Samantha thought she would never have a baby; it was something she had never really felt would happen for her. But here she was pregnant and happy. She wanted everything to be natural and to birth at home. She and her partner Derek prepared and dreamed about the birth of their baby. They had started their care with a different practice but soon discovered their wishes for a peaceful homebirth would not be respected. Not only did the practice not attend births at home but the hospital they were affiliated with had a very high rate of cesarean section. She transferred her care to us in her second trimester and her pregnancy proceeded uneventfully. At 41 weeks, her baby had not yet made an appearance and according to our guidelines we began testing to insure all was well with baby and mother. Samantha and her baby passed all testing with flying colors. She would soon reach 42 weeks and that is our cut off for a safe homebirth. We discussed the options with Sam and Derek, she could wait for labor to begin on its own or try a castor oil induction. If her baby had not made an appearance by Monday, the birth would be an induction in the hospital. So on Friday, Samantha agreed to try a castor oil induction. She bravely drank the castor oil shakes four hours apart, and coped with the resulting purging that followed. For awhile after the second dose she was having contractions every five minutes but the contractions slowed and she decided to nap. After a two hour rest Samantha awoke with a stronger contraction, she called out to Dylan as she attempted to rise from the bed and was startled when warm fluid began to pour forth. She was so happy her water was breaking, indeed the baby would make her arrival today.
Dylan called me I asked about the color of the fluid. It was clear. And the baby? Yes, she was moving; not certain about contractions as Sam had just woken up. I instructed them to time contractions for 30 minutes and call me back. I got a call about 20 minutes later and good news: contractions were strong and regular. I inhaled my dinner and headed out.
The evening had become dark and windy and as I drove the 45 minutes to the birth. A brisk rain began to fall. The rain passed quickly and I arrived to find Sam lying naked on her bed with Dylan and her doula, Anna, in attendance. I listened to the baby’s heartbeat: strong and regular. The contractions were strong and coming about every 3-5 minutes. Sam asked me to check her dilatation as she lay on her side in the bed. Her cervix was 3-4 cms dilated and about halfway thinned out – a big change from her exam in the office a few days ago when it was closed. However, her cervix was way off to the right side; this sometimes occurs when the baby’s head is tipped off to the side and can make birth more difficult. I encouraged her to get up and change her position. She bravely rose and began to follow the commands of her laboring body. She swayed and knelt, she sat on the birth ball and then the toilet. She held her partner as her doula rubbed her back. She spoke to god alone….oh god oh god. My assistant arrived and we waited. The baby’s heartbeat was still strong and steady. As the full moon rose, so did Samantha’s cries. Now there was a deepening, a grunting to her sounds. She returned to the toilet and began to spontaneously bear down. I attempted to listen to the baby but the tones were slow, very slow. Wondering if it was mother’s heartbeat, I asked her to return to the bed where I could better listen. Still slow 80…90…another surge and push heart tones 70… her cervix was completely open and the baby was descening rapidly – the probable reason for the decreased heartbeat; normal is 110-160. And it never returned to the 120-130 it had been before. Another push and the baby began to crown 60…70…I knew this baby needed to be born. My assistant had moved the oxygen closer to the bed in the event we would need to resuscitate this little one. “Push hard now, push for your baby,” I encouraged Samantha, as I made a tiny cut to help. One more push and out the baby came. Her eyes were open wide with surprise. Her arms stretched out to her mother as she she gasped and cried out. We all sighed with relief and joy. I told Sam that I was sorry I needed to cut her but I was concerned for the baby. She smiled, looking at the not-so-tiny (she was 9 pounds) girl in her arms. “It’s fine Pam, it’s just fine.”
It is a rare occurrence in our practice that we perform an episiotomy, the small cut to open the women’s vagina, for the birth of the baby. We much prefer to allow her body to stretch and even tear a bit as that usually heals better and is less painful. I have always said the only reason to do an episiotomy is if I think the baby is in distress and that I can get it out faster with the cut. Our episiotomy rate over the past ten years is 2% and in the past year, 1.5%. In my first six years with Midwifery Care Associates I did not perform a single episiotomy. However, I do believe there are times when it is the right decision, and this was one of those times.
We have used castor oil very successfully in our practice for both home and hospital births. It can be useful when the bag of water has broken but labor has not begun. Also, it can jump-start a labor when it has not begun by 41-42 weeks. In our practice we have had a 95% success rate with castor oil to induce labor; 10% of these labors did require additional augmentation with pitocin. The cesarean rate in this group was 5%. It is important that your care provider be aware if you decide to try castor oil as there are instances when it is not safe or appropriate.