"A man's heart deviseth his way: but the LORD directeth his steps." (Proverbs 16.9)
"Whaaaat?"
My poor husband was mumbling, not yet half awake as I shuddered violently.
"I. . . I think we have bed bugs."
A frantic 3 a.m. search on July 12th revealed no bugs and Ermias's incredible patience with his potentially-crazy, 37-weeks pregnant wife. I would continue scratching what seemed to be invisible bug bites--no redness, no welts, no bite marks--all through church the next morning. My midwife Joanna suspected a liver problem and drew blood at my next appointment. The day after my phone rang with half the lab results, extremely elevated liver enzyme levels, which allowed for a preliminary diagnosis: intrahepatic cholestasis of pregnancy (ICP).
My fingers curled tighter around the phone as Joanna explained. ICP is a rare (1-2 out of 1,000) pregnancy complication that involves a malfunctioning of the liver in the third trimester, and as the problem can sometimes put babies in danger, doctors typically opt for early inductions. We were still waiting on one more lab result to give a firm diagnosis, but Joanna told us to head to Bluefield for another biophysical profile (a long, detailed ultrasound) the next day.
My voice on that call was so much calmer than I felt. A call to my mom right after didn't even bring up the feeling rattling low inside me.
No. No, no, no, no, no.
I wasn't supposed to be at risk for anything. From the day we decided we were open to having children until that moment I had done everything in my power to be as low-risk as possible. I was in the best shape of my life when I got pregnant. I took those horrid vitamins faithfully. I ate well and ran until 30 weeks and practiced yoga and worked deliberately on my stress levels. I had my doctor's blessing on the homebirth I had been planning on since I had begun researching American obstetric practices and statistics as a college junior. I had done everything right; I was supposed to be fine.
Wednesday's ultrasound was comforting as the tech found nothing amiss, but the research I kept finding wasn't. Because ICP moms' livers don't release bile in a timely fashion, bile salts escape into other body tissues (a process that researchers assume causes the itching) and can possibly pass through the placenta. Some experts due to animal studies are beginning to suggest that the bile salts can cause structural changes on the cellular level in the placenta and umbilical cord and also instigate colon activity, making some babies pass a significant amount of meconium. So either by having their placentas and umbilical cords damaged or by inhaling meconium, 10-15% of babies from moms with untreated ICP die, usually during the 37th to 39th week. While a few newer studies suggest that these tragedies rarely occur to moms with bile salt levels under 40 (although a few incidences exist) and typically occur when the levels are over 100, the increased risk leads most obstetricians to choose "active management" (induction at 37 weeks or whenever complete lung development has been established) over "expectant management" (watching mom and baby like a hawk and inducing only if baby shows signs of distress).
And I still believe that in general babies should get to pick their own birthdays; that mom's bodies know how to birth and should be mostly left alone to do what they were designed to do; that the end of the third trimester is not a waste of time but rather a significant season of growth and development. But the precious knobs of feet and knees bulging out under my ribcage were sending a sickly-sweet wave across my chest. She's okay; she's okay; she's okay. Breathe. But then--Is that it? Is that the last time I'll feel her move? I wanted to make a solid decision and the most recent research I could find was sketchy at best. I would reread the research that suggested expectant management was a legitimate option for women with lower bile salt levels and hold out hope mine would come back very low. And then after another reassuring sweep of toes my heart would freeze again.
Am I going to come this far and then never, never get to hold her?
And I knew that no matter what decision we made, it was possible the Lord had been planning to give us just thirty-seven weeks with this little girl all along. My parents got 38.5 weeks with my sister and then two more in a NICU before Jesus took Abigail to Heaven; dear friends got 36 or 37 weeks with their daughter before an ultrasound showed no heartbeat. And I wanted to be good, wanted to be the super-Christian with all kinds of faith in the sovereignty of God.
But I was not. By Wednesday night I was sobbing into my husband's chest, this unholy idea running wild through my heart: I don't want to trust the Lord. Even though He would remain in control whether I chose to trust Him or not, I didn't want Him to be, didn't want to be still, didn't want to accept whatever He had planned. Because that plan might have been to take her home and I never, never, never wanted to be okay with that. She's mine; she's mine; she's mine. You can't have her; she's mine.
