Dear Kat

I thought it might be useful to send you the full account of our birth story, just I case it might ever come in useful for other cholestasis sufferers and/or anyone anticipating an early induction for whatever reason. This is a bit of an epic, but I know I was grateful to read whatever I could over the weeks leading to Megan’s birth, and success stories (few and far between) were a particular highlight in the journey. Writing it has been very cathartic too. It all feels like another lifetime, even though it is less than two weeks since the real (pre-baby!) rollercoaster set off.

So, the most important thing is that I am writing this one-handed (my left…I’m not left-handed, but you do what you do!), with a totally blissful 9-day-old baby girl enjoying a little light supper cradled in my other arm. Despite the exhaustion and the worry that we’re not fluent in baby cries yet, I have never been happier and the love just gets more intense every minute.

The first of many lessons she has taught us is that plans don’t always turn out as you’d hope (but wishes sometimes do!).

This time two weeks ago, we were in the running for a homebirth; I have (had, I can say now!) a fear of hospitals and so all the mental and emotional preparation we’d done had focused on this scenario and no other (though I knew I’d possibly have to transfer in, I was actually really confident that going as far as possible at home with the help of hypnobirthing would either make that scenario unlikely, or at least totally manageable). At the same time, I was starting to get very itchy. It was annoying at first and only intermittent, occasionally interfering with sleep. To be honest, I wasn’t sleeping full nights anyway, and was always wide awake between 3 and 5 in the morning. Some nights, I would get up to the bathroom and then couldn’t focus on anything but the itch. I, unconsciously, would rub my feet on our doormat before going back to bed because it felt good. But all pregnant women get itchy, right? My belly and boobs had been itchy pretty much every time air got to them from about 12 weeks or so. I casually mentioned the recent increase to my midwife at a 35 week check up (the same check up at which we were all getting excited about arranging our home birth). She didn’t think it seemed serious (I, with hindsight, was probably playing it down a bit, saying that I didn’t know how much of it was psychosomatic: that’s the sneaky thing about itching – just try not to scratch somewhere when you wonder if you are still itchy!), but she thought it was worth doing some tests for a condition called obstetric cholestasis (OC) along with the standard 34/35 week blood tests.

Obstetric cholestasis is a condition that only occurs in pregnancy. It’s apparently rare (1 in 100), certain ethnic groups are more prone to it than others (I’m not one of those groups) and there are possibly genetic factors (if your mum or sister had it, chances are you will too, but, here again, I don’t have a genetic history either). Frankly, it just feels cruelly random to me. The body becomes inefficient at absorbing bile acids and the build up causes excruciating itching, especially in the feet (and hands, though not so much in my experience). Very little is known about the causes and risks of cholestasis, but it is believed to be linked to premature birth (‘pre-due/guess date’ would be more accurate, since it’s often diagnosed post-37 weeks), whether spontaneous or because of induction; slightly raised incidence of stillbirth the closer babies go to full term (at 37-38 weeks this risks of stillbirth are equal to the risk generally); and post-partum haemorrhage in the mother (to do with inefficient absorption of vitamin K as a result of raised bile acid). The key word here, though, is “believed”; few studies have been successfully undertaken. The jury’s out, but the hospitals do not want to take risks, and will express this all very bluntly to you (one doctor told me I was risking “bleeding massively”: nice choice of words!), until, like me, you are backed into a corner, feeling overwhelmingly irresponsible for even contemplating risking the life of your unborn child, or her mother. Interestingly, the stats not shared by the hospital were those relating to the risks of early birth, induction, the possible/probable cascade of interventions, c-section, etc, as compared with those for cholestasis.

So, from a lovely pregnancy, which had been low risk from day 1, I became “abnormal” and high risk. I hadn’t even suffered from morning sickness, feeling only mild nausea when hungry. I was very healthy and fit before pregnancy too, having spent three months on sabbatical in Montreal, running, doing yoga, eating well and relaxing. I have no history of liver trouble, or anything else for that matter. I had done everything I could through pregnancy to prepare my mind and body for natural birth (hypnobirthing with Kat being a hugely important part of this). Now, I’m 90% likely to have OC in a future pregnancy, so will be high risk again (though I feel more likely to push for a home birth next time).

