Thursday, July 24, 2008
Monday, July 21, 2008
I feel nostalgic for our trip....so I will post links to our travel blog from the next 7 weeks. You may click or not. Get jealous or not. But it was the first holiday my husband and I had taken together since 1983, before children. The trip was also a reward for completing my studies, commenced in 2002 to become an RN and then a midwife. I was so excited, I was jealous of myself! I would giggle at the thought of it.
And the reality of being elsewhere with Don, in other countries, with no-one else to please or consider but ourselves was intoxicating.It was such a great trip. The DVD of stuff from the video camera arrived just last week (long story, very dull), so we have been watching it and seeing some bits we'd nearly forgotten already.
The original posts from circa this date are here and here on our World Tour blog. See if you can click somewhere to go to a central page and find the photo albums for the places too, there's some lovely stuff. Natalie may recognise La Jolle from the San Diego stuff...sigh.
Thursday, July 17, 2008
Tuesday, July 15, 2008
You have each sent me this honour currently doing the rounds. Forgive me if I don't send it back directly (although you both deserve it).
The only catch is that I have to pass it on to SEVEN others (by making a comment and telling them I've done it, and to come and get the pic from my blog, then pass it on, citing me as their source).
I have 63 feeds on my bloglines (!) and some of them have already received it - but I suppose that doesn't matter really as, if I think they're brillante (brilliant?), then they just are.
I received a package from the generous Victoria this week. She was kindly giving away prints of her insightful and quirky collage art. My loyalty can't be bought, but I'm really thrilled to receive these pieces from her. Tagged!
Next - the wicked and awesome Kelley, who tells it like it is. I laugh and I cry reading her blog. She won't be surprised...it is all due to her awesomeness.
Hmm, three to go. Jess has already received it, but tough. I'm a fan.
As a nod in the direction of midwifery I will nominate my friend in Alaska - Lisa. She is a terrific midwife and knitter - I'm so jealous of her knitting ability, and I dream of being such an accomplished health professional as she is. Brilliant (and tagged).
Finally, I also really enjoy the gentleness of Jenny's blog. Her sweet little dolls are just amazing. And I am nostalgic for her stay at home life - I didn't fully appreciate it when I had it. And although my house could never be that tidy, I hope it is as much a home as hers clearly is.
Speaking of tidy houses, sigh. Mine is definitely not tidy currently, much to my husband's annoyance. I had some fun late last week preparing a package for a friend who just needed one. I had a great time, and rediscovered stuff I hadn't seen in ages. But in terms of denting the stash...it didn't go close!
I have been having a clothes blitz lately, and threw out quite ruthlessly. I can now fit (nearly) all of my clothes in the drawers and cupboards. I should take a leaf out of Widget's book and get organised. Unfortunately op-shops have been calling quite loudly lately -and boy have we scored! I have found some really sweet pieces of moulded glass, sugar bowls and the like that I have been happy to adopt. Some great shirts for craft fabric, some vintage dresses with beautiful English lawn. And Stephanie found some great pieces of clothing including 2 jackets, a sassy skirt and a sweet top.
I am trying to get better at throwing out something everytime something begs to come home with me. And I will get better at it, or be smothered in the attempt.
I have a social week coming up. It is a year this week since our class finished the midwifery course. I have been a midwife for a year!!! Yay!! A bunch of us are going out for dinner on Thursday night to catch up. Some have had babies, some have new jobs, some are working as midwives, some not. It will be great to see them, especially the ones I haven't seen for a while.
Happy 1st Anniversary Curtin Midwives 2006-2007!
Hubby and I are going to an art show on Friday night, and then away for a grown-up night on Saturday night. Can't wait!
Thursday, July 10, 2008
I had the care of a woman early this week who was keen for a VBAC after her first labour ended in a CS for non-dilation in first stage. Her cervix had not dilated past 4cm 6 hours after reaching that stage. She wanted a VBAC because she had found recovery from the CS to be very difficult, understandably, and was keen to avoid the same again.
