Sunday, December 26, 2004

A Series of FORTUNATE Events!

Client came for childbirth class on Sunday and looked kinda funny.

Near the end of class, she asked me for a pad and I raised my eyebrows and asked why. She said she couldn't stop peeing and I asked if I could have some of her pee in her undies. She laughed (she is a joy-filled client) and I said perhaps she had ruptured her membranes. It was clear, so she wasn't sure, but it had started leaking at 2am (it was now 1pm the same day). I got my prenatal bag and nitrazine paper and checked and ayup, it was positive for amniotic fluid. She had no contractions. I did a sterile vaginal exam and she was 1-2/40%/-2. I was disappointed and concerned.

This client had also chosen to do a GBS test and was positive. She did the alternative regimen, but remained positive 2 weeks later and wanted antibiotics during labor because of this.

We were on a time limit.

I gave the client several options including the hospital induction route... cimicifuga and cauliphylum; castor oil; nipple stimulation; visualization; acupuncture. She was game for them... all but the hospital one.

On the way home, she called the acupuncturist who came to her home within an hour. She had begun the C&C in the office and was taking that every 4 hours. She knew to put nothing in the vagina and was taking her temperature every 4 hours, too. I was going to meet her at 7pm (18 hours post-rupture) to start IV antibiotics.

I got to the client's house at 7pm and loved her house! She had just moved in with her roomate... her man is in South America having just gotten his visa to come to the US. She was going to move to a local Indian Reservation to birth at her mom's (she wanted a teepee birth, but that didn't pan out; she is Native American), but knowing that there was a possibility of transferring to the hospital that was a few miles from her own home, she decided to stay home.

The CNM in the practice came and we had a long talk about what might come down the pike without labor even a hint. She tried to get a vein three times and missed. I was going to try next and then kept thinking: save something in case you go to L&D.

It was 9:30pm and her family was starting to assemble. We needed to make some decisions.

She had had 3 acupuncture treatments (was having her third at 9:30pm) and not a hint of contrations.

After discussions, she decided to move to the hospital. Never ever did we "see" this birth in the hospital. It was very odd.

So, we get to the hospital at midnight and she is admitted from Triage by 2:15am. She decided to fudge 12 hours off her real rupture of membranes time. She didn't come up with that idea on her own. We offered ideas of how to speak about her membranes and it worked. "I wasn't sure, but I thought I started leaking at 2 or so." and then I piped up and said, "and so I checked and she was positive!" They wrote 2pm instead of the true 2am. Her sterile VE showed 1-2 cm/40%/-2.

Once in L&D (we had a HUGE room), I finally sat with my leg up and the drama of admitting began. One nurse tried to start the IV twice and blew the veins the same as the CNM did at the house. Another nurse came in and didn't even feel and started the IV within seconds. I want her to start all my IVs!! The pit was started and the long night continued.

I went to the car to sleep at 3:30am. Her mom slept on the pull out chair thingie I had my leg up on. I awoke at 6am and went back in. Nothing happening. That is how it was all day. The pit was increased every 20-40 minutes and then by noon, she was at the max amount. A nurse took me aside at 8am and asked if I knew where this was going. I said that I did. The OR was what she meant. She said she would probably have the baby by noon.

Later, we were told the doc would be in around noon and a decision would be made. No vaginal exams until the doc. I told the client and her mom the doc wouldn't be there until 1:30. At 3pm, a new nurse (we had a bevy of nurses) came in and said the doc was held up at another hospital and gave orders to up the pitocin.

Very shortly after, the client began feeling the contractions and having to breathe through them. I was extremely tired and called my midwife-friend in to help me. I needed to sleep. She got there quickly, but by the time she got there, I didn't want to even go sleep in the car lest I miss something!

The doc got there at 5pm and did a vaginal exam. She was 2/80%/-1. It didn't look good. But, there was some change, so she wanted to wait awhile and see what happened. Maybe another hour. The nurse (and I) thought she heard some late decelerations and the doc ordered an intrauterine pressure catheter (IUPC) and the doc, 2 contractions after the last exam, put the IUPC in and commented that mom was now 3 cm. Woo hoo! Hope!

Nurses would say, "you know, she will be having this baby one way or another by midnight" and I believed them. I couldn't believe we had bought so much time so far!