The tests for OC look at two main indicators: liver function (ALT) and bile acids. The first test can be done in a couple of hours, the bile acids test, which is the main indicator of OC, is only done once a week at least at UCLH. (Incidentally, a friend with this (rare?!) condition who had her baby at Lewisham said they take two weeks.) At 36 weeks, tests showed an ALT score of 35 (normal range 0-35, so borderline) and the bile acids were 5 (normal range 0-14). The itching was, at this point, intermittent, but the tests were inconclusive so the chances of homebirth started to slip away. I decided to take action, consulting various people (including the wondrous Kat and our incredible doula, Paula!) and being advised on liver-friendly diet, herbal remedies and detoxing juices. Next test, at 37 weeks, showed raised ALT (55) and slightly raised bile (6). The next, a few days later showed 65 and 10. Climbing, but, so far, so inconclusive. However, by the end of the week, the itching had become intolerable and there were a few very horrible nights of horrendous itching and almost no sleep. I was awake and sobbing with the pain and frustration, asking Adam to stroke my legs and feet, the slight pressure detracting a tiny bit from the pain of the itch. We started now to acknowledge that it was likely there’d be no homebirth and arranged to see Kat to work on coming to terms with the change and addressing and conquering fears of hospitals. After that, we took ourselves away for the night to a hotel with a pool, thinking that the R&R (not to mention a cooling swim) might help, but that night saw the worst of the symptoms; you know you’re in a bad place when you start scratching your feet and legs with your sturdiest Denman hairbrush!

Back to the MFAU we went, spending four hours there one day and three the next, I was put through several blood tests, a liver scan, a growth scan for baby and 20 mins of fetal monitoring (all the while using Kat’s techniques to keep me level). The ALT score was massively increased (140), I never found out the final bile acid numbers. I was prescribed some effective medicine (ursodeoxycholic acid) to treat the itching, aqueous cream with 2% menthol to detract, and an antihistamine to make me drowsy, and, finally, I had a firm diagnosis for obstetric cholestasis. Induction was advised, following a rather interesting discussion with the doctor saying it was a rule that you couldn’t have home birth with it and would have induction, Adam and Paula (who came from another birth close by for moral support: what a team we had involved!), saying it wasn’t a rule was it, him them changing his story and agreeing it wasn’t, but we were accepting risk if we refused to do it that week. We left the hospital with an induction booked in for Thursday, but agreeing that we’d be thinking long and hard about it; it wasn’t a done deal.

Following much soul searching, many tears and lots of deep breathing that evening, the next morning I decided to keep the date. To be honest, I was at my wit’s end. Worn down by too little sleep, too many hospital appointments, too many times being told I was accepting risk if I didn’t agree to induction, I somehow moved myself into a place of acceptance. On Wednesday morning, we rang the hospital, confirmed the appointment, and I emailed Kat to ask for any words of wisdom to help me through the induction. She was going to be in Clissold Park that morning. So, after a reflexology appointment (more on that below), I took myself off there to speak to Kat about how to make induction and hypnobirthing compatible.

From the beginning of the week, I had been reassessing the old wish list (ever mindful of Kat’s advice not to ‘plan’). I decided to go all out for natural induction. Acupuncture, two lots of reflexology (the first of which made our baby very active and the second was on the morning of her birth, at which I could feel period-pain sort of murmurings), curry, squats, birthing ball exercises, camel walking (taught in my pregnancy yoga class, apparently good for making baby descend). The weather being glorious, I had been walking miles for about two weeks (a couple of miles a day) and, on the morning the baby was born, I walked to and from Clissold Park to see Kat. (While sitting in the park, as well as some general wellbeing, I got an amusing sunburn V on my chest which features in the first photographs of our daughter’s life.) Kat had some excellent advice about induction, most encouraging was the news of birthing mums who managed to generate enough natural oxytocin that the drip could eventually be turned off. I was up for that challenge! We talked about my feelings that the baby might be starting to think about arriving anyway; those murmurings still playing on my mind, but I didn’t dare hope. While I was there, a couple whose baby had been born, famously, in a hotel after the hospital had decided labour wasn’t far enough along came to say hi. Seeing them with their gorgeous baby boy was hugely beneficial. I saw and heard for myself how you just accommodate changed circumstances. I finally got it. Hypnobirthing isn’t about the physical place, though getting that right does help, of course; it was never about a pool, my living room, curling up in my own bed straight afterwards. Those were the optimum circumstances. But it was really about me, my head, my ability to focus.

