To tear or not to tear?

Ask your mother if she had an episiotomy, and chances are good she will say yes. A few decades ago, they were routinely given to all laboring women with the belief that if you cut the perineum you would reduce the chances of a 4th degree tear.

A fourth degree tear is when the tearing goes completely through the perineum, all the way from the vagina to the rectum. It requires a lot of stitches to repair, and causes significant pain in the postpartum period, as well as greater blood loss and a host of problems where excretion (pooping) is concerned. Naturally, this is something that everyone hopes to avoid experiencing, and if cutting the perineum with scissors reduced the severity of tearing, we would not complain about the prevalence of such a procedure.

After nearly 100 years of routine episiotomies being performed on all laboring mothers in the belief that physicians were reducing rates of severe tearing, the first clinical trials on episotomies were conducted. Study after study during the 1980s and 1990s showed  that episiotomies significantly increased the rates of tearing.

The Cochrane Collaboration analyzes data from scientific studies to present the most up-to-date and accurate information about medical research. It’s recent review on several clinical trials show routine episiotomies to be completely unjustified; they are associated with worse rates of tearing. (1)

But what about an episiotomy when a tear is believed to be imminent? If the care provider sees that the tissue in the perineum is blanching and expects it to tear, would it be better if it were cut or if it tore spontaneously? Multiple studies suggest the answer is no, and that an episiotomy increases damage to the perineum, even when it is done in an effort to “save the rectum.” (2) (3) (4)

So how can you prevent tearing? Avoiding an episiotomy or forceps assisted delivery certainly helps. Pushing (spontaneous being preferred over the valsalva “hold your breath” technique) and position of delivery (side lying being one of the best) may also play a role. But I’m convinced that one of the biggest factors is speed of delivery.

There have been a couple studies showing lower rates of tearing associated with delivering the baby’s head in between contractions rather that during a contraction. (5) This is a common practice among midwives, but rarely seen with obstetricians.

Not surprisingly, the studies I saw of midwife attended births had dramatically lower rates of third and fourth degree tears than surveys of births attended by OBGYNs. For example, a study of 1,211 women delivered by midwives showed only 14 women with third or fourth degree tears (6). Another large study where most births were attended by midwives showed only 0.25% (96 out of 38,252) women experienced severe tearing.(7) Most studies that I saw with obstetricians attending the deliveries had higher rates of tearing. The highest one I saw reported that 7.4% of the women experienced 3rd or 4th degree lacerations.(8)

I have a friend who has 5 children and has experienced fourth degree tears with two of her deliveries. She gave me permission to share her stories here, and I think her births are a vivid example of how strongly speed of delivery influences tearing.

Brandy obviously has an amazing pelvis that has no trouble birthing a baby. Here are brief snapshots of her births:

Baby 1:

Went to the hospital because her water broke. Didn’t feel contractions and was assumed to be in early labor until transition, which happened very quickly. Told the nurse (who hadn’t checked her yet)  that she needed to push and the nurse didn’t believe her. She pushed with the next contraction, and there was panic and commotion as the nurse went to get the midwife and they tried to get a tracing on the baby’s heart rate. Since they couldn’t find a heart beat they were yelling to push, push, PUSH! And Brandy did: with the next two contractions (and in between them) she pushed with all she had and the baby came out like a football, super fast. Brandy had broken blood vessels all over her face and upper body from the strain of pushing, as well as a fourth degree tear all the way through to the rectum. The stitching, blood loss, and postpartum pain in the perineum were much worse than the delivery and took a long time to heal.

Baby 2:

After such a quick first delivery there was some concern that she wouldn’t be able to make it to the hospital with this baby. At 41 weeks a vaginal exam showed some dilation and Brandy was told to come in with the next contractions she felt. She did, and the midwife broke her water at 4 cm, Brandy had a few hours of regular more intense contractions. Then she was tired and laid down to rest. The contractions stopped. The midwife checked her and found her fully dilated. “You’re 10 cm.” She said “Let me know when you feel another contraction and I’ll come back” and then the midwife left the room. (!!!) Suddenly, there was an intense contraction and Brandy was pushing (“It was like vomiting the opposite direction- there was no stopping it”). Her husband ran to the hallway to call for help, and when he returned the baby was delivering and Brandy was panicking because she was alone. She was laying on her back with her feet resting on the bed. The baby was out in two pushes. The midwife barely made it back in time. The baby had her hand up and her hand was born with her head. There was a mild second degree tear.

