Briefcase on the Kitchen Table

I was so excited when we got pregnant. I didn’t even think I was; I was only a day late and having all the symptoms associated with the coming of Aunt Flow. However we were going to a party the next day and I knew I would be drinking alcohol. On the off-chance that we had finally created the little life we were so desperately wanting, I decided to take a home pregnancy test before I took the dog out for her 5:30 AM walk. And holy cow- there was the positive.

I am type-A to a fault and had been patiently waiting to have a baby.  In the interim, I had read article after article about pregnancy, breastfeeding, birth plans, doulas, midwives, European trends in birth, the American OBGYN system, etc. Even with that knowledge, the second we found out we were pregnant my husband and I delved into research. We ordered books, I walked every day, drank massive amounts of water, avoided sweets, etc. I was determined to have this pregnancy go smoothly and have the birth experience I had always envisioned.

Now, pregnancy is crazy, right? I mean what else can give an otherwise perfectly healthy person complicated but temporary conditions? Conditions like diabetes and extreme high blood pressure- conditions that will almost instantly disappear upon birthing your little human. I celebrated each hurdle past these issues- passed the glucose test with flying colors, blood pressure looked good, placenta positioning was fine, kiddo was breech but two weeks of Spinning Babies and little man was back to the head-down position I needed him in. I was making mental tick marks down my list of possible prenatal complications.

As we began the third trimester Avery and I attended our multi-week birth class. The class went through all the information we would need for a hospital birth with an emphasis on natural labor and delivery (natural meaning no medications and no interventions). I am not opposed to interventions; however I am a believer that my body was designed to make and birth children. We picked a hospital with an awesome staff that had nurses and midwives who would support us taking our time and laboring naturally. We bought a birth ball, I set my playlist, I bought a comfortable robe and slippers so that I could walk the halls while laboring, we made sure we toured the delivery rooms with bathtubs as I was confident water would be a help with natural pain relief. I made sure I was in good physical and psychological shape walking and doing squats every day and reading a small library’s worth of books on natural labor and delivery.

Then around week 36 I got itchy- really itchy. Especially my hands, feet, legs, and arms and especially at night. NOTHING was touching it. Not Benadryl, oatmeal baths, lotion, nothing. I had literally scratched myself open. My husband was getting phantom itching watching me scratch. It would get the worst around 6:00 PM every night until about 5:00 AM. I couldn’t sleep I was itching so much. I wasn’t even going to mention it at my 37-week appointment; I assumed it was just a mix of hormones, stretching skin, and weather because it was starting to get cold so I was spending my days in buildings with the dry heat on.  Plus, there was nothing in any of our books about itchiness. I had literally made a list of all the common and even uncommon complications to watch for in pregnancy and itchiness was not one of them. My husband was the one who asked that I mention it to my OB. So, casually, at the end of my 37-week appointment, I mentioned that I was itchy. My doc looked over my hands and feet that were now covered in scabbed-over scratch marks (not usually an area your OBGYN checks) and asked if the itching was much more severe at night. When your doctor asks such a pointed question, you know something is up. She told me she thought I may have cholestasis, also called ICP. The itching wasn’t ON my skin, it was UNDER my skin.

Intrahepatic Cholestasis of Pregnancy is yet another weird condition that can be brought on by pregnancy and will disappear almost immediately after birth. It wasn’t in any of my books because it is rare occurring in only 0.1% of pregnancies. For a little biology lesson, essentially it is the liver reacting badly to pregnancy. One of the liver’s functions is to process the bile acids out of your blood because they are toxic to the human body. Cholestasis is when this process is no longer working. For us adults, it is almost always just a very uncomfortable inconvenience, only seriously effecting the mother’s long-term liver function in the very worst cases. For unborn babes it is more serious. Because the increased bile acid is blood-born, that amazing organ that is the placenta does not protect the kiddo. Cholestasis increases the chance of meconium in the baby’s water-world by as much as 50% which is dangerous for them to aspirate. It also increases the chance of stillbirth by a multiple of three. It increases the risk of abnormal heart beat and respiratory issues for the baby and preterm labor and hemorrhage for the mama. All in all, just not something your OBGYN wants to see.

