Saturday, November 13, 2004

25 Hour Precipitous Delivery - Part 3

Once we were all assembled in the hospital, things lightened up. The un-laboring mom was glad the doc was there. The grandmother was thrilled we were there. Dad, calm as always, was fine we were there. I was very disappointed, but also very relieved we were there considering the issues at hand. I asked one of the other midwives to come and give report before leaving, so she did and I was grateful. The other midwife left before we left for the hospital.

Our nurse was fantastic. She was kind, respectful, cheerful and wanted my client to have all the things she wanted even as her plans totally shifted from a homebirth.

An anesthesiologist came in to start the IV and had to poke twice before getting it into her antecubital (inner elbow)... (we were vindicated!)... a horrid place since she couldn't bend her arm at all. I asked for an arm board, but they had to order it from the pharmacy. It still hasn't come in 2 weeks later. Mom did her best to not bend the arm, but worried most about nursing.

Once the doc came in, he did a vaginal exam and found her to be about 5-6 cm. Continuing to progress without contractions, he was glad she was there, too. He asked if the pit had been started yet and the nurse laughed and said she was still getting everything together. The client asked if she could have some cranberry juice... said that was the only reason she agreed to come into the hospital... and the kind nurse said she didn't think that would be allowed. The doc, sitting in the rocking chair across the room, said, "she can have as much as she wants!" and the nurse quickly brought one of those pitchers filled with cranberry juice and ice! I expected those little half cup thingies; she did good.

Mom asked if she could get the IV out right after the birth and the doc mentioned her history of bleeding and that perhaps they will leave it in for awhile. The nurse said to the doc that usually the IV is left in until the woman has voided (peed) twice. The doc laughed as he looked up at the nurse and said, "so, you void once and I'll void once and then we'll take it out!" We all laughed. I thought that was indicative of the kindness of this doc.

As we did introductions, the doc got around to me and said, "I remember you," as he shook my hand and I repeated my name. And I had hair 2 years ago!

So, the pit was started and every 20 minutes it was moved up a degree. We ordered food, ate food, including mom inbetween the contractions she was beginning to have about 2 hours into the pit upping.

At one point, I looked at mom and told her that we had spent so much time on the preparations for her birth, I hadn't totally explored how to support her physically/emotionally during contractions. We'd assumed she wouldn't have any and here she was, having them now. She said she would let me know how I could help when it got to that time.

Time passes and our lovely nurse has to go home. We begged for a nice nurse... PLEASE find us THE nurse that is your twin... and she said she would do what she could. Apparently, she couldn't do much. We got a brusque and disrespectful-of-contractions nurse who apparently forgot my client didn't have an epidural. She tried to move the monitor belts during contractions, talked when it was inappropriate, and was just too fast zipping around the room. We gave her about 10 minutes before I told my client that I wasn't so thrilled with her. She said she wasn't either and we strategized about asking for another nurse when the phone rang. I picked it up and it was the nurse who'd just gotten off shift. Puzzled, I listened as she kinda whispered that we might really consider asking for another nurse. I couldn't believe what I was hearing!! Never, in all these years, has a nurse EVER called to say that about the nurse that followed.

I went to the nurse's station and let the nurse sitting there know we wanted to see the charge nurse and re-entered the client's room to hear the grandmother, a charge nurse herself, having a mini-fit about our asking for a new nurse.

Instead of getting a new nurse, labor zoomed into high gear and the client began shaking and sweating... her typical THE BABY IS COMING NOW signs, so she told the nurse to get the doctor. The nurse buzzed the nurse's head on the bed and then reconsidered, saying she needed to do an exam before calling the doctor... that she needed to make sure mom was complete. I told her I was sure she was complete, but the nurse told me to examine her or she would and I wasn't about to knowing the baby was probably right there!

The fuzzy nurse voice over the intercom said, "May I help you?" in that muffled microphone way of hospital's and the nurse said, "never mind" at the exact same time the client SCREAMED: GET THE DOCTOR IN HERE NOW!!!!!! Within seconds, the room filled with nurses who wanted to see what was going on and the mom screamed again to get the doctor because the baby was coming. The nurses left and our nurse was tsk tsking the client and then the nurse looked right at me and said, "glove." I stood looking at her thinking, "she wants me to open her gloves? she wants a glove?" and then she yelled, "glove up!"

Oh my god! She was going to have me catch?!? I washed fast and then gloved and told dad to glove and I grabbed a washcloth because mom blew her bottom out last time and we were going to work to go nice and slow this time. She had another contraction and the head began showing and then the doc walked in.

