Monday, July 27, 2009

Reflective practice

I am surfacing after a weekend of night shift. Only 3 nights, but what a 3 nights.

I have worked my bum off and been in the deep end, with back-up from colleagues so I wasn't alone, but it has been a very difficult stint.

On the first night I was with a woman who began experiencing a lot of bleeding while in labour with a very prem stillbirth. I really felt for her as her tiny baby was suddenly born in the midst of a roomful of medical and midwifery staff swinging into action to prepare for fluid resuscitation and transfusion. She was fairly calm, but I am so sad that she was unable to have due privacy at that time. She remained brave and dry-eyed, but the drips in inconvenient places meant it was difficult to hold her baby and touch him as he lay on her chest. It was my fiftieth birth, and although I am very fussy about what I call 'mine', and this one was half caught by the doctor during the emergency, I am honoured to claim this little one as a milestone birth, my first time to receive a stillborn. I had cared for his Mum before, during and after the birth and I am touched by our time together. She had left by the time I returned the next night, but for that ten hours I was 'with woman' with her.

The second night I received a woman having her second baby. She had been having a long early labour and was really tired, but it looked like she was kicking into gear and we were ready to catch the little one. Sleep is not really an option when in labour, but she was really keen to do so. She was labouring spontaneously, and coping well. She had had her first child with no pain relief and I was expecting her to do the same. I felt sure there was a baby not far away, and so did a colleague giving a tea relief. She felt the need to urinate frequently so her husband would half-drag her to the bathroom, as she was swaying on her feet. We encourage mobilising in labour so I wasn't concerned. She seemed to 'hit the wall' after a while, and suddenly stopped speaking English, or at least making sense, except for whining and saying 'I can't'. Her blood pressure was creeping up, nothing particularly extreme but she was quite uncooperative, and behaving like a dead duck. She wouldn't even acknowledge questions or make eye contact. I never start an assessment, especially an internal assessment without explicit verbal consent including eye contact permission. I felt myself withdrawing from her emotionally, which rang alarm bells for me, as it is unusual for my patience to be bested. She was going off the boil, but we were all keen for her to have a normal birth with this spontaneous labour, and she wasn't playing the game. She started vomiting, usually a good sign of transition, with a baby not far behind. She was begging for pain relief, as is common, but transient for most women near the end. However she kept vomiting, and I suddenly felt she needed some fluids. But first I checked the BP. It was suddenly high, things were not right, and giving her fluids might not be the right thing. Could she birth quickly and it would be over, or was something going wrong? This was more than me being 'over her'. I felt she'd taken a bad turn, and called for her to be reviewed by the doc.

Within half an hour she was bled, examined, diagnosed with pre-eclampsia, had an epidural underway, monitoring and all the bells and whistles. But it was hard work, as she would/could not engage with staff. Her husband kept trying to speak for her and give consent, but that it not quite good enough. If she is to agree legally to these invasive procedures, such as epidural, and internal assessments, she must give proper consent, or it is assault. And still no baby in sight. I was relieved to get a meal break as it was 8 hours into my shift and I was at the end of my tether, and I really needed sustenance and to regroup. The other staff were all saying what hard work that room was, so I felt a bit better about being so out of sorts with the atmosphere. When I returned, the epidural was in situ but she was still in a bit of pain, but after a top-up we started winning that battle too. The baby was tricky to pick up through her abdomen, and she had a rapid pulse herself that was easy to interpret as the baby's. All in all a very trying night, and I thought I wasn't going to see this baby at all. Just before the end of the shift the doctor came to review her again, and to see whether she had dilated fully or not, and lo and behold she had. She was quite reluctant to push, 'I'm too tired', but this time I did speak quite plainly to her and insist that 'yes you can, then you can rest, so stop making a fuss, lets get this job finished'. We repositioned her for pushing and had her begin the job. We couldn't do it for her! The next shift arrived and a student midwife gloved up and bustled up expectantly. Rarely, I said 'actually, I'm catching this one, I've worked bloody hard all night for this baby. Catch with me, but this one has MY name on it!' The baby was born just before 7.30 am, and although I had vowed to have stern words with her, she was really just too pretty to be cross with her for long. She was quiet and alert, big dark eyes and a head of curls, and her Mum was all of a sudden chatty and interactive and full of thanks, and delighted to have a second girl. I earned my sleep, but didn't sleep well. More's the pity....

