Thursday, October 9, 2008

Second stage

Hello again world.

I had 2 lovely shifts with a student midwife earlier this week. Yes, really, and no drama was attracted! It was such a wonderful change (for us both). We were both just delighted with our birth together on Monday.

We entered for an afternoon shift to an 18 year old primip who had just achieved full dilation about 30-ish minutes ago. Her morning midwife was gentle and very low-key and non-interventionist, and has recently returned to the hospital after a long stint working with homebirths, so I knew she had really good assessment skills and faith in the natural process. It was a spontaneous labour and the room was calm, and the only attachments were the CTG because the woman had opted for an epidural. She was standing at the foot of the bed as we entered and the bed was arranged as a big low armchair for her to sit upright in if she wanted to. It was good to see it like that, I had forgotten that it could be put in that arrangement.

We were waiting for the contractions to do the work of inching the baby closer to the exit for the next hour before starting any active pushing. So we just encouraged her to stay upright and rest as she was comfortable with her epidural and quite mobile as well. Its a good combination when you can get it. She had her Mum and a sister-in-law with her, her partner was quite squeamish and was waiting outside by mutual consent. This was women's work.

After a while it was time to start having a push. It often takes a long time to get the hang of pushing a baby out, especially in a woman with an epidural. They don't get the same sensations of the baby within that an undrugged woman does, nor do they get the expulsive reflex that is just irresistible and almost pleasurable. The midwife uses words to guide her pushing efforts, or gives feedback as she can see the progress (or lack of it) of the push. It is a tricky process. I usually start by describing what I'm looking for - a flowering open of all the bits that are usually tucked up, as they expand in the way Nature designed. I will see an expansion of the perineal area, a parting of the labia, a pouting of the bottom, a tiny bit of stool pushed out in advance of a descending head - these are the signs we look for that tell us descent is happening. Most women are (understandably) reluctant to think of the appearance of poop as a 'good thing' but we midwives are very encouraged by it.

At 1.45 she started pushing. Her contractions were quite short, and it was difficult to get much momentum going with the pushes as they would die away just as she got to full push power. There was nothing visible after half an hour of pushing. One of the docs came in and suggested a bit of synto to help strengthen and lengthen the contractions, as she was well covered by the epidural and it shouldn't distress her. So we all agreed on that, and stopped pushing for 45 minutes to let them build up and for more descent. She walked to the toilet, remained upright, and saved her energy while we went to tea.

At 3pm we started again. The woman was really mobile and I was confident that she could position quite freely to assist descent. The baby wasn't huge, but the other midwife felt the head was sitting a little tilted off to one side instead of presenting the central back of her head to the exit. I hadn't examined her at all, but trusted the assessment, and the slow progress with pushing backed it up. The answer in this situation is positioning. Keep moving. Have three contractions in that position - if no progress - CHANGE something. Free mobility is really so useful in second stage - e.g. walking up stairs, crawling up or down stairs, lunging or clambering like a bear up on the bed or over a chair can shift the angles of the head in relation to the pelvis and provide that 'give' that gets things moving. So in this case, with a young fit, mobile young woman I was determined to give it a go, and keep birth normal!

I can't do it, its not working she cried. Nonsense - it just hasn't worked yet sweetie. You're doing so well, you're really actively giving birth here, not having it taken from you. Pull it out, suck it out! she moaned. No, we may need to ask for a hand in a while, but first we need to know you have tried everything! Leave no stone unturned for you to give birth unassisted and push this baby out on your own. She agreed that was worth doing.

By this time I had her standing on one leg with her other leg kneeling up on the bed at near right angles. I was kneeling behind her, gently stroking the base of her spine and hips, encouraging her to rock in wide circles while I spoke soothingly to her, encouraging her to sway her pelvis to shake that baby loose. She was in a bit of a trance. With each push she would strain, and then hold back as she sensed something shift. She didn't want to poop or fart. I told her quite plainly that I would cheer if she farted in my face! It would mean something was moving. We all had a laugh and with the next contraction a teeny bit of poop came out - hooray we were on the move!

