Agony and Ecstasy

A somewhat young, shy woman having her 2nd baby called me with bleeding: two clots the size of toonies. No contractions, baby moving well. Went in at 1730 for an non-stress test, which was normal (or "reactive"). Literally five minutes after I put her on the monitor, she had a contraction. After checking her (and she was 3 cm with the head nicely down at -1) I did an OB consult for antenatal bleeding, and the decision was made to wait and observe her. An hour later the OB checked her and Sure enough, she went into labour!

During the waiting period between when we did her NST and when her contractions were strong enough to bring her to L&D we had a discussion about labour and pain relief. She had expressed a desire prenatally to avoid an epidural. She had one with her first, which was a really hard back labour, and wanted to avoid one this time. So We came up wtih a strategy: cope as long as possible with different positions, then get in the bath, then if things get really bad, then try the nitrous oxide (laughing gas). She was keen on this plan, and I was excited about this labour, as I feel that having made this plan with her somehow bonded us.

About 9pm she said that they were strong enough that she would have paged me. So, with contractions every 5-6 minutes at about 1030pm I took her from triage to a labour room to break her water and get her on the way. I checked her at that point and she was four cm but the head was way up at -4!! So needless to say, I didn't break her water. A cord prolapse was the last thing I wanted! So had her walk and do squats for an hour and the head came down nicely to -2 and five cm. So at midnight I broke her water for lots and lots of clear fluid. Her contractions took about an hour to pick up, and she was coping nicely while sitting on the ball. Checked her at 4am and she was still 5 but the head was down to 0 station and the cervix had thinned to about 1cm (from being about 1 inch thick), so no intervention necessary. After 2.5 hours, was 6 but was completely thinned out. After that, she wanted into the bath, which relaxed her nicely, but after half an hour, the contractions were getting stronger and she wanted out.

Then things really started picking up. She started the "I can't do this" and wanted something for pain, so I got out the gas, which worked nicely for about 1/2 an hour, then she requested an epidural. So I went through the drill with her about how I would check her first, then we would have to run an IV, and sometimes in a second baby the baby comes before we could get it in. Did she still want to go for it? YES!!! Okay, so I paged neighbour midwife to come in as my epidural certification is not through yet. As soon as I came back in the room, she gave an involuntary push! Checked her, 8cm. Repaged midwife to hurry. With next contraction, saw head (then madly rushed around getting everything together). The contraction after that, there was a good 2 inches of head showing. I took the mom's hand and put it on her baby's head, and the joy of touching her baby and knowing that she was so very nearly done was beautiful. And then she did what I have not ever seen a mother do, and that is keep her hand on the baby as she gently birthed the head, then as the body glided out. She controlled the birth of the head so beautifully that she didn't tear in the least - no stitches! Seeing her ecstasy at the birth was so beautiful. What a glorious birth!

Just Hoover the kid out

Well, in one week I have seen my first forceps delivery and first vacuum delivery.
I attended to back up for neighbour midiwfe at a first time mother's delivery. She was doing great, but as soon as she started pushing, the heart rate started dropping significantly (down to 50s). So the OB was called in, first to put a scalp clip in: a wee tiny wire that screws in the baby's scalp [yes, I know, barbaric] in order to get a good reading of the baby's heart rate. Then later we were still getting decels and they were taking longer to recover, and the OB concurred that we needed a vacuum delivery. So, the suction was attached and over a few contractions and a small episiotomy the baby was born, and thankfully, was fine. The umbilical cord was short and tightly around the baby's neck, which was no surprise since the heartbeat was reflecting that very picture.

Clinic day #17

No concerns, no problems, no sweat.
Nice.

home birth, update on long haul

Had a sweet home birth to which I was the second midwife.
Everything was going well until the head was born and shoulders didn't. Took a bit of effort on the primary midwife's part.
It was nice to be at a relatively normal birth.

Update on long haul birth: mom has major infection, and the stitches have come apart in her perineum, impossible to tell about the rectum at this point. They will wait until the infection is gone before repairing it. I feel so bad for the mother... at least nursing is going well and baby is gaining very well.