So, I felt calm. I enjoyed some lunch in the park and decided to walk home with an ice cream. As I walked through Highbury Fields (around 1:30 or so), I started to feel some back pain, which I thought little of; I was 8.5 months pregnant and walking in hot sunshine. With hindsight, these were the early surges. I arrived home at 2ish, desperate for the loo (as usual!) and there it was, a bloody show, not much, but enough for me to feel excited. I had no thoughts that I was in labour, but I was pleased that my body seemed to be preparing itself; the induction seemed more likely to be a success (this is how the hospital describe it: success and failure). At about 4pm, I felt unmistakably that the back pains were actually surges. I contacted Adam, really excited, telling him that I was sure it was starting.

Surges continued, but were manageable with breathing and hip swinging (learned from yet another amazing complementary therapist, the pregnancy yoga instructor). I just settled on my birthing ball in front of the ironing board and watched Atonement! The surges got more intense, but between them I felt in good shape; this is exactly what I’d wished for! A friend popped round at around 7 (slightly stunned to be having a catch-up with her friend in labour!). At around 8pm, I was in the bath on all fours having stronger surges and, in between, Adam fed me lamb passanda from our local take away, to the sound of Pulp playing on the stereo. At that point we thought we’d end up going in during the night or possibly the next day. But we were happy to know I wouldn’t need induction, and probably wouldn’t need a C-section because my body and baby were apparently ready. So all was well! All surges were in the lower back, and never went into the front. I don’t know if the baby was posterior.

But then there was some red bleeding in the bath and then in the toilet. Very scary. I insisted Adam call the hospital; all mid-wives were busy and so they said they’d call back. They never did. (We later discovered the evening of 1 May was very busy for the UCH natal unit.) More blood and I started to panic. Adam dialled 999 and spoke to the ambulance service. Shortly afterwards, a paramedic arrived in a car, with three more rocking up in an ambulance. They all stood in the hallway while I was on all fours in the bathroom, unable to move because of the intensity of the surges. They said some blood is not unusual in birth, of itself, and they didn’t seem worried (our midwife has since explained that when labour is progressing quickly, the speedy dilation can make stronger bleeding happen). One of the guys seemed amused and told me to expect several hours of this! One surge came with an urge to push (I didn’t really know that it was the urge to push the baby – the feelings are in the back passage, not the front – not where I’d expected!), but I was told don’t push or I’d hurt myself (and possibly have the baby on the bathroom floor, he didn’t need to say). The surges were still only about 40 seconds every 3 mins, so too early to go to hospital but for the bleeding and the cholestasis complication. They decided to take us in, so I put my slippers on, Adam fed the cats, grabbed the suitcase and car seat, and got in the ambulance. I could only move to the ambulance between contractions, as they were strong by then.

On the ride over (no siren so not that quick, but that was probably best) I tried gas and air, but it just didn’t seem to do anything. Surges continued but we weren’t timing them and assumed it was all hours away and that we were just going in for safety. Adam was communicating with Paula, telling her we’d see her for the action in the morning. At this point, I was scared (because of the blood) that I was losing my baby. Another part of me knew I wasn’t, but was thinking that there was no way I could take more intensity or frequency and that I might go against my own wishes and ask for help. I now know, or at least think, that I was in transition at this point.

