READ ABOUT THE BACKSTORY TO LEVI'S BIRTH IN PART 1 HERE.
READ ABOUT MY CHOLESTASIS DIAGNOSIS IN PART 2 HERE.
Part two left off with a somber diagnosis. But I want this final part to breathe hope into quick and unwanted changes in birth plans — even inductions. I've yet to meet a woman who is excited to be induced. Even if you're post dates and super done being pregnant, induction usually means more pain, more drugs, more risk and a higher likelihood of the whole ordeal ending in surgery. I remember Googling the phrase "positive induction story" and found virtually nothing that fit the bill. As I write this out at a year postpartum, I'm now able to look back and realize that mine was indeed a positive medical induction, and I believe that my chosen birth team and preparatory steps helped get me there.
Preparing for Induction
We had gotten the call from our midwife about my test results about an hour before our big co-ed baby shower (when I was 35w1d). I had that hour to cry and then put the biggest smile on that I could muster — I'm a slow processor and wasn't ready to make it the topic of the party yet. I somehow had the foresight to ask our midwife about the Strep B test, which I hadn't taken yet. I wanted to avoid antibiotics, and I knew that protocol at the hospital was automatic antibiotics if you haven't been tested, so our midwife offered to test me at the birth center right after the baby shower. In just a few days I found out I was negative. I had been diligent in my preparation for this test as well, so this small victory was welcomed.
The Monday of my 35th week, we saw the one perinatologist in town — the 'high risk' guy. His nurse hooked me up to the fetal heart rate monitor for my first of several nonstress tests (NST). She also checked my fluid levels and found them to be excellent — another win! Throughout that final week of my pregnancy, Levi (who still didn't have an official name at the time) and his heart were doing so well. The focal point of my fears began to move away from thoughts of cholestasis and stillbirth and onto the induction process I had come to dread so deeply.
That same Monday prior to his birth I also had to find a doctor to take me on. Rather than going back to the crowded clinic that did our first prenatal appointment, I opted to explore better options. Our midwives' top suggestion was Dr. Melissa Drake. She graciously squeezed us in last minute that day, and I was so relieved at how comfortable I felt around her — she assured us that our 'birth plan' was right up her alley and that our wishes were all within reach.
Between the perinatologist and our new OB, it was also decided that I would be induced that Friday, the day I was to turn 36 weeks, as opposed to 37 weeks, which we had previously been told. The nationally agreed protocol for cholestasis inductions had apparently just changed from 37 to 36 weeks.
Monday was a big day — following all of the appointments and NSTs, we were told to head to the hospital itself that evening for a much longer monitoring session. My husband and I were wedged into a tiny antepartum room in the Labor & Delivery wing at Santa Barbara Cottage Hospital, and my belly was strapped with the fetal heart rate monitors.
That night, after conferring with our midwives and OB, I decided to accept the steroid shot offered to me. If a baby is at risk of being born too early (prior to 37 weeks), giving the mother steroids before the birth can help her unborn baby's lungs develop faster. This reduces the risk of the newborn having serious complications or dying. I was also immediately put on the drug Ursodiol (Ursodeoxycholic acid), even though it wasn't known to cure anything, but rather simply manage the symptoms. [I ended up quitting the Ursodiol the day before my induction because I believed that it was either weakening my immune system or causing side effects that mimicked the common cold. Either way, it was making me feel yucky, and the cons outweighed the pros at that point.]
I had another blood test taken that evening to redo the hepatic function panel and bile acids testing. We briefly chatted with the perinatologist and a few compassionate nurses who all explained that while my new test results were actually quite improved (yay!), you're typically labelled for good with the cholestasis diagnosis once you get it. I had spent the week prior drinking shots of lemon juice and olive oil in the morning, downing detoxifying green juices, supplementing with milk thistle and dandelion root...anything 'pregnancy safe' that might help my liver readjust. And it helped, just not enough. They also checked me that evening, and no one was surprised that my 35w3d cervix was not dilated — even though the monitor was tracking some pretty impressive looking Braxton Hicks (that I wasn't feeling).
