Wednesday, August 6, 2008

Telling tales

So, I have finished this stint of nights and it was pretty good really.

On Saturday night I had the care of a woman having her second child. She didn't speak a lot of English and seemed to be coping fairly well with labour but it was getting tough. For a change, it was a spontaneous labour with no risk factors that would necessitate continuous monitoring so I just listened in each 15 minutes for the length of a contraction or so to check the baby out. When she entered the transition phase she became very vocal and thrashy and grabby. I hadn't examined her for a few hours and when she started involuntarily pushing and started asking for an injection for pain relief, I offered to examine her to see if it was safe for the baby to receive a drug so close to birth. I was fairly sure the cervix was fully dilated and it was, and the head was quite close to the world, so the answer would be no (to drugs). She was disappointed about the drugs, and I'm sure swore a bit in frustration in her own language. I just smiled encouragingly. Within 5 pushes the baby was out and the medical student with me had half-caught another one for her book. It was a girl, there was much delight in the room, and they couldn't dress her in pink from head to toe quickly enough! Dad hadn't seen the birth of number one, so was pretty impressed with his wife. And the baby was such a cutey, little Ishmeet.

Across the hall an hour later, around 3am, a shocked, and shivering woman was wheeled in by ambulance (shaking is fairly normal after birth). The ambo walking after her had a silver wrapped bundle in her was a baby! I briefly congratulated her on the little one and went back to my room, but soon I was called in to be another pair of hands in what turned out to be quite a drama. It was a cold night, expected to be 3 degrees C, and the woman had been asleep alone in the house with her 2 year old when she was woken by sudden strong labour pains. The contractions were coming so thick and fast she couldn't get to the phone to call for help. The baby was born 30 minutes later in the bathroom as Mum sat on the loo, splash, clunk! Poor woman. She pulled baby out and wrapped him in a towel and struggled to the phone where she called an ambulance and her Mum. She then had a big bleed, and ..and..oh dear, it would not have been pretty. The woman herself was still sobbing in hysterical shock and really seriously cold. We kept taking her temperature and not quite believing it was so low, but I called for a special warmer from theatre, and warm IV fluids to raise her temperature as soon as we could. The baby was also seriously cold. We are taught that babies must be warm, pink, sweet and clean. Meaning they must be ideally between 36.5-37.1C, have good circulation and heart rate, adequate blood glucose levels and be kept free from infection. Between being so cold, and banging his head at birth he was not in fantastic shape. He was taken to the nursery pretty quickly where he was in a pretty bad way for a few days. I haven't heard how he is today. Mum continued to bleed, and with a poor circulation due to low body temperature it was hard to get it all under control. We kept having to remove the blankets from her to assess her loss, put in catheters, new drips, massage the fundus. Her mother arrived after finding someone to look after the 2 year old, and was still beside herself with shock. She said the house looked like a murder scene, and was clearly very traumatised even by the aftermath. She shuttled up and down to the nursery seeing the baby, and then the woman, who was moved to special care once she had been slightly stabilised after 3 hours of constant attention. It took 12 hours or so to get her temperature back up. It was quite a night.

I was pleased to work with a homebirth family requiring a CS last week. The baby was in a persistent and damnably unfavourable position for a homebirth and there was a very clear plan to transfer for CS after a bit of labour, which is what happened. Baby was born just after midnight and went skin to skin after the resps were established at 30-40 seconds. She was pretty squished from the labour and the unusual position in the uterus. They had half an hour together on the table, then she went to Dad and returned to Mum in recovery 10 minutes later, where she had the first of many feeds as she remained skin to skin for essentially the next 6 hours. There were no beds for postnatal care so she came back to LBS with me and I looked after them for the rest of the night. Baby Ryder didn't even get weighed until 6 hours of age because she just fed from side to side for all that time. It was really nice, a lovely family, so gentle and calm with their baby (who could suck for Australia if a place came up on the national team!)

