if I was eating enough. She told me she had a big problem with my decision not to take her recommended vitamins. "Other clients of hers who felt poorly with previous pregnancies, find that they feel much better with the current pregnancy when they take her all-natural megavitamins. If I didn't want to take them, I could just continue to feel tired." If birth providers weren't limited, she would have been told to leave. She did retract a little bit when I pulled out all the different teas and vitamins and shakes I had and was willing to take. I must say it is hard to accept being talked to like this when I have been around so many empowering doulas and midwives. Words can have a powerful effect. I read Gail Hart's timely article in Summer 2003 Midwifery Today summarizing this in reference to why woman choose to birth unassisted, "Are we so untrusting of birth that we must carry and recommend a bags of herbs and medications, put our client on special diets ... do we horrify them with our talk of risks, consequences, worries, fears..." In my own article, Reflections of my Obstetrical Training, I referred to the family practice department I trained with being more open minded compared to the obstetrics department. One of the points the family practice faculty made was not to force horse pills down the throats of our nauseated first trimester patients: give it some time. A point was made that with good nutrition many of our healthy patients could do fine without vitamins, whereas, for the high risk obstetric patients it probably was better to get them on a compliant vitamin schedule. So hearing the midwife endorse a certain brand and tell me that I needed those specific MVI, calcium, Vitamin C, B12 complex, and alfalfa really was imposing on my training that was freeing me from rigid OB routines and also conveyed it to me that my body could not labor naturally if I didn't follow her recommendations. If I didn't feel so scolded, perhaps, I could have fully explained this. Funny, she barely mentioned raspberry tea. Her company must not sell it. This is what I did take: four gummies or Flinstones daily, raspberry tea, which I really did enjoy drinking hot or cold, Ovaltine or Noni shake, and eventually Vitamin C. I have heard good things about alfalfa reducing post partum bleeding, but my gag reflex was strong this pregnancy and I found it very unpleasant to swallow the large tablet.

I had also given her copies of my stories that has been previously published or soon-to-be published in Midwifery Today. I told her these topics I wrote about were more important than what I could tell her clinically. To this day, I am not sure if she has read my birth story. After several months she commented on the Reflections of my Obstetrical Training. These were not very long stories. You'd think she be curious about what I would have to say and want to talk about my feelings. I did not feel very valued as a client. I did not bother to pull out my artwork --pregnancy photography-- to share or my belly mask. I did not sense an interest.

I really want to be able to promote birth choices in my new community, a role I am very comfortable with, but I didn't like how things were going, for myself, let alone to be recommending these choices to other woman. I felt gypped of my chance to brag about my pregnancy and my well-thought out decision to not birth in a hospital. I did not feel like I was making a well-thought out choice.

As far as labs go, I didnt have much of a problem if she couldn't order them. It was my third pregnancy; some things just dont change. She did request a blood count. My husband wanted a triple screen for reassurance, even though I knew I wouldnt pursue an amniocentesis no matter what the results. I took it casually; Get the test and he'll be off my back. What a surprise to see that it was positive test for Down's and Spina Bifida. I cant tell you how much anxiety this provoked in my husband, and myself and even the midwife. I finally came to terms with how many times this particular test gives false results and could put it behind me. As I looked at the calculations and values that went into getting the results, I saw plenty of room for error. I can't say I recommend this test routinely or lightly.

To top off our communication problems, she talked about local issues in a way that made me feel very uncomfortable. It's hard to pinpoint exactly what bothered me, everybodys entitled to have their own opinion, but I think it was that she made assumptions that I shared the same small town beliefs. There was no open end for me to  express my own thoughts. I couldn't be myself, and when I finally did tell her otherewise, it was awkward. I felt like I was the first person ever that didn't share the South's conservative political and religious agenda; I am a Yankee at heart. Even if I did share the same views coming from an international diverse back ground (South Florida, Atlanta, New York and medical school) you learn to not make assumption about people and respect their opinion. It was just one more communication barrier blocking me from fully enjoying my prenatal care. Other woman from the area probably would have been excited to find a midwife with the typical regional values and presentation and not have found this to be a difficulty at all.