Baby 3:

This one was a planned homebirth. She called the midwife when she had painful contractions 7 to 10 minutes apart. (Nearly a week prior to this she had several days with non-painful contractions and had dilated to 3 cm). She thought maybe she needed to empty her bladder. She sat on the toilet for a few minutes and tried to pee, and then realized that the effort to pee was actually pushing the baby down. The next contraction she tried her best not to push and called to her husband “I need you now!” He came in and saw that the baby’s head was crowning. Her water broke then, and her husband said “We need to get you to the bed.” In between contractions he helped her stand up, and just the act of standing up was enough to push the baby out. They both caught the baby in their hands and wrapped her in a towel. This baby was born just about as quickly as the first two, but Brandy was trying very hard not to push so that she didn’t birth the baby into the toilet, and she delivered in between contractions. There was no tearing.

Baby 4:

This one is back at the hospital and induced with cytotec because Brandy was having frequent non painful contractions and starting to dilate. Had 8 hours of labor with sharp pains, then her water was broken. Shortly after the amniotomy she felt that she was completely dilated. She was directed to get into the standard hospital position, being partly reclined on her back with her knees bent and legs held up. The Doctor said “You can push now” and her husband said sternly: “She will do whatever she feels she needs to do.” Nurse and doctor did not offer further directions or instructions and Brandy breathed the baby out much like she had with her third, pushing as little as she could. She had a second degree tear requiring several stitches but it healed well.

Baby 5:

This one at the same hospital and with the same doctor as their 4th baby. Baby induced two days after due date with pitocin drip. The water was broken when she was about 4 cm dilated. The doctor stayed in the room for about and hour and a half, and when she was nearly completely dilated he said she could push if she wanted. She felt some pressure to push since the Dr. suggested it and the nurse got her into the default delivery position laying on her back with her knees held up high on either side. She was then told to push and pushed with the first contraction, then realized that it did not feel good to push like that.  She tried to breath normally and pretend she wasn’t having a contraction when the next one came. She felt a little nervous and scared and she wasn’t sure if it was okay that she hadn’t pushed during that second contraction. The third contraction came and Brandy was again told to push. She did, and the baby came out very quickly. She had a complete fourth degree tear again and it didn’t heal well. At 3 weeks post-partum she had to go into surgery and have the stitching redone because a hole had opened up between the vagina and rectum above the perineum. She had 4 months of incredibly limited mobility: she couldn’t take long strides when walking, going up or down stairs was difficult. It over a year before things healed completely so that she could have a bowel movement without intense pain.

In these 5 births, none of the babies were macroscopic (too large), none were posterior. Forceps were not used and episiotomies were not cut. Brandy obviously had a pelvis that birthed babies easily, and the key was to not push them out too quickly. The largest baby (8 pounds 8 ounces) was the third baby delivered at home with no tearing.

(And for you first time moms out there who are reading this: don’t worry; it is very rare for someone to deliver babies this quickly.)

It’s so worthwhile to talk to your nurse and Dr. about preventing tearing when you are in labor. Warm compresses and perineal massage have not been shown to reduce rates of tearing (6), but you might as well try them. They will certainly not cause worse tearing like the episiotomy, and they may serve the important function of reminding those attending the birth that preventing a tear is important to you.

Hopefully, they will be paying attention to how quickly the head is descending and once the head is crowning they will tell you and help you to push gently with contractions (or not at all if possible) and deliver the head slowly in between contractions. If you do not have any medication you may feel a “ring of fire” as the head crowns, which is your body’s way of telling you not to push.

Too often the cure (stitches) is preferred over the prevention (a gentle and slow delivery). But I think most care providers are happy to help you achieve this if you ask for it and remind them (and of course if the baby’s heart tones are reassuring).

(1) Carroli G. Belizan J. Episiotomy for vaginal birth. Cochrane Database Syst. Rev. 2000;(2):CDOOOO81.

