Tuesday, July 1, 2008

Teaching tools

It had to happen one day.

On each of the last two night shifts I have been assigned a senior medical student. One hopes these students witness an easy, natural, spontaneous labour and birth, with no dramas, bells or whistles. Sigh. You want to make God laugh, just tell him your plans.

Night ONE. Enter the room to a very young woman, unaccompanied, in spontaneous labour with first baby. Progressing well, has an epidural in place, which means there needs to be fetal monitoring. The fetal heartbeat is a bit fast, just above the normal range, but Mum has a slight temp and this is often the cause. I was still taking handover when the heart sounds took a dive. And kept diving. From 170 beats per minute to 55 bpm. Roll over, take pressure off the cord, roll the other way, no recovery, its been a minute, call for urgent assistance, warn the Mum, the team comes flying in, after another minute it starts to pick up and ticks along to its usual merry rate. Phew. Wide awake now and well on our toes. Explain to the med student that that is NOT a normal pattern.

Twenty minutes later it does the same thing. Stormtroopers re-enter, this time the recovery is a little quicker, hmm, little tricker baby. Where is that cord? Are you holding it? Is it wrapped around an arm? The cervix is dilating well, its nearly fully dilated now, it won't be long until this little one can be pushed out if necessary. Keep watch.

Dive three. Reposition and watch and wait, call the coordinator, ah yes, here comes the recovery, and the cervix is now fully dilated. Good, lets hope she can get some descent with just the contractions in the next half-hour or so, don't want to push too early with a primip. We top up her epidural as the pain was breaking through again and I'm sent to tea with another midwife covering in the room. I get a banana and half a cuppa into me when I am called back for another deceleration. It is recovering by the time I get there, but the coordinator is a bit concerned as the docs are all in theatre for emergencies, and this baby is still playing tricks that may need some urgent assistance. Bugger! We start her pushing just as a relative arrives, an aunt who looks as though she has had plenty of experience in childbirth. Yep, 9 babies, she tells us proudly. Oh, we are so glad to see you, you're just the tonic and company your niece needs right now. After 4 contractions worth of pushing the fetal heartrate takes another dive, and stays down this time. Get a senior-ish doctor out of bed as all the rest are still in theatre, and she decides to do a forceps birth there and then. We quickly get a strong top-up into the epidural, while the heart rate crawls back up. The medical student got an eyeful of a very confronting birth over the next 6 contractions, as we all worked together with the young woman, her aunt and the doc to bring the baby suddenly into the world. She, the baby, was not impressed! She was born in great condition and squawked loudly for the next hour. My back-up midwife was fantastic, very supportive and on the ball, encouraging me to stay with the girl and keep her on track and accepting all the delegation really efficiently. It was my first time seeing forceps in the room (instead of transferring to theatre) and it was not pretty. Somehow the draping of the operating environment seems neater, or something. There was a lot of blood, and flesh, and stitching required. Poor kid. She was pretty shocked. I think I was too. The med student told me later she was surprised you could pull so hard with forceps, but didn't seem particularly phased by the experience. She was called to theatre a little later to witness an emergency CS, so had a fairly full night of viewing!

From my perspective I was disappointed she saw such a violent emergency with so much drama preceding it. One aims to show a woman moving and coping well with contractions, with minimal monitoring, as a role model of a normal physiological process. It is too easy for the medical model to be seen as the norm, and there is such limited opportunity for them to see a normal birth, so they may never know the difference between the physiological and the managed. They will rarely see the way it can be. As an advocate for normal birth it is frustrating. But the vicissitudes of working in a large high risk hospital mean that it can be weeks between us midwives seeing one of those too. Sigh.

So, night TWO. Assigned another student, pick up a woman from the assessment area in early labour with baby number 3. Waters broken 12 hours ago, meconium stained fluid draining. Needs monitoring and a drip to get things established as the baby may be compromised. She had had two previous vaginal births with minimal analgesia, both over 9lbs and this one was a similar size. Should be a straight forward labour and birth with continuous monitoring required and a paediatrician at birth due to the meconium. Do you hear God starting to chuckle?

She was attended by her teenage sister, and her hubby was on his way back to the hospital. The woman herself was really cheerful and positive, a short round young woman who had complete confidence in her ability to just get on with it. And so we started. The baby was initially in a posterior position and a bit tricky to monitor with that lovely plump tummy. Bub was really active, and turning to a more favourable position for descent, and unfortunately the need for monitoring meant she had to be near or on the bed with me holding the heart thingy all the time. She didn't complain, and I gave her frequent toilet breaks to apply gravity and some hula dancing to shake things up. Hubby was back by midnight and sat dozing in a chair, but could be encouraged to apply sacral pressure as long as he didn't have to see anything gory. He wasn't good with body fluids or hospitals. At one stage he threw up in the bathroom, and stayed a bit pale, but came back to do his bit with the back pressure. He was full of praise for his wife's talent at labour and birthing, and was most assured things would be well over by dawn. The sister was soundly asleep.

