Chris Rael CHURCH OF BETTY

THE BIRTH OF ALEX: Home, Hospital, and Bringing It All Together at St. Vincent’s

By Chris Rael, Brooklyn NY, Valentine’s Day 2010

Alexander "Sasha" Rael

When Vlada became pregnant with my son Alexander, she wanted to give birth at home. I hadn’t thought much about such things, but intuitively I was all for it. A 39-year-old woman having her first child is a higher risk candidate for home birth, but Vlada was exceedingly fit and constitutionally positive. She enjoyed a near ideal pregnancy. Every exam, every test indicated a healthy mother and baby. She had no morning sickness. Other than bouts of inevitable fatigue, she felt energetic enough to pursue her usual activities. She looked great – tall, lean, athletic with a basketball tummy.

All I needed to get on board with home birth was confidence that a sensible plan B was in place. We started by enlisting an experienced, no-nonsense midwife. I felt instinctive trust and professional respect for Joan. She was compassionate but direct, in command of her craft. I knew she wouldn’t hesitate to make the call should medical intervention become necessary.

Vlada and I didn’t know each other well when Alex was conceived. The pregnancy was a period of faith and discovery, romantic and supportive. To my astonishment, I didn’t wish for a second that it wasn’t happening. Our happiness cast a radiant veneer on our expectations for a natural delivery.

A former partner of mine questioned our judgment, belittling the choice of home birth at 40 as narcissistic and arrogant. Indeed, many seemed taken aback by our plans. Unfamiliar with these attitudes, I was puzzled by the conceptual resistance. Giving birth is a normal biological process, I figured. If there’s a problem, address it. But why begin in problem mode?

Vlada showed me Abby Epstein’s documentary The Business of Being Born, a scathing critique of the American birth industry. In keeping with my own insider perspective on the business of healthcare, I easily recognized the depicted trends motivated by expedience, assembly-line efficiency, and yes, profit. I believed hospital physicians would be quick to medicate and quick to cut, because that’s what they know, what they do, and how they must operate to keep pace with volume. I believed the quality of the mother’s experience, and the emotional introduction of mother and child, would be a decidedly lower priority in the hospital setting.

While my first concern was always their safety, I wanted Vlada to have a chance for the natural experience she wanted, to give birth in comforting, loving surroundings, to be alert and undrugged when receiving Alex into her arms for the first time. Armed with Joan’s experienced eye, our contingency plans, and Vlada’s dazzling health, why not try?

The due date had been estimated in the vicinity of January 15-17. With my birthday on the 16^th, we wondered if father and son might share birthdays. Both Joan and Jamie, our doula, stopped by and declared our home preparations complete. Vlada visited Joan for weekly check-ups. The due date came and went. Alex remained strong. Everyone seemed fine; it was just taking a while.

Two weeks past due approached. No one panicked, but two-weeks-late is a red flag. On Friday the 29^th, a sonogram revealed that Alex remained healthy as an ox. That night, I watched Vlada bravely accept the possibility she may have to relinquish her home birth vision. On Saturday, Joan ‘stripped her membranes’, a cervical procedure that sometimes facilitates labor. Late that night, the contractions started. Perfect! Finally.

“This is great,” I thought. “The contractions will be mild and far apart for hours. We can get some rest before the hard work starts tomorrow.” Which is just what happened. Perfect… Vlada endured contractions all Sunday, but they stayed short and far apart for a long time. We didn’t even call the doula til mid-afternoon. When Jamie arrived, the action started getting more intense. Vlada was in pain. “Perfect,” I thought. “She’s getting there.”

Jamie and I scooted around the apartment filling pools, cleaning utensils, massaging Vlada, timing contractions. They were getting longer and coming closer together. Vlada was truly suffering now. “Perfect”, I thought. “She’s hitting the wall, the moment you read about in the books, where they want to give up just before they deliver. We’re getting there!”

We finally summoned Joan, who examined Vlada at 11:30 Sunday night. She was only 2 centimeters dilated. We were shocked. All that work… Vlada had already labored an unusually long time. We thought she was almost done, when in fact she’d barely started. The decision to go to the hospital was a no brainer. Not surprisingly, Vlada relinquished her vision of a drug-free delivery. Inducement was needed, and pain relief loomed. The four of us piled into two cars for the Birthing Center at St. Vincent’s in Greenwich Village, one of the few hospitals that works cooperatively with midwives. Joan was affiliated there.