I had said this refrain before. When she was a tiny little bean whose chance of miscarriage was still high. When she was 20 weeks, fully formed but having lungs just a little too underdeveloped to make it. Over and over this whole pregnancy Lord had to remind me to leave my hands open because that posture is the only way to receive a gift, to say yes to His giving AND His taking because He will always be good even if I don't understand. But I had no faith left to believe the truth I had already learned. Trying to decide which route to go medically left me wound terrified in the lie that I was in control, that I had the power to determine by my choices whether my daughter lived or died. That if I was just smart enough, I could give her the best life possible.
That if I wasn't, I might kill her.
The morning of July 16th was perhaps the most difficult few hours of my life. We didn't have the second half of the lab results, didn't have a full diagnosis, didn't have a concrete decision on how to proceed. And even though my daughter didn't usually start moving until after breakfast, her stillness made every part of my body hurt. I paced under the soft kitchen light in the early-morning quite, manually manipulating the lump of her under my right rib in an attempt to disturb her sleep. Please move, girlie. Just do something. Come on, baby, please.
Panic feels like ice shards in the veins, a sense of stabbing and then a cold emptiness. My pleading turned into the faithless prayers I had been trying to pretend I didn't need to pray. I don't want to trust You, Jesus. I have to, but I don't want to. Please let her move. Please help me trust You. I want to be able to trust You.
But please let her move. Please.
Yet as the day went on a song I had learned in high school filled in all the cold empty:
"Yes and amen to everything that's in Your heart.
Yes and amen to everything that You have planned.
We live to see Your kingdom come,
To see Your perfect will be done on earth."
I didn't get farther into the lyrics than that; I didn't need to. Despite the kicking I felt later that day, the fear hadn't left; my chest would be sore from all the times my heart froze that day. But I no longer fell for the lie that I could change this story's ending, and I stopped feeling the need to come up with or fake a confidence in God's sovereignty that I didn't feel. My job wasn't to be a spiritual superhero, but rather to come in broken and spread out all the enemy was whispering before the Lord and pray like King Jehoshaphat "We don't know what to do, but our eyes are on you."
And then the God Who is our banner, the place we look to for victory, planted five Aarons and Hurs in front of me that day to hold up my hands, to pray for peace and faith for me that I needed to receive miraculously from Jesus because I didn't have any left. It was these women whose kindness and faith made me willing when the second half of the labs came in that evening with levels just under that 40-cutoff (31.2) to cry, to tell my midwife that I was done wondering every moment if my baby had died, and to make the decision to call my doctor about induction.
Five-a.m. wake-ups are not exactly our cup of tea in the Mekonnen household, but at 5:50 we were winding down the mountainside's near-empty roads for a 7:30 appointment in Bluefield. After consulting with Joanna, my doctor decided Thursday night to wait until the morning to make the decision to induce or not. A non-stress test, two blood pressure readings, another ultrasound, and a blood draw later, we learned that while baby girl was doing quite well and her heart sounded beautiful, one of my liver enzyme levels was even higher and my blood pressure was still up a little bit. Even though we knew the high liver enzyme levels were due to the ICP, high blood pressure plus high liver enzyme levels can be indicative of preeclampsia, another serious complication, and there was no way to tell whether my blood pressure was just up a little because I was 38 weeks pregnant by then and my body was merely tired or if I had preeclampsia (we later could conclude I didn't). Thus, an order for an induction was sent to the hospital across the street. I stared at Ermias's fingers interlaced in mine, breathed a sigh of relief, and then cried. She was safe and I was getting freedom from the anxiety of that week; I was not getting the birth I had so meticulously planned for. She wouldn't be in danger, but she wouldn't get to come peacefully, full-sized and on her own terms. Happy and sad and so very overwhelmed all in one moment. Yes and amen. Yes and amen. Yes and amen.
We grabbed Subway because I was starving and Joanna insisted I eat before heading to the hospital. The sweet charge nurse who came in first after we were admitted couldn't get out of the room fast enough for me; I almost made it to her leaving before wringing my husband's hand and burying my face in the paper-thin hospital pillow. A port for an IV dangled out of an arm already sore from all the blood draws that week. That horrendous hospital gown was so big it drowned my 38-weeks pregnant frame. I was wrapped in two different monitors and a screen ticked up and down with my baby's every heartbeat after a week of being unable to breathe from thinking about nothing but her heartbeats. Mostly, I wasn't home. I was tired and emotionally exhausted and now had to face the physically hardest work I'd ever do and I would have traded anything just to go home and sleep for two days. Yes and amen. Yes and amen. Yes and amen.
