Caesar Queen

I'm home after a knackering day at work.

I was the midwife attending the elective CS today (a.k.a. the section queen). You carry a pager and run up and down to the wards and get to meet the women beforehand.

I was as busy as a bee, even though there were only 3 CS booked. I picked up an undergraduate nursing student too, who was meant to be in the day surgery unit, but it was quiet so she hung out with me instead. She wants to be a midwife, so she had a good time (I think).

The first baby was really big. Over 4kg, and it was a bit of a struggle to persuade him to come out! What a whopper, a welcome second son named Angelo. His Mum was unattended in theatre as her husband was minding the 3 y.o. outside. That was a bit sad, but we helped her to have a long cuddle with him before taking him to the ward. He was plump and gorgeous.

The second birth was from pregnancy number 11 for the next woman. She had a long and tragic obstetric history with two miscarriages, two ectopics, a neonatal death at 8 days and two stillbirths plus 3 livebirths, two of these by CS (including one classical section at 26 weeks). All babies but one of the stillbirths had been girls. In this pregnancy her cervix had been supported by a special stitch to help keep the internal door (the os) closed. She and her husband did not know the sex of this last baby, saying "It is up to God, this is our last child even if it is another girl". We were all most delighted to welcome a little boy mid-morning, who seemed vigorous at first, but started to struggle a bit with breathing after 8-10 minutes. Luckily I had hung on to the paediatrician for a bit longer, and she called her registrar to review him. His oxygen levels were only at 80% and he was pushing in his abdominal muscles to exhale and grunting and 'singing'. We took him down to the nursery where he was given CPAP to help keep his lungs from collapsing. Mum and Dad were pretty brave about sending him off so soon, Dad came too, and we were all agreed that God was actually pretty good to give them a son, and for there to be facilities to help him when needed. He was just a bit undercooked at 37 weeks and a few days, and I'm sure he'll be fine in a few days or so.

The student was getting quite an education about the role of the midwife! Today when little Mohammed went off, I had just finished talking with her about how the midwife is essentially in theatre for the emotional support of the mother, and the physical support of the baby, as the theatre staff are there for the clinical support of the Mum. I would in no way consider myself as flash in the neonatal support area, but today I knew a baby with respiratory distress when I saw one. Phew. I was glad I had the paed with me as we put the monitors on him and gave him oxygen, then the registrar took over the oxygen CPAP from me as he arrived.

One of the medical students I had last week mentioned how she saw me keeping tabs on so many things at once- blood loss, neonatal adaptation and respiratory sounds, guiding her hands, noting times and obs mentally while doing other things. I was grateful and slightly surprised to hear her observation, because I realized that she was right. All of a sudden I am doing all those things at once. Multi-tasking - Woo-hoo!

So, back to the day. I ran up and down stairs between theatre and LBS all day, retrieving paperwork, getting ice for blood gases, taking placentas to the fridge, getting changed, seeing women, taking babies to wards, all interspersed with standing for long periods waiting for surgeons to enter and go through adhesions etc, while teaching their own more junior staff the finer points of CS techniques. It makes my back ache to stand in theatre!

Our third baby of the day was another big baby, a near to term girl, who also needed to be squeezed out of the incision! In the end they used forceps. She was snuggled on to her mother's chest for a while before we headed up to the ward. Baby Sairharni weighed just over 4kg too, and joins her big brother in the family. She has the longest eyelashes I have seen for some time.

Back to LBS, paperwork, weighing placentas, showing the student the finer points of placenta examination, entering all the many details in the birth register, sending paperwork all over the hospital and then it was time for home.

It was a lovely day, but I am a bit achey. I've had some panadol, now its time for a cuppa, and a good sit down.

I feel another brooch coming on.....

Wild Woman - correction Women

Hot off the needle. I can see a few of these being made while watching Olympics coverage! And now I have made the second one too!

This is Polly. She has a brooch back and is about 4 and a half inches high.