What else? Hmm, lots of things. A young woman with a stillbirth, a 2.2L PPH and really high blood pressure - she really hit the bad luck jackpot, poor girl. Another couple of PPHs, 1.8L, and 800mls, that is always a fun way to start the shift! A really intrusive friend at a birth who just wouldn't shut up while she was pushing, and later while the mother and baby were bonding and trying to feed. I felt like saying - if I rip the baby from his mothers arms and weigh him (to give you the information you're clearly dying to be the one to spread) will you PLEASE shut up and f*** off? But of course I didn't. I just kept addressing the new mother directly in a quiet voice and ignoring her friend, or gently but firmly correcting all the negativity the friend was spouting that was all about her, not the precious moments she was intruding upon in the room she was a guest within. We did all sigh with happiness and the mother actually stated "oh its so quiet" as soon as the friend left. The Mum and Dad were so enraptured with their little fella, Jacob, who was extremely edible, all 8lbs 5oz of him. Quite, quite yummy he was.

There's been quite a bit of time on night shift to get to know some other midwives better, which has been nice. Some new staff, some staff returning from maternity leave. Some politics, some passion, some laughs and frustrations. Helping each other with the formal wording required in our competency documents for professional development. Sorting out the state of midwifery in Australia vs England. All sorts of things. Challenging and exploring each other's views on a range of topics. Burnout, job satisfaction, intervention rates, is normal birth possible in a high risk setting?

I was pleased to be able to see that doctor who had given me such grief over the woman wanting a VBAC. She assessed another woman whose cervix had not dilated over an 11 hour period and there was a fully agreed and harmonious collective decision to go for CS. When I asked her off to one side to give me some technical details related to reason for section, i.e urgency of need, and reason for CS she said 'failure to progress'. I took a deep breath and said 'actually - how about we put the reason as delay in first stage progress, so the woman doesn't start her mothering journey being labelled 'a failure' ". She looked taken aback a little, but said "well, its probably the same thing, but I can see how that would make a difference to the woman, so yes, fine". I was quietly pleased, and hope I have sown the seed for a change in her thinking. This step had been suggested to me by professor of midwifery who I had contacted after the first incident had distressed me. It was a really good idea from her.

I'm coming to the realisation that I have become comfortable as a midwife now. Maybe it is just feeling more consolidated in my skills. I feel this second stint on LBS, following from the stint in the community on the visiting midwifery service has seen me become so, and I can feel that I might be ready to start making some decisions in my future directions. Some of the clinical midwives I work with have been asking my intentions, and have all said they could see me working in the community, but I don't think I'm ready for that. However if the chance came up at a more caseload model of care - where a small practise of midwives are assigned the care of women and back each other up to provide antenatal, intrapartum and postnatal care that would be a good way for me to go, I feel. Maybe in a birth centre setting.The drawback of that model apparently is the on-call work, but there is one very near where I live, which could make the on-call work more manageable. I feel the time is right to start making plans to actively seek those opportunities, and to gain the skills I will need to be competitive when I apply.

I am still looking and reflecting within as I practise, but I am now more able to raise my eyes from the road, and look to the journey ahead. Its a big wide world out there.


Natalie said...

You bring right in to the action and keep a great deal of the emotion in there as well... such interesting stories and accounts. I love that you removed the *failure.*

Frogdancer said...

This was a lovely thing to read. I'm sitting at my desk at work, feeling headachey and hoping like hell that I haven't caught Jordan's flu. This was a beautifully written account that made me feel a lot better.

infomidwife said...

What a enormous range of experience this stretch of night shift has given you. i really enjoyed reading your account of events, great reflection. It would be interesting to find out how many women birth at home without a midwife - the unplanned, unexpected birth. Maybe we could look at having a callout system for women in such cases, food for thought! not that would of saved the woman in your story, but maybe she & the baby would not be so cold.

Anonymous said...

Gosh I love your posts. Really takes me right there to the moment.

Lisa W. said...

you've been a busy little midwife! nice job of reframing the "failure". I've had 3 malpresentations this week (gah!).....a face presentation at 35 wk that delivered vag, a frank breech that we sectioned and an ELBOW presentation that we tried in vain to reposition manually that also went to section. That was certainly an unusual and perplexing exam!

widget said...

such a simple step to remove one word, but the ramifications are huge. I am so impressed. I love your blog - it keeps me real.....Thank you!

Lisa Barrett said...

I'm wondering why anyone would think that 11 hours in the first stage of labour is delay, prolonged or a failure. Change of word doesn't change the outcome. I appreciate what you did for the woman but wouldn't it have just been better to wait for the baby to be born?