With the IUPC in, the nurse became alarmed because for the first time they could SEE the contractions my client was experiencing. She is a master meditator and she was extremely peaceful and none of the nurses thought she was feeling a thing when she was, in fact, doing slight breathing for quite awhile. She didn't get "working-feeling" contractions until 3:30pm or so, though. When the nurse saw the contractions on the monitor, she stood and watched because my client did NOT have an epidural and was experiencing massive contractions. For those that know: the TOCO was nearly zero'd out... 3-5 being the baseline. When she had a contraction, it would go to 80-90 each time... some of them off the damn paper and higher! The other midwife and I were worried about the client's uterus! The alarmed nurse turned the pit down after about 3 minutes seeing the strip. She was having contractions every 45 - 60 seconds and while they were short, they were hard. She ended up turning the pit down 4 times before it settled where it did.

Now, the doc was supposed to come back after feeding her cats (after her 5pm visit), but she was called to the other hospital again and wasn't there. My client labored on. I took a nap from 6:30-8pm. I thought I was going to throw up I was so tired. I laid down in my car and shut my eyes and then the other midwife called me. 90 minutes had passed! I went back upstairs.

A vaginal exam at 9pm found my client 3/100%/-1. Change! A long discussion about getting an epidural or just asking for a cesarean began. The other midwife and I shared our thoughts and in the end the mom decided to let the doc make the choice (via phone). The doc voted for epidural because she was... you guessed it... at another hospital! Wheee!

The epidural went in at 10pm. Quick, easy, and comfortable. Mom went to sleep and the midwife and I went to eat. We were in the lobby yacking and heard a call to her room so we hightailed it over there. Apparently, at 10:30, she was 5cm and now, at 11:15pm, she was complete!

Mom felt some urge to push and pushed really well with the nurse's fingers inside showing her where to push. All those things she learned in class to not do were inacted. She laughed a lot about that happening. Even the exercises about working with pain so it doesn't overtake you... she had to focus and make the pain hurt or her contractions would peter out and go bye bye.

So, she is pushing and the nurse is readying the room, so I ask if I can sterile glove and help my client. Sure! she says. I glove up and work with the client about where to push. We get the client to put her hands in her vagina and feel the head and she does over and over. Joyous! Her face was filled with bliss (and we said as much several times). She was ecstatic that she was having a vaginal birth after being led all the entire day that a cesarean was where she was going. She was more than bliss-filled.

The doc was called and she got there, gowned and sat behind me watching. As she was gowning, I said to her to just let me know when she needed me to move, that I would jump off the bed the second she needed me to. I worked with the client until about 3 contractions from delivery and the other midwife shoo'd me away from her vagina. I asked her later why she didn't wait for the doc to say something and she said she was the kind of doc that wouldn't say anything and then be very angry afterwards. Oh. So, I trust my midwife-friend, so moved and they broke the bed and put her feet in the pedals inbetween contractions and the head came out and the baby was born and it was delicious and fabulous and wondrous all at once! We all wept with joy!

It is a boy and he is gorgous! A Native American mom and an Hispanic dad. Oh, how yummy he is. 8 pounds 10 ounces. Small tears that needed repair (I think from the doc's pulling on her vagina... I was very gentle and had no blood when I was in there), all inside.

The baby was doing great, but has had some transient tachypnea and they were especially freaking because of all the time with ruptured membranes and the GBS issue, but he is fine.

The baby did end up with ABO blood incompatibility and under the bililights for a couple of days. Mom just got home and told me the baby continues with some tachypnea at times. We'll watch that. They gave her a lot of education about GBS infection, so I won't have to harp on her or anything.

Because of the ABO incompatibility, this baby would have also been hospitalized after birth. His jaundice levels rose high and went high FAST (15 at about 30 hours postpartum) and while the bili experience was not as positive as my last client's (nursing in the bed, keeping the baby in the room under the lights, etc.), mom is coping well and has been out of the hospital for a day now (the baby is 6 days old now) and nursing is moving along beautifully!

What a cool story of hope for me. I am constantly surprised and amazed.

Wednesday, December 01, 2004

Forced Cesarean

We drove 90 miles at 80 mph to get to the hospital that was supposed to treat us nicely... kindly. We passed at least 8 other hospitals along the way and left two, much closer, behind us. We had been led to believe that the university hospital, a hospital that also had a birth center on a separate floor run by over a dozen CNMs, would be a safe space for us midwives who had to transfer a client in the midst of labor and birth. Absolute emergencies, of course, went to the closest hospitals, but this wasn’t an emergency. Yet.