I needle felted the base from hand-dyed merino wool and pink chiffon. The hair/ruff/mane is from a trim I'm fond of and it made a great textured base for the embellishments.

The skirt is individual lace motifs stitched together, coloured and embellished. She took about 4 hours to make.

Ah, I do like a hand stitching project. Even if it does involve a few seed beads being spilled. (At this point I shall apologise for Blogger being most uncivilized about formatting and ignoring my paragraph marks. Just pretend I have been educated and formatted this correctly. OK?)

She was most satisfying to make. And I just know she'll need some sisters. I can barely sleep for all the images of them in my head. Shame I ever have to go to work really. I kinda miss being a full time crafter, but just as well that I LOVE being a midwife too eh?

Well, who have we here? A sister already? Why yes, her name is simply Woman. She was my first one nearly finished, then Polly butted in. Woman is patient. She didn't mind that her woolly minded sister jumped the queue.

Isn't her face beautiful? These faces (along with the arms & legs) are bought pieces, from Artgirlz. I coloured them with some groovy special marker pens. Variegated threads work wonders with these kinds of stitcheries. As you can see, they sometimes make just the hair you need. Just what I needed. Woman is about 4 inches tall, including dangles.

In other news ... Steph has got a laptop computer, wirelessly connected, so by default - I have this computer all to myself, and coincidentally that also means that no-one else need come in this room for computing (or any other purposes really) but me. Yes- just me. So I rule this room! My cunning plan to clutter it up so badly that no-one else could find a thing has worked! Total world domination is only a heartbeat away!!!!!!! I may get delusions of grandeur and start calling it a studio soon. I have plans y'know :)

This time a year ago we were coming to the end of our week in London. The weather was divine, the art was superb, the city was like a childhood story and a Monopoly board come to life. We went to the Proms (terrible program), we ate like royalty at my aunts' house, we tubed and walked, and M&S'd and Westminster Abbeyed in pure delight. I'm so pleased I've been there and can't wait to go again. I can scarcely believe I have been to (and enjoyed) so many of the world's greatest cities. I am a very lucky girl.

Our next stop (Aug 12) was Edinburgh and a few days in Scotland which was also absolutely wonderful (even if drizzly in an entirely appropriate Scottish way). I'll catch you up on those when next I post.

Ciao.

Telling tales

So, I have finished this stint of nights and it was pretty good really.

On Saturday night I had the care of a woman having her second child. She didn't speak a lot of English and seemed to be coping fairly well with labour but it was getting tough. For a change, it was a spontaneous labour with no risk factors that would necessitate continuous monitoring so I just listened in each 15 minutes for the length of a contraction or so to check the baby out. When she entered the transition phase she became very vocal and thrashy and grabby. I hadn't examined her for a few hours and when she started involuntarily pushing and started asking for an injection for pain relief, I offered to examine her to see if it was safe for the baby to receive a drug so close to birth. I was fairly sure the cervix was fully dilated and it was, and the head was quite close to the world, so the answer would be no (to drugs). She was disappointed about the drugs, and I'm sure swore a bit in frustration in her own language. I just smiled encouragingly. Within 5 pushes the baby was out and the medical student with me had half-caught another one for her book. It was a girl, there was much delight in the room, and they couldn't dress her in pink from head to toe quickly enough! Dad hadn't seen the birth of number one, so was pretty impressed with his wife. And the baby was such a cutey, little Ishmeet.

