Thursday, October 15, 2009

Night shift news

Hello world. Phew. Night shift and labrynthitis are a bad combination.

It was getting better until sleep disturbance and nausea kicked in, or they kicked each other in....or, oh heck who knows? Anyway I'm on the second of 3 days off, before I lose 5 days of my life with 4 nightshifts over the weekend. Sigh.

I did three shifts with two nights early this week. Good shifts, if slightly mad. Really busy on Monday night. Dementedly so, poor coordinator was tearing her hair out. I happened to be in the rooms in her eyeline so every time I walked past I would get another little job to do. "quick - 29 weeker coming in, wants to push, you're it!" The woman arrives, screeches to a halt in a room with a big resus unit hastily assembled in a just cleaned room, not very distressed or labouring particularly, a little pain arrives, doesn't palp too strongly, yes waters have broken...or have they? The story is convincing with a witness. Ooh, baby's coming! she wails. Can I check? May I begin? Cervix long and closed and tucked away behind baby's head, just where it belongs. Excellent. Good news! You're not going to have your baby in the next hour. Lets take you back around to the assessment unit, where you can get sorted and admitted. Its too late for a fetal fibronectin test (which will indicate if she's likely to labour in the next week) as I have examined her, but it turns out she is known to staff as a 'frequent flyer' with every little thing and vague twinge. Ambulance guys have to take things on face value and bring em in, and if things were as presented we were ready to deal with it. As it was the floor of that room could now continue to dry undisturbed.

I had been sent to theatre on arrival for a breech CS. Lovely couple, sweet baby, wet and steaming to her chest, alert and responsive. Great photos, happy relatives. I was happily present when the grandparents learned the sex of their newborn first grandchild and saw him, travelling with us to the ward. Joy all around. Told her about a clinic at our hospital for women experiencing second birth after CS, so she could start planning her next birth. Back to LBS and had a cuppa.

Technically had 2 women at this point, being induced. Gave antibiotics to one of them. The other one was snoring. Got given another woman, a multip in early labour at 4cm, contracting irregularly...but who knows, sometimes multiparous women only need half an hour of good contractions before they produce the goods. Settled her into a room on my corridor (yeah, I had a whole one to myself by this time) and went in search of a listening lead for my CTG. Bloody hell, none to be found. Grabbed a handheld Doptone and made use of that instead. Major language barrier, my Mandarin is not that hot, but we established a pleasant simple rapport as I listened in and then made tea for her and her mother. I left her to it and popped in each half hour. She went off the boil, well....was never really simmering in my time with her anyway. She went on to birth at 11-ish in the morning.

In the meantime I was still dogsbodying my way through the night, attending an imminent birth of a 7th child, there was thick meconium so I called a paed for the birth and prepared the cot in case he didn't make it in time. The fetal heartrate dropped dramatically, and the baby was not coming despite vigorous pushing from the experienced mum. Sunny-side up, we all said, but the heartrate was getting really low. We'd called a few docs when the FH dropped and they quickly attached a simple suction device and helped baby out, covered in mec. He was floppy and flat as a tack, but we didn't stimulate him immediately, as the paed needed to suck out his airway so he didn't breathe mec into his lungs. HR was 40 while we poised ourselves ready to commence chest compressions, right, GO! A minute of compressions and oxygen saw his heartrate improve but he was still completely non-responsive and floppy, I ducked out to grab an oximeter from the room next door (where the 29 weeker didn't deliver) and when I came back baby was squawking and starfishing and protesting at his awakening. Poor little mite, it was all a bit sudden, but he was down and on the way out, and as much as I promote gentle birth, I was quite glad to see him yelling. I stayed there for another half hour, to get him settled and cuddled up and fed, and documenting the resus, then returned to my odd jobs. I was most grateful to get a dinner break, then I received another semi-labouring second-timer who had a quick birth last time. She too was not quite ready to labour, but I made her comfortable, hubby re-parked the car (during which time she didn't have a single contraction) and she went on to birth at 5.30 later that day. I handed over 3 women to 3 different midwives and staggered home, literally walking home half asleep.