(2) Dannecker C. et al. April 2004 Episiotomy and Perineal Tears Presumed to be Imminent: The Influence on the Urethral Pressure Profile, Analmanometric, and Other Pelvic Floor Findings-Follow-up Study of a Randomized, Controlled Trial. Acta Obstetricia et Gynecologica Scandinavica Vol 83, Issue 4, p 364-368

(3) DiPiazza et al. June 2006. Risk Factors for Anal Sphincter Tear in Multiparas. Obstetrics and Gynecology; Vol 107, Issue 6, p 1233-1237.

(4) Clemons et al. May 2005. Decreased anal sphincter lacerations associated with restrictive episiotomy use. American Journal of Obstetrics and Gynecology. 192(5):1620-5.

(5) May 2007. Albers et al. Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth. Journal of Midwifery and Women’s Health. Volume 52, Issue 3, p 246-253

(6) Leah et al. Dec 2010. Midwifery Care Measures in the Second Stage of Labor and Reduction of Genital Tract Tauma at Birth: A Randomized Trial. Journal of Midwifery and Women’s Health. Vol 50, Issue 5 p 365-372

(7) Groutz et al. April 2011. Third-and fourth-degree perineal tears: pervalence and risk factors in the third millennium. American Journal of Obstetrics and Gynecology. Vol 404 Issue 4. Pages 347

(8) Dandolu et al. 2005 Risk factors for obstetrical anal sphincter lacerations. International Urogynecology Journal.Vol 16, no 4, 304-307

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My second birth

Our second baby was was born early on a Monday morning, sometime after 2:00 a.m. We’re not exactly sure of the time because she came at home and looking at the clock was low down on the priority list. But I did happen to notice that the placenta was delivered at 2:25.

I had “false” or prodromal labor nearly every day for an entire week before she was born. When I had contractions they would usually last for several hours and stop after I ate something. Five days before she was born I was checked and declared to be 3 cm dilated and moderately effaced. The day before her birth I thought we were getting very close, and I should have trusted my instinct. I had an abrupt mood change and could only handle the contractions if I was in certain positions: leaning forward, standing, on my hands and knees. Sitting down or laying down were intolerable. I had a slight urge to push with a few of the contractions. I told Serge I thought it felt like transition.

I second guessed myself because I thought transition was supposed to be harder- the contractions just didn’t hurt enough. And I didn’t think it would be possible for my labor to stall in transition. So when the 3 hours of contractions every 5 minutes slowed down and then stopped I told myself that maybe this was still early labor. Maybe I was going to be in labor every day for another week before our baby was born. Maybe I was going to be pregnant forever.

Here’s a picture of me taken that Sunday, the day before our unplanned homebirth:I was reluctant to go to the hospital because I was GBS positive and I had declined the antibiotics. I wanted my water to break as late as possible and wanted as few interventions as possible. In hindsight I can see that I had some significant anxiety about the hospital and how I would be treated there.

After that last round of more intense labor Sunday afternoon I was tired and grumpy and just wanted to take a nap, eat a good meal, and wallow in a little self pity. I did all three and before going to bed we discussed the plan for the upcoming day. Serge had a final exam first thing in the morning. Hopefully the baby wouldn’t be born during his final. We agreed that if I woke up with contractions I would eat something and see if they went away. I wanted Serge to get as much sleep as he could.

Sure enough, I woke up around 1 a.m. with a really decent contraction. I got out of bed quietly and went right downstairs to eat. After a bowl of ceral with milk and a few cups of strawberries I went to the bathroom and then I woke up my sister. I asked her to put on a movie. So far I had only had two contractions, but they had really surprised me with how intense they were. I felt a little in awe of how powerful and strong they were. At 1:31 I wrote a note in my journal and decided I should time the next few contractions while I tried to relax:

1:34 a.m., 20 seconds; 1:42 a.m., 56 seconds; 1:49 a.m., 20 seconds; 1:51 a.m., 43
seconds; 1:53 a.m., 34 seconds; 1:55 a.m., 55 seconds. (So that was 8 min apart, then 7, then 2 min apart, 2 min apart, 2 min apart!)

