What do I know now that I didn't know this time last week? (Will I love this question?)
Well, I know that keeping labour normal is not always a job for which one will receive thanks. Not that I expect any in particular. But in the case I'm thinking of, should I have done so?
The unit was crazy, like....Crazy! There had been 10 inductions started the night before and they were all coming home to roost, so to speak.
I had already seen the couple I had been caring for the previous evening (one of the inductions), who had just had their baby at lunchtime, an hour or so before I started. He was a whopper! 9lbs 14oz (4.485kg - the same as my son!) it was a pretty yukky birth in the end (he had a REALLY big head!) and she was being stitched up pretty extensively. I spent an hour or so in their room, cleaning up the chaos post-birth, and organising some solid pain relief for her immediately and planning the next few days worth of it too! There was pressure to get her up to the ward quickly as labouring women were piling up in the corridors and there was a room crisis.
So I was removed from the first couple (their morning midwife took them up to the ward) while I was allocated to another room - their third midwife of the day in all the shuffling around. There was a young woman of 25, labouring spontaneously, hot and heavy. Just holding it together with the use of gas. Oh, and she'd had a shot of morphine too. The husband was in and out of the room, and was clearly quite anxious and unsure of his role. She was attended by her Mum and sister, who were in a great rythm with her, and she sought them as each wave came. She was really focused, eyes open and intense with each contraction, membranes intact. Just how we midwives would expect it to be. Woo-hoo I thought, another spontaneously labouring primip! I know normal birth! I can keep birth normal! I can do this!
I introduced myself softly between contractions, watching quietly as the labour continued thick and fast. Checked the room quietly, gathered a few things ready to meet a baby in the next hour or so. She was so in the zone, sitting cross-legged on the bed. I was just in awe, in fact at one point I was moved to tears by her beauty and strength, she was that amazing. I almost never cry at births, and this is certainly the first time I had cried watching someone labour! Her mother and sister were a little surprised, but I decided to be unashamed about my damp face and silently pointed to her and gave a pat of my heart, acknowledging her effect upon me. They whispered to me "are you always like this?" to which I shook my head- but she is that good.
Every now and then she would rouse and speak, I took her BP every 2 hours, someone came and took the CTG machine (we weren't using it, I could use the Doppler). At one point she asked for an epidural, and her Mum asked her to wait another half-hour, which she agreed to. She sailed through that and on and didn't ask too hard again. Her husband was worried, will she be strong enough to push the baby out after all this pain now? I can't stand seeing her in pain like this. I told him that women were so much tougher than they looked, that's the way God made 'em and that his wife was an absolute Goddess and doing it all superbly.
The madness outside was not getting much better. I was asked to 'prang her' (i.e. rupture the membranes) and get her going and out of there! Well, no! I decided. She was in spontaneous labour, the cervix was dilating steadily (I was watching the line), the waters were intact and she was only just coping with the pattern of contractions now, without bringing them harder and faster, not to mention the effects on the baby - who may need those waters to help him turn to a good position for birth. There was no indication that an ARM was necessary. I regretted performing a belated ARM on staff request on a 34 weeker a few weeks ago who shot into a less than favourable position and ended up being born abdominally via CS. I was not keen to go back there again. I felt I would make the decision for the preservation of normal. So I ignored the request.
The woman refused to reposition, or get up for a wee. When she asked again for an epidural I offered to examine her and see if she was near the finishing line and that may help her decide if she wanted one or not, if the birth was going to be soon. After a wait of a few really intense contractions, she was 7cm dilated. There was a brief discussion of pros and cons of epidural, and I stated that of course she could have one if she wanted one, but that it would be a shame to turn a normal labour into an abnormal one - with a monitor and bells and whistles etc. She was doing so well. The contractions were so powerful, she was so focused .... she lost herself in the next one and kinda never brought the subject up again for a while.
I went for a meal break, ex-HB midwife relieved me and persuaded her up for a wee. Hooray! I was expecting her to report feeling pushy any time. She did report rectal pressure with the peak, but not overwhelming. There was a bunch of mucous - a good sign. It was all really intense, but 7pm came and no baby.
Back to sitting on the loo, listening in to the fetal heart regularly, noticing that the rate is always in a similar range - definitely fetal, but not widely varying, during or after a contraction. I encouraged her to drink fluids, which she did. She was getting really exhausted and desperate and whiny (its typical transitional behaviour) and I was pretty sure she was fully or close to. She agreed to be examined - I thought it was 8-9cm dilated, but there was a pulsating bit off to one side that i was sure was a front fontanelle, and a gap at the left back - bugger! She nearly hit the roof during the exam, which I apologised for, but it was important that I rule out the pulsation as NOT being due to a cord presentation. She stayed on her back, gasping as the next contraction hit, and just lay there. It was horrible to watch. I did that to her. She was coping before and now, for this one, she wasn't. When it passed I helped her immediately to a sitting position and reminded her that she was comfortable in this spot and she would be again, lets regain that working formula.