If you like birth stories, read on. If not, scroll down to the last paragraph. :)
Two significant caveats before we get into the story: Moms are brave people. Delivering a baby naturally is brave; getting a catheter and anesthesia put into your spine is brave; laying on an operating table in good faith, unable to see and holding your breath until your precious baby cries, is brave. I am not special because I had a somewhat-natural birth; I am blessed because I had a team of people who armed me with information and encouragement so that I could have the best birth possible given the circumstances I was dealt. Secondly, please also understand that I am not against doctors and nurses. With the exception of one moderately-grumpy older woman, I had an incredible team of nurses and a wonderful doctor (a backup for my OB, who had scheduled vacation that day) who were genuinely kind and did their jobs very well. I do, however, take issue with some of the general practices in the American labor and delivery system. In a well-meaning attempt to take care of every single eventuality, legally protect doctors, and provide care to an enormous number of women, those responsible for this system, along with a mostly-negative media portrayal of birth, have created a culture in which many women know neither how strong they are nor what their rights and options are. Deliberately managing one's own birth to create the best possible experience wouldn't be such a foreign concept if the right education and support were given to expecting moms. I hope my story gives you some ideas about what my experience with receiving care from a midwife taught me and how it enabled me to have a wonderful hospital birth.
I had heard that women "forget" the pain of labor because of the delight of having a new baby; I didn't think that saying meant literal amnesia! I had to be informed by my midwife at my first postpartum visit about several points during that day because I literally have no conscious memory of them happening! From what I remember and what I've been told, here's how that day went and some reflections.
My doctor chose a drug called Cytotec for the induction. Most inductions involve Pitocin, which is an artificial version of the hormone that naturally causes labor. By using Cytotec, I gave my body the chance to make its own hormones and do its own work. With each dose I was required to stay attached to the monitors and lay in the bed for one hour. This stipulation was perhaps the hardest part of the process; being unable to move during labor makes every single contraction so much worse. My sister had come to hang out with us that afternoon, but by the end of the hour on the monitors with the second dose I asked her to go home; I was just too uncomfortable to socialize. My midwife and her assistant Mary showed up not long thereafter. Wearing gauges and bright tattoos, Mary isn't a midwifery stereotype, but she possesses an incredible sense of intuition. I barely had to do or say anything for Mary to respond, and she often determined what I needed before I asked for it.
Several hours later I was laying over the ball my midwife's assistant had brought, sobbing. I remember saying "There's just no break. There should be a break. There's just no break." Inductions are difficult for many reasons, but one of them is that the mom's body may not be ready to go into labor yet. Imagine setting the stage for a play. The director has announced a general timeframe for when they typically start, but the play only begins whenever everything is ready. Instead of allowing my body to determine when to pull back the curtain and begin the drama with the stage all set and everyone in place, Cytotec pulled the curtain when there was very little on the stage and none of the players were in place. To make matters worse, my daughter was posterior (face up) and had her head ramming against my pubic bone, leaving a visible, temporary indent just above her forehead. I had severe pelvic pain and wasn't getting any "in-between-contractions" moments at all. My nurse suggested a drug called Stadol, a narcotic that Joanna promised would help me sleep. Choosing to take that drug was the best decision I made all day. I slept for three hours and woke up with a radical peace in my heart. As I had to get to 3-4 cm dilated before I could even receive an epidural, I became determined to just do my best and then make a decision every step of the way. The drug wore off, the contractions rolled on (finally with a discernible wave-like pattern), and I got excited for time since the itching began. In my mind taking the Stadol meant I was no longer having a natural birth. Suddenly I no longer felt pressured to maintain the status of perfectly natural for this birth; I could just work hard and get excited that with each wave I was one contraction closer to holding my baby. Yes and amen. Yes and amen. Yes and amen.
From that point on the rest of the story is mostly a blur. I remember bartering with my sweet night nurse for the right to wear my own clothes (I got permission for the pants; I sneaked the bra and tennis shoes, figuring making an apology would be easier than asking permission) as I made endless laps around Bluefield's tiny labor and delivery (L&D) ward. At that point my contractions must have been decently strong (though I don't remember being in any serious pain) because my memory is foggy about the chronology. I know that I received a third dose of Cytotec because nothing had changed much, that I chose to get a second dose of Stadol, and that I slept again, although fitfully because subsequent does of Stadol are increasingly less effective.