With that last contraction I realized that this had to be the real deal, and what was I doing writing down how far apart they were when we had to get to the hospital pronto!!!  So I gave orders to wake up Serge and grab the bags and fetch the babysitter for our oldest child, who was asleep upstairs.

While my sister woke up Serge I made phone calls. Soon we got a call back from the midwife. I told her we were coming in and she said she’d have a nurse check me when we got to the hospital. “A nurse?” I said, “When are you going to be there?” She said it would take her a little over a half hour and I told her I thought she had better hurry because the baby was going to be coming soon. When I announced to our doula (who was also our next door neighbor) that this time it was for real she asked how I was feeling and I said: “Great when I’m not having a contraction”.

Then there was a bit of a hustle and bustle as I got changed into a bathrobe and we got things squared away to leave. I was standing at the bottom of the stairs when our doula came in and I’d just started into a contraction. I looked at her and focused on her face and on feeling support and encouragement from her. She was breathing with me and it was very nice to have her there.

I was walking through our kitchen on my way to our car when I had a powerful contraction with quite the urge to push, and my water broke (slight trickle). I reached my hand down and I could feel the baby’s head only an inch or two away from crowning. So I announced to Serge that we could either have the baby in the car, or at home, and that I was not getting in the car.

I walked into the living room and knelt down in front of the couch, and the next several contractions (and birth) were done with me kneeling over our couch (sort of a modified hands and knees position- it just felt best at the time).

Our doula said “call an ambulance” and Serge and I in unison said “No. DON’T make any phone calls”. **(Note: I do not recommend this or defend it, I’m just telling you what happened.) I said that my sister had better have the camera and be filming, told our doula to put some towels in the drier, and asked Serge to try and support the perineum and apply counter pressure.

The head crowned and during those few contractions I had a little debate about pushing: I knew that if I could avoid pushing during the contraction that we could ease the head out more slowly and avoid a tear. On the other hand, I sure felt like I wanted to push, and what were a few stitches compared to having the baby out?

During the contraction when the baby was born I said “I need to push!” and suddenly went to a more upright position. Serge said “the baby!” and he and our doula both helped to ease the baby to the floor. The baby came out really quickly, from the head crowning to being delivered to her waist occurred in about 2 seconds. She was as pink as could be and crying before her legs were delivered.I’ve seen a couple dozen births in birthing videos, and (at the time of this writing) a half dozen births in real life, and I have never seen a baby born as pink and vocal as our little baby was.

I turned around and sat down, then I picked up our little one and Serge laid some towels over her so she wouldn’t get cold. She was super pink and breathing really well. As soon as she was covered and next to me she stopped crying.Since the baby was looking great and I felt so good I just wanted to stay put until the placenta came on it’s own. Serge asked if I wanted anything, and I said: “Yes! A smoothy!” I was SO hungry! I ate a smoothy and two bowls of soup. Our midwife called and asked if we were coming, we said we’d be on our way soon but we’d already had the baby. About 10 minutes after the delivery our baby started opening her mouth and rooting. I helped her out and she latched right on and started to nurse.

The placenta flopped out on it’s own about 10 minutes after the birth. Our doula said I gave a little grunt and looked like I pushed just before it came out, but I don’t remember feeling anything. We caught it in one of our soup pots.  Serge and my sister linked arms underneath me to carry me to the car. I held the baby, our doula held the soup pot with the placenta, and another neighbor opened doors as our funny-looking procession made it’s way out to the car.

I did have a tear along where I had torn with my first. But it was superficial and less severe than the second degree tear I had with my first delivery. The midwife said that it was almost all in the skin and only needed a couple stitches in the muscle tissue. Our baby was detached from her placenta while I was stitched up, and the nurses commented that she looked a little shaky and they wondered if her blood sugar was low. At the same time our midwife told me that I was bleeding a little more than she liked and she wanted to give me a shot of pitocin if that was okay with me. I asked if I could hold our baby and try nursing first and she said sure. Our little one latched on well and nursed for a whole 45 minutes. That took care of the bleeding for me and any blood sugar issue for her. Hurray for nursing!