When my doctor said that she was pretty sure I had ICP she also advised that if I did have it, it was the best case scenario. The only foolproof option to mitigate risks for the baby is to get the little one out of its mother. My doc said they never want to do that before 37 weeks and that if I had developed ICP earlier in the pregnancy it would have involved some pretty high strength drugs and a whole lot of fetal monitoring. I was 37-weeks-and-one-day on the date of my appointment so, even if it was determined that cholestasis was what I had, we would just induce labor immediately. The next step was a fasting blood test for which I had to eat nothing for twelve hours prior to getting my blood drawn. Telling a nearly nine-month pregnant woman not to eat was probably the riskiest part of this endeavor. I showed up bright and early at the lab the next morning (at 6:30) and then afterwards went straight to a restaurant and ate world’s largest breakfast before heading to work. And then we had to wait.

That weekend Avery and I started prepping things in case we received the “You have ICP” phone call. On Monday morning when I was sitting in my office I got the call from my OBGYN. She told me the test came back positive for ICP; my bile acids were way too high. She asked if I wanted to have the baby on Tuesday or Wednesday. It was surreal. I thought I had at least two more weeks. I asked her if the levels were safe enough to wait until Wednesday and she said they were so long as I came in for fetal monitoring. I told my boss my maternity leave would need to begin Thursday (yes I still worked Tuesday and Wednesday- what else was I going to do?). I called my parents who were going to come watch our house and our dog; they were supposed to leave for Boston in just a couple of days and they needed to cancel their travel plans. The non-stress heart rate test for our little man looked great so Wednesday, Halloween, the day I would hit 38 weeks, Avery and I would go to the hospital at 5:00 PM to start induction.

I was nervous. I knew people who had had great luck with induction. I also knew that an induction can be a high predictor of cesarean section when done pre-term. Trying to jump start the body into something it’s not naturally ready for doesn’t always work out. I also knew about the “cascade of interventions”; that utilizing one intervention- in this case, induction- often leads to more and more medical interventions throughout the process. My husband on the other hand was worried that I would fight all interventions despite having to be induced just so that I could stick to our birth plan. We had learned all about Pitocin, the drug used to induce labor, in our birth class and we knew that it could bring contractions with an intensity and duration that was beyond what a woman’s body would create naturally. Avery was scared that I was so committed to my all-natural birth plan that I would cling to sustaining any part of it I could, even in the face of having to start the process artificially. I assured him I would NOT do that- it was still my goal to go as far as possible naturally but I knew we were now staring down a potentially long and painful labor process because of the induction and I would not stick to the plan just out of pride. We also tried EVERYTHING we could for the two days leading up to checking into the hospital to get labor to start on its own- I ate an entire pineapple, I constantly bounced on my birth ball when I was home, I took long walks, ate spicy food, took herbal supplements, drank raspberry tea, and more. I also spent some time talking on the phone to my friends and family who had experienced inductions so I could be in the right headspace.

On Wednesday a little before 5:00 pm we checked into the hospital. I still requested a tub room- trying to stick to the plan. We settled into our space and the nurse started me on Cytotec, a cervical-ripening drug. I appreciated my doctor’s approach to induction- slow and steady. I also had to be hooked up continuously to the fetal monitors because of the induction, something that was not in our plan but was necessary to make sure none of the medications sent the baby into distress. The Cytotec brought on my first low-grade contractions. Avery spent that night sleeping on a convertible hospital chair. I could not sleep. I was starting to feel my body get ready to deliver our little boy. I had contractions every seven to ten minutes throughout the night and the nurse had to come in with some frequency to administer more Cytotec, check my vitals, and position the fetal monitors. I watched the arc of my contractions on the screen and was more excited than anything. The contractions were just an uncomfortable twinge at this point but between that and the relentless itching, it was enough to keep me awake.