The morning midwife was due off shift, but was keen to see a bit of this baby's head. Alas that bit of poop was all we could manage for the next 15 minutes. She went off after giving a top-up of the epidural as the woman was feeling the contractions again and we felt the relaxation of less pain for her would help us all out if it was going to be a long process, and frankly, with such slow progress it was likely she would end up with an assisted birth. She left at 3.35pm.

A bit more poop. Change position. Back onto the bed to push sitting back a bit, on the side now. More poop. Finally we had some labial parting, but then she would hold back when it moved forward - it does feel a bit freaky, but I remind women that if it feels scary you're doing it right! I encouraged her to feel inside and tell me what she could feel. She was reluctant, but I could do it if I wanted to. There was a little head about an inch inside. Swollen on top but finally close to the world. With the next contraction she had a go and felt it too. Eee-ew! she said and wiped her finger- but her eyes lit up a bit - it was real. There really was a baby coming! It was 3.45pm.

The contractions were still quite short, but I would get her to do 'one more push for luck' as it was easing off, which unless I asked for it she would try and get away without doing it. 18 year-olds are so cheeky! It became a running joke. At 3.47 there was enough labial parting to get a peek of the head with pushes. Head on view. At last. The trace never looks good with pushing especially at this late stage. It is physiologically normal for the heartrate to reduce with the contraction and expulsive effort, and to recover between contractions as the squeeze is off, but it is watched nervously nonetheless and with central monitoring there are often many people watching. This means that there will frequently be someone at the door asking if things are alright, or actually entering the room and tempted to intervene if they don't quite trust that things are well or moving fast enough.

That little head stayed elusively away from the exit. She just wouldn't crown. I started to mentally prepare for a shoulder dystocia (as is often preceded by slow descent) and quietly communicated this to the student, planning which side we would apply suprapubic pressure from and getting the bed controller at the ready for fast maneuvring in case of emergency.

I heard the door open as she was pushing again. I spoke more loudly than I usually do and said "good girl, yes, thats much more head than we've seen so far, ooh look at that hair! Good pushing, nearly there" as the feet at the curtain identified themselves as the consultant. A quick peep around the curtain to glimpse the vertex for himself and he melted away again with encouraging noises. It was 4pm.

With the next contraction there was a little more head to see, but still not too much. I examined her to see if there was a band of tight tissue, considering an episiotomy, and feeling only a smallish band of the hymenal ring, but a lot of moulding of the head and it was still a bit tilted. It was a tightish fit (what you would expect really) but I could slide my finger all around the head and couldn't feel a hand as well or anything, so we would just wait. Maybe consider legs pulled right back, and recline back a bit more. Ah there we go, thats the best we've seen, we are nearly crowning now. The shortish contractions inched along but came frequently enough. The woman was getting desperate despite our encouragement - can't you suck it out? No honey - its honestly not worth opening the sterile packs - baby is right there. Don't give up, she'll be here any minute. She could shoot out like a pea with the next contraction. It was 4.15.

I heard the sound of the vacuum trolley being wheeled outside the door. At 4.17 the door opened again. It was the young female doctor who started the synto. Ah very clever, she cried as she could see the almost crowning head. Our eyes met and we were thinking the same thing. She came in for backup- we both prepared for a shoulder dystocia by dropping the head of the bed, with legs pulled back. Finally the head crowned, followed slowly by the face and then the chin. We waited for a turtle sign, where the chin pulls back into the vagina as the shoulders hook up on the pelvis. No turtle sign, feel around for a cord at the neck, no, no cord, ready student? Its all yours, OK hon one last push now - here she comes! It was 4.20pm and cheers erupted in the room, the young Mum was sobbing with relief and joy, her Mum was misting up and SIL too, and she came forward to cut the cord. Little Aliyah was a bit stunned but soon had a brief yell and then lay frowning and blinking on her mother's chest in the afternoon light as she was cuddled and wiped.