A few days after she was born I was watching the video of her delivery and realized that she was probably delievered posterior. I say probably because as the head is crowning the view wobbles over to our book case and a second later when it’s back she is delivered past her shoulders. If she were delivered anterior then she would have had to turn nearly 180 degrees as soon as her shoulders were delivered, which is possible but I think highly unlikely. The posterior position also explains the bizarre labor pattern, and our second baby also had a case of torticolis: the muscles on one side of her neck were less developed from her favoring a certain position in the womb. So perhaps she really was somehow stuck in a posterior presentation during that week before her delivery?See how skinny and smaller the left side of her neck looks compared to her right side when she was 4 days old? The pediatrician said she might need physical therapy, but by the two week appointment he wasn’t sure which side had been affected; it corrected itself quickly.

We stayed at the hospital for 48 hours after the birth to monitor the baby in case of GBS. The pediatrician had recommended that our baby be given antibiotics by IV but I requested that she be given IM shots instead. He agreed and she received two doses of Ampicillin and Gentamicin during our stay. Blood had been drawn for a culture and when it was still negative 40+ hours after the birth we were clear to return home.

I enjoyed our hospital stay, mostly because the food was wonderful and they brought me second and third helpings of whatever I requested. I thought the nurses were great but I had the sense that our pediatrician was a little perturbed with my attitude (I don’t think he was very comfortable with me declining the antibiotics routinely given to women who test positive for Group B Strep). Since this experience I’ve made a point to ask all the pediatricians I can about their opinions on how a GBS+ mom and newborn should be treated if the mom declines antibiotics or just doesn’t have time to get the antibiotics during labor. I’ve found that opinions vary WIDELY.

Back to our second birth….

In telling our birth story the thing that everyone can’t believe is the location. It was kind of  nice to have her at home. It definitely added a bit of additional excitement to the whole experience. And I loved the fact that I could eat so much immediately after the birth. But for me the most important parts of the birth were the support I had and how calm and peaceful I felt during the whole experience. And that could have been just the same at the hospital.

I had the most incredible feeling of joy after she was born. Not more than a few minutes after the birth I thought to myself “I can’t wait to do that again!” and I started wondering if I could convince Serge to try to get pregnant in three months so we could have another baby in the Spring of the following year. When I asked him what he thought about another baby in a year he told me I was completely crazy, and 4 weeks later when I was a sleep deprived post-partum wreck I thought that idea was crazy too.

But that gives you an idea of just how great the birth experience of our second child was. If I could choose a day to repeat over and over again like in the movie “Groundhog Day”, it would be her birth. Of course labor was intense and painful, but the physical sensations had a purpose and the powerful instinct was awesome and amazing to experience. I think part of the reason that I felt her birth was so wonderful was that I was so well rested. I had eaten a good meal and slept for 4 hours before I woke up for that last round of approximately 15 contractions before she was born. (Our sweet second daughter at 7 weeks)

So with my second labor and delivery being one of the highlights of my life, I was definitely looking forward to experiencing birth again. I thought my body was made to have babies and had such grand plans for the next birth. Sometimes when you get a little too puffed up life teaches you a lesson, and my third pregnancy was quite the learning experience.

My first birth

When we were pregnant with our first baby I was determined to have a birth with as few interventions as possible. In particular, I did NOT want an epidural.  My husband and I took two birthing classes (one was hypnobirthing, one was a general childbirth education series) and I read a half dozen books about birth. We hired a doula.

I first heard the word “doula” when I was a teenager and a neighbor told me that her first birth had ended in a cesarean and the OB had told her that she could never have a vaginal birth: her pelvis was too small and narrow. She hired a doula (who was also a midwife) for her second birth and after many hours of labor at home she had a successful VBAC at the local hospital. She thought the doula made a world of difference. Right then and there I decided that when I had a baby, I would have a doula.

I had my 37 week appointment on a Friday afternoon and was checked for the first time, I was 3 cm and 70% effaced. After the appointment I had some bleeding. I was concerned and called our Doula; she said it was common to have bleeding after a vaginal exam, and the mucos plug could have been dislodged, so I shouldn’t worry too much. A few hours later my husband and I went to a church activity and played “water balloon volleyball.” I didn’t feel well and didn’t want to play, and on the way home (a two block walk) I complained that I was so tired and disappointed that a short excursion like this would be so exhausting. I wanted soup. My better half dutifully fetched some from the grocery store; 4 cans because he wasn’t sure what would sound best. I surprised us both by eating 3 cans in one sitting. I was hungry!

