By Sarah Hood, CPM, APRN, CNM of Home Sweet Home Midwifery
Part of having a small home birth practice means that no two days are ever the same. So, when prompted to write about a day in the life of a home birth midwife, the first challenge was finding the right day. I picked this day because not only does it contain a lovely birth, but it illustrates some of the routine challenges inherent in this work.
It's Thursday evening and my midwifery partner, Tress, is leaving town tomorrow. She has two clients who are both having their first baby, one who is 41+ weeks and one who is 40 weeks. So in addition to 4 of my own clients (41, 40, 39 and 39). I will be on call for these two if they don’t have their babies before she leaves. I’ve been a bit stressed out about all these people who are going to have their babies and hoping they don’t all have them at the same time, but on my drive home from work tonight I calm myself by figuring that probably only 3 people will even have their babies this week. That’s a busy week, but I can handle it. It is supposed to rain tonight, so maybe someone will go into labor, meaning there will be less potential for everyone to go into labor all at once. I think these things even though I know it’s pointless to speculate because birth is so unpredictable.
On Friday morning I wake up and see a text from Tress, it looks like she is at a birth! Yes! I think, let’s get that 41+ client out of the way! I open the text to read the whole thing and see she is with her other client (the one who is 40 weeks). Oh well, I’m happy for her that she is in labor. We stay for at least 2 hours after every birth, so Tress knows if the baby isn’t born soon she will need me to come out as well because today it’s not just babies, she also has a plane to catch. I get myself ready to go, pack snacks in my bag, and put my scrubs on while I am getting my oldest daughter ready for camp. As I am doing her hair she wants to know why I have scrubs on and I tell her I probably have to go to a birth later. She is distressed because she thinks this means I will not make it to her camp performance which is at 5pm today. I tell her I don’t think the birth will take that long and I hope that’s true because I had to miss her last camp performance for a birth. Thankfully we live in the days of video technology, but I do hope I don’t have to miss this one.
I drop her off at camp and return home. About 15 minutes later Tress calls to say labor is going well, but there’s no baby yet and she will need me. I find that the faster I am trying to get out the door, the more likely one of my children will need something. This time my youngest picks this moment to want some food and she wants some popcorn. Because the last bag I made was under-popped and I’m trying to get it right this time, I accidentally burn the microwave popcorn. Like really, really, really burn it. So bad it’s still smoking after a couple minutes and I pour water on it. Now the whole house smells like burnt popcorn and I have set off a minor crisis. In our house we usually just pop kernels, so the microwave popcorn bags are a treat they often bring home from grandma’s house and this means we can’t just pop another one. When the crisis is mostly resolved I get in the car. Then I realize that I smell pretty strongly of burnt popcorn. I go back inside and change my shirt. I still smell like burnt popcorn a little, so I roll the windows down to try and air myself out as I drive.
This client's house is a 30 minute drive on mostly country roads which is always lovely, especially in the daytime. On the way there I put on my watch, which I keep in the car, and I think about the other things happening that day. My 41 week client is having a biophysical profile in about an hour and I need to set up Tress’s 41 week client with a BPP on Monday as well since Tress wasn’t able to do it yesterday. I also have a couple people I need to get back to about times for setting up consultations. This is one of the times I think it would be nice to just be a midwife and not have to do a bunch of other jobs as well. It’s hard because the things I could have an assistant do only amounts to 5-10 hours per month, so it’s not like I can employ a whole other person just for that. We do have someone helping us with admin tasks from time to time, but there’s always going to be things that need to be done quickly that we have to do ourselves. I was given good directions a couple days earlier when I met this client at one of her prenatal visits and I find the house easily. She’s laboring in the tub. Tress says she can leave her stuff and the student with her can take it back to the office, but I prefer to bring m y own kit in so that I know exactly where everything is.
It usually takes me 2 trips to the car to bring in my things. Typically I grab my birth bag and the neonatal resuscitation bag on the first trip. The birth bag has all the emergency medications in it as well as doppler, gloves, flashlights, mirrors and instruments. The neonatal resuscitation bag has all the things for basic neonatal resuscitation. So those 2 bags have everything I need if I walk into a precipitous birth and have to deal with something before I have a chance to make my second trip. Honestly, we never use most of the things in those bags. Usually I only use the doppler, gloves, flashlight, mirror, instruments, newborn stethoscope and the sterilizing wipes. There are also some supplies that mostly stay in the car. I have a box of IV supplies, a birth stool and extras of a lot of things including a change of scrubs. On my second trip I grab my prenatal bag (because it has the blood pressure cuff in it) and the newborn bag which has measuring tapes, scales, thermometer, the oxygen tank (which we very rarely use), and my knitting bag which I also pack with snacks and water.