The next four days felt very surreal. The bartering phase of my grief was over and I knew we were checking into the hospital that Friday night, like it or not. We met with the student midwife who was with me at almost all my birth center appointments and hired her on to our new birth team as our doula, which brought all sorts of relief. I raced through my 'last month to-do list' in a few days and packed a larger bag for the hospital than I had planned for the birth center. I had bags — BAGS — of food, an army of essential oils, my trusty diffuser, pages of guidance, affirmations, instructions for my husband and nurses (concerning how to use said oils) and a suitcase of comfiness that was going to get me through a potentially lengthy stay at the hospital. [I'll post my packing lists, essential oil guides for birth and hospital food lists in detail soon.] This PinkBlush robe (cheaper on Amazon a the time) was the best decision, as were these comfy sleep/nursing/maternity bras. I also grabbed one of these tiny portable fans in case any waves of sweat and nausea hit during labor at the hospital.
A midwife mentioned that I needed to prepare for a small baby, something I hadn't really considered up until this point, since I had been a larger baby myself. My hope was for him to be at least six pounds. Even still, I scavenged around town for preemie-sized clothing. I also ordered this one by L'ovedBaby and this one by Little Me, as well as this preemie HALO Micro-Fleece SleepSack Swaddle and this preemie SwaddleMe Original Swaddle.)
I also spent those four days trying every possible natural induction method I'd ever heard of. I knew the likelihood of going into spontaneous labor at 35 weeks was slim, but I figured that anything I could do naturally pre-hospital could only help the medical induction go smoother. The week included acupuncture, foot reflexology, massage, chiropractor visits with acupressure, birth prep herbal supplements, rounds of homeopathic pellets, tons of evening primrose oil gel caps wedged inside me, lots of sex, hot baths and red raspberry leaf tea. (I did not ingest castor oil or get an enema.)
The First 24 Hours in the Hospital
We checked into the Labor & Delivery wing Friday at 8pm, the night I turned 36 weeks. It felt eerily anticlimactic, as I was mildly panicking inside while the nurses and staff we met were going about business as usual, which makes sense because, after all, this is their job and they deal with this every day. The night began by getting my hep-lock set up (the IV catheter threaded into a peripheral vein and capped off for later when it's time for Pitocin). It took multiple tries by multiple nurses to get it in successfully, and of course I started blacking out. The rest of the night's agenda included getting acquainted with the wireless (thank the LORD!) fetal heart monitor and taking an Ambien because, yes, apparently it's fine this late in pregnancy and every doctor, nurse and midwife agreed that I'd need it.
My newly found but already greatly loved OB was a huge fan of letting Mother Nature run its course as much as possible. In my case, the very fact that I was there for an induction meant we were tripping M. Nature up quite a bit already. But the plan was to start slow and do the bare minimum to get this labor started. We were in agreement to skip Cytotec*. Instead, at 10pm we began with one dose of Cervidil (Dinoprostone), which is a gel that can be inserted as a suppository intravaginally. It contains prostaglandins to ripen the cervix and encourage labor to start on its own. I was to start with one dose that evening, try to sleep through the night with the Ambien, and then get checked in the morning before the second dose of Cervidil. If things were still at a standstill, my OB was up for trying an older but drug-free technique called the Foley bulb, a catheter balloon that can be used to mechanically dilate the cervix (a small rubber tubing is placed through the cervix and a balloon inside the tubing is inflated just inside the inner edge of the cervix).
That first night in the hospital was not my favorite. Even with the Ambien, I barely slept. The beds in L&D aren't meant for overnight sleeping like the ones in the Postpartum wing are. My husband was in a sleeping bag on the window seat cushions, and a nurse came to check my blood pressure every hour, while also helping me wobble on Ambien with the rolling IV pole to the bathroom several times (trying not to wake David because I'm such a kind and considerate wife).
I had mild contractions on the Cervidil, but nothing to write home about. They were comparable to the bouts of Braxton Hicks I had had throughout my third trimester. By morning we were all wide awake, and I was ready to be checked again around 10am. I had made it to 1cm dilated overnight (while still not very effaced) and was beginning to feel more mild cramping. Everyone seemed pleased with the (albeit small) progress from the first Cervidil, so we did not put a second one in. I moved around the room, squatting and standing in the shower. I ate as much as I could and rubbed Clary Sage essential oil on my ankles.
By noon I was up to 2cm and feeling more tightening about every 2-3 minutes, but it wasn't outrightly painful. The squiggles on the monitor screen made it look more severe than it was. I was tired and bored and uncomfortable. A nurse had swept my membranes around noon when she checked me and was told I was around 40% effaced. The Foley bulb was decided against since the Cervidil had gotten us this far already. I disliked all the checks but knew it was part of the induction game and a necessary evil in order to decide how to proceed.