At 10:00 p.m. we had just knelt down to say our evening prayers when I announced: “Either my water just broke or I wet my pants!” A few minutes of waiting and watching and we determined that it had to be the former: there was no odor or color to the fluid and it kept coming out in little dribbles every few minutes. We called our doula, hoping she would say “It’s fine to labor at home for a few hours” but she confirmed that the hospital was where we were supposed to go. I was nervous because I hadn’t felt anything and I knew I would be looking at some interventions if I didn’t have contractions soon.

My husband gave me a blessing, we said a prayer, and after a shower and eating and drinking one more time we were on our way.Check in was at 11:30 p.m. I was declared 4 cm and 90% effaced and told that our Dr. estimated quite generously, so progress had indeed been made since the previous exam 9 hours ago. We were strapped to the monitors and Serge read some relaxation scripts and we tried to get a little rest, but I was too excited to sleep.The nurse told us that by 4:30 a.m. I would need pitocin and an antibiotic if things hadn’t progressed enough, so I was praying for contractions. The monitor showed I was having irregular contractions, although I wasn’t feeling anything. I had asked our Dr. if I could labor without an IV, and he assured me it would be no problem. I asked him to write it in my chart because the doula said that 2 liters of saline were routinely given to all laboring women at this hospital. He chucked and scribbled a note and said it would be no problem.

I explained to the nurse my strong desire not to have an IV (chemotherapy caused me to have intense nausea associated with fluids by IV), she smiled and said that would be no problem and then came back with a pole in hand and said “we’ll just give you a few liters.”

Again I told her I didn’t want the IV. She said she’d call the Dr. She returned shortly and said that the Dr. had told her to give me a few liters of fluid. I got down on my knees and pleaded: “I’m more apprehensive about having an IV than I am about experiencing childbirth. Please! Can I do this without the IV? I promise I’m well hydrated!” She called the Dr. again and reported that he said “Give her what she wants.” Phew!

She put in a “heplock”, which was ready access to a vein and then capped off. Even just the couple ml of saline she put in to clear the line made my stomach turn and brought an awful taste to my mouth. I was so grateful not to be required to have a liter of fluid.

Within the next hour I started feeling slight “crampy feelings” that came every 3 to 5 minutes, and then they intensified to a level where I would need to stop talking or moving and focus on breathing through them. Our doula suggested trying several different positions now to see what felt most comfortable. I thought the birthing stool was terrible for contractions (but a few hours later when I was fully dilated I loved it) and preferred standing and hands and knees. The “slow dance” was my favorite. I found the deep breathing I had practiced to be very helpful and was surprised to discover that I did not like having contractions with my eyes closed.

At 2:50 a.m. I was checked and found to be 7 cm and 100% effaced. At 3:00 a.m. I was very thirsty and the half a cup of ice chips that I was allowed was just not cutting it. So I excused myself to the restroom several times and used the urine collection cups (not sterile, but I knew they would be clean) to get drinks from sink faucet. I also snuck a granola bar and felt a lot better after having had a drink and a snack.

At 4:00 a.m. I was 10 cm dilated. They had filled up the Jacuzzi for me but said I was too far dilated to use it, so I got in the shower for about 10 minutes and it felt great.

Our nurse checked me after I was fully dilated to try to estimate when to call our Doctor. She had me lay flat on my back and then push during a contraction while she checked me so that the Dr. could arrive in the ideal “10 to 15 minutes before delivery window.” I felt like I needed all my concentration to do my slow breathing during the contractions, but I still felt like things were doable. It was intense, but I was feeling alright. The contraction on my back was a different story: the pain was so much worse that I felt like I almost lost consciousness.