Around 6 a.m. Saturday morning my night nurse came in to tell me she was leaving and that someone would be in to draw my blood shortly. I vaguely remember the blood draw and getting up to to the bathroom. After that I worked through at least one contracting on the birth ball Mary. As I stood up from the ball to move through a contraction I apparently said "Oh, gross!" and my midwife woke up chuckling; she knew exactly what was happening. After a week of reading about the dangers of meconium aspiration with ICP babies, I was thrilled my broken waters were all clear. That moment was much like taking an on-ramp to a major highway. I entered what Joanna calls "labor-land" and remember almost nothing from there out. Labor pain is insane; it's not something to casually sign up for. But then neither is motherhood. I told Joanna after that first post-waters-breaking contraction I thought my hips were breaking apart. She got excited and said that sounded like genuine labor (compared to the not-so-productive pelvic pain I had experienced in the beginning).
Ermias, Joanna, and Mary were my angels for the next four hours. My sweet husband made me drink water, held my hands, and told me over and over I could do it. He was exactly what I needed him to be, but we both later said there was no way we could have done this alone. While my diagnosis did cause me to lose the exact birth I wanted, what I gained from Joanna far surpassed what I paid for. I gained prenatal appointments so relaxed I looked forward to them. I gained the education and the confidence to make decisions about my care, like choosing the Stadol and not getting an epidural and asking for an internal monitor so I could move a bit more freely because the external one kept slipping when I'd move with a contraction. Most importantly, I gained two doulas (birth assistants) who were worth their weight in gold. Movies show women in labor belting out high-pitched, feminine wails; I sounded like a cross between a mama bear and a Mac truck. Joanna kept encouraging me not to be afraid of those sounds and that they were helpful to me and my baby. Because of the crazy hip pain (due to my daughter's being posterior), she and Mary did nothing but squeeze my hips together through every contraction, taking turns until they were so exhausted they had to do it together, one person on each side. At some point I gave in to the seemingly endless waves and stopped getting scared each time they swelled. My moans got even lower and much quieter. I had no knowledge of time passing. I was only present for that contraction, could only handle that one moment.
I remember at one point a nurse checking me and saying those blessed words "she's complete." I had expected to be excited to be near the end, but I wasn't sure I could take anything more. Dr. Edwards had said in the beginning I could push in any position I wanted and I definitely took him up on that offer. At one point I had my head and hands on the raise head of the bed and my feet on the lower part. My midwife laughed at my crazy downward dog. For a moment I realized just how many people were in the room to see these antics but then promptly forgot to care. My room was crowded partly because there were no other women on the L&D side of floor that day and partly because L&D nurses rarely get to see a physiologic (no anesthesia) second-stage labor. Seeing my daughter's head and then watching it disappear without the power to fully deliver her was demoralizing. I kept telling Joanna I didn't have the strength to do this. Then at 12:20-something, in another moment I don't remember, I stopped having contractions entirely and fell fast asleep for five minutes (a physical phenomenon some moms get at the very end of labor). Apparently that nap was what I needed, and at 12:30 on the nose Aliyah Faith came screaming into this world. My doctor held her uncertainly, not sure what to do with a mom who both delivered on her hands and knees and wanted delayed cord clamping. Joanna smiled, asked "Want to see how we do it at home?" and slid my little girl through my legs into my arms before turning me over.
The fog that had surrounded the past few hours instantly disappated, and I could do nothing but look at her. I remembering hearing I had a second-degree tear and something about giving me a little Pitocin to ensure no hemorrhaging (which moms with ICP have a somewhat higher chance of). I didn't care. I looked to my husband to confirm that we were still going with the name we had picked a week or so before. Aliyah Faith was left on my chest for nearly an hour and nursed for almost 45 minutes before the nurses and Ermias took her to be weighed, measured, and bathed. As my postpartum nurse was walking me to my I recovery room on the other side of the floor I got a sight that remains one of my favorite snapshots of the day: my precious parents with their noses plastered to the nursery window. After thirteen babies of their own, they finally had a grandbaby.
Aliyah (ah-LEE-uh) is an Arabic name usually spelled with two As and meaning "the highest one." But writing one A leaves the English transliteration of a Hebrew word pronounced AH-lee-uh. If a Jewish family is "making aliyah," they are moving back to the nation of Israel, making a physical and spiritual journey home. Ermias's prayer and mine is that whatever the road may look like for our daughter--difficult or easy, short or long--her life will be a constant aliyah, a pilgrimage of yes and amen that takes her all the way home.