Still no panic. I felt confident in the outcome. We wouldn’t be able to do it the way Vlada had hoped, but the medical support would see her through. It was turning out that she was one of the women who legitimately needed it. After her already-long labor, there was a sense of relief for both of us.

We checked into the Birthing Center after midnight on Monday, February 1. It takes a while to get set up. First, she had to be hydrated before they could give her an epidural for pain. What a relief to see her relax in the midst of her arduous battle. They got the pitocin – inducement medication – going as soon as they could. Part of the vision of natural birth is the absence of pitocin, which can induce unnaturally powerful and painful contractions. It is now used routinely in most hospitals, and we didn’t want it used unnecessarily on Vlada. Of course now it was necessary, and we were counting on it.

The doctors at St. V’s were mostly in their 30s. To my 49-year-old eyes they seemed like kids, which was somehow positively energizing. These young professionals exuded competence and confidence, compassion and respect for their patients. Their bedside manner impressed me, as did their recognition of Joan’s credibility. When options were discussed, they did their best to preserve as much of the natural birth process as possible. It seemed to matter to them.

Things wore on unexpectedly. The pitocin worked slowly; Vlada’s dilation was plodding and gradual. Alex remained high in her abdomen. Meanwhile, the doctors became concerned about her body chemistry. Hours went by. Eventually they expressed concern that Vlada may be developing HELLP syndrome: hemolysis, elevated liver enzymes, and low platelet count. If the baby stayed in much longer, her kidneys could shut down or she could have a brain seizure.

“Well, let’s get him out,” I said. But it wasn’t that simple: C-section is high risk for women with HELLP syndrome; blood doesn’t clot normally. The doctors’ concern was palpable. The last thing they wanted to do was cut her. But Alex couldn’t stay inside much longer. When they broke her water, meconium – Alex’s prenatal waste – was found in the fluid. His overstay in the womb had him swallowing and breathing the same toxins that were endangering Vlada.

Remarkably, the doctors then turned back to Joan, the midwife. “We need you to do what you do in order for us to do what we do.” They asked Joan to work with Vlada to push the baby down as far as possible. They didn’t want to cut. If Vlada could push him down enough, the doctors could retrieve Alex by other means, and he could be delivered vaginally. This was the only route to safety for mother and child. The toxicity in Vlada’s system would naturally subside with the successful delivery of Alex.

How’s that for a scenario turning the childbirth conversation on its ear? The medical contingent needed the naturalists and vice versa, and we needed them all. Full cooperation between all caregivers was critical. Joan urgently guided Vlada’s pushing, expertly repositioning her periodically, encouraging her every step of the way. I was at her head and Jamie was at her feet; the nurses were also deeply involved. Vlada worked like a warrior for an hour-and-a-half, sometimes making progress (measured in painstaking millimeters), sometimes not.

The doctors would check in periodically, encouraged to see some progress, but not impressed nearly enough. Finally a deadline was established. Joan had one half-hour more to move Alex down. If he wasn’t down far enough by then, they would have to resort to a high-risk emergency Cesarian. I stepped outside for some air. The labor had been so grueling. I couldn’t comprehend the physical magnitude of Vlada’s task. It seemed he’d never come out. I never stopped believing in them for an instant, but had to face the possibility that either or both of them might not make it. So tired, so difficult… I had to be strong for them. She could not falter, so neither could I.

We went back to work. Joan, Jamie, the nurses and I gathered around Vlada like faith healers, voices rising with each contraction, summoning my son into the world. Vlada pushed in resolute silence over and over again, achieving the seemingly impossible in micrometers. Our evangelical-toned cheerleading and the building drama began drawing curious glances from hospital staff, ducking in and out of the room.

After half an hour, the moment of truth came. Kyle, a young, kind and level-headed doctor, would make the call on whether he could help Alex out via either forceps or vacuum delivery. Upon examining her, he nodded his head in approval. Vlada had achieved her goal. Kyle would attempt a delivery by forceps.

Forceps and vacuum deliveries both incur some risk; head injury to the baby is possible. Forceps are considered lower risk than the vacuum procedure, so they started there. Doctors Kyle and Maurice attempted to position the forceps for some 10 minutes before Kyle declared he would not make the attempt. He did not feel confident he could position the forceps effectively without risking injury to Alex. Never had I felt such gratitude for the caution and humility of a doctor. Instead the team would attempt the higher-risk vacuum delivery, necessary in this case.