The next night I was allocated to first-timer who had been stuck at 2 cm, on stacks of synto. Everyone assumed she was for the chop, but my student and I breezed in with positive attitudes and explained about cervical effacement and assured her that the cervix was ready to get on with it now and start dilating. And it came true! Her epidural had been working really well, and continued to do so. The trace had been really good, and was mostly good still, it just had a pattern of decelerations one sees with head compression, followed by a period of sleep where the trace looks quiet. We worked our butts off in that room, keeping the trace well monitored, adjusting the receivers, keeping the epidural well topped up, fending off doctors who kept showing up and scaring the woman, talking about 'heart rate dips, can only do it for so long, then they get tired' wanting to do fetal scalp samples, but every time that dear little baby showed a fabulous acceleration when it was needed and warded off intervention. In the end she was born easily and quite beautifully, despite the doctors inviting themselves into the room and standing at the end of the bed and itching to get their hands in there, and asking if we had episiotomy scissors. We held them off, almost literally, and the little one emerged via the student and I to her stunned and thrilled Mum and grandma, after a mammoth effort. The doctors disappeared like magic, and the student and I dealt with a snapped cord and got the placenta out without them, whole and intact, although we did invite the doctors back to do some straightforward suturing and assist with management of a slow PPH, which had been anticipated after that much synto. There was no CS. There was no transfer to theatre for placenta removal, there was a beautiful healthy 3.7kg baby and her Mum staying in the same room, where they had stoically borne their labour together. It was a great result really.

I was sad that the docs felt they had a right to come in uninvited and stand at the end of the bed, scolding her at her to 'push into your bottom' (as if any of them had ever done it themselves). If we hadn't been there they would have held her vagina open so they could see the descent and crowning better! I feel sad that they so rarely see the way a midwife conducts a birth, with gentle encouragement and positive language. We see their way of work frequently, and frankly it can be pretty brutal sometimes. It is noteworthy when its not. Sometimes it seems that they know no other way but fear and mistrust of birth, and litigation, and invading the privacy of the moment in their relentless quest for accountability. We will call them in if we need them. We do, honestly. Just like we did for the little one with thick mec and the really declining heart rate. I like having docs there to expand the skill level if need be. They are our back-up. We work together. I don't mean to doctor-bash. This is more a doctor-whinge maybe. But when they come in uninvited I can sometimes hear myself sounding a bit terse as I respond to their appearance, at which time I politely and pointedly introduce them to the woman and her family as if they had entered the woman's home, which in effect, the birthing space is, or should be. I try to believe that they KNOW this is the case, but somehow they don't behave that way. I'm sure they think I'm a grumpy cow towards them some days. Thats to the ones that aren't arrogant. When they are being mentored by the insufferably arrogant, they are just asking for terseness.

But I can guarantee them this. If, and when, any of them are in my care when they are labouring and birthing I will protect their rights to privacy and advocate just as strongly on their behalf as I do for any woman I care for. And I will use my clinical judgement to call for back-up when the situation warrants it.

Because I love being a midwife.


Debby said...

The doctors are sometimes a massive cloud of negativity...'you can't' or 'I'll have to'...etc. I've never heard those words from a midwife. Never.

Madre Adoptiva said...

I so love your stories of labor and delivery. And I love your way with it all. So gentle and loving. Those doctors could certainly stand to learn a lot from you!

Kelly said...

yay you. ilove your birth stories too- and go ahead, give em a bash- what do they care? ;-)

Anonymous said...

I am interested in the confidentiality and ethical issues around providing so much information about the women,families and staff you work with.

Anonymous said...

"I will protect their rights to privacy and advocate just as strongly on their behalf as I do for any woman"
so my question is do you let the women you are working with know you will using their information and birth stories on your blog??

Anonymous said...

Great post as always, I do love reading your stories, very much. Hats off to your advocacy. x

InfoMidwife said...

Hi Laura, I am responding to both anonymous comments... I do not see anything in these stories that breach privacy or confidentiality. The information is of a general nature, no names or hospitals, no identifying promts, just a reflective story of a birthing experience from a midwives point of view.
I have more of a problem with people who do not leave a name when responding to a blog... where is the ethics in that? I am not sure what ethical breach the anon writer is refering to, because these reflections are a personal journey of a midwife, respecting the clients confidentiality. Personally when I read your blogs Laura it seems to me that you go to great lengths to protect the clients confidentiality as well as your colleagues. They are great reflective stories.... well done, keep up the good work.

persiflage said...

Your posts are so interesting, and it is always such a relief when there is a good healthy birth and baby. I have enjoyed your comments on my travels, and your having window-shopped in the same place.

em.s said...

you work soooooo hard! I hope you're getting some time for yourself??

Anonymous said...

Helloooo where are you?

Kelly said...

anon needs to go read some ob/gyn blogs to get some REAL perspective. Blogging about YOUR expereince of your life and telling names are not the same thing. Keep going laura