As he gloved, I removed mine and moved to the side of the bed, near mom's head. She was stirrup'd, draped, and then the baby, coming out without a contraction, continued progressing outward. The stupid nurse was to my left and was exhorting this mom to PUSH, PUSH, HOLD YOUR BREATH! And I glanced at her and wondered what the hell she was looking at when she seemed to be looking at the client's vagina. I whispered in mom's ear, "slow, slow, you don't need to push, the baby is coming nice and slow... good, good... that is perfect..." blah blah blah. It was all overlaid with the family exclaiming how much of the baby was showing and mom not pushing as the baby slid out.

I'd missed a hospital catch by about 60 seconds.

Pitocin was pumped into her IV and an IM methergine was injected. There was no bleeding. Her placenta was born within a couple of moments, but still no bleeding. I was so relieved and firmly believe that having the IV in place with the meds kept her safe. There was no tear this time and mom was thrilled!

Despite the stupid IV placement, mom began nursing her 4th daughter and we talked and shared thoughts and after about 90 minutes, it was time for me to go. The rest of the family had already gone.

The next day, I talked to mom who told me the IV was still in. She'd hemorrhaged 4 hours after the birth!

I felt weak as I imagined that happening if she'd delivered at home. Even if we had had the IV in... even if we had kept her from bleeding initially... if she bled 4 hours postpartum, she would have been alone and had to be transported - alone. Our decision to transfer was the right one.

Mom, 2 weeks later, is doing well. There are sad moments of not having her so-hoped-for homebirth and we'll keep talking about it and working through it.

4 beautiful girls.

An alive mom whose bleeding was controlled with meds.

How blessed to live in these times.

25 Hour Precipitous Delivery - Part 2

Labor started and stopped several times throughout the night and day. Walking, thinking, sitting... sometimes they would come... and others, they would go. There didn't seem to be much rhyme or reason to their flow, and it was frustrating at times, sleepy at others.

I was asked to do a vaginal exam a couple of times (by the mom) and could see that she was dilating even without contractions. Starting at 2 cm, she then was 5 cm several hours later.

After about 15 hours, mom tried some blue and black cohosh, but the two doses caused dips in the baby's heart rate... from the 150's down to the 110's... so we abandoned any more of that. I didn't want to move to castor oil either, because if the baby was having moments of difficulty with B&B, then what would she do with something more aggressive?

The two midwives working with me were great. During the night, they spooned on the couch because it was freezing in the house. I slept in the car for awhile, then in one of the children's beds, setting my phone alarm for every hour to listen... and then not listening at all from 3-6 am when we sent everyone to bed and we all slept for 3 hours straight.

Once up, that was when we tried more walking and the B&B, and at one point, I was really, really tired and needed to sleep and one midwife, too, said she would, so I asked the third, the only one there not being paid, to hang out with mom. She had this great idea to get her out to walk. (We'd all suggested it for HOURS for her to go out and walk... seeing expanse, not walking in circles around the back yard, really walking and not strolling... but she wanted nothing to do with that.) I chuckled as I readied for a nap, knowing mom wouldn't be going out (modesty, needing to pee lots, and headstrong desires), but was amazed when I turned the corner and she was putting make-up and clothes on to head out!

I went for my nap and awoke feeling a distinct shift in energy. Finding everyone, mom was on the birth ball in her pjs after her walk(s) and having an inward energy.

This client lives at her in-law's home, so we spent most of the labor in her bedroom. Very modest, she sat on the ball in there, laid in the bed, sat on the chair occasionally. She also is a doula and knows the ins and outs of getting labors going/continuing. She knew her history of hemorrhage. She knew she could/should be out walking more. She told us as much.

She knew the energy of those around her could totally affect her labor.

Yet, she sat in the room, laid on the bed, and had invited her mother, an OB nurse, to the birth anyway. Her mom, from pregnancy, was disturbed about the homebirth. She hadn't been told about it last time because the client knew what she would say. After the transport experience, mom was so angry she would attempt a homebirth again. 4 midwives showed up at the 36 week home visit and answered all the mom's questions.

Yes, we understood the risks.

Yes, we were going to put a hep lock in (saline lock, actually) and have a 250 ml bag of LR with a pit and a meth in the bag for her.

No, we didn't want a homebirth if it wasn't going to be safe.

