Monday, February 11, 2008

Resuming my life

Yawn...I'm coming off night shift again, which means staying up too late at night for a while until I can convince myself that no-one is about to come in through my front door in labour and expect me to catch their baby. What a thought!

I am a person who dreams about work when immersed in it intently. Which has its drawbacks when I wake up disoriented in the middle of the night to a darkened room, and spend a minute or so trying to sort out where the woman is, and how did I fall asleep on the job? and where is the monitor? Why is the room SO dark? Why can't I feel a fundus and bump and why isn't it contracting? Oh my God someone will think I'm negligent and how long has this woman/baby been unmidwifed?... Until my husband removes my hand from his non-fundus/bump (well, a bit bumpy) and says go back to sleep, dear, and I realize that I'm in my own bed and its dark because i sleep in the dark and get the picture.

I've always been a vivid dreamer with a tendency to sleep-acting-out. DH tells of me sitting bolt upright in bed one night early in our marriage and saying authoritatively " WE always use two detonators!" (don't ask me! I still have no idea). Or the time I insisted he get all the goats out of the room. I do recall fervently attempting to drag his thigh out of the bed and put it back in the cot, trying to figure out which end the baby's head was (the said child was already back in his cot after a breastfeed, but he was about the size of a man's thigh!).

Anyway... I'm slowly adjusting my body clock again. This is a new trick for me. I had never worked a night shift in my life before September 2006, and my colleagues laugh with incredulity (envy?) when I tell them, regaling me with tales of their teenage shifts being a second year student nurse and being in charge of wards of 40 old men in the night. Its fascinating to think of the change in practise in a generation or so, from hospital training to university based nursing. I have been an RN for 2 or so years and still never coordinated a shift, nor am I likely to in the forseeable future. I feel quite unprepared for such a role, but I suppose if I put my mind to it I could do it. Heavens - what a thought! It looks like a combination of keeping a finger on the pulse, being answerable to all above, and being answered to by all below, being the communal problem-solver and being reliant on the initiative and responsibility of the team on the floor. Predictability of situations, learned through experience, helps with anticipation of likely changing events. And so it is that after about 18 months in such an environment I am truly coming to understand the functioning of the place.

This may sound like an 'about bloody time' realisation to you, dear reader. But to me its a result of reflecting on my bemused pseudofunction within an, at times, unfathomable machine. I'm sure I have irritated the crap out of some of my colleagues with my innocence of ward function. I LOOK old and sensible, but I am a complete beginner in this field. Unlike many of my age peers in the hospital I do not come from a background of running wards at the age of 19, so I actually don't have a clue of many things. Sigh. I must be such a trial to them. I must do better.

What I HAVE been doing with my life is functioning outside the hospital system. Which is a skill in itself. And it does give me a sense of where the people in my care will be functioning when they return to their lives. So I do understand about early (and later) parenting challenges, and the loneliness of mothering a kid with colic or a disability, about playgroup, and child-care, and having sick and ageing relatives, about engaging endlessly with therapy services, about being part of a community, a school, support groups, hosting families from other cultures, and being a family assimilating into another community in another country. I've done it from a position of relative material comfort with a husband in a fairly well paid job, but I grew up in a less affluent family so I understand the difference. We've only ever been a one-car family, and until mid-2005 I had never worked full-time since becoming a mum. I've been very lucky to have had the luxury of being a mostly stay at home mum to my children.

So, hmm, what does this reflection achieve? Well, maybe its to remind me that I have not wasted my years, but have been accumulating knowledge and maybe some wisdom that I can share with people I work with. I want to be thoughtful about how I interact with people, I like to understand where they're coming from and find some commonality, or maybe be stimulated by the differences between us. I am rarely put off by difference, I'm usually curious about it. Always have been. Are you?

On my last 2 nights at work this weekend I cared for a woman who had a really high BMI. That's a Body Mass Index - a measure of a healthy bodyweight. Between 20-25 is considered healthy. [Calculated by dividing one's weight in kilograms by the height in metres squared e.g 68kg divided by (1.68 x 1.68) = 24 = OK] This woman's was 51. She was large. Really large. And was with us to have her labour induced at 38 weeks due to a previous stillbirth at term plus 5 days, her first baby. This was baby number 4. Numbers 2 and 3 were fine and dandy having also been induced at 38-39 weeks. She had had 3 vaginal births and although large had average blood pressure and no diabetes or anything.