Our doula's text to my husband after the first Cervidil was removed: "Thats actually pretty impressive! Smart body!" I smiled feebly.
By 3pm I was at 3cm after a short nap and wandering the halls. My OB popped in later that afternoon and we talked about starting me on a small drip of Pitocin that evening. Contractions were far apart but somewhat consistent at that point — and still very, very mild in my "first time mom" opinion. I was talking through them fine, laughing, and walking around predominantly unaffected. After another blood draw I was checked yet again — still 3cm but more effaced. Baby had dropped a bit and by 8:30pm they labelled his position a -1.
"Her body is doing all the normal early labor stuff. That's great!" — another encouraging text from the best doula ever.
The Second 24 Hours in the Hospital
Pitocin was started at 9pm, but at an extremely low dose (0.5 mU/min) — again, hoping Mother Nature would take over quickly! I didn't feel much change, so at 10pm a nurse upped it to 1 mU/min, and then increased it to 2 at 10:45pm, and then 3 later that night. All I remember was Dr. Drake stopping by around midnight, making rounds in a cute black leather jacket, reassuring me that things were going as well as we could have hoped. That night was also not fun, but I was able to stay in bed, propped uncomfortably by hospital pillows and constantly being checked on by nurses who needed blood pressure readings, fetal heart monitor adjustments and my temperature at all hours of the night. By the time the sun was coming up, I was getting nervous that my body would be too fatigued to handle labor well by the time it finally kicked in.
It felt like such a Catch-22 — I was petrified of the Pitocin-induced contractions I knew were coming, but I also knew that they had to get worse in order for the baby to come. I decided to spend Sunday on my feet as much as possible, or at least sitting on a birth ball doing hip rotations. This was my second morning waking up in the hospital, and by this time my chosen OB was out of town so the OB covering her stopped by around 8am to check me and decided to break my water. Everything ran clear so no extra concerns came up. I was still only 3-4cm dilated and 70% effaced. The plan was to take me off Pitocin completely for a few hours to allow me to walk around on the outside veranda at the hospital, eat and rest a bit. I paced and squatted and high-kneed my way all over that hospital wing...but with the Pitocin gone, the contractions simmered down as well. I was frustrated, but thankfully not in any pain.
The on-call OB came back in around noon to assess the situation and restart the Pitocin. His response to my disappointment was the phrase, "This isn't the Labor & Labor wing...it's the Labor & Delivery wing! We've gotta get this baby out!" Not a fan. He started me on 1 mU/min of Pitocin again at 12:30pm and then made a quick jump to 3 at 1:30pm. We spent the afternoon playing cards. I watched a little Felicity on my iPad. I bounced on the ball. I stood in a hot shower and tried to sing the baby down and out. This was the most I had felt contractions so far, but I was still using words like "annoying" and "tight" and "uncomfortable," as opposed to "painful" or "unbearable." A nurse jumped the Pitocin up by 1 every half hour from then on, per protocol.
By 3:45pm I was up to 7 mU/min. The contractions were just starting to feel like what I had imagined contractions to feel like, and according to the monitor, they were up to 2-3 minutes long and less than 4 minutes apart, which surprised the nurse. I was growing weary in my discomfort and focusing a lot more on my breath. Our doula would need a 45-minute heads-up to get to us, and we were told to call her when I felt like it was getting too tough to manage or I was checked and found to be 7cm...whichever came first.
Ground, Toilet, Bed, Baby
Around 4:30pm we were watching the 90s film The Cutting Edge (I have no idea why and I have zero interest in ever finishing it.) Within seconds I went from nonchalantly bouncing on the ball to grasping at the floor on my hands and knees, reeling in pain so deep I was stricken with silence. David's last text to our doula was, "She's on hands and knees to deal with the pain. Gonna get in the tub soon. Probably would be helpful to have you start making your way here."
Ha, the tub. Before induction became my story, I had grand visions of candlelit baths at the birth center as I peacefully breathed my baby into a world of warm water. So once the contractions brought me to the ground, the nurse on duty began filling up the tub with warm water. I barely noticed. And when I finally did notice, I said a firm "NO," although I'm not sure any sound came out. I was dizzy with pain and worried I was going to throw up.