By the morning the nurse checked me and, just with the Cytotec, I was at 2 centimeters and contracting regularly. I was allowed to eat breakfast and take a good shower in order to get ready for the main event. They started Pitocin in my IV and my OBGYN broke my water. There was no meconium in the fluid- another ICP hurdle cleared. I’ll tell you what though, that Pitocin was not playing any games! By noon the contractions were coming fast and furious but I felt good. Avery and I were using all of the tricks we learned in class. I was able to sit in the shower for 15 minutes (no bath allowed after my water was broken). Avery followed me with a water-bottle, keeping me hydrated. I tried a ton of different positions until I figured out my favorite was facing the wall behind the hospital bed and draping myself over the back of the upright mattress. Avery put photos of my favorite beach on the wall to give me something to focus on and he played my favorite music. Our nurse was constantly on hand and helping with tips, tricks, and touch to help me stay as comfortable as possible. Every hour or two the dose of Pitocin would be increased. Around 3:00 pm the back labor became intense and my OBGYN discovered that Sam had turned, still head down but facing a less-than-ideal way however we were still on track. Then, at 8:00 pm that night, it was like a switch flipped. The Pitocin had just been increased and all of the sudden there were no breaks of any kind between contractions. Worse yet, I could feel them all the way through my thighs to my knees making my favorite position impossible because I didn’t trust my legs. Avery just refers to this as “the bad hour”. I wasn’t even cognizant of who was coming in and out of the room. I had to lay on my back making the back-labor even worse. I barely remember Avery sitting next to me rubbing my arm and giving words of encouragement. My doctor, who was determined to be the one to deliver my baby despite her shift being over, consulted with others and the recommendation of an epidural was made. She had helped us develop our natural birth plan and was very supportive of it however she felt that, because of the Pitocin, an epidural might actually relax me enough to progress more and that I may slow my process if I continued to refuse any pain meds. I love my doctor and trust her implicitly. I asked to be checked and I was at six centimeters, now 27 hours into the process. I looked at Avery who gave no pressure in any direction, and I told him there was no way to continue like this for four more centimeters and I agreed to the epidural.

The anesthesiologist was there in minutes and Avery was booted out of the room. I sat up in the bed and our wonderful nurse stood in front of me squeezing my hands because I was still having constant Pitocin contractions but was not allowed to move. I barely remember getting the epidural but the relief- oh the sweet relief- was immediate. Avery came back in and we caught our breath. I asked my parents to drive to the hospital for a morale-booster visit. I called my sisters. Around 11:00 pm Avery laid down to get some rest and I tried to as well, finally getting a couple of hours of sleep. My nurse woke me just before 2:00 AM to check me and I was at 10 centimeters. I was ecstatic! My biggest fear in all of this was that, either because of the induction or the epidural, I wouldn’t get to 10 and we were there! I hooted at Avery to wake up and another nurse came in and began turning on the lights. I asked that we back off of the epidural a bit so that I could feel the contractions and push with them. My doctor, who had gone home but left orders to call her when I reached 10, was on her way.

And then I pushed. I pushed for two and a half hours. I pushed in every position I could manage with the epidural. I puked and pushed some more. And nothing. Sam didn’t want to descend.

Around 4:00 AM my doctor started talking about needing to discuss a c-section. I asked for more time. She agreed. By 4:30 there was still no movement. I could feel where Sam was- he was stuck because of the way he was facing and his head had started to swell from all of the pushing. My doctor looked at me and said she didn’t like my heart rate and didn’t like the baby’s heart rate and it was her recommendation that we go in for an unplanned c-section. I immediately started crying. My doctor rushed to the top of the bed and hugged me- she knew how badly I wanted a natural labor and delivery experience and how frustrated I was that ICP had wrecked my plans. I had done everything, EVERYTHING, to prepare for this, to learn all I would need to know in order not to end up HERE. She talked to me as a doctor but also as a woman. She asked me what was going through my head. I told her all of it, every racing thought- asking why we did everything we did over the last day and a half for it to come to this, that I wanted more babies in the future and didn’t want to have to have them all via c-section, that I was afraid of such a major surgery, etc. She listened and comforted and after about five minutes of conversation, I headed to the operating room for the c-section I swore I would never have with my head feeling clearer and excited to meet my baby. Avery called my parents to let them know what was going on. He changed into scrubs.