The vacuum procedure consists of placing a suction disk on the baby’s head, adhering it, and literally yanking him out by means of a strong cord. The yank must be timed with the mother’s contractions; the mother must help. In our high-tech world, there’s something almost primitive about the process. In this instance, it made simple and elegant sense.

In the first attempt, the suction disk popped off Alex’s head, flying out of Vlada with a whip-like crack. For a split second I had the bizarre illusion of my son’s head popping off entirely. “Whoa!” Joan and the doctors assured us this was not unusual and could happen several times before achieving success. Indeed, the second and third attempts yielded the same nerve wracking result.

I was positioned at Vlada’s head, whispering loving encouragement in her ear, supporting her neck during her pushes. From this vantage point, I saw most of the medical staff gathered at the back of the room, watching with baited breath. The ring of four doctors poised around Vlada and the rest in the back shared facial expressions taught with utter suspense. The scene surpassed any television ER melodrama I’d seen.

Attempt number 4: “Go Vlada! Push push push! That’s it!” Holding her neck and shoulders, with a slightly higher sight line than Vlada herself, I saw the somewhat compressed, gooey head of my little boy emerge into the light. Kyle was pulling hard, applying serious muscle at strategic angles to protect the baby’s fragile neck. “Omigod!” The excitement of this moment transforms the energy of the body. “Keep going Vlada! Don’t stop!” My exhausted heroine bore down once more. In a moment, the rest of Alex’s body slipped out. After 46 hours of labor, my son was born.

Such exhilaration! The closest thing to it I’d experienced was my first glimpse of the Grand Canyon, which literally sucks the air out of the lungs, making one light in the head and acutely alert at the same time. “Baby you did it!” Vlada immediately stretched out her arms. “Can I hold him?” I knew the answer was no; Alex was swept to the adjacent room to be checked, before his visit to the neonatal ICU. “They have to take him to make sure he’s okay, baby. You can hold him in a minute.”

We held each other in wonder and relief, hugged Joan, thanked the doctors as they sewed stitches into Vlada. From the next room, we heard Alex’s first cry – the sweetest sound in the world. Soon I was called in to see him. He was beautifully funny, slick, red in the face (some abrasions and skin irritation from his harrowing journey), and somehow old-manlike. The little guy seemed to have been here before.

He was big! Almost 10 pounds, long, gangly, lots of hair, curiously powerful. He was feisty. Even with meconium in his lungs and stomach, he was hearty. The placenta was big as a Frisbee; no wonder he was lodged so tightly. Before heading to the NICU, the nurses brought him to Vlada, who held him for the first time. A tender, unforgettable sight.

The NICU doctors and nurses took excellent care of Alex for several days, while Vlada recovered her strength upstairs. This story is populated with heroes and people doing their jobs well, starting with Vlada and Alex, to Joan the remarkable midwife, Jamie the doula and me, to the kind and attentive nursing staff at St. Vincent’s Birthing Center, to the caring and competent doctors in the delivery room, NICU and recovery wing. Everyone was incredible. Their combined efforts saved my new family’s lives.

I feel deeply fortunate (and grateful to Joan) that we brought Vlada to St. V’s. It is a rare facility in its openness to midwifery, while providing state-of-the-art medical care as needed. I honestly know of no other place in the city where we could have expected such a wondrous outcome. The unique blend of medical support and midwifery Vlada needed was not readily available elsewhere.

St. Vincent’s is a New York treasure. It works. Lives are saved there every day. Without it, lives would be lost. Without it, my child and his mother could have been lost. Unbelievably, it is now in danger of being closed, its services lost to the community. Why? Because of a hostile corporate takeover by another hospital.

I don’t know what we would have done without St. V’s. I will never forget their caring, their kindness, their faithful and professional fulfillment of their mission. This is practically unheard of in New York City. By definition, the loss of any New York hospital guarantees more death in the adjacent community. Those who would close a hospital are therefore directly responsible for this death. That those who would facilitate such death-for-profit are healthcare providers is grotesque and cynical beyond description.

Thanks to St. V’s, my story has a happy ending. It casts some interesting angles on the home-birth vs. hospital-birth debate. Any differing decision by us, or any of the caregivers, at any juncture could have yielded very different results. One could second-guess or coulda-woulda-shoulda til the cows come home. All I can say is I felt surrounded by committed, loving people at every juncture through this process, for which I’ll be eternally grateful. As challenging and frightening as it was at times, it was a journey imbued with value that will frame the beginning of my son’s life with even richer meaning. Such heightened appreciation for the preciousness of life is an inspiring start to our new family’s adventure.