I always envisioned prenatal care with a home birth midwife to be laid back, enthusiastic, and encouraging. My appointments with her continued to be quick, uncomfortable, and somber. I dreaded them. I kept holding on to the hope that towards the end our weekly appointments-- we would get to know and understand each other better. It effected me physically, too. When she checked my blood pressure it was often on the high end. I checked it on my own several times and it was always on the lower side.

I still had a problem of not having a local doula either. When I was about 32 weeks another  doula who is 45- minutes away posted to the yahoogroup that she desperately wanted more birth experience. She seemed to beg for someone to take her under their wing. I thought she could be a good match for my birth needs. I responded to her post. Without even calling me to get details, she determined that I lived too far. Frustrating.

The one good thing is that my friends in Florida continued to provide the optimism I needed. I was actually enjoying this pregnancy despite all this. It was suggested several times that I look into unassisted birth. Mistakenly it was assumed because my husband and I are physicians we could handle it. Going back to my birth plan, I thought birth was a time to be shared, not go into isolation. Woman who had unassisted birth often had above-average-supportive husbands. My husband and I mutually agreed that he did not fit this role. I wanted to know if I was alone for a long labor who would help me change positions, take photos, watch my other children, explain to my children what was going on, make phone calls, get snacks, help clean-up, do laundry, and comfort me. I certainly could not do all that. A planned unassisted birth was not for me. I want a strong birth team.

Several of my doula friends expressed sincere interest all along in coming to me for my due date. It was so hard to believe this could come true. I was a long ways away. At the 35-weeks, I went down to Florida to visit. I was proud to flaunt my pregnancy around people who cared. A midwife and several doulas were interested in caravanning to me  got together for a meeting while I was visiting to work it out the plans. I was with four women who made me feel on top of the world. I felt like my birth was the most important birth in the world. I felt like my family and needs were important. What a high! All childbearing woman should feel this way. They were actually excited to come to me and stay awhile with me around my due date. This was beginning to look like reality, not just a dream. No one knows how much their enthusiasm meant to me. I could be happy about this and enjoy the last month of my pregnancy! It wasn't too late to change providers.

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Karen Regena, Me, Dawn, Lori and our kids

Shortly after my visit to Florida, I had a 36-week prenatal appointment with the local midwife. She routinely went through her questions and fetal exam. She gets through quickly with minimum conversation and says this just gets to be "cut and dry." I guess she was trying to minimize her haste and her mutual discomfort. I felt like shouting to the midwife, "Cut and dry? I am 36 weeks pregnant. You bring a birth kit. We are supposed to be planning my birth. My sons are attentively watching you. I am thrilled with their curiosity. You're suppose to be telling me how exciting this is and how wonderful my birth will be. You are supposed to give me positive affirmations. Will my birth be cut and dry too?" When I told my husband about this, he thought that she just treats me more formally because I'm a physician, others probably get more pampering. (I want to be pampered!) She is bringing her partner to meet me the next appointment. Not that it matters anymore, but it is a let down realizing she did not make it a priority for us to meet earlier then full term. I asked to meet her at the first appointment. The mundane routine and undermining was not what I chose midwifery care for. If I was this uncomfortable, I couldn't even imagine what she thought of me. She couldn't be at ease either. How could I surrender to the joys and pains of birth if we had no relationship?

She left. I took A few deep breaths and decided to vent and email my Florida birth team. I could relax. I knew help was on the way. How could childbearing women from my Florida home take the birth support in that community for granted? They are so lucky to have birth choices.

The manuscript, Responding to Cultural Diversity in Womens Health, published by the Royal Womens Hospital and the University of Melbourne, Australia, defines "culture as a way of life; it may encompass, spiritual beliefs, and practices, values, language, customs, diet, and styles of communication [and] there is considerable diversity among and within cultures, including relation to age, marital status, socio-economic or educational backgrounds, religious beliefs, ethnicity, levels of urbanization, regional variations, and duration of residence." I identified with all the defined criteria.

