I further interviewed Madisyn Miller (’22), who was featured in last week’s article about parenting while pursuing an education (Madisyn Miller’s journey to parenting in college), about her experience giving birth to her son Ezra through an emergency cesarean section. Miller’s story happened in the context of a critical issue in the United States of America’s healthcare system: the rising maternal mortality rate. The United States has the highest maternal mortality rate compared to similarly wealthy countries, with an average of 17.4 maternal deaths out of 100,000 live births, but some studies suggest even higher numbers. In 1987, that number was 7.2 maternal deaths out of 100,000 live births.
Many sources suggest that unnecessary C-sections and lack of proper pre or postnatal care. Racial and ethnic factors also play a role in these numbers. While Miller’s C-section was medically necessary, only roughly 15% of all C-sections in the U.S. are. However, of births in the United States, about 32% are C-sections. When deciding how to have a baby, families are given the option to schedule C-sections at or close to their due date.
Miller’s birth plans were already hindered by her move to Traverse City after the fall semester of her second year at Hope College. Her primary doctor throughout her pregnancy worked at Holland Hospital. However, after moving, Miller discovered that Traverse City’s Munson Medical Center doesn’t “allow you to take a tour unless your obstetrician [OB] was up there. When you go to Holland [Hospital] you get an in-depth tour, and Munson won’t tell you anything.” In light of this news, Miller and her then boyfriend and now fiancé, Adam Kovacs, decided together that it “was probably going to be better [to be induced at Holland Hospital] because if we did wait we would be up in Traverse City, and my water would break, and then it’s a two-and-a-half hour long drive down to Holland. We mapped it out and looked at all the hospitals on the way and we decided to just get induced and have it happen where we feel comfortable and stable, where there’s family around.”
The process of inducing labor requires Pitocin, a synthetic version of oxytocin. Oxytocin typically stimulates labor naturally in women, but in an induction, Pitocin does the job instead. Unless inducing labor is an elective choice like Miller’s, doctors typically suggest inducing labor when a woman is a week or two past her due date to ensure the safety of the baby and mother during birth. A full-term pregnancy lasts 40 weeks, and Miller was induced at 39 weeks and six days.
The labor process has several stages: early labor, active labor and the transition phase. Each of these phases are characterized by how dilated the cervix is, with full dilation at ten centimeters (for reference, about the size of a bagel). Each contraction stimulates the cervix to dilate further, and each stage of labor is increasingly intense and painful, with contractions that lengthen and come more rapidly each time. Typically, first-time mothers give birth after about six-and-a-half to eight hours of active labor. These mothers also typically spend half an hour to an hour pushing contractions.
A large proponent of natural childbirth, Miller came to Holland Hospital on January 14 with her paper birth plan that described all of her desires about what should happen during and following her labor. “I wanted people to push me to my breaking point, and after that I wanted to do the epidural,” Miller said when describing what her plan detailed. An epidural is one of several pain relief options for women in labor. Epidural anesthesia is regional and blocks pain from the lower spinal segments, meaning that it completely blocks the pain of contractions. An epidural is given through an injection into the lower back, where a small tube is then inserted to administer the anesthesia. “I went into the experience very au natural. I wanted to be fully present for the birth. I wanted to see it.” Miller did not initially want an epidural and absolutely did not want to have a C-section, so did not prepare herself mentally before labor to potentially go through one.
The obstetrician (OB) gave Miller her first dose of Pitocin that night, and early labor began. “I went through labor at night, and it wasn’t bad. It was enough to wake you up a little bit, but then you fall right back asleep,” Miller said. “It was probably eight o’clock the next morning when my OB came in and she was like ‘Hey, just letting you know that we aren’t progressing as much as I’d like, so we are giving you another dose of Pitocin, and we are also going to break your water.’ So they broke my water, and it had his poop [meconium stool] in it. They kind of got a little scared because it meant he had a good chance of drinking it or sucking it in, as that’s how they learn to breathe with amniotic fluid, so they were worried it was going to get inside his lungs. And I was like ‘oh, oh no,’ you know, starting to get a little worried.”
After the second dose of Pitocin and breaking the water, Miller’s active labor really started. “My contractions were awful, just like everyone else’s, but oh my goodness. I remember switching from the ball to the bed to the ball to the bed, and by two o’clock I had been in labor, like hard labor, for about six hours. By that time I had had two hours of pushing contractions, like minute on minute off, but I couldn’t push because I was at like four centimeters [dilated],” Miller said. “After about two hours of that I was like ‘Epidural. It’s time.’ It was very nice to have a break. I did two whole hours of pushing contractions and people usually go through like 45 minutes. I felt bad about [the epidural] but at the same time being able to relax for like ten seconds felt so good.”