Across the hall an hour later, around 3am, a shocked, and shivering woman was wheeled in by ambulance (shaking is fairly normal after birth). The ambo walking after her had a silver wrapped bundle in her jacket...it was a baby! I briefly congratulated her on the little one and went back to my room, but soon I was called in to be another pair of hands in what turned out to be quite a drama. It was a cold night, expected to be 3 degrees C, and the woman had been asleep alone in the house with her 2 year old when she was woken by sudden strong labour pains. The contractions were coming so thick and fast she couldn't get to the phone to call for help. The baby was born 30 minutes later in the bathroom as Mum sat on the loo, splash, clunk! Poor woman. She pulled baby out and wrapped him in a towel and struggled to the phone where she called an ambulance and her Mum. She then had a big bleed, and ..and..oh dear, it would not have been pretty. The woman herself was still sobbing in hysterical shock and really seriously cold. We kept taking her temperature and not quite believing it was so low, but I called for a special warmer from theatre, and warm IV fluids to raise her temperature as soon as we could. The baby was also seriously cold. We are taught that babies must be warm, pink, sweet and clean. Meaning they must be ideally between 36.5-37.1C, have good circulation and heart rate, adequate blood glucose levels and be kept free from infection. Between being so cold, and banging his head at birth he was not in fantastic shape. He was taken to the nursery pretty quickly where he was in a pretty bad way for a few days. I haven't heard how he is today. Mum continued to bleed, and with a poor circulation due to low body temperature it was hard to get it all under control. We kept having to remove the blankets from her to assess her loss, put in catheters, new drips, massage the fundus. Her mother arrived after finding someone to look after the 2 year old, and was still beside herself with shock. She said the house looked like a murder scene, and was clearly very traumatised even by the aftermath. She shuttled up and down to the nursery seeing the baby, and then the woman, who was moved to special care once she had been slightly stabilised after 3 hours of constant attention. It took 12 hours or so to get her temperature back up. It was quite a night.

I was pleased to work with a homebirth family requiring a CS last week. The baby was in a persistent and damnably unfavourable position for a homebirth and there was a very clear plan to transfer for CS after a bit of labour, which is what happened. Baby was born just after midnight and went skin to skin after the resps were established at 30-40 seconds. She was pretty squished from the labour and the unusual position in the uterus. They had half an hour together on the table, then she went to Dad and returned to Mum in recovery 10 minutes later, where she had the first of many feeds as she remained skin to skin for essentially the next 6 hours. There were no beds for postnatal care so she came back to LBS with me and I looked after them for the rest of the night. Baby Ryder didn't even get weighed until 6 hours of age because she just fed from side to side for all that time. It was really nice, a lovely family, so gentle and calm with their baby (who could suck for Australia if a place came up on the national team!)

What else? Hmm, lots of things. A young woman with a stillbirth, a 2.2L PPH and really high blood pressure - she really hit the bad luck jackpot, poor girl. Another couple of PPHs, 1.8L, and 800mls, that is always a fun way to start the shift! A really intrusive friend at a birth who just wouldn't shut up while she was pushing, and later while the mother and baby were bonding and trying to feed. I felt like saying - if I rip the baby from his mothers arms and weigh him (to give you the information you're clearly dying to be the one to spread) will you PLEASE shut up and f*** off? But of course I didn't. I just kept addressing the new mother directly in a quiet voice and ignoring her friend, or gently but firmly correcting all the negativity the friend was spouting that was all about her, not the precious moments she was intruding upon in the room she was a guest within. We did all sigh with happiness and the mother actually stated "oh its so quiet" as soon as the friend left. The Mum and Dad were so enraptured with their little fella, Jacob, who was extremely edible, all 8lbs 5oz of him. Quite, quite yummy he was.

There's been quite a bit of time on night shift to get to know some other midwives better, which has been nice. Some new staff, some staff returning from maternity leave. Some politics, some passion, some laughs and frustrations. Helping each other with the formal wording required in our competency documents for professional development. Sorting out the state of midwifery in Australia vs England. All sorts of things. Challenging and exploring each other's views on a range of topics. Burnout, job satisfaction, intervention rates, is normal birth possible in a high risk setting?