"Its Toes!" My Birth Story

My midwife recognized my facial expression. "She's ready to push," she told my doulas. I felt a sense of confusion as I did have the urge to push, but never recognized going through transition. All of a sudden I have a strange sensation in my vagina. "Something's coming out," I announce, thinking it is a huge clot, but certain that its not a head crowning. My midwife and doulas reposition me to look and my six-year old exclaims, "It's toes!"

Toes? How could it be? So many sets of hands have been on my abdomen: several midwives, physician friends, and doulas. This baby was vertex. There was no doubt. When did this baby flip? Then I recalled stumbling in my bathroom about a week ago and being stunned and sore. Could that have turned my baby? I griped a few days about the pain without making a big deal about slipping because as far as the pain, I am not sure it was much different than any fullterm pregnancy-type discomfort until I had a chance to rethink it.

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Regena, Lori, and William

I saw my life flash before me, as I thought of different scenarios. Had this last minute discovery of a double footling breech occurred in a hospital, I would have had an anesthesia masked slapped on my face, as I got wisked to surgery to have my abdomen and uterus barbarically cut opened. Or had I let my quick labor progress at home unassisted without an experienced midwife present, I may have lost my life, my son's life or both. A double footling breech required skillful maneuvering (including posterior rotation and flexion at the neck) to prevent the chin from getting stuck in the pubic ring. This is not something that can be done alone. I sensed the confidence of my midwife to handle this. I also noticed she was able to keep my husband, John the doctor, calm. Both gave me the strength I needed. I was determined to push my baby out on the next contraction. I thought I only have a few minutes to give a grand finale type push with all my might before my baby would be compromised. On the next two successive contractions, I wailed the largest scream without holding anything back and pushed with every bit of energy I could muster up. What a relief it was to feel my babies body slip out and hear him cry.

It boggles my mind to think how fortunate I was to have the birth team that I did. Lori Nelson LM, and doulas Dawn Bond and Regena Winchell traveled 600 miles to be with me. My husband took on employment out of state. We were living far away from our "home" during my pregnancy. Interviewing several local midwives through my pregnancy. I went on with prenatal care with a midwife who I'm glad avoided intervention, but still of a clinically oriented mindset and not as much into my emotional over-neediness as I would have liked. Doulas weren't abundant either in this foreign place. Locally, I did not have much support. I kept in contact with my birth friends at home through email. Early in my pregnancy a few had expressed interest in being present at my birth. I thought, "Right! How is it ever going to work out that you come 600 miles to catch my birth?" As my pregnancy progressed, the doulas still insisted they were coming. I was gaining confidence that I would have at least one of them present to work along side the local midwife on my birth team. It was still hard to imagine, but I figured it would all work out in the end. At my weekly prenatal appointments we would have plenty of time to work out birth plan details, as I got to know my local midwife better. Then something unexpected happened. I received an email from Dawn stating that Lori wanted to caravan with her to be at my birth. I must be dreaming; this is too good to be true. I could have two midwifery teams at my birth! What an incredible time of bonding and camaraderie this would be. I had one last trip back home planned. I met with Lori and my doulas during this visit and sealed the plans for their journey to me. They made me feel as if my pregnancy and birth were the most important thing going on in the world. A feeling all woman should experience when pregnant.

