Day 12: Peace in the Midst of the Storm

Karen is one of my doula-friends in Bakersfield. She is reliable, knowledgeable, and serves families in a loving and caring way. I remember when she had this client, because she asked me what my experience was with cholestasis as a doula. One thing I realized was, information changes, and I had old information. Karen has recently been able to help me navigate a similar situation as I have supported a client through this condition -- doula sisters are always good to have! Sharing and integrating knowledge keeps us all informed and better able to help families as they whether their own storms. 

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​Justine was a young woman, expecting her first baby when she asked me to be her doula.  In a roundabout way she was family.  Even though there was no genetic connection between us, I immediately felt bonded to her as if she was family.  She and her husband, David, were so excited about welcoming their baby into their family.  From the beginning she had a hunch that she was carrying a little girl, which was later confirmed.

She was appalled to learn that her regular OB/GYN had a policy to automatically induce a woman as soon as she hit the 40 week mark.  Justine had done her research and knew that this was not an evidence based policy.  She also really wanted an unmedicated delivery and knew that this policy would throw a road block up for that.  Early in her pregnancy she discussed this with me, and we were able to get her under the care of another OB who had a much friendlier attitude towards her desires to attempt an unmedicated and intervention free delivery. 

She had just formed an affinity for this new OB when life presented the first “storm” of her pregnancy.  Within a week of each other, she and David both lost their jobs, which meant that she lost her insurance policy!  I went to her next appointment with her to the doctor.  Her plan was to tell him that she had lost her insurance, had applied for Medi-Cal (the California form of Medicaid) and ask him for a recommendation for an OB who would have similar practices and also took her Medi-Cal insurance.  All this stress, combined with her pregnancy hormones, had kind of left her in a very fragile emotional state.  She was crying as she explained all this to him.  He gave her a big hug and informed her that, while he did not advertise it, he was actually an approved Medi-Cal provider!  She could continue to see him!  Not only that, but he worked with her husband (whose prior job had been in pharmaceutical sales) and helped him find new employment!  She began to have faith that things were going to work out fine!
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Things were going along quite well with her pregnancy.  She found out that she was carrying a baby girl and they selected the name “Noah Grace” for her.  Did you know that there was a female person in the Bible named “Noah”?  I certainly didn’t!  The story is found in Numbers 27.  She was quite a woman for her day.  You can read about her story here . What an amazing woman to be named after!

We did a private childbirth and breastfeeding education class in their home. They were both so excited about what they were learning about the physiology of birth and coping techniques for labor. Of course we touched on interventions (including inductions) and complications, but all of us thought that this info would be unnecessary in their actual birth. However, within a few days, the second “storm” arrived: she called me complaining about intense itching, mostly on her hands and feet.

I advised Justine to contact her OB right away. I knew that she had had a pre-existing condition with her liver and was quite concerned.  Her doctor also suspected that this was being caused by an issue with her liver and she was quite quickly diagnosed with Cholestasis (a problem where the mother’s liver is producing excessive bile acids). This condition, in addition to causing the intense itching, can also result in a fetal death in the last few weeks of pregnancy. Justine was placed on medication to control the bile acids. Medi-Cal delayed in getting the prescription filled, and she told me that many nights David would place his hands on her and pray for her for relief of the itching just so she could get some sleep! She truly felt like his prayers helped her both physically and emotionally. She was also referred to a perinatologist for concurrent care along with her regular OB. Overnight, Justine’s and David’s focus switched from preparing for an intervention free birth, to a quest to just birth a live baby. She did say that one bright side of having to see the perinatologist on a weekly basis was that it also gave her an opportunity to see her precious baby girl on ultrasound every week. It was comforting to see that visual reminder that baby Noah was growing and thriving. 

from icpcare.org

Her concern was compounded by the fact that her own mother had died at an early age due to liver failure, and Justine has had elevated liver enzymes herself in the past. The perinatologist explained to Justine (which concurred with the research she was already doing) that her baby would have to be delivered at 37 weeks to reduce the risk of stillbirth (a recommendation that is changing now to 36 weeks gestation). In a facebook post just a few days before her baby’s birth, Justine wrote, “Everyday I get asked when my due date is and and every time I have to explain that my baby will come early due to Cholestasis of Pregnancy. Most people assume I'm fine because I look okay and since the itching is gone they assume I must be better but the truth is that I constantly am concerned with my growing child and the closer to my due date I get the more I worry!” 

Upon the recommendation of her perinatologist, Justine was admitted to the hospital at 37 weeks for an induction. At her OB appointment just prior to her admittance, the doctor declined to even do a vaginal exam. He told her that he was certain that her body was truly not ready for labor and so there was really no need for it.  Instead he sent her to the hospital for the induction. This started her third and final storm of this pregnancy. She was admitted and they started the process. Justine was given a vaginal dose of Cervadil (a cervical ripening drug). When the nurse inserted the Cervadil, she informed Justine that she was already 2 cm dilated and 50% effaced! That was so comforting to her as she was certain that her cervix was not going to be anywhere ready for delivery yet! It was like her baby girl was telling her that everything was going to be alright with her coming at 37 weeks!

​Justine gradually began dilating and effacing and having some contractions. This process was very slow getting started, but picked up over the next few hours. About 13 hours after the medicine was inserted, Justine was almost 4 cm dilated. She had a very painful moment, which she had a difficult time recovering from, when the nurse was having trouble removing the cervadil strip.  She did ask for some IV pain medication to cope with that pain. At this point she, along with her doctor, made the decision to rupture her membranes to see if she would continue to labor on her own, without the need for Pitocin. This accomplished exactly what she had hoped for and her contractions picked up significantly.  She asked for IV pain meds again. She was having a difficult time coping with the frequency and intensity of her contractions. She said that if felt like she was getting no break between them at all.  About an hour later she made a decision to get an epidural for pain management. Finally she was able to rest and let her body do its job.

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About 14 hours after getting the epidural, and after getting some much needed rest, she was ready for pushing! Soon after, Justine had her precious Noah Grace in her arms. Baby weighed a healthy 7lbs 6oz and had Apgar scores of 8 and 9! It was like she knew she was coming early and just developed a bit early to make things easier! Baby appeared to suffer no ill effects at all from her early delivery!

Justine said “Having you as a doula emplowered me to be brave when I was oh so scared, and helped me to have the knowledge so that I can now help other women!”Today, Miss Noah Grace is quickly approaching her first birthday! She and momma are both in good health, and baby is still nursing like a champ! 

Working with Justine and David was such an honor! They were truly a team in every aspect of her pregnancy and delivery. Their love for each other, their faith in God, and their trust in their health care team got them through a very scary time in their lives. While they say that they learned from me, I know that it was truly I who learned the most from them!

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Karen Berhow serves the greater Bakersfield, CA area. She has over 20 years experience supporting women through labor and birth. Although she started helping friends, she is now a professional doula, offering childbirth classes, breastfeeding help, and general support for new families. Karen has been on the Board of Directors for the Bakersfield Birth Network, and she loves her involvement with other professionals as they try to bring awareness of birth options to their area. The mother of three grown children, she recognizes her personal birth experiences shaped and motivated her to reach out and help others on their journeys. 

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