I was pleased to be able to see that doctor who had given me such grief over the woman wanting a VBAC. She assessed another woman whose cervix had not dilated over an 11 hour period and there was a fully agreed and harmonious collective decision to go for CS. When I asked her off to one side to give me some technical details related to reason for section, i.e urgency of need, and reason for CS she said 'failure to progress'. I took a deep breath and said 'actually - how about we put the reason as delay in first stage progress, so the woman doesn't start her mothering journey being labelled 'a failure' ". She looked taken aback a little, but said "well, its probably the same thing, but I can see how that would make a difference to the woman, so yes, fine". I was quietly pleased, and hope I have sown the seed for a change in her thinking. This step had been suggested to me by professor of midwifery who I had contacted after the first incident had distressed me. It was a really good idea from her.

I'm coming to the realisation that I have become comfortable as a midwife now. Maybe it is just feeling more consolidated in my skills. I feel this second stint on LBS, following from the stint in the community on the visiting midwifery service has seen me become so, and I can feel that I might be ready to start making some decisions in my future directions. Some of the clinical midwives I work with have been asking my intentions, and have all said they could see me working in the community, but I don't think I'm ready for that. However if the chance came up at a more caseload model of care - where a small practise of midwives are assigned the care of women and back each other up to provide antenatal, intrapartum and postnatal care that would be a good way for me to go, I feel. Maybe in a birth centre setting.The drawback of that model apparently is the on-call work, but there is one very near where I live, which could make the on-call work more manageable. I feel the time is right to start making plans to actively seek those opportunities, and to gain the skills I will need to be competitive when I apply.

I am still looking and reflecting within as I practise, but I am now more able to raise my eyes from the road, and look to the journey ahead. Its a big wide world out there.

Nightshift Haze

Hey all

I am alive, and on night shift, 2 down and 2 to go. I am not actually up right now, I'm just on the 'need a pee-go for a walk past the computer-if I don't talk to anyone I'll go back to sleep ASAP' break that night shifters do. Kinda the equivalent of sleep walking. Ooh, my son just arrived home and is in danger of talking to me too much....hug me and nick off boy!

I've been cruisin a bit, and still in lazy days mode (see last post).

I've been making bags. Yummy.

I've been to a craft and quilting show. Double yummy! Check out the Wild Woman brooches at this place. Uh-oh, a new obsession may lurk to go with healing dolls. I'm part way through a set of three already. I felted the base of part-felted merino wool and thread embellishment. Its very satisfying to do. And I love the name Wild Woman - so tempting.

Work has been really good. Caught a few, seen a few, interesting tales to tell for another day. Thinking a lot about hypothermia and circulating volumes etc - its been a physiology lesson for the last few days, plus the effects of hypothermia on the newborn - I've been hitting the books to revise my stuff.

In the meantime this time a year ago we were in New York. Sigh. It was a great few days in a fabulous city. I have not given you specific links for our time in the Grand Canyon, New Orleans, Little Rock Arkansas to see the presidential library of Bill Clinton, and unexpected night in Dallas Forth Worth and a compressed trip to Madison Wisconsion. But if you take the link (and look in archives under July and August 2007) you can see the little amount we wrote from these places, or the photo albums from there. It was really hard to find public internet in the USA. We won't make that mistake again.

Dear Lesley is back in WA for a few days following the death of a dear friend. So tragic. I will see her later in the week. I look forward to her moving home so I can see her without the thought that someone is seriously ill or worse when I see her.

Yawn, I will be back I promise......Oh bugger, there is cool reggae playing (softly) and I'm hungry. And I've got a friend coming for dinner for her birthday - it will have to be an IOU present - a future pleasure present. I just hope I can grab a banana and get back to sleep.

See ya

Lazy days

I am feeling lazy today.

I'm on days off before a 4 day/night stint from Saturday onwards. I've had a lovely week at work, with some nice women. I saw 35 week twins born on Monday morning - really quickly to a first timer, who I then saw out walking in the corridors later that day! Cigarettes are a powerful motivator!