We drove in a caravan, me behind the laboring client whose husband was driving, the other midwife right behind me and then family members behind them. Thankfully, most of the evening traffic had abated, so the gang stayed pretty much together until we got a lot closer to the hospital downtown.

I kept begging God to let the baby come in the van. Please, please, please just let the baby come now.

When we left the house, mom was 7-8 cm and the baby was a –2 station. A huge difference from complete and 0 station before the hugely bulging membranes ruptured. Sometimes membranes not rupturing make me angry! They aren’t always misleading, but this time, those membranes told a whole different story than when they were gone and the head got to tell the story. At least the fluid was clear. I was so worried the fluids wouldn’t be clear once the membranes broke, but that was a pleasant surprise. It is one reason we don’t like breaking them; what we don’t know won’t scare us.

The other midwife and I paved the way for the client who was waiting for a wheelchair to bring her up. Does she want to try for a vaginal birth? Well, we doubt that will happen at this point, but, of course, if possible! The charge nurse tsk tsking in the background as she was assigned a bed.

Into the room the entourage goes and mom is hooked, hollering, up to the monitor and asked a dozen questions. Everything is going too fast! It isn’t an absolute emergency. A female resident comes in and says she wants to check my client and she submits to only the 4th exam of the labor. She has a cervical lip and the baby is +2. What?!? She is fractions of inches from having this baby vaginally! The doctor wants to see if she can lift the lip and has my client push with all her might as another nurse is prepping her for an IV and others are bustling about the room. She pushes as best as she can after not pushing for the entire 2 hour journey down to the hospital and into that bed and the doctor takes her hand out and says, “sorry, don’t think it’s going to happen.”

And that’s it.

And that’s it?!

My mind races as I think of alternatives to a cesarean for a cervical lip with a baby at a +2 station (+4 is the baby’s head visible at the entroitus). I mention to the doc that some midwives will use ice in a sterile glove on a swollen lip... might we try that? She said she wasn't comfortable with that, but interesting concept.

I discuss with the client... quietly... but quickly... that an epidural might do the trick. An hour or two without pushing/pressure might relieve the lip’s pressure and the baby could come sliding out. Positive, loving words of encouragement, her perfection, how great she worked all the way down from another county. I nurse starts the IV angrily in the back of her hand causing my client to holler and wince. The anesthesiologist is going to come in now, another nurse says, to discuss her spinal for the cesarean.

Somewhere in all of this is the absence of the CNM who was supposed to meet us in the room. She had an emergency transport from upstairs to L&D, so couldn't meet us. Had that happened, we might never had experienced the story below.

Later, another CNM told me that the new slew of residents and attendings hadn't been sufficiently brainwashed by the CNMs yet to leave things alone. They were eager to cut and learn. Why on my client?

I note a waif of a woman at the bottom of the bed staring, but say nothing to her as I discuss strategy with my client; there are so many people in the room already. The nurse walks out the door and I let her know that my client would really like to discuss an epidural so she might have her vaginal birth after cesarean and the curtain drops in a huff.

Waif woman, it turns out, has been eavesdropping and also happens to be the Attending Physician; the Queen of All Decision Making. The attending says she just doesn’t see how a vaginal birth is going to happen... mom has been through SO much already, isn’t it time to just have the baby in her arms now?

The anesthesiologist comes in and does his Spinal Spiel... checking for dentures, size of the mouth and throat, going over allergies, discussing previous surgeries... and the other midwife, gently, touches his shoulder to explain that mom had to be poked three times for her epidural last time. He shrugs her hand off as if she were a poisonous spider without any other acknowledgement of our presence.

Mom, in so much pain, enduring the indignities of these people’s questions, being poked, prodded, having the monitors adjusted over and over during contractions (they always forget that not everyone has epidurals and adjust them during contractions)... all she wants is a moment of relief.

She says to the anesthesiologist, a male doc, that she wants an epidural because she wants to try and have a vaginal birth. The attending butts her head in there and says she doesn’t think that is going to happen... and look! the baby is starting to show signs of stress now. Look at those late decels. What?! I go to the machine and see no late decels, but plenty of head compression decels and find hope in them... wanting to scream at the attending for her hate and venom of disbelief in my client and her ability to birth vaginally.