After get all my stuff in I help Tress sort out a minor knitting snafu and we listen to the baby. Then Tress leaves for her trip. I haven’t worked with this student since she was a newbie and she is in the primary phase now, so it is interesting to see how she has changed, now taking the lead instead of learning how to do things. Labor seems to be going well and we all feel like we will be getting to the pushing part before too long. I generally try not to hover, so I sit at the kitchen table and pull out my yarn. I usually have a knitting project with me, but today it’s a tunisian crochet baby blanket I have just started. It’s nice to have some hand work with you at a birth. One thing I have always done since I started attending births is just listening to someone’s contractions. Your ears and attention can be open even when your hands are busy. You can often tell a lot by listening. In addition to basic frequency and duration, the relative intensity, how well someone is coping, and the spontaneous pushing urge can often be heard.
This woman is vocalizing quite a lot and it’s a little hard to tell if the pushing is really unavoidable or not. There’s also a little something sharp in her vocalizations that makes me think of pain instead of just intensity and she is saying her back is hurting a lot. I wonder if the baby might be a little crooked or something, making labor a little more difficult for her. She feels like the baby is never coming out. I ask her to try and relax during the next contraction and not push to help me figure out if pushing is the right thing to be doing now. She is unable to not push, so that’s a pretty good indication that her body is actually in the pushing phase. We do cervical exams sometimes, but it’s not always needed. She seems to want to be in a squat, which is a hard position to maintain, so we ask if she wants to try the birth stool. My birth stool is actually a tall bamboo squatty potty that a former student got for me. It’s a nice tool to have and many babies have been born on it. It’s sturdy, smooth, easy to wipe down, and most importantly, it fits easily with my other birth supplies in the back of my little hatchback!
When she gets on the birth stool we can tell how low the baby is and after a couple of pushes we can see the top of his little head. Her husband sits behind her and helps her squat onto the birth stool. In between contractions she stands and sways her hips. This change of position and movement is great for labor progress. Every time she pushes we see more and more of the head. We encourage her and eventually the head does not recede between contractions. With the next one we start seeing a lot more head and the whole head is born. The student is delivering the baby, but I’ve got a hand on supporting the perineum because sometimes it’s quite useful to have more than two hands! As the baby's shoulders start to emerge we see a little hand as well, that’s probably what was causing that sharper pain she was having. The rest of his body comes out, he is lifted up to his mom and he starts to cry right away. Hooray!
She wants to get off the birth stool, so I grab some chux pads to put on her bed. As I’m arranging things, she walks over, not even waiting for us to help her, she sure didn’t want to be on that birth stool any longer! This baby has a gloriously thick umbilical cord that is coiled like a telephone cord. After a while, the student helps with delivering the placenta. If all is well at this point, we usually leave the family to get acquainted for a while, just checking in to make sure there isn’t too much bleeding for the next hour. Her doula fixes her a peanut butter sandwich and some scrambled eggs. It doesn’t sound fancy, but I’m sure it’s one of the best meals she has ever eaten. Back in the kitchen I check my phone and have gotten a text from my 41 week client asking how her BPP looked. I check the report and then call the ultrasound department to get some more specific information they didn’t include. I tell her it looks ok and that I will call her in an hour or so after I am done here. I also call and schedule the BPP for Tress’s client. This is one of my least favorite things to do because the schedulers often don’t know exactly what we are talking about and we have to be put on hold a lot. I also take this time to return an email and a text to folks wanting to set up consultations and to text my husband to tell him the baby is here and I should be home in time to make it to our daughter’s 5pm performance.
Often babies will latch on during this first hour, but this one really doesn’t seem interested. We go ahead and do the newborn exam, sometimes that will irritate them a bit and they might be interested in nursing afterwards. At the newborn exam we do a full head-to-toe exam, checking their reflexes, listening to their heart and lungs, looking for birthmarks and any obvious anomalies. We also measure them and check their weight, which is everyone’s favorite part. This baby weighed 9# 8oz! The activity must have awoken his nursing instinct because he latches on after we are done.
We also have to look and see if the mom had any tears during the birth. She did, which is not surprising considering he had that nuchal hand. They are substantial enough that stitches are needed and we have lidocaine, suture, and instruments for this. After that’s done we review her postpartum instructions, check some vitals, and leave. She knows that she can call me if she has any concerns and that I will be back in 2 days to see her again and to do the newborn metabolic screen, CCHD screening, and hearing screening. I also check in with families 12-24 hours after the birth via text just to make sure everything is going alright and that the baby has been nursing.
I get into my car at 4:20pm and my daughter’s show is 45 minutes away. I call my husband to tell him I will just have to meet them there. Then I call my 41 week client and talk to her about her BPP. She is eager to get labor started, and it sounds like she lost some of her mucous plug today. If she doesn’t go into labor tonight I plan to meet her at the office tomorrow morning to do an NST and to try and sweep her membranes. She plans to take castor oil after that and hopes the combination will get things moving. It’s rush hour, but I manage to dodge the worst roads and I only miss the first number of the show. Afterwards, my daughter wants to go out for ice cream as a treat so we go to a local ice cream shop even though it is then that the rain starts to pour down again. When we get home the house still smells a little like burnt popcorn.
While I am making dinner I get a text from Tress’s 41+ week client. She has been having contractions every 20 minutes. I give her my standard early labor recommendation of eating and trying to sleep if she can. I hope she does go into labor tonight and I tell her I’m going to bed early so I will be well rested when she calls.
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