As I got into the weekly appointments with the local midwife, I still wasn't feeling anymore comfortable. She referred to my appointments as routine; specifically calling them "cut and dry." My activity level had tapered off at the end of my pregnancy because of discomfort. She seemed to be bothered by this and actually stated something implying that I would have trouble laboring six or more hours for because I was sedentary. My six-year old son was very inquisitive at all our appointments. He was brushed off. " You do have a sitter for him, don't you?" This made me so angry. "No, I do not have a sitter for him. He wants to watch, take photographs, and comfort me during labor." Also, it seemed my blood pressure ran on the high side of normal in her presence only. She seemed to have a time limit of 30 minutes to discuss my plans at each visit, she even brought her partners with her at 38 weeks and three woman were in and out in the allotted 30 minutes! Many midwives would allow about 60 minutes for an appointment. I sensed the other two would have liked to stay longer and develop rapport, but the boss had them out the door quickly. After this 38-week appointment I began to wonder if this group could even work with my highly coveted team. As the time was getting closer to their arrival it was beginning to seem like two teams presence at birth was unnecessary. This thought was freeing. I could be selfish and just have those I feel comfortable with be around me during labor. I wanted to let the local team go. But who knew when labor would start. If I could only hang on until Lori and all got here.

They did arrive September 11th, a week before my due date. What a relief-- a midwife and two doulas in my house. We stayed up way too late talking about my pregnancy, my birth plans, my five and six-year-old sons level of participation, my husband's role and anything related. There was so much to talk about. How could the other team limit their time to 30 minutes? All this talk got my hormones going. I knew it wouldnt be long.

In the morning Lori noticed that I had the waddle and complexion of someone being in prelabor. I didnt even tell her the Braxton Hicks contractions were getting regular! She assessed the heart tones and we went about our day. As the contractions were still regular, we made a belly cast. Lori showed my sons, William and Scott all her midwife equipment as she set up and demonstrated on stuffed animals. They thought Lori was the coolest. In fact I think her coddling them solidified the two older brothers bond with with their baby brother. All the while us woman still discussed birth, babies, breastfeeding. Interestingly Lori told us several scenarios she wished never to deliver. A footling breech was one of them. Little did she know what lied ahead of her.

 

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Dawn making my belly cast (check back for a finished pictre of the cast.)

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Lori massaging my legs

Throughout the day my doulas questioned if I was even in labor, I seemed so calm. After the cast was done, the contractions were even more convincing. I sat on the birth ball as Dawn massaged my back. After I changed positions to the rocking chair Lori massaged my feet and calves, emphasizing the uterine pressure points. My husband came home from work finally and he questioned if the labor was real. We were all too peaceful. I was not out of control. I was still able to laugh at our womanly humor or things my boys were doing. Lori also told him jokingly "We do not need a doctor to diagnosis labor," sensing he thought we did, "the signs are unmistakable." I thought back to the labor and delivery suite. I thought that the fetal heart rate monitor sounding like horses racing. In training those monitors always got my own heart going and my adrenaline flowing. Those monitors may prove "labor," but I knew I could not labor naturally with the distraction of the monitor noise in the background. I still also felt like joking and told my husband he could be reassured I am in labor since I am no longer at the computer or on the phone with my other long-distance doulas Bernadette and Karen who could not be present.

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We had spoke earlier of positions that I might feel comfortable laboring in. I visualized squatting or sitting. These positions did not seem right to me now. After the foot massage I tried lying in bed just to get some rest. At a certain point it seemed natural to sit on the side of the bed with my feet propped on the bed stool and the doulas on either side of me providing comforting touch. This intuitive position turned out to be critical as Lori would need me on my back with my bottom at the edge of the bed to safely deliver my son. I kept listening for signs that my body was reaching transition. (I see now I was not going to experience this phase.) I was visualizing the babys head coming down, my cervix opening and the kind of sensations I would have in my perineum. I did not have that familiar feel from my previous pregnancies. I felt like reaching down to my perineum and reaching inside of me to see if I could feel a babys head, but I did not reach down. I also wanted to ask if they see a head, but I did not. I thought it would be discouraging if they told me, "No." I just kept visualizing that the head was crowning. That is when William announced, "Its toes!"

