Monday, January 19, 2009

The calm and then the storm.

Both metaphorically and literally...

Yesterday was very quiet, no babies, not even any laboring women, just scrubbing things (and there is much to be scrubbed!) and chatting with midwives and trying madly to not get too dehydrated.

Last night, replete with rumbly sky and lightening it rained, and rained and rained. I rustled up an umbrella this morning and strolled through the rain to the hospital this morning. By 8am we were hopping. Three women presented for inductions, two in spontaneous labor. I did the intake for one of the spontaneous mama's. I checked her first (we don't admit women unless they are at least 4 cm dilated) and found her 2-3, her cervix busily effacing. I then took her vitals which were all normal and popped her on the CTG for a quick strip. Her contractions were coming steadily every 5 minutes or so, and her baby was having variable decels like clockwork with every one. So I sat and watched the monitor and rubbed her back and watched her baby's heartrate rise and fall, waiting to see if anything more ominous would happen. Sure enough within 10 or so contractions, the bell curve shifted a little to the right, and we slid into late decel territory. I grabbed a doc, who proceeded to break her water apparrently with the intent to rule out a cord compression (by tempting a prolapse I thought!). Oddly though, the decels stopped and shortly she was taken off the CTG and was sent off to labor.

I then admitted a woman who's last baby was born still, with no cause ever determined. She was scheduled for another miso induction at 38 weeks. Her admit checks all looked good, the miso was placed, and she too was sent off to labor.

Mama number three for the morning was a woman who started her pregnancy only a few months after her 14th birthday. She too was being induced, having reached 42 weeks.

Shortly after 9, the mother of a woman grabbed me and pointed to her friend who was clearly thinking seriously about pushing a baby out. I grabbed her chart, beckoned her into the Labor ward and did a quick check, confirming that she was in fact complete and her baby was beginning to decend. I noted the scar on her belly, and realized that she too was a VBAC (my second in a week!). In hindsight the reasonably quick decent followed by a sloooooow crown, should have been a tip off, but I was so busy guarding her perineum that when the head finally delivered and then failed to restitute, it took me a 30 seconds or so to collect my thoughts and then address what turned out to my my first solo shoulder dystocia.

I thought for a second how I would ask her to flip to her hands and knees, then abandoned that in favor of instructing the nurse assisting me to pull her knees into McRoberts and do some suprapubic pressure. A couple of pushes but no movement from the shoulder. I felt deeply around baby's neck, and got a good sense of how tight it was in there (noting as I did how tight that nuchal cord was!), I attempted Rubins, still nothing. Baby's head is getting quite dark. I'm frustrated by the lack of options I have with her in lithotomy, so I insert my hand along the side of baby's head, and ran it around quickly, sliding my hand into the curve of her sacrum, feeling that carefully preserved perineum 'give' as I did so but finding baby's posterior shoulder, then reaching past it into baby's armpit then easing it and baby's arm up and out. Baby spilled out with a small torrent of thick mec, was a little flat, but came around quickly. She had pushed her a little girl into the world, her first vaginal birth. She sobbed with what I imagine was relief and no small amount of joy that she had her much wanted daughter. She reached up the way a few of these gorgeous Ni-Van women have and stroked my cheek silently, but with a big smile.

All I had to say quietly, with a big smile was "You did it!"

With impeccable timing the two med students walked in just as my still shaking hands delivered her placenta, and I asked one if he was interested in doing the repair. He did, and I helped him repair his first 2nd degree lac.

As we finished up with that birth we walked out just as the earlier woman with the variables was wheeled quickly out the door to the OR after the next CTG tracing done showed a very unhappy baby having deep, deep (to the 70's for a minute or so at a time) decels. I looked at the head MW and we agreed that decels of any description at 2-3cm probably never bode well for a normal labor course. Baby was delivered happy with a tight double nuchal cord (so much for no cord compression) but went to breast with no problems when her mom was returned to the floor.

An hour before I was due to head home, another mother was put in the labor ward with some funky irregular contraction pattern, a bag of fluids and some Synto was hung to try to even things out. Mama was desperately unhappy. Shreiking and slapping at her mother who was supporting her, and thrashing about on the bed. I sat down with her, held her hand and asked her to focus on me. I spoke soothingly with her, explaining that the contraction was waning, that she could have a rest, and that that contraction was one less. She calmed a bit, and a bit more again when I told her she could get up off the bed and walk about with her IV if she wanted. She seemed to be calmer and coping better, so I stepped out to complete some paperwork.

A short while later she was screaming and as I walked in the MW was trying to examine her. She virtually levitated off the bed, refusing abjectly to the exam, tears coursing down her cheeks. Everyone in the room was yelling at her. I squeezed in next to her, got her attention, took her hand and began speaking quietly to her, asking for her to look at me. She calmed down a bit and the midwife tried to examine her again. Once again she began screaming, begging for her mother to take her away, shreiking that she was dying. I very nearly got, but narrowly dodged a swift kick in the belly, which I think freaked out the midwife more than me. I went around the other side of her bed, sat down next to her head, held her hand and began talking quietly to her. The next exam attempt was successful - in that the exam could be performed - and the MW reduced the last cm or so of cervical lip with her first few virtually hysterical pushes.

I've rarely seen a woman so completely terrified and undone by the sensations of labor, this was more than simply pain, she was absolutely out of her mind with fear and pain and God knows what else. All I kept thinking was "What on earth has happened to you?" Though appallingly the answer to that seems pretty clear. I've never wanted pain medication for someone so badly as I did working with this woman this afternoon.

As she began pushing she gradually seemed to dissociate, her eyes glazed over and rolled back, she found a rhythmic rocking rhythm and assumed a keening breathing between contractions. Gradually, as she calmed outwardly, more and more people left the room. This relieved me. I felt acutely that I wanted as few people as possible in the room with us as she did this work. And work she did. She seemed to be somewhere else entirely but she pushed her baby down. Another sloooow crown, the largest caput I've ever seen, and as there was 6 or 7 cm of head visible, there were bony sutures palpable at 1 o'clock which had me thinking I might be shortly looking at an OP presentation. Instead, when baby's head did slide out, it did so offering me his right coronal suture and the top of one ear first. The most stunning acynclitic molding I have ever seen, and a very stunned floppy baby who took some work to get him to come around properly.

Likewise his mother took some coming around. She seemed stunned, and disinterested in her baby as he was worked on across the room. I continued to talk to her quietly and kept explaining what was happening, everything I was doing as I delivered her placenta and then inspected her (intact!) perineum. I encouraged her mother to stay with her. In a short time baby was whisked off to the nursery (some respiratory distress) and she was left there with her Mom, curled up on her side, apparently asleep but when I touched her hip, she opened her eyes, smiled faintly at me, and reached up to touch my face with another whispered "Tankyu."

Today, with her, I wished over and over that I could speak more than my presently fractured Bislama. Odd though, that her birth is the one I found hardest today, and not the heartstopping "stuck-ness' of that first shoulder dystocia.


CFB said...

Thanks for the update. Eeek.

minority midwife said...

Morag. What a phenomenal job you're doing. Great job on that SD and helping that obviously traumatized mama. I am so friggin proud of you, and so happy you're writing this all down.