She had presented to the assessment area of LBS, a day or so past her due date, contracting strongly but irregularly and was keen for an epidural. Her cervix was dilated about 1.5cm, but was fully effaced- a bit early for an epidural. She was given a shot of opiate - which knocked off the contractions and had a sleep. When she woke up she started contracting strongly again, and was very anxious to get an epidural. This was not a method of pain relief she had used with her previous labour. She was transferred around to the labour room where she tried to settle in and get the contractions started again, as they had died away. I was assigned her care and after an initial chat it was clear she felt under the pump to labour that day as there was a CS scheduled for her the following day. She was also quite cross that she had been given the opiate earlieras she felt it had dampened down a happening thing. I spoke quietly to her, encouraging her to set aside everything else that was going through her head, and to give herself time and space to just be in the room, in this moment. We worked together quietly to create a space where she could feel safe, dark and quiet.
After a while, and a rupture of membranes by a doctor(2cm), she recommenced contracting. They were strong and lasted for 45 secs or so, but were irregular in their pattern. 2-3:10, then a gap, then 5-6:20. The baby was lying in a posterior position, which does cause an irregular pattern, but something just wasn't convincing as the pattern was too easily disturbed.
When planning a labour after CS the accepted wisdom is to avoid the use of artificial hormone stimulation i.e. syntocinon/pitocin, as this is technically contraindicated as a use of the drug when there is a uterine scar. The big scary bugaboo is uterine rupture along the previous scar. The incidence in natural labour is quoted at 1:80 - 1:200. That's 79:80 and 199:200 where it doesn't occur (if you're thinking positively). Under syntocinon augmentation/induction the incidence rises significantly. This woman had done some reading and consulted some people in the lead-up to this labour and her understanding was quite clear. Avoid use of synto.
Four hours after the ARM I examined her again, very little change (2.5-3cm). There was a different doctor hovering outside the door, who demanded the information and ordered an epidural and another examination in an hour. Then synto was to be started if there was no change. AN HOUR! She hadn't even met the woman, felt the contractions, heard her fears. The next shift came on as this occured and we collectively decided that this was not in her interests and she could decline this plan if she wanted. She declined, I documented it.
I was torn in many directions. I felt psychologically that this woman needed to do something different in this current labour to change the script from her previous labour. Her first labour had been induced from scratch, building up to maximum synto use, with a stalled dilation under a theoretically adequate pattern of contractions. She herself had little faith in the ability of synto to cause cervical change in her. We had been keeping upright or on all fours to encourage rotation of the baby to a more favourable position. She had been off for walks. She was trying nipple stimulation to encourage contractions.
We're taught that there are often mental blocks to cervical dilation related to fear of pain, anxiety of other nature, insecurities of all sorts. One of the challenges for the midwife is to identify and work with the woman to push through, allay or dissolve these factors, making the conditions right for relaxation and cervical dilation will follow. It so happened that the next shift midwife was one who had cared for this same woman in her first labour! I was unsure whether this was a positive or negative factor for the woman. Was this to be a re-living of the script?
The next midwife was having a quiet and assertive advocacy argument with the doctor in the corridor outside. I was very grateful to see it, as I don't have a lot of experience in caring for VBAC candidates and felt a little shocked and out of my depth at this challenge. There are practical factors to be faced either way.
I can see the doctor's point of view - no amount of standing around watching and creating a nurturing environment is going to establish a truly effective trial of contractions. Except that I felt we had been getting somewhere psychologically up until the point of that examination at the time of shift change. If the cervix had been dilated 5cm at that point I felt we would have been home and hosed. But honestly, there had been very little change in nearly 4 hours of strong but not always regular contractions. Her body clearly wasn't quite ready to do this.
There was the question of pain relief. This was a back labour, and was pretty painful. The afternoon midwife felt an epidural was not the way to go, as it often knocks off contractions a bit if used too early - which this was on the borderline of being. Her recommendation was for a shot of opiate - which the woman herself didn't want because it had diminished the labour 12 hours earlier. The doctor didn't care which method was used as long as the synto went up, sooner rather than later so the woman and the baby were less tired than they would be if we held off for a further two hours, which was the general preference in the room. Tick tock tick tock. Bloody hell, we felt we were getting nowhere.
The doctor entered the room for the first time (uninvited). It felt like an ambush. There was a lot of 'baby getting tired' language (the trace was excellent), contractions have to be effective (she hadn't palpated a single one), the pattern isn't established yet (well, I'd pay that one). She asked who had done the last assessment and insisted that I repeat it now (2 hours later) and a plan would become clear if there had been any change with the spontaneous (under pressure, very disturbed, doubt creeping in) contractions.