My first fifteen minutes in the OR Avery was not allowed in because they had to get me prepped. The same anesthesiologist from earlier was there to numb me for surgery. My familiar nurses were there, recognizable only by their eyes over their surgical masks. I saw the baby warmer and couldn’t believe it was about to hold my son. Avery came in and sat by my head. My teeth were chattering from all of the drugs in my system. My doctor said they were ready to start and I felt pressure (but no pain) on my lower abdomen. A few minutes passed- doc said they they were about to pull the baby out and asked Avery if he would like to look over the sheet that separates the medical and non-medical universes in a c-section operating room to which he said no. Samuel was so far down the birth canal that another doctor had to push him back up to the c-section incision (positioning that led to him having a coned shaped head for the first 24 hours as though he actually was born vaginally). And then, in no time at all, I heard the most beautiful cry. A nurse stepped to our side of the dividing curtain and I saw my wet, long-fingered, dark-haired little boy and I cried, tears leaking down the sides of my face. Avery went over to the warmer and started calling out to me “Ten fingers! Ten toes! Your ears!” After a few minutes of clean up, Avery walked back over to my head with the sweetest little baby-burrito I had ever seen. I couldn’t touch my son because my arms were secured under the sheet. Avery leaned forward and touched Samuel’s forehead to mine.  The closing-up process took far longer than the opening-up process and I laid there staring at my son. After what seemed like forever, I felt a new sensation from my chest down and realized I had been wrapped in blankets. The doctors and nurses transferred me back to my hospital bed. My anesthesiologist asked how I was feeling. I said fine. He asked if I could feel my arms alright and I told him they felt normal. He asked me to bend one slightly and then uttered my most favorite sentence ever; he looked at Avery and said, “Alright Dad, time for Mama to meet her baby,” and Samuel was placed into my arms for the first time. Sam and I rode back to the hospital room together on that wheeled bed, me feeling like it was a chariot ride after coming out of a long battle victorious.

On Friday November 2, 2018 at 5:19 am, thirty-six hours and nineteen minutes after we began our induction process my beautiful, perfect, baby boy, Samuel Lawrence Archer had entered the world.

Avery and I had planned on spending a quiet hour together after the birth of Samuel before calling family and friends. Because of all of the follow up that has to happen after a c-section (the details of which are for another time) there was medical staff in and out of our room constantly and the hour flew by. We couldn’t wait any longer so called my parents and told them to come to the hospital. I Facetimed my teary sisters. I started responding to a glut of texts I had received on Thursday from people who wondered why they hadn’t heard about a baby being born yet.

That day people visited. I began a pain regiment. I took a shower, paranoid about my incision. Finally, four hours after surgery, I was allowed to eat some food. I drank more water than I knew I could hold. I started shedding the tubes and wires as I cleared my post-op checks one by one. We spent another three days in the hospital due to Sam’s weight loss and jaundice. In Christine’s all natural-birth universe, I was only going to be in the hospital for forty-eight hours maximum. Finally on Monday afternoon, five nights and six days after checking in, Avery and I took our son home.

In the aftermath, as much joy and happiness as there has been, there has also been sadness. In a way, I needed to mourn for the birth I had always envisioned but that never came to be. I still get little pangs of sadness, frustration, and even envy when I think about how everything ultimately occurred or talk to someone whose labor and delivery were textbook. Right after Samuel was born I would express these feelings and people would say “the important thing is that he is here and he is healthy.”  I would nod my head because, as a mother, that’s what I am supposed to think, right? But it wasn’t. Of COURSE I was thankful that he was here and healthy but I also had (have) feelings of loss and sadness over the experience I wanted to have, that I worked very hard to manifest. I have no complaints about our process- our hospital, doctors, and nurses were amazing and I felt informed and in control of the decisions every step of the way. I am more just sad that developing ICP made so many of the decisions necessary. I am still hoping to have my natural (or at least vaginal) labor and delivery some day. But I may not. There is a 80%-90% chance I will develop cholestasis with any future pregnancy and if I do, an induction after c-section is not recommended. Right now I am giving my body time to heal and I feel more like my old self with the addition of a raised, deep-red scar across the top of my bikini line. I know I am not done processing all that happened at the end of my pregnancy- not trusting my own body and having the panicked desire to correct course without any ability to do so. I will say though, in reflection, I have found joy in the process. I am more adaptable than I ever would have believed, more honest and self-advocating than I realized. I have an incredible husband who was the best birth partner I could have hoped for, an amazing supportive family, and the most caring group of friends. Most importantly, now I get to be a mama, something I have wanted and waited for my entire life. My little guy is the most difficult, most joyous, most exhausting, most fun thing I have ever done- and he was unequivocally worth every single itch.

When I was pregnant I loved reading other women’s birth stories; I found them enlightening and empowering. I hope you can find the wonder (or the camaraderie) in ours. Our labor and delivery were harder than some and easier than others . If you start itching during your pregnancy please talk to your doctor. A simple blood test is all that is required to determine if you have ICP. If you have developed ICP, please check out resources like those at icpcare.org  to get support and find out to best care for you and your baby.