Yes, we all have practice with hemorrhages. (2 LMs, 1 CNM, and me)

Yet, once in labor, mom was a pill. She could not stop making comments about how dangerous her daughter was being. I could tell she was really trying to not be so mean (it could have been worse?). Sometimes. Just like docs play the "if she were MY daughter..." card, this mom also played that card: When their daughters (meaning us midwives) are the ones in this position, they can make their own choices.

Never underestimate the power of pitocin.

You have three other kids to live for, why are you putting yourself at such a risk?

How long will you give her (with her membranes ruptured)? (My answer: until she delivers)

During pow wows together, one midwife wanted to find the psychological reasons for her labor dystocia. I didn't care. I also knew the mom better and knew her level of compliance and desire to actively participate in her pregnancy, labor, and birth. It just wasn't her thing to DO something. Later, when the walking midwife's husband brought their baby to nurse (she'd run out of the house without the pump), the client told me how much she hated the walking. The midwife exhorting her to walk faster and she walked so much she sweat. At one point, she begged to go to the bathroom, and when she opened the bathroom door afterwards, the midwife was there again, ready to walk and walk. The client, momentarily compliant (read: open to the power of suggestion), headed out again. When she got back to pee the second time, she said she felt yucky so wanted to shower. The walking midwife thought that was a great idea! She could stimulate contrations in the shower... nipple stimulation and more. My client took a 3 minute shower and reappeared with her pajamas on. The walking midwife was so disappointed they weren't heading out again.

I didn't have the energy to deal with the "why's" of the clients desires. Why did she invite her mom in the first place? Why did she allow her mom to say these things outloud? Why didn't she tell her mom to shut up? Why did she tell us "no" that we didn't need to say anything to her mom about a positive attitude? I didn't care at that point. Those things could be explored later because they weren't going to make a whit of difference with this mom (or this type of mom).

Instead, I wanted to explore what was going on physically. Mom didn't want me to strip her again. She asked for a vag exam, but pushed me out after finding dilation quick and fast. She was continuing to dilate with no contractions.

And we didn't have the Hep lock in.

When we arrived, I had everything laid out and one midwife tried to get the IV going, but couldn't get a vein. After she tried twice, the other midwife tried and didn't get it either. Now, this mom was a champion sport in allowing herself to be poked so many times. The second midwife tried 3 times and couldn't get it. The OB nurse grandmother looked and wouldn't attempt a vein anywhere. We abandoned the IV plans. Red flag for me.

It was about 18 hours after her water broke when I started hints about going to the hospital. Her mother was dropping bombs whereas I was trickling droplets about it. By 20 hours, after another pow wow with the midwives, I really thought it was best if we go since she continued dilating... was a 5-6 at that point.

One midwife was missing and she had asked us to only call in an absolute emergency (she was in the northeast looking at fall leaves with her husband; her first vacation in years). The client said she wanted to know her opinion, so I called and left a message since she didn't answer. I went back in and said we might just have to make a decision without her.

The three midwives and I sat on the client's bed and talked with her, her husband, and her doula about the options ahead. If we had the IV in, it would be safer with how silent her labor was going. I was very concerned that if she kept dilating, that eventually, she would have a baby, yet also have a uterus that was in complete atony and she could bleed as we did bimanual compression, give IM meds while waiting the 3-5 min for them to kick in and allow EMS to arrive as she, once again, had a harrowing, naked experience in an ambulance and in the hospital. I felt controlled was a much better option. It just took her time to ponder the options herself.

What were those options?

* Stay at home and wait to go into transition (going into labor wasn't going to happen)

* Go to the hospital without a fever, without meconium, without contractions and have pitocin (we felt that, surely, she would have a whiff of pit and cough the baby out) and leave asap afterwards.

* Send us home and call us when labor kicked in (that wasn't remotely going to happen, but was certainly an option)

She loved her doctor, who, apparently, backs up another midwife in the community (whom I have never met), but he was away in Africa and she didn't want anyone else. I asked her to call his office and ask when he got back and they told her he'd been back for 10 days! They said he was on-call at the hospital (the term is Doc in the Box), so the client called L&D and found her beloved doctor.

I met this doc last time after her transport and he was very kind and loving. He never gave her a hard time about the home birth and, in fact, didn't even give her grief about wanting another homebirth this time! Something other docs, even supportive ones, would have had cows over.

The doc suggested she come on in, sniff the cork (of pitocin) and have her baby. We concurred.