I met her when the midwives were having difficulty maintaining contact with the baby's heartbeat. Baby was very active, and the woman's tummy made for a positioning barrier where we would normally have good contact with baby. It was a challenge, and she was fed-up with being treated like an obstacle to be got around. It was difficult to avoid the feeling she was being judged for her size. No midwife would ever want a woman to be so overweight, for herself let alone the challenges of parenting three small children, but the issue before us was that due to the measures being undertaken to induce labour she needed to be monitored for periods. And so we struggled on. I was lucky and managed to get a period of good trace so was able to undo the tethers, and let her settle down to sleep. The other midwives wanted to kiss me, as they had been frustrated for ages. It was pretty hard work and the woman was quite negative, however, I managed as a fresh face to jolly her out of herself and she was smiling when I left.

The second night I came on and she was still there, but was heading for a section as she hadn't dilated at all after 12 or so hours of hormones, and the baby's head was really high, and the cervix firmish and long. Bummer. She was quite distraught, and terrified, and mutinous, and wanted to just go home and go into labour herself. After I arrived and gave her a hug and we had a chat she started contracting more steadily and strongly and I encouraged her to get up and walk around, for a change of scene while we waited for theatre and in the sneaky hope that she would dilate suddenly and pop a baby out into my hands before we could get there! She had in fact not been out of bed much in the last day, which was surprising given that they were trying to get her into labour. It wouldn't be unheard of for a woman who had birthed before to have a fast spontaneous labour and do so. But she only spent 15 mins out before going back to bed.

She asked me to examine her after a half-hour to see if there had been any changes, and in fact there were! but sadly not enough to call it established labour and change the recommendation for CS. She reluctantly accepted the situation and we headed upstairs, where she had the spinal epidural and proceeded to have a beautiful, placid, vernix covered and rosebud-lipped baby girl before midnight. I was able to spend the whole time with her and her husband and new daughter and took her to the ward where we handed her to the care of a lovely warm ward midwife. She did say that the CS wasn't nearly as bad as she thought it would be, and she was delighted with her baby, and hoped she could at last get some sleep now after two days and nights in hospital! I hope she did.

I then returned to LBS and cried. I felt I had failed her as her midwife and should have fought harder for her to be given extra time to go into labour on her own, with walking and gravity, even though she was exhausted from lack of sleep. The baby's trace was fine. The coordinator did tell the doctors of the small changes after the decision, but there were not enough to change the outcome, and in fact when the baby was born she had a big bruise on the back of her head from being contracted against a hard unripe cervix all day. We had caused that injury, with our chemicals and hormones. Our reasons were that we wanted to avoid the outcome of a repeat unexplained stillbirth at term in that mother. But that meant that her body never had a chance to go into labour naturally again. And she has now had a CS at a very high BMI after an unsuccessful induction attempt (I refuse to call it a failed induction).

Her recovery will be very difficult. Her wound stands a high chance of becoming infected, and she is at risk of postnatal depression due both to her history and the surgical outcome of this pregnancy. Our hospital statistics will record her birth as one of those 'horror' outcomes where the hospital has to cope with doing CS on grossly obese women and needed extra staff to help transfer her to the theatre trolley at night time when staffing is already short, and an extra person to scrub in to hold up her tummy to get to the operation site. And aren't our theatre staff clever to devise systems to support the pendulous fat on these women? She will be a number and a BMI on a sheet somewhere.

But I know that she was really sensitive about her pendulous tummy. And preferred to hold it aside herself. And I will never know the reason she is so big, but I know that her body allowed her to conceive at that weight, and that she had made 3 babies already at that weight, so her body had adapted to it. I feel really sad that the fat was seen before the woman inside. The fat was less than ideal, but the woman needed our care. Yes she was prickly, and defensive, and scared, but she needed us to not judge her in that moment and just care for her.

A group of us sat around and talked about the issue of judging pregnant women on their size. I was a bit teary about it. And I still am now writing this. I hope I was with woman, not just that fat woman. I aim to be 'largely positive', while working to support women make better choices about their health and planning for child-bearing.

In the meantime I sure hope this woman leaves our care feeling she has received it.


Jennifer said...

