Saturday, November 13, 2004

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!)

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