My midwife remained in total control as she adjusted her plan and safely delivered David. She observed his black and blue legs. Not sure if it was cyanosis she immediately delivered to him three puffs of mouth to mouth resuscitation as a precaution. He pinked and she placed him on my chest. The first thing I looked for was his ears and spine to eliminate any concern over Down's Syndrome and Spina Bifida. I had an abnormal triple screen earlier in my pregnancy. I opted not to have an ultrasound or alpha fetal protein knowing I wanted this baby no matter what. The moment I finally anticipated to see if this test was right or wrong had come. Seeing he was healthy, I felt a major relief and I am not sure I had yet processed how close to death this little one had just been. I am assuming few midwives or physicians could skillfully deliver a footling breech without complications: broken arm, palsy, cord compression or prolapse, still born, etc... All we had was two bruised legs and a cephalohematoma. I did discover an unexpected advantage of breech birth-- we had two wide open, big brown eyes, not swollen in from his breech position-- just as curious to meet us as we to meet him.

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I wondered if I tore. Lori delayed checking and let us celebrate before examining my perineum. This intentional postponement I never gave a thought about because in my residency training, we examined the cervix and perineum right away. The thought was, "While the mothers are admiring their babies, they won't notice the cervix exam as much." What a way to foster bonding and initiate nursing. Having now experienced three vaginal deliveries, that exam was almost the worst part of giving birth. John got to cut the cord. His official toast was, " I am not sure if William and Scotts umbilical cord were ever cut, so I am going to make sure David's cord is." Lori also weighed him in our presence. Unbelievably he weighed even nine pounds, exactly what William and Scott both weighed. After all this, Lori checked my perineum. It was intact. No stitches required after this breech birth.

I did have to call the other midwife soon and tell her I delivered. I felt greatly challenged to do this with positive closure. I called the next morning and told her I had a healthy baby boy the night before and she did not need to "be on call for me." I am sure she was speechless, but what did she think when I told her he was a double footling breech. She probably was thankful she was not there.

So many thoughts about this birth flowed through my mind. First, when many people think about homebirth they think how dangerous. I was thinking the opposite; how traumatic it would have been for my family if we were in the hospital, I would be knifed open and have a different set of birth memories and long healing process. Personally, my very first reaction to homebirth was not about safety but about the mess and who would clean it up. Many reassured me homebirth was much cleaner.

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The doulas told me that they clean the mess and start the laundry before they go. Ironically, my birth being a breech was particularly messy especially with meconium squirting out as his abdomen was compressed through the birth canal. My doulas and midwife were there to clean it up as I bonded. As I announced the news to others the next day, I was also noticing that they dont even realize or appreciate the skill my midwife demonstrated as she delivered him. Many just thought a " A breech how different." My other thoughts were about how lucky I was to have had three birth providers in my home for over five nights to focus on me. It was amazing that their schedules all worked out, their other clients delivered early, and their families allowed them to come. I never heard of a midwife willing to travel so far and sleep in a child's top bunk not even knowing when labor might occur. These five days were like a modern day Red Tent, a place where woman celebrate the cycles of life while sharing secrets and friendship.

I am truly amazed at how this all worked out. I may never understand how and why it did but I can say that I am proud to have delivered my double footling breech baby in the safety of my own bed on September 12th around 11:10 p.m. and I am entitled to all the bragging rights that goes along with it. May David Stuart Coquelet go through life always landing on his feet first.

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My Midwife's Story

Labor had been going very well. Blood pressures were normal and fetal heart tones were good through uterine contractions without decelerations. We were all relaxed and confident. At Denise's request, I had not done any vaginal exams but the emotional and physical sign posts were unmistakable. Denise arched her back and moaned with a deep guttural sound. At the peak of the contraction was a subtle catch in her voice, she was almost ready to push. I put on my gloves and waited. The next contraction swelled and with it came the moment we had been waiting for all day long: stage two, pushing. The baby was almost here. We were all encircled at the foot of the bed, excitedly watching her perineum, waiting for the door to open like family and friends waiting in the darkness at a surprise party only we were the ones to be surprised.