The timeline of the following two hours is incredibly fuzzy in my memory. All of our natural birth and labor tools for pain management went directly out the window. The next 45 minutes was just David, me and our designated nurse. [Side note: We had had so many amazing nurses over our two nights there, but my appointed nurse when I finally went into labor made me feel uneasy — she was obsessed with following protocol at all costs and wasn't understanding. She kept trying to rub my back and get me to move to the bed when all I wanted was her to leave me be and leave the room.]
Our natural birth educator had been all about keeping the mom moving during labor — the dad's role was to get her to sip fluids so she'd have to pee (hydration!), then get her to walk a few feet to the toilet (movement!), and then hang out on the toilet for a while (squatting position!) before repeating it all over again. Well, that's essentially what happened (once) over the next half our before Alissa our doula arrived. The pain was overtaking me on the ground. I felt like everything was happening to me and nothing about the situation felt empowering. I was still wearing disposable underwear from when they had broken my waters that morning. I was hot but couldn't fully take off anything on my upper half because my arm was strapped to the IV pole. I felt like a dog on a leash. I wasn't in control. The peanut ball they had in the room was an awkward shape to try to lay on or lean on or even hold onto when I was on the floor. David tried to help in every possible way he could think of, but the reality was that we were wedged into a corner of the hospital room with the massive IV stand interrupting my every move.
After about 20 minutes of floor time and barely being able to talk or tell David what I needed, I remember muttering something about how I would be okay with looking into an epidural soon. When we were planning on the birth center, I knew epidurals weren't an option, and I was great with that because I knew I could do it (women have done it since the beginning of time) and it would be easier if it just wasn't an option to ask for in the first place. Going into my induction I remember telling David that all the rules of the game had changed. This was already going to be a fairly unnatural labor thanks to the Pit, and I wanted to be gracious with myself as I knew I'd be taking on a much faster and greater volume of pain potentially. My husband knows me well, and although he remembers feeling woozy watching me in such excruciating pain, he knew I was strong and that ultimately I wanted to forgo pain meds. He said Alissa was almost here and we could discuss our options with her. Between that conversation and Alissa's arrival, he helped me hobble into the bathroom, which only further confirmed that there was absolutely no chance I was getting into a tub. So, I sat on the toilet and David squatted facing me.
I truly had over a page of 'things to do to help ease labor pain' printed out, and every, single, one of them was rendered useless in the face of this pain that had gone from 0-60 in a matter of minutes. I only said about three sentences once we were in the bathroom portion of my labor. One of them was, "TURN IT OFF," as soon as my sweet husband started playing soft worship music from his phone (sorry, Kari Jobe, no hard feelings!). The second phrase was something along the lines of, "You need gum." My sense of smell was so powerful throughout labor and anything slightly off started waves of nausea — sorry husband (again, no hard feelings!).
I don't remember ever feeling a distinct 'dropping' sensation, but by the time I was sitting on the toilet, the upper, abdominal-wrapping pain of the initial contractions had focused down lower and was now coming in strong, full-body quakes. I felt helpless as I couldn't figure out whether or not to lean on David, grab his shoulders, wrap my arms around his neck, or get off the toilet altogether. But then the noises started. In past birth stories the primal screams that many women talk about always stood out to me. I was intrigued and a little terrified by them. And now I was feeling these uncontrollable, gut-wrenching sounds roaring out of the deepest parts of my chest cavity. I felt zero control over my own voice — at one point I wondered if I was actually having a seizure. The length of these contracting roars was increasing at the base of each of them I found I was struggling to catch my breath enough before the next one would start. The nurse came in and annoyingly pondered to herself that she had never seen such long contractions back to back like this so fast. Even David, who had obviously never seen a woman in active labor before, witnessed the fact that I could barely breathe in between them.
Alissa arrived (hallelujah!) and became an advocate for getting the Pit turned off since my body was clearly taking over now. The nurse came back in with the blood pressure cuff, which I wouldn't have even noticed had my hand not started to seize mid-contraction. I couldn't move my fingers. I remember David yelling at the nurse to take it off, but once she did, she started wrapping it around my calf because, "I've still got to get a good reading!" I was enraged, but only momentarily because the lion inside me took over again a few seconds later.