What an effort! A three hour fifty minute second stage. Admittedly with an hour and a bit for descent initially, followed by another 45 minute rest, but it was still pretty prolonged for a hospital birth and she still managed to push her baby out. We were all absolutely rapt. I felt like a Midwife! It was rare to get the space to conduct such an active second stage, with minimal intervention from docs or others, and the woman herself was just terrific. She tried so hard, and pushed so hard, and cooperated, and hung in there despite collywobbles at times. It was such a group effort. We were all just thrilled to bits. And an intact perineum with minimal blood loss. Baby number ten for the student midwife, who was just tickled pink. She too felt we had dodged a bullet, no assisted delivery, a truly active second stage even with the epidural. She said she learned so much about positioning, and moulding and understanding the principles of descent and pushing with an asynclitic presentation (the tilted head). It was just great.

Dad came in within minutes and was suitably delighted and misty to meet his daughter. Baby Aliyah saddled up for a feed promptly, and boy could she suck! What a talent. Her mother had great nipple shape too so it was easy to put it all together with minimal assistance from us. We couldn't praise them enough.

I saw them again the next day and they were doing just great, all smiles, very comfortable and pleased with themselves. What a lovely start for this little family. I'm so pleased for them.

The morning midwife saw me the next day and was skipping that we had achieved a spontaneous birth. I was still grinning too! I swear I must have had the Jedi mind control that day - to talk soothingly to all the docs and others, reassuring them and having them melt away while we had that head on view for so long. It was fascinating, and I suppose that they must have had confidence in me to call them if we needed help. I was completely fine with the backup of the doc at the last minute, in cases of shoulder dystocia you don't want to muck around, but the student midwife got the catch after all her hard work that afternoon. It was win-win.

Our next shift together was also terrific, a lovely woman and her husband and Mum, where she had had a shoulder dystocia with her previous birth, so it was certainly the flavour of the week! She laboured really intensely with us all shift, and we were sure we would get to see her little one, but she went on to birth an hour or so after the end of our shift. The birth was straightforward with no emergency, so we were pleased to hear that even though we didn't get to see her baby.

Achieving that birth on Monday has boosted my confidence in my 'normal birthing' skills, that are easy to lose in a tertiary hospital environment. I do recognise normal. I can model the normal to my student midwife. I can keep birth normal. I can recognise if things deviate from normal and am trained to respond appropriately, but all the time I am shaping my care and responding to the needs of the woman at the centre. It is good to have this experience after a few weeks of turmoil and drama (which is still playing out).

I love being a midwife.


Kelley said...

I wish you were with me at the birth of Moo. Some of my midwives were so patient, but others were horrible. I got to meet a few seeing I was in labour for 38 hours.


Lesley said...

Just a great story to read. Wonderful.
I'm loving your 'Small World' series of pics of microscopic things. Some of them are extraordinary!

infomidwife said...

all I can say is FANTASTIC - this is a wonderful story and a tremendous experience for your student midwife, she will remember this and it will guide her in the future - well done Laura.

Alby Mangroves said...

I love that you love it! Another one for the record books :)

Kel said...

as a home birther and non midwife or hospy person, im surprised at how you appear to describe non-interventionist birth in the hospital setting to be quite a rare thing. i think i had hoped that NCB in hospital was becoming more a norm. keep up the normal modelling, *bells n whistles* as a health educator in the tertiary setting it is this modelling which appears to be so important. your love of your job comes through always when you descibe a birth at work.

em.s said...

that story was awesome. I'm kinda teary (not abnormal for a pregnant woman, i know!) i wish you were MY midwife!!!!!

lisa tilse . the red thread said...

Wow, what a wonderful post! I just stopped by here after seeing your comment on Elsita's blog. I haven't got to read anything else here yet, but I will! What an amazing job you have.