"Something's coming out," Denise moaned, as she tilted her pelvis forward. I dipped my fingers in the oil, ready to perform the familiar perineal massage, that eased the baby's head out without tears, but as the door opened I did not see the dark curly hair that we all anticipated. What came instead were two purple feet with ten perfect little toes. My eyes opened wide as adrenaline surged through my system. I did not speak immediately intending to keep the family calm, but William, Denises watchful six-year old son cried out "It's toes!" About a hundred things ran through my mind at once. How could this have been missed? I had my hands on her belly all that day. Well this makes sense now; heart tones had been difficult to get throughout the day. I had thought, "How could this baby still be shifting from one side of the uterus to the other so frequently?" I immediately assessed the situation and mentally ran through her history: the size of her other babies, how long had she pushed, previous complications (especially shoulder dystocia). I knew that her last baby, a nine pound baby came quickly. She had a good history.

I delivered plenty of breeches, but I knew ahead of time if the baby was Complete or Frank. After all, I had access to technology. Ultrasounds were a must, if I was unsure of a baby's position. As homebirth midwives, we always had to be ready for the unexpected. I had said that very day to Denise and her doulas that I would not deliver a planned footling breech. Just too many risks both medically and politically. I guess God had other plans and traveled me 600 miles to learn another humbling lesson. Thank God, I had two wonderful and experienced doulas at my side.

With the tiny feet's emergence, I took a breath, centered my mind and heart and prayed. My hands knew the way. I could feel the tension behind me. I attempted to set this two-physician family at ease. "Look," I exclaimed, as I waited for another contraction, "The baby is ticklish!" I ran my finger down his foot. He wiggled his little toes. William standing at my side, with his camera in hand grinned and touched the baby's foot and then took a picture of the tiny purple feet.

I knew all of the risks at hand, but management of this footling went perfectly. I went into autopilot. There was no prolapse of the cord (one of the fatal complications of a footling breech); fetal heart tones were perfect in the 150's. Next, the baby came to the knees and then the thighs. I could finally reach inside and feel the cervix. It had to be fully dilated to continue. I felt around the top, and then the back. The cervix was out of the way. With the next contraction, the baby delivered to the chest and I eased the cord down. The arms were up over the babys head. I rotated the baby, first to the right and then to the left, as I brought one arm and then the other across the chest and over the perineum. Only the head was still inside and it was deflexed and the mouth out-of-reach. I had to move quickly. The two doulas brought Denise closer to the edge of the bed. Supportively, I dangled the baby down and the occiput came under the pubic bone. I then put my finger in David's mouth to flex the head and then lifted. His face delivered over the intact perineum. David was limp, but I knew this was common with breeches. I quickly brought his tiny mouth to mine, and filled his lungs with three puffs of my air. I felt him tense in my hands. I looked down, he sputtered arched his back, let out a welcome cry and up to mommys tummy he went. Everyone responded with the typical oohs, ahhs, applause, and tears of any birth I had attended. I breathed a sigh of relief and a prayer of thanks. "Welcome sweetie, that was quite a performance," I cooed as I witnessed the naked little boy blush pink.

I remember when my mother, her sisters, and my grandmothers used to talk about breech births. Three of my aunts had had them, and three out of my grandmothers eight children, were breech. They were considered normal then; just a variation of normal. As the days have passed, I am awed at David's journey. I will hang, in my office, the picture of the tiny purple feet standing outside of his warm wet world like a trophy. I am honored that God would bring me 600 miles to gift me with this awesome experience. But, I am also saddened that so few practitioners will ever stand at the foot of a womans bed, and watch with surprise, as two tiny feet emerge over a womans perineum, instead of the anticipated dark curly hair.

Double Footling Breech
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Happy and Healthy!
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At 4 months old!

 
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Denise Punger MD FAAFP IBCLC
4640 S. 25th Street
Ft. Pierce, Florida, 34981
772-466-8884
Copyright 2005