At this point no one had checked me since late that morning when I had been 3cm. Alissa (who was fully capable of checking me herself) knew she couldn't because she was technically just my guest in the hospital — but she wanted to. And I wanted her to. Especially after I told them it felt like I was pushing. The nurse was shocked that I already felt like I was pushing, and kind of shoved it aside in a "you're just a first-time mom who doesn't know anything" kind of way. Alissa and David were more concerned that I was indeed pushing, but possibly against a very small cervical dilation, which would be more painful and ultimately futile. The nurse wanted to check me but said she would only do it if I was on the bed, which was a good 15 feet away in the other room (in other words, YEAH RIGHT). Meanwhile, I was still barely able to breathe in between the roaring urges, my whole body shaking with each one.
Alissa brought a wet rag with drops of peppermint oil and draped it over the back of my neck — possibly the only little piece of helpfulness since the contractions had begun. Amidst trying to catch my breath, I finally reached down to see what was actually happening to my body, and I felt something that I was sure was his head. It had all happened so fast, and no one believed I had dilated that much that quickly, but lo and behold I had essentially gone through transition while I was on the toilet without even realizing what stage I was in.
I do not remember walking to the bed. Or getting on it. But they allowed me to lay on my side because I had made it clear previously that I have an old tailbone injury that would make laboring on my back excruciating (thank you, chiropractic doctor Nicole Barry for enlightening me here!). So there we were, my eyes were closed tight while the nurse and doula peered down below and quickly verified that I WAS AT A TEN AND SHOULD PUSH WHEN I FELT LIKE PUSHING!
I would not say I enjoyed pushing (many women claim they do!), but it was my favorite of the three stages for a few reasons. It meant the end was in sight. It was painful, but involved muscle groups that I felt more familiar with and familiarity is comforting. I was more actively participating in progress. For the next ten minutes I pushed only when my body urged me to, with Alissa and David encouraging me along. I remember opening my eyes briefly at one point to suddenly see SO MANY NURSES flooding the room, as well as the on-call doctor casually walk in just in the nick of time. He nudged Alissa on the shoulder and said, "Tap, tap, my turn." #ugh
I still had the nurse from the day trying to get my blood pressure cuff on, while also rubbing the fetal heart monitor over my lower abdomen (yes, as I was pushing) to check on the baby as he exited the birth canal. Alissa was holding one of my legs at one point (bless her). Suddenly there was a bit of franticness as the doctor told me to hold my breath and count as I pushed even though I didn't feel a contraction. [This was something I had NOT wanted to do, and it was in these next moments that I tore some. Later they told me it was because they couldn't find his heartbeat momentarily and the cord was getting wrapped, so they wanted him out faster than I would have liked. I realize this was all for the safety of my baby's life — but I'll always be curious if the outcome would have been even more successful if they had let nature fully take its course.] I remember feeling like I was tearing forward, up toward my stomach, which I had not expected to feel (thankfully I didn't tear that direction at all, but the feeling was powerful and frightening).
And then, after just a few of the instructed pushes, a flush of relief swept over me and he was here and he was well. My first words, post all the screaming, were, "IS HE OKAY?!" Because he was "late preterm" they rushed him to a cart just a few feet away (in my room) to check his lungs and vitals (all with victorious results!). He didn't need any help. Looking back, I'm surprised I wasn't near as sad as I had imagined about not getting that immediate skin-to-skin contact or delayed cord clamping. But those 5-10 minutes following his arrival were so blurred by my intense relief and joy that he was out and he was okay — there were no regrets.
David ended up getting to cut the stump of the cord a little shorter since the doctor had quickly cut it to get his levels checked. David stayed with him all within my line of sight while I remained on the bed and awaited the placenta. My clothes were half-off but trapped on my arm due to the IV tower that still loomed. I was stitched up slowly, but relatively painlessly, and halfway through, Levi was placed on my chest. His eyes were wide open, and his skin was wrinkly. He looked so tiny, but he ended up being over my goal weight! A solid six pounds, three ounces and nineteen inches long. My sweet boy, Levi Caspian Given had arrived.
*Cytotec (generic name: misoprostol) is a drug approved by the FDA for reducing the risk of gastric ulcers, but is often used off-label in pregnancy to induce labor and ripen the cervix despite being classified by the FDA as a Pregnancy Category X drug due to its abortifacient property, meaning the risks of prescribing the drug to pregnant women outweighs the potential benefits (SOURCE).