While mom was making her decision, her mother came into the room and stood there. The client told her mom she was hearing about her options and the mom said, "you know your options already" and the client said, "without you. I want to decide without you" yet mom stood in the doorway as we sat in uncomfortable silence waiting for her to leave. She ended up stomping off and the husband closed the door gently behind her.

She had made her decision and once it was voiced, began gathering her things for the hospital -stopped at one point and cried. I pulled her into my arms and cried with her as we shared the disappointment for what she wanted so badly and what we had worked so hard to accomplish. I didn't make any comments about safety or this is for the best or we tried everything. I merely held her and cried with her as she mourned her last opportunity for a homebirth that was beautiful and gentle. (She would have no more children... it was already a surgically done deal.)

She finished getting ready and we packed my midwifery equipment up and got it into the car. (God, I love my organized birth kit! It set up and broke down in mere minutes!)

25 Hour Precipitous Delivery - Part 1

Yay! She had the baby. I'd been up since 5am and Athena was really pounding my head (but not quite as bad as when I almost called 911), so I left childbirth class early so I could go home and go to bed. On the way home, I called Sarah and I was hungry, so we were going to stop at Wendy's for a quick bite (she was on-duty).

She'd waited for me at the end of the ramp, but I headed to the next exit as she got onto the highway in front of me to do the same. She was further ahead and I couldn't see her, but I expected to at the light at the end of the ramp. When I didn't, I asked where she was and she told me as a red Izuzu came flying past me and the ran a way red light and continued speeding towards Sarah. I kinda gasped and screamed as I told her about the guy and said he was coming up behind her on her right.

And she got him.

laugh laugh

I went to Wendy's and sat in the car waiting for her while reading.

My client (J) called saying she'd either ruptured her membranes or was wetting her pants. I was on my way and called the other 2 midwives to alert them. My original back-up was still seeing fall leaves in the northeast.

Getting to her house, I gave her some nitrazine and she showed me it was, indeed, a deep blue color; membranes broken!

I called the other midwives who were hurrying over (remember, her last labor was half an hour... seconds after her membranes ruptured... and she'd hemorrhaged so badly she needed to be transported. I missed that birth, but made it for the hemorrhage and got her antecubetal [inside the elbow] vein to start the IV before the transport. Her Hgb 4 hours postpartum was an 8... transfusion material right there, but Hgb's go down over the first 48 hours before showing the true hemorrhage experience; she wasn't ever tested after the 8) and I began setting up.

Setting up for myself was relaxed and comfortable. I have been exhorted to set-up by other midwives when working with them, but for myself, it was gentle and easy. I'd already arranged my bags appropriately (although, rearranged them some after the experience of using my new organizational skills), so it wasn't so difficult getting things out and in their proper places.

We knew we were going to do an IV, so I pulled the equipment and supplies out for that and set them on the chair. The oxygen was on and readied, the birth equipment in my new carry-all was ready on top of the oxygen tank, the blankets and towels and washcloths with one hat were sandwiched between the heating pads on my NEW resuscitation board a client made for me last week (I love love love it, but the way... he made it with a handle cut into it and it is sturdy and holds all the equipment perfectly for the baby! I told him to come up with a price because other midwives are going to want one, too... it fits perfectly in a standard pillowcase. I have wanted one for years!), got the stuff out of her bins... Chux, peroxide, etc. and had things where they needed to be and removed things from the small room when they weren't going to be needed for awhile. I was pleased.

Sarah called in the meantime and asked where I was and when I told her that J was going to have her baby, she asked if she could bring me food. I told her sure! and then later realized she was in uniform and how humorous this could be.

We talked about crampiness and bloody show (there was none), that I didn't need to do an exam until she asked, but that I wanted to minimize them and she agreed. I'd taken vitals before even setting up and began charting the labor notes and forms that come with birthing (dates and times of significant events in labor); all was great.

Sarah arrived all bulky in her cop uniform bringing Wendy's. She sat at the kitchen counter waiting for the rest of the folks to arrive as I continued going back and forth setting up. Her mom came in breathless... is the baby here?!? why is the Sheriff here?! And we giggled, introducing Sarah as she sat eating her Wendy's. Friend after family member, the same scenario ocurred as J laughed about their nervousness when she was still walking around.

The first other midwife arrived, not nervous, knowing it was going to be Sarah and she laughed seeing her in her uniform as opposed to nice clothes at the office. She is SO imposing in that uniform!

The other midwife arrived and we began our sitting and talking that would continue through the night and into the next day.