I write this in a linear fashion. This was not linear. This was layer over layer of fear and anger and waves of loud and huge contractions and disbelief and shock and noise and undermining and lying and people talking all at once and hurry! hurry! hurry!

My client asked for a few minutes with her family, leaving the other midwife and I with her husband as she said she really wanted to stop the pain and to try for a vaginal birth. I asked her if she wanted to see the strip because I didn’t believe they were late decels at all and she said she couldn’t look as yet another contraction pulled at her body.

The docs came back in... three now... the original resident, the attending and the anesthesiologist... and the CNM, too... and as my client asked for an epidural, the attending lowered the client’s bed some... pointing to the monitor showing what a hard time the baby was having now. There wasn’t time to see anymore. It was time to go back now!

The anesthesiologist began discussing the epidural and that it wouldn’t last long... maybe two hours... and it wouldn’t be able to be used for the actual surgery. She didn’t care! The attending had to have given him a glaring, evil look or kicked him under the bed or something because then he started this whole other voice.

A grapeseed of evil surrounded by a honeycomb.

Now, if you have an epidural in here, if we have to go back, I just might not be able to re-dose it. Sometimes it’s hard to do that.

Remember, there is a lot of commotion still going on... still so much noise and activity. But he created this tiny pocket of silence where only the client, the husband, the midwife, and I could hear.

So, if you can’t be re-dosed, then, gee, I guess you’ll just have to have general anesthesia for your surgery.

My head swirled. I thought I was going to vomit as his threat washed over me. I wanted to take the IV pole next to me and smash his arrogant head with it, letting him feel the agony he was causing other women at his hands.

There were no options. They evaporated with his remark. This man, no matter what, was going to have needles next to my client’s spinal cord and he had the power to make that experience hell or tolerable. My only regret is not begging my client, just one more time, to try without medication. It was ludicrous since she’d been in good active labor for about 50 hours at that point; it wouldn’t have been fair to do so, but since it is human nature to replay things a thousand times, that is my only major regret.

I wasn’t sure if my client “heard” what he said, but I leaned over and whispered to her, through tears, “you have to go back now” and she said, “okay.”

Promises were made about keeping mother and baby together, Duramorph being used so mom could be pain-free long, but still mobile, and mom was wheeled out of the room with the chaos, leaving dad, the other midwife, and me.

Dad was in the OR for the birth and remarked that someone had to go to the end of the table to dislodge the baby’s head from the pelvis before she could be born abdominally. Another wave of nausea swept over me.

Mom was taken across the hospital to the “overflow” recovery room... the PACU... where no babies are allowed, where moms are not allowed any visitors at all... where the recovery period is 4 hours as opposed to the 2 hour max in standard OB Recovery Rooms. The baby was taken to NICU and found, quickly, to have low glucose. (All this happened within the first hour postpartum.) The nurses wanted to give her a bottle of formula and when dad refused, they readied an IV solution of dextrose! An IV!! Through careful and kind negotiation, dad convinced an NICU nurse to take the baby to the PACU to nurse on mom and, blessedly, they did (after much arguing about policies). The baby’s glucose never went down again.

Mom was left alone in recovery despite my trying to get in. When we sent the baby, the mother-in-law (MIL), an NICU nurse herself, tried to stay, but the client said she wanted to sleep. The PACU nurse made snotty comments about mom sleeping so well until the family interrupted. I asked dad if he told the nurse to shove it and that mom would MUCH rather lose some sleep to nursing than sleep through the first 4 hours postpartum without nursing. He said he said something to that effect.

Mom's belly incision was made above the old incision... and in a drunken fashion. The resident's first incision on a belly? We are waiting for the records to see what the uterine incision will be... hopefully, the same incision, but, considering the surgical and emotional punishment foisted on her throughout her short L&D experience, I wouldn't doubt if they gave her a vertical incision on her uterus.

After the baby nursed, I gathered myself together, said my good-byes to the troups and went home. I’d gone to the mom’s home 23.5 hours earlier, fully anticipating a wondrous and amazing birth. And here I was going home, defeated. Feeling so useless as a midwife. Feeling powerless as a doula. Feeling useless even as a friend.

I sobbed the entire way home.