Then they wheeled us straight up to the labour ward. My waters broke in the lift: time check, 9:30pm. We arrive at the ward, and were told there were no rooms. A very busy time for the ward, no one had called them ahead, what were they to do, etc etc. Adam pointed out that I couldn’t choose when I went into labour. (We later learned that the induction booked for the next morning would have been put off due to the ward being full; so much for it being urgent!) The Blitz spirit kicked in and they decided to move me into a broom cupboard, at least when I said I felt the urge to push. Actually it was an ex-triage room, now used mainly for storage, although still clean and with some relevant kit in there, and they got everything else they needed. But it felt a little like a broom cupboard.

Monitors were strapped on. Scary moment when we couldn’t hear the heart beat, but it was just the monitor positioning. Then the internal exam was done, which was the most painful bit. Turns out that this is because I was fully dilated and that an earlier examination wouldn’t have felt so intense (although the message that I was fully dilated didn’t actually get through to me for a while). I breathed through the surges, resisting pain relief. They attached a heart rate monitor to the baby’s head to get a clearer signal. Pop. Pop, pop, pop, it went.

Some meconium and the heart beat suggested the baby was in a little distress, so I was told to push or breathe it out, but they were slightly concerned about time – though never once did they speak in scary language, apparently happy for me to set the pace. It was at that point that I realised that I was fully dilated – the midwife who did the examination, a rather brusque woman, who went as soon as she’d done that, hadn’t told me so I’d been clenching! Lots of general advice and supportive coaching from the two excellent midwives (Lucy and Kelly), a bit of rowing–style coxing from Adam as to when to breathe and push, and I went for it. After about three really big pushes, the baby crowned and came out in one or two more. Bloody hell, it happened fast. 10.58pm. Healthy, happy, hairy baby, skin to skin! Name? Megan Victoria Kramer. 5lb 8oz, 48 cm long. Passed the APGAR (9 after a minute, then 10 after 5 minutes. She passed her first exam! Am so proud!) Cord pulsed and only cut when stopped. Vitamin K injection in Megan’s heel (strongly advised for the cholestasis). Euphoria that I had done it naturally, and with no pain relief. And so fast! It was truly amazing. The placenta came shortly afterwards after syntocinon to help it along (lotus birth was out because of the risk of haemorrhage associated with cholestasis). Paula arrived shortly thereafter and kept me in a nice calm state while my stitches were done; it was a first degree tear (internal, requiring a couple of stitches, which they did with a local anaesthetic). She helped get Megan feeding (little guzzler started straight away!) and was generally a brilliant presence.

Phew.

We spent the night in a private room, me with Megan kangaroo style in my nightie because she was a bit cold. I didn’t sleep. The euphoric feeling and the wonder of this tiny person kept sleep at bay. I was utterly content though. I could hear my baby’s daddy snoring away on his camp bed, and feel my baby’s heart beating against my chest. Bliss. I will never forget it.

Of course, first days of Megan’s life have felt almost as eventful with lack of sleep, our feelings of incompetence, and breast feeding, but that is another story…

So, my advice? You don’t have to believe their plans of induction. Contact a reflexologist and get walking, and do believe you can take control of your destiny! Even if they do induce, the warm ups you’ll get are bound to help things along.

I can’t tell you how wonderfully supported we’ve felt through this whole process, by Paula, by Kat, by Alethea, the incredible community midwife (who phoned to check I was okay about the induction when I’d already gone into labour and was positively gleeful on the phone when I told her my suspicions!), the midwives at UCLH (perhaps not the one who did the internal…), my yoga instructor, my fitness instructor, acupuncturist, reflexologist…. What a team! I can’t thank them all enough.

Now: this little monkey has dropped off while feeding (again!), so it’s time for bed for us both (Adam was sent ages ago to keep his daytime strength up).

I hope this story can help someone. And, if it is never read again, writing it has been helpful for me and it has been empowering reliving it all. I’m unashamedly proud of what I achieved and wildly in love with my little family. May 2013 is a good month!

All our best,

Kathryn, Adam and Megan
XXX