By 2am things were getting pretty full on with contractions. Gas was being used and she was really hilarious under the influence, but it helped immensely. We encouraged her to position herself for comfort, and examined her for the first time. 5cm dilated. Hmm, a little less than we expected but steady and not that surprising given the non engagement yet of the head. The fluid was getting a bit thicker and I asked a more senior midwife to come and check my abdominal palpation. She agreed with my assessment, and confirmed the fluid was thicker. The trace was good, heart-rate good. Just as she was leaving the dad tried to cross the room to go to the bathroom. I heard a thump. He had fainted. It was a bit busy in there for a while as I organised oxygen and some staff to attend him, and the woman was pretty desperate and calling for me to apply back pressure with each contraction as the sister slept on. My hands were full. Hubby was taken away and not keen to come back, and I was under pressure to take a tea break, but she pleaded with me to not go. I felt sure she would start pushing very soon, in fact she had a lot of involuntary pushing with contractions, and was shaking in a transitional way. Another assessment showed 7cm so we got her up again for another plie and hula dance, and had her climb up on a higher than normal bed, and kneel up and down repeatedly to encourage the last bit of rotation and engagement of the head. Finally another midwife came in and insisted I leave for a meal break at 3.55am. I reluctantly agreed, assuring the woman I would come straight back if called.

My backside had just hit the toilet seat when I heard the phone ring - Laura - get back right now! I finished my wee and ran.

I entered the room to find a green head between her legs and a wide-eyed look of shock on her face. Clever girl, that was quick! I pulled some sterile gloves on as others called the paeds and I eased the rest of the head out. The face was slow to emerge and people were passing me suction to suck the meconium from his mouth and nose. It all seemed to happen in slow motion. I could sense the activity behind me. His head slowly rotated to Mum's left thigh and I got her to push but he wouldn't come out. No cord around his neck, but he was stuck pretty tight. Call for assistance. Legs went up, knees to nipples, more pushing, normal traction, no progress. His head was turning a deep shade of violet, and I could see his white neck. I called for supra-pubic pressure which was applied, and I carefully kept the traction on. After about 15 seconds he started to budge and slowly corkscrewed in stages from his mother's body. It was nearly two minutes from head to body delivery and I was very relieved to guide him out in a rush of fluid and meconium and blood. Clamp and cut, hand him to the paeds and he started gurgling and crying within 20 secs. Phew.

It was my first shoulder dystocia birth, and I had anticipated it as a possibility with this birth. He was a really big baby 4720g - or 10lbs 6 ozs plus change, and really long too. The placenta was pretty tricky as well and Mum lost a bit of blood initially, but was soon well contracted. A doctor had arrived with the assist call and helped get the membranes out and confirmed the bleeding had stopped. We were shocked to see that the perineum was intact! OMG! After hauling that toddler out of her! Holy crap!

There was a lot of mess, which we just threw a sheet over, as the sister was taken from the room in a wheelchair as she had almost fainted. It was quite some 10 minutes really. And once again my medical student had got more drama than we bargained for! Oh dear.

After 15 minutes and a quick cover-up of the mess, Dad was brought in to meet his son, and praise his sweet little wife who was recovering from the shock of it all. Baby JJ was a bit pale and shocked, but admired by all. He was so big he was almost hanging over the edge of the warming cot, and the wraps seemed tiny. They were all pretty pleased with themselves and he got stuck in to a feed fairly soon, and pinked up nicely, even if he did have green hair!

I got to have some dinner about 5am while bub was at the breast. They were up on the ward by 6.15am, after we had photos together to celebrate our joint achievement. The sister and the med student were de-briefed about the events, and assured that although the last 2 minutes had been a bit hairy for all concerned we were pleased with the outcomes, and were they OK? The sister was pretty freaked out by the green head appearing so suddenly, but was reassured that it was fairly normal when a baby had done a poo before birth. She had a cuddle alone with the baby while Mum was in the shower and was interacting well with him and telling him all about it. The med student was going off to learn more about shoulder dystocia and emergency drills!

It had been a real effort, that labour and birth. It was the first time a woman had really leant on me so heavily during labour, and called my name so repeatedly. There was a lot to balance - the positioning, the trace, the meconium, the fainting family, the documentation, the assessments, the being with woman in a tight spot. I was grateful to be very well backed up by other staff who supported everything I was doing, and without whom I would have felt a bit scared. It was a challenging shift and I learned heaps.

I'm getting the hang of this.


Frogdancer said...

I really should stop whining about report writing.....
Well done!

widget said...

omg! You do have such INTERESTING evenets in your job. Your students were lucky to have you explain these things to them. Well done!

Alby Mangroves said...

As Ron Weasley would say; Bloody Hell! I need a cuppa just reading it, let alone living it! WOW

thenerms said...

Oh my goodness Laura...
I remember that shoulder dystocia, I had that with my twins. Do you remember.. you were there. Thank goodness.

I am exhausted just reading your blog and your wonderful day at the office. Well done..!!

Lesley said...

No wonder you were so exhausted that morning/night when I tried to skype you!
All going so beautifully - well done you. They're lucky women to have you with them, even with all the s-t-u-f-f happening!

Louise said...

You are amazing woman!!! I have finally joined blog land this morning!! If you have any tips on how this all works I would really appreciate it. Love you and miss you!!! Mwa mwa. You are doing a fantastic job out there xxxx Louise

Kelley said...

my job is not nearly as interesting, but probably as bloody ;)

Julie said...

I just found your blog through Alby Mangles blog. Wow, you have some amazing stories. I've had two bubs, all pretty "textbook" I was told, even though it doesn't feel like it at the time. Makes me feel lucky when you hear all about other peoples birth dramas.

alexandra said...

Wow, your stories are amazing. I've been so lucky to have two very straight forward natural births with midwives in a birth centre, reading these stories is a real eye opener. I could keep reading for hours, alas, I have to go and play trains with my eldest!