I then had a young woman on Tuesday afternoon who was a bit depressive, had a really flat affect plus immature petulance on top of it. Now that the epidural was in effect she remained whining and grumpy with her partner, playing one family member attendant off against the other in the matter of who gets to cut the cord. Spare me. Her mother stood around telling about her births, even during contractions. It was a bit intrusive. The young woman birthed really beautifully in the end, had a pretty horrendous and challenging tear internally (with an intact perineum - ironic) and I was fulsome in my praise of her for holding it together when she just shut out all the outside influence crap and just focused with me. I made a subtle point of keeping the young father involved in the birth, he ended up doing the second umbilical cut that actually is the closest to the navel. There's more than one opportunity to cut a cord if there's competition!

When the baby (another 35 weeker) had to go to the nursery, young Dad got the chance to step up as there must be a parent at all times with any visitor to the nursery. The girl's mother had been interacting and answering all the questions the paed asked of the new mother, even standing between the resus cot and the bed so her daughter couldn't quite see what was going on! We kept moving the cot and pointedly turning the baby to a better line of sight for her. Anyway, the young Dad got a bit of status back by accompanying the baby with me to the SCN. Later he also came back to the room when she was being sutured and I asked the others to leave while he stayed by her side, and just quietly kissed her hand and connected with her as she bravely endured the stitching under (pretty solid) epidural cover. He glowed and nodded with pride at my repeated murmurings of praise for her for the way she birthed so calmly, and they both took in the information I gave them about the next few days and what they could expect with a baby in the SCN. They are very young, and I prefer to give them information that allows them to walk through the experience with better knowledge than they may have gained from watching any 'Home and Away' style melodrama. There are much better ways of being.

Once she was stitched up, fed and showered we went to the ward briefly then she walked down to the SCN with me and took her sister in with her to see the little one. He had had a partial lung collapse by this time and was in the higher level nursery with some breathing support, but she was pretty calm, just asking and accepting the reassurance from the doctor, nurse and myself that he would recover and mature well in this supported environment. What he was experiencing was not uncommon with 35 weekers and within a day or so he would off support and continue the task of finishing his growth. He wasn't quite cooked yet. I was really proud of her in the end.

Now I'm on days off I'm engrossed in re-reading a book I haven't read for years from a series and author whose work I just adore.

By Robin Hobb - this book, Fools Errand, is book one of the Tawny Man series - the third trilogy of a three trilogy set about a mythical and mystical place with dragons, telepathic magic, nobility and prophets. I first read them years ago and have recommended them ever since to all and sundry. So absorbing and I just can't put it down. It's nearly noon and I'm still in my PJs. I had all sorts of plans today...sewing, painting, tidying the house for our dinner guests tonight, shopping cooking ... showering!

And here I sit, ass getting broader. Sigh.

Here - enjoy another couple of One Year Ago World Tour flashbacks. The photos are from our last days in San Diego with Lesley and David Z, old Perth friends now living in SD. It was such a thrill to see them in their new environment, and we were so grateful to have a homely like place to start our trip (as you'll see in the links!)

LZ and I are partners in crime from waaaaaay back in 1990 - and in the next few days you will see links that take us from playgroup to Las Vegas and the Grand Canyon Arizona!!!! Yeah baby!

Looking back.

One year ago today my husband and I were flying across the Pacific ocean. It is one year ago today since the final installment of Harry Potter was released - I know because I got the first copy of it from Sydney Airport. Don was standing tapping his foot as our Sydney-LA flight started boarding as the sales embargo lifted! It was all well planned - and there was NO WAY I was flying across the Pacific without it!
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.

Enjoy.

My wordles for the day

I saw this on Twiddletails.

She got it from here.

I wish I could make it bigger....sigh. Another toy to while away my hours.

Blushing now

Ooh, thanks Lesley and Alby.

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.

Lets start in Oz then. I've been having fun and making plans with Frogdancer and Widget this week - teacher tag x 2.

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!

See ya!

The battle for VBAC

I've been thinking alot this week about vaginal birth after caesarean (VBAC).

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.

Teaching tools

It had to happen one day.

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.