The woman agreed. The doctor left the room, her views and orders were clear. I did the deed. There was very little change.
What I know is that to achieve any vaginal birth, whether the first or the seventeenth, for VBAC or not, the cervix must dilate. The baby cannot be born through a closed or semi-opened door. End of story. No matter what one believes, or what the environment one creates. Babies are born with their mothers clinging in trees to avoid being swept away in floodwaters. Does that desperately unfavourable and exposed environment inhibit cervical dilatation? Clearly not.
My emotions were swirling. I would not lie to this woman. I felt her crumbling hopes acutely, her self-belief, her visualisations for cervical opening evaporating by degrees. I felt she had spent the last two hours being undermined by a series of factors, but was that really true? What if her cervix was one of those that just didn't dilate? Sure she was anxious and a bit nervy, but I would be in her place too. Was it my belief in her that was wavering? Or was it a growing acceptance of reality?
I saw the logic of the doc's plan. Let's have this labour declare itself one way or another sooner rather than later. Was I being pie in the sky waiting for spontaneous labour to 'win'? As much as I wanted nature to take over if I could protect the environment and sing Kumbayah sincerely enough, was it always going to be a losing battle in this woman? I have seen VBACs achieved before, with and without the use of synto. I just wish it didn't have the reek of 'doctor getting all her ducks in a row by knock-off time' about it.
I stayed for the discussion about synto Vs pain relief. They looked to me for guidance and I felt like a traitor discussing the benefits of a compromise, with a trial of synto under controlled conditions, yes, start with an opiate for pain relief (not my first preference for this woman, an epidural may have been the psychological script change she needed), you can always move up to epidural (oh God, that trace is going to suffer with morphine and an epi, hope the baby is alright when he/she is born around 8-10pm - my estimate - probably by repeat CS). It was time for me to leave.
I phoned later that night and she ended up with a repeat CS at 8-ish pm. A little girl. They already had a boy at home. They would be really pleased to meet her, I know. I confess I had a bit of a tear about the outcome.
I have been troubled for days about this 'failure'. Was the failure mine for not creating the environment appropriately? Did I do her a disservice by holding on to her birth plan too solidly - trying to create a safe space for her with time to get into labour. I wasn't convinced she was in established labour except for maybe the last hour before the lunchtime assessment. The contractions were sneakily irrregular. Yet only days before I had seen a woman give birth to her 7th child with a similar pattern of contractions. Through a cervix that had dilated. Was this woman doomed to a repeat CS by a physiological anomaly of her own body, regardless of my supportive touch and words? Kumbayah humbug! Did this anomaly cause a script re-run?
I am trying hard to love this question. I suspect there are different answers in each woman. I was always taught that the CS to avoid is the first one. With the syrocketing CS rate in this country, state and the facility I work in I am certainly keen to work to avoid the first in all women in my care. Have I seen any soft decisions for CS? Hell yeah. I have also seen many vaginal births that may have not been achieved in other facilities. Some women have one CS for breech and then just never think about not having a VBAC with the next. In some countries it is the same, one just assumes she will have a VBAC unless there is another really good reason (placenta praevia, severely bad trace, placental abruption - which can give a subtly bad trace, cord presentations, delayed progress in first stage of labour). Breech presentation in first-timers is another common reason for a first CS- I am in two minds about this one. One school of thought says that this leads to de-skilling of midwives and obstetric staff as they never get to manage a breech birth, so never develop confidence in it. Others think that the consequences of a bad breech birth for the baby and woman can be catastrophic, e.g. with a trapped head. I know of a recent case of this, the staff still pale at the memory, the baby was not good (i.e. nearly died) but is coming good now apparently.
So,VBAC is quite a fraught issue in my profession. It is not the case that all vaginal birth is better than birth by CS. They say that recovery from a good CS is much better than from a bad vaginal birth (i.e. instrumental births with minimal analgesia and 3rd or 4th degree tears). There is definitely a place for the use of CS. The World Health Organisation accepts that CS is appropriate for births in about 10-15% of women, and women die daily for lack of skilled surgeons to support the needs of these women. Would the woman of this story be one of those who falls into this category? Whose cervix hasn't fully dilated with either an induction of labour or a spontaneous and augmented labour? Would she be the mother of two living children? Albeit recovering from a second non-elective CS? We'll never know.
Tuesday, July 1, 2008
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.