A few hours later at about five o’clock, more nurses began appearing in Miller’s room. The monitor recording Miller’s labor was showing that with every contraction, the baby’s heart rate was dipping slightly under the normal 120 to 160 beats per minute (bpm). “My OB came in and she’s like ‘It’s the end of my 24-hour shift, and I’m going to talk to the next OB about this, but I’m not super worried about it. We are going to watch it. It might have something to do with how his head is placed or his neck is placed,’” Miller told me. “She checked me, and I was at six [centimeters dilated].” At that point there were several nurses and nursing students in Miller’s room, and Kovacs decided to take a break and grab some food. “He was with me all day screaming from like eight a.m., and after all my screaming he just needed like ten minutes. I was like ‘Yeah I’m fine. You go eat your burger downstairs,’” Miller said.
“From the time it took the old OB to tell the new OB about what was happening [with the heart rate dips] and the new OB to come in it got really bad,” Miller said. “In the matter of like 30 minutes, that’s when his heart rate got between 50 and 70 [bpm]. The new OB looked at it and said ‘Oh, that’s not what she [the old OB] told me. That’s a lot lower. And it’s happening every single contraction. I’m going to stand right here for 2 minutes, I’m going to watch it.’” Miller remembers privately thinking to herself, “‘I hope this doesn’t mean that I have to have a C-section.” After two minutes the OB said ‘This is happening every single contraction, and if this happens one more time I’m taking you in for a C-section.’”
“I remember thinking ‘Oh. Whoa,’ and I started hyperventilating a little,” Miller told me. “So they gave me an oxygen mask, and of course you have so many hormones, and then they’re like your baby is so bad right now that we have to go and surgically take him out. It’s overwhelming.” Kovacs was still gone eating dinner. “They’re like ‘Where’s Adam? You need Adam now.’ I was like ‘Now? I’ve been in labor for like twelve hours at this point. What do you mean now?’ They’re like ‘No, this is happening now.’ It was like a movie. Like my OB is in my line of view over top of me because I’m laying in bed. And she moved and there were like 14,000 people in my room. And a million people started coming in and prepping me.”
“Everyone is like ‘Where the heck is Adam. We gotta go,’ and I remember trying to call Adam and I couldn’t reach him. Later Adam told me that he didn’t get any calls from me, even though I called him. The hospital had spotty signal. He also said that he had just finished eating and so he put his phone in his pocket and brought his tray to where it needed to be. That’s how quickly, like two or three minutes, and then he took out his phone after he put his tray down and saw a lot of texts from me to come back up to the room quickly. So he ran up the stairs and got there, and a nurse had a stack of clothes ready for him. I was just sitting there sobbing and I remember my tears would fall into my ears because I was laying all the way back,” Miller said. They rushed her to the operating room.
At some point during this process, either in the delivery or operating room, Miller told me that her OB “had these tweezers and said ‘If you feel these [poke you] then I won’t start because that means you can still feel.’ You can’t feel the contractions with an epidural, but when someone touches your stomach you can feel it.”
In the operating room, the OB touched Miller with the tweezers. “I remember saying ‘Hey, I can feel that,’ and I remember looking up and telling the anesthesiologist that I could feel it. And he told the OB ‘She felt that. Don’t go,’ and I heard the OB say ‘I don’t care, we have to get this baby out now.’ Then they started the surgery. I felt the difference between the scalpel and the scissors. I could feel everything, and it was awful. I screamed the whole time. Every single thing they did, I screamed.”
“After we absorbed what had happened and talked about it for a couple days, Adam told me that they told him to stand across the hallway while we’re getting her on the operating table,” Miller continued. “So from the time it took them to wheel me in and the surgery team to tell the anesthesiologist assistant to go get him [Kovacs], I was already open, and they were already in me, and I was screaming. That is how fast it was going. But I think Ezra’s heart rate was like 50 [bpm] and below every single time [I had a contraction]. And of course it’s a minute on and minute off for contractions, so that’s a minute of his heart rate being at 50.”
“It was so traumatic,” Miller reflected. “I really wanted Adam to cut the cord too, and things just happened way too fast, and he didn’t get to. It’s awful because I don’t even know who cut his cord, and I’ll never be able to figure it out either. It’s so sad. That hurts me a lot. I wrote on [the plan] that if a C-section happens, I still want Adam to cut the cord. That is important to me. He helped me bring this baby into the world and he should be a part of the birth.”
“The OB came and told me later that the cord was wrapped tight around his neck. It happened after the last ultrasound at 20 weeks [getstation] so we had no clue at all. They made sure Ezra was okay, and then Adam brought him over, put him on top of my chest and showed him to me. As soon as we were out of the operating room they allowed me to do skin-to-skin. Which I’m really happy they did, but I was such a big proponent for skin-to-skin right away,” Miller said. “And I was shaking uncontrollably. It was all the medications. And you just gave birth so your body is in shock, and then you have the epidural and the meds, and I just sat there and shook for probably two hours after birth,” Miller said. “When I got out of surgery and was still shaking, I was having a rough time breastfeeding. I remember a nurse putting a nipple shield on me, and that hindered some of my breastfeeding later.” Miller eventually asked for a lactation consultant at the hospital to help establish breastfeeding and get Ezra to latch.