At this point I had some decisions to make. I felt that with a deflexed or neutral positioned head, even with membranes still intact, it may be a bit longer yet until she was ready to push this baby out. As I had tried to tuck the baby's head down to chin on chest, it had almost risen away from me - yet on abdo palp it felt well down, although in the pelvis it was barely at spines. Her blood pressure had also crept up, not startling, but a sign of prolonged pain/stress. The fetal heart rate variability told me that the baby was either asleep or starting to get stressed. I was getting concerned about her and felt that with all these factors I should have her reviewed. I had kept her normal, but I also recognised that this was deviating from the norm and starting to add up to needing a second opinion. The first step before any further assessment would be possible was to get her out of pain, so as not to cause her trauma.
I apologised again for the stressful VE. Then I suggested she have an epidural, as although she was progressing well, I felt it may be a while yet due to the baby's position and she may need break from pain before the effort of pushing (funny how we can couch the same words as the husband in our favour when we have to, eh?). She readily agreed. Gratefully agreed. Almost kissed my feet agreed!
So then we waited for an anaesthetist. And waited. Finally after 45 minutes (the longest 45 mins in her life I bet) a consultant comes in from home. He is fast and good, considering we don't even have IV access yet. I had everything assembled, the machine, the epidural stuff, the IV stuff. It is in quite quickly, just in time for the night shift staff member to come on. I was attaching the trace as she entered, doing BPs, the woman was smiling, hubby smiling, the intensity was all altered. We were saying that we had waited for a while to meet this baby and the night midwife was going to catch him instead of me - yet I would have bet good money that I would see this baby before the end of my shift! Oh well.
And then we saw the trace. Gulp. It was pretty awful. Late dips all over, pretty crappy variability. Still contracting frequently but oh my, that baby was not coping well. It was the first time we had put a trace on him - there was no reason to - this woman was normal, low risk, and now look at it! The night shift midwife scooted me out the door as I had a morning shift the next day. She is a very capable new midwife with ICU experience, and loves a challenge. So I went home.
I slept really badly. I woke up at midnight and couldn't get back to sleep until 2-ish, and then only fitfully. My alarm was going off at 6, and so when I woke up and started tossing again at 5.30 I gave up and got up.
I dragged my yawning butt into work, where I found out that the baby was born by vacuum extraction at 1.26am, and needed a bit of resus with Apgars of 4 and 9. They had ruptured membranes not long after I left (when she was comfy and in no pain) and there was thickish meconium. Followed by fetal blood samples every hour or so, which weren't too dire, so she was allowed to push for a while before they dragged that 4kg baby out of her when the trace got too terrible to watch any more. Baby was sent to nursery for a while due to respiratory distress. I saw them briefly the next day, still with the whole entourage in tow, and trying to breast feed the baby with 6 people in the room. Sigh - what are their chances of establishing that?
So, in terms of normal childbirth, what did I preserve? Was I all misty eyed about my ideals for her birth? Everything I did was on her birth plan. Should I have said YES, Certainly! when she first asked for an epidural? Which wasn't on her birth plan, and of course she can change her mind, although could she have known that she would cope so beautifully that her midwife would see such beauty and cry, for fuck's sake? Was I so busy singing Kumbayah and reassuring the husband that 'this is all normal' that I ignored danger signs? Was it that dangerous? If I had blindly followed orders and 'pranged her' at 3.45pm and given her an epidural at that time would the mec have been picked up earlier? Was it there then? Did she actually care about having a normal birth? Or does her idea of a normal birth include an epidural? Cos it technically isn't...and introduces all sorts of interventions that can start the cascade of interventions that lead to CS ...oh for God sakes...you KNOW all this!
I'm a bit frustrated and bewildered. Is this a win some/lose some situation? Cos if it is, I could have just saved her all the trouble and pain and got her an epidural 5 hours earlier - even though it would have meant finding a spare CTG machine in a full LBS with all the women on all the monitors already...sigh. Has anyone been done a favour here? Answers on a postcard please.
In other news - something else I know now, that I didn't know last week, is how to suture perineums. I did a workshop yesterday. It was fun! Yes, really. I can now be Really Useful. I took to those knots like a duck to water. It was fun having a trial run on a piece of mutton. It took a while, but I think I am willing to do it under supervision this weekend when I am working 5 shifts in a stretch. (We then had to undo all the stitches so the demonstrator could take it home for her dog! )