After declaring me ready to push and calling the Dr. we got set up for delivery: I wanted to be upright, so I was on a birthing stool on top of the bed. The squatting bar was in front of me and at just the right height for me to rest my forehead on it inbetween contractions. This is how we delivered:I had decided that I was not a fan of “purple faced pushing” and I was in favor of “breathing my baby down” rather than pushing him out. The nurse and doctor kept telling me to hold my breath and push, and I ignored them and just kept blowing it out. I tried pushing a couple times for just a half second or so but it didn’t feel good, there was too much pressure when I pushed. Our doula started telling me to push too, getting about 2 inches from my face and telling me to hold my breath. I remember thinking: “Traitor doula!” and I ignored her too. They kept trying to motivate me by telling me that I would be done sooner if I pushed, and I just wanted them to leave me alone. I wasn’t in a hurry.

I thought about telling Serge to tell them what I was thinking because I didn’t feel like talking, but decided that I didn’t even want to say that. I was not in the mood for conversation. When I told Serge this after the delivery he laughed and said he would have had no idea what to say if I’d told him “tell them what I’m thinking. I don’t want to talk right now.” I was surprised that he didn’t know. It took me a few more years to fully appreciate that even though he loved and knew me very well, he could not read my mind.

At 5:10 a.m. our doula held a small mirror so that I could see the head was crowning: there was about a 2 inch circle of the head visible. At the same time the Dr. told me that the baby’s heart rate had dropped to around 60 beats per minute, and he wouldn’t be okay with his heart rate that low for too long, so I needed to get him out. That was motivation for me to push, and so with the next contraction I pushed just like they’d told me to and the head was delivered in less than a second. Then they switched to “Stop! Don’t push anymore!” After the Dr. suctioned his mouth out the shoulders came easily (and with hardly any effort on my part).

I didn’t feel anything during that last contraction when the head was delivered and I felt like I observed it third person; it was an odd sensation to see it but not feel it. They placed our darling son on my stomach and put a heated blanket over him immediately after birth. He was a little dusky colored but pinked up as he took his first few breaths and sneezed. His face was squashed and he was messy and a little odd looking, but I didn’t care at all. I was so full of happiness and had such a strong feeling of love for this little human being in my arms. It was amazing. Although I knew I was pregnant and that this was the end result, it was still a surprise to see him: a real live person, new to the world. What a miracle.The placenta delivered a few minutes later and the Dr. said I’d lost about 250 ml of blood and I had some tearing and he’d like to start a pitocin drip if that was okay with me. I said it was fine. I felt so great at this point I doubted that anything could bother me. The tearing looked to me to be severe: I had split open from the vagina down to the anus and the whole perineum was a ragged mess. The Dr. said it wasn’t too bad, “just second degree”, and I appreciated his optimistic tone, but it took quite a while to stitch up and required a layer or two of stitches in the muscle followed by a layer in the skin. While he was stitching he got outside of the area he had numbed, but the endorphin release from the birth was so powerful that although I could feel the stitching it didn’t hurt.

The doctor showed me the placenta and let me hold it and explained how it worked. I thought it was really cool to see. I was surprised by how small it was: the umbilical cord wasn’t much thicker than my little finger and the placenta was maybe 7 inches in diameter. Our baby was on the smaller side too: 6 pounds 9 ounces.
Then we had an hour of cuddling and trying to figure out nursing before our first born went to the nursery. He never latched on very well and I was a little disgruntled that they took him when they did; I had almost gotten him to nurse and thought that I might have succeeded if we’d had just 10 or 15 more minutes.

When I got out of bed I picked up our bags to walk over to our postpartum room and the nurse and doula laughed and told me I had to get in a wheel chair and that I should take it easy. I felt so good after his birth, like I could’ve run a mile. A week after our son was born we drove by the hospital and as soon as I saw the building I was flooded with a happy joyful feeling “that’s where our darling baby was born.” But in the subsequent year there was a shift: as I retold the story I focused more energy on the few very minor things that hadn’t gone as smoothly: the pressure to have an IV, taking the baby to the nursery before we had successfully nursed.

I complained about these things too much and was developing an anti-hospital attitude. Around this time I re-read what I had written the day after his birth and was surprised by how positive and joyful my story was. At the time I did not really care about the IV and the rocky start to breastfeeding. Having had a healthy baby and having had the birth experience I had hoped for was a joy that completely overcame those hiccups. I made an effort then to recapture that perspective, but the hospital phobia and anxiety that someone was going to interfere in my birth remained and was part of the reason that our second baby was born in our living room.