Miller and Kovacs got back to their room around eight that night. With visiting hours ending at nine that night, Miller and Kovacs decided to let their family visit Ezra for one hour, which they had agreed on as an appropriate amount of time before labor anyway. “And even though I had just been through so much, I’m like ‘That’s fine just an hour so they can come in and see him, and then we’re done.’ It’s so much on the first day,” Miller shared. “As soon as they shut the door I remember looking at Adam and just bawling. And Adam was like ‘Madi do you need a pain pill?’ and I was like ‘No.’ I just was emotionally having a breakdown for a second because I couldn’t handle it. How traumatic. And I remember him saying ‘Ok we’ll go to counseling, are you okay?’ and I was like ‘No I need to cry.’ I never wanted a C-section.”
“I processed it every day and cried every day for a month,” she told me. “I remember letting my emotions express, that’s how I got through it. I would cry or get mad, and Adam would sit with me and help me through whatever I was feeling. Adam was my emotional support.” Miller did not end up going to therapy for her traumatic birth experience as Kovacs and other resources provided support for her adjustment to motherhood.
The first year after giving birth is a turbulent time for all new mothers, but about 15% of women get postpartum depression or anxiety within that year, although it is believed that this affects more people than the statistics say. Factors like an unplanned C-section and traumatic birth experiences increase the likelihood of experiencing postpartum depression. Symptoms are similar to clinical depression but also include difficulty bonding with the baby and can extend to intense guilt and anxiety associated with the baby. Some mothers experience it to such an extent that they feel they don’t love or care for their baby, and may even have thoughts about hurting themselves or the baby. However, there is not a lot of support for women suffering in their new role of motherhood.
In one story of postpartum depression, a mother reached out to doctors because she was having unwelcome thoughts of hurting her baby. She knew she did not actually want to do this and was trying to get help for her condition. Despite seeking help, after reaching out for help with her mental health, “her children were removed from the home she shares with her husband and were placed in the care of a relative” (https://www.mother.ly/news/alabama-mother-seeking-mental-health-treatment-lost-custody-of-her-kids-instead). The mother was forced to spend nights without her children and was told in court that she was a danger to her child. Instead of helping mothers adjust to life with a baby, medical and government professionals have sometimes chosen to tear apart families and take babies away from families even while research suggests that intrusive thoughts of harm are common among postpartum mothers, and that these thoughts show no associated increased risk of harm coming to the baby.
“Besides Adam, I think the only person who sat down with me and checked [for postpartum depression symptoms] was my WIC [Special Supplemental Nutrition Program for Women, Infants, and Children] case manager,” Miller shared with me. “She would come every month to check on Ezra, and she also checked on me. The system really should be improved! What if I wasn’t on WIC? Who would have checked on me? Maybe the pediatricians who see us every month could ask a couple of questions and make sure we [mothers] are also okay.” Some pediatricians do give new mothers a form to fill out that screens them for postpartum depression. When I went to the pediatrician with my son and filled the form out, it disappeared behind the front desk, and I never heard back despite feeling as though I was struggling emotionally to adjust and was dealing with very strong anxiety.
Although screening for postpartum depression should be common for women, there is no institutionalized routine through which women receive support except one check-up appointment approximately six weeks after giving birth. Even then, it is still up to the mother to decide to share those feelings and to reach out for help. Some women, like Miller, reach out to support groups like La Leche League and receive support through WIC, but not all mothers have the resources or know of other mothers that they can reach out to for help. It takes a lot of courage to make yourself vulnerable about struggling with motherhood when it can often be brushed off as “baby blues” or not taken seriously because “you have such a cute baby though!”
Miller, fortunately, did not struggle with postpartum depression. “I think that I became emotionally normal after about three months. I started to enjoy parenthood a lot more, and I wasn’t in pain. Physically, I felt the same by five months when my scar healed, but it wasn’t until I stopped breastfeeding that I felt 100% like myself again. Otherwise I was always at the mercy of feedings,” Miller said of her recovery.
Miller now can reflect on her experience giving birth to Ezra with some gratitude for the doctor who caused her so much pain. “At the time it was really easy to be mad at the person who caused you pain instead of seeing the meaning behind it. Would I still have Ezra if she had waited a couple more minutes?” Miller wonders. Although Miller wishes to have a natural birth in the future, she seeks to approach it in a more inclusive way. “If something were to go wrong in the future, I have to be able to accept what is going to happen; I can still fear it, but before, I wouldn’t allow myself to even think about a C-section. In the end, I would do it three times over if it means I get a healthy and beautiful Ezra again.”