What a tremendous amount to think about, to ponder. Clearly your care of the woman was the best that you were able to make it -- and you, working within a system that you yourself just spoke of being new to, and still feeling somewhat an outsider in, made a difference for her. Even if it didn't feel like an ideal outcome for all the reasons you wrote of, the ideal outcome was the birth of a live baby and a mother who lived to go home with her baby. I keep thinking about, too, how you said that people look at you and make the assumption that you've been doing this work all along, that you know it all and have the answers -- and your own wisdom about the knowledge and skills you DO have but that are outside of the ward's usual parameters. i think your story about this woman and your observations about yourself intersect beautifully here, and she was lucky to have you there for her.

I remember talking with a nurse who was checking on me before she left her shift for the night, while the midwife and MD shifts were also changing. It was dinner time -- just before 6:00 p.m., and I had been in labor for about 17 hours and in the hospital for about 6 hours; I was one of those first-time labors that started all quick and promising and then turned into a marathon (at that point it turned out I still had 12 hours to go). Anyway, the trend in the US is to try and "un-do" all the negatives in the past for women and childbirth by giving the mother complete control -- "you run the show," they basically tell us, "you tell us how you want this to go." And being my first (and only, but that's another story!), I wanted to give birth as naturally as possible, I wanted to work with a midwife, but I was not shunning modern medicine and was open to what made medical, safe sense. I just didn't know what choices were best for me since I'd never done the thing before. Anyway, this nurse seemed to genuinely like me and had gone out of her way to come in and talk to me without anyone else in the room. She wanted me to understand what the shift change would mean, how it would impact my care options (starting fresh with a whole new group of people), what various timetables would look like given that she knew that I'd already been at it for so long. A long story, but my point was that she made all the difference to me -- she clued me in to the behind the scenes workings that would influence my own experience, and she helped me make a choice, even though officially she wasn't supposed to be doing that. I probably would have ended up with a CS instead of "just" being induced, if it weren't for her.

We carry our birth stories with us for life. We think about and probably never have the opportunity to adequately thank the hospital staff who work with us. Every day you are at work, helping women, you are being written lovingly into their own life histories. No matter the outcome, they will remember your kindness and will be able to close their eyes and hear your voice, maybe see your face, even if they don't remember your name. That's as much as one human can give to another in that kind of relationship, you know.

Laura Jane said...

Thanks Jennifer for your thoughtful and reflective comments. I have had a few misgivings about this post. It is an honest account of my feelings about the birth, but I wonder when and where and what her reflections about the birth will be.

As you said, we carry our birth stories with us for life. I recall having a similar long labour with my first, which is quite common with first births and went through 3 shifts of staff before he was born on the 4th shift change.

The thing that made all the difference to me at the moment of his birth was that my best friend who was with me in the room urged me (after his head had been hauled out of me by a vacuum machine after 3 hours of pushing) to 'touch the baby's head, Laura, I'll help you' Followed by 'c'mon, pull him out, I'll guide your hands'

There are close-up photos of his head at my perineum with my hands reaching for him. And then, with her help, I, ME, HIS MOTHER, birthed that baby and drew him from within my body. She caught his hips and he landed on top of me like a blue porcelain dragon with a big frown and grimace on his face. He was 9lbs 14oz and I recall the sense of his weight on my newly emptied insides! He needed a bit of resus but was soon fine.

My friend's intervention and urging at exactly the right moment transformed a powerless labour experience into one of empowered birth. I will always be grateful to her for that, and in fact now as a midwife I frequently urge mums to do the same.

Thanks again for your visit and comment.

Lisa W. said...

Laura, lovely post! I wanted to share with you a patient i had when i was first becoming a midwife. she was 5'0 and 342lbs...and came to care at 6wks...she was SO VERY COMFORTABLE with her body and taught me so much that i really got over my "fat phobia". when she got to 10wks and i could check heart tones, she lifted up her pannus and put a pillow under her hips, when i needed to check an abscess on her thigh, she just picked up and hauled around different lipomatous structures until i could see and palpate what i needed. during her exams, we just worked at finding positions. her lack of self consciousness helped me gain confidence and now a lot of my colleagues send me the "big girls". basically i find that if you are non judgemental and can help someone be comfortable with their body, good things can happen. lets hope she doesn't get an infection or a dihescense and has lots of good help at home for her other kiddos. hugs to you...the price of competence is experience.