The third night was the last straw. We arrived to some devastating news of the death of a young doctor in a car crash. She was a vibrant talented young woman, and we were all reeling in shock. Red-eyed, we made our way into our allocated rooms and tried to quietly compose ourselves. In my room a woman had just started pushing, and her midwife stayed to complete the birth. I was happy to be the background second midwife witnessing. There was some blood on the emerging head, a sign of a vaginal tear somewhere that can't be helped until the baby and placenta is out. The baby was born after a massive effort, a lovely girl welcomed with crows of delight and rejoicing over who had won the bets. Followed by bleeding. A lot of bleeding. Blood started pouring onto the floor. I was reminded of the first time I had seen such a thing, and I had a rough idea that it took about a litre on the bed to do such a thing....Call in the storm troops, get it all happening, the family still on the phone as it unfolds, baby in arms, Mum sweating and feeling the effects. 2.2 litres measured so far. Off to theatre with no time for a breastfeed.

Word kept coming up and down from theatres. She would be a bit longer, still bleeding, baby was frantic, skin to skin with Dad, the drop of colostrum I had managed to express as we were preparing for theatre not satisfying her at all. Dad asked for a bottle, and we had the discussion about breast first, second and third, but he asked a lot of good questions about breast stimulation that I was happy to answer that skin to skin and breastfeeding could be resumed within minutes of the reunion...whenever that would be. We weighed and measured the baby, she had some more skin to skin time with Dad and he fed her a small amount of formula while she was on his chest, so there was the association with skin. It was definitely a compromise, but a realistic one given the condition of the Mum. I took them to the special care unit to wait for her, then popped into theatre to see how things were going. The bleeding was now controlled with some 'big guns'. I told her about the baby's weight, and praised her bravery, and reassured her that the baby was skin to skin with Dad and waiting for her.

There was a big bag of linen waiting to be weighed for blood loss. The total was large. Ten times the loss we normally expect. A massive PPH. I mean massive. Out of the blue, in a first timer with a spontaneous labour. Once again, we saved a life today.

One of the doctors spent the rest of the shift speculating on what would have happened in the case of such a catastrophic haemorrhage if she had birthed at home, and the answer was clearly not favourable. Does one take the risk of first-time birth at home and take the consequences in these outlying cases? Or does one practice in caution, perhaps risking over caution, with no belief in normal birth and physiology. It is easy to see the slippery slope to constantly defensive practise that has led to the over medicalisation of birth such as we see today.

In three nights I had seen a normal unmedicated birth of a very prem stillborn, with bleeding complications. I had seen a spontaneous labour blow into pre-eclampsia within hours, followed by a normal birth. And another spontaneous labour and normal birth followed by major bleeding. These are among the emergencies midwives prepare for, and when one works in a big hospital one can expect to see a higher rate of complications. But it is sobering nonetheless.

I continue to believe that women should be offered a choice of place of birth, and I hope one day to work in a model of care that allows me to provide the full continuum of care to women including labour and birth wherever they choose, or it is collectively deemed safe. Not 'dominated by fear of the outlying event' safe. That said, I can't imagine how awful it would be to be faced with such a PPH at home with 2 midwives present, without the extensive range of PPH drugs, waiting for an ambulance to transport, without a theatre with the equipment that saved that woman's life. It would certainly shake, if not permanently scar, one's confidence, whatever one's faith in women's physiology and normal birth.

I have seen way too much blood this weekend. But I being a midwife.


Lesley said...

What a tough week, you poor thing.
Big hug coming your way on Wednesday!

I'm glad to know what has been happening, as your fb updates have been a little sketchy and worrying.

Janet said...

What a testing week for you, Laura. It's so important the work you do, being "with woman" as you say. On both occasions I've given birth in a big hospital, I've had midwives that have been really with me. It makes such a difference.


Debby said...

Laura Jane: I love that you are a midwife. My first child was a caesarian. My second was a VBAC, one of the first in the military (and what a battle that was). When I watched the doctor writing 'HIGH RISK PREGNANCY' across the front of my medical chart on my very first visit for my third pregnancy, I left, came home and found a midwife. It was a remarkably uneventful pregnancy, and a very fast delivery of a 10 lb 4 oz baby girl. Pregnancy taught me to trust myself and my body.

Lisa L said...

omg...sounds intense! pph's are terrifying

Stomper Girl said...

Gosh that sounds like a hard week. I hope you are resting up now.

widget said...


Hope you are able to sleep now.

An amazing read.