Clinic day #16

Had clinic rescheduled due to long haul birth. Also had 4 home visits rescheduled for afternoon.

Second last appointment brought in a woman bleeding. She is at the end of her pregnancy, and from the amount I was pretty sure it was from her cervix changing and some intercourse, but her abdomen was firmer than usual and she described some achiness in her uterus, so I decided that a non-stress-test was in order. So we went to University hospital and I put her on the monitor: she had a very active baby with beautiful accelerations in the heartbeat and 2 contractions in an hour. I also did a vag exam and found her to be 1 cm and a soft cervix that almost felt friable, as if if I pulled on it too hard it would tear. Lots of bloody show on my glove.

Sent her home with instructions to page if increased bleeding or decreased baby movements. Or of course labour.

Oops, just got a call, must run!

In for the long haul

Monday evening 2300: call from young primip thinking she is in labour after contractions all day. Go to check: 1cm, thick cervix. Thinking that this is another round of false labour...

Tuesday morning 0630: contractions didn't quit and got stronger, head to home and check: 1cm, but 50% effaced, perhaps this is the real deal starting...
1000: contractions are 2-3 minutes apart, and mom is falling apart. Head to hospital for assessment
1100: 2cm
1400: 3cm, 90%eff, contractions intensifying
1800: appears as if transitional: shaking, nauseous... 3.5cm. gr. Broke her water
2000: just barely 4cm, requesting epidural and IV oxytocin started for slow progress.

Wednesday morning 0100: 8cm
0300: severe fetal bradycardia when changed her position to empty bladder: resolved after stop IV and 2 position changes: 9cm
0530: another fetal bradycardia completely dilated, head nice and low, +2station, resolved when bladder emptied of 700cc and position changed. Pushing.
0730: still +2 station. Mother exhausted and starting to freak out.
OB consulted, for my very first forceps delivery at 0952 (had to wait for anaesthesia). Large mediolateral episiotomy for bradycardia down to 50s and a Direct OP with asynclitic molding. The epis extended to the rectal mucosa. Baby came out nearly flat but responded fairly well to PPV: Apgars of 6 and 8.
Mom and Dad both relieved and exhausted.
Midwife relieved and exhausted.

Clinic day #15

*a few backup visits: uneventful
*a few early pregnancy visits: uneventful
*a few later pregnancy visits: uneventful (except for needing an anaesthesia consult for obesity... still pretty uneventful)
*one crazy fast prenatal - 3 minutes!!! She was late and my next client was already there... and there was really nothing to discuss or go over: fast but uneventful!
*one intake: uneventful

A good uneventful day.

Clinic day #14

Uneventful day... I got all my appointments done except for one and was paged out to the birth. The poor woman was already in the waiting room! I returned the next day for her prenatal, after a glorious 12 hours of sleep!

Men: a pillar of strength. Or just a pillar.

I primaried for a beautiful home birth on Tuesday evening. Second baby, no stitches needed, baby quite mucousy at birth, but cleared nicely after nursing.

Went for the day one visit, and the babys lungs sounded really wet. Suctioned, and they still sounded wet. All else looked well, but I decided that I wanted a paediatrician's opinion. So I called the paed on call, and his secretary returned my call saying to be at the General in 1/2 an hour. Well, this family lived 15-20 minutes out of town, so we were going to have to boogey. So when I told the dad that it wasn't an emergency, but that the doctor could see us in 1/2 an hour so we needed to go now, he just stood there with this deer in the headlights look. I realized that he was paralyzed with fear. So I had to order him around: go to the car and get the carseat. I'll put the baby in, now you go help your wife get ready...

Turns out that the baby was fine... babys lungs did sound a bit wet but it was likely referred noise from the nasal congestion, and the paed didn't think it was bad enough to do a chest x-ray. At the two day visit, baby sounded perfect.

The race for a New Year's baby

I have a client whose water broke early: at 35 weeks and a few days. We were unable to go to the University hospital because they were so busy that they couldn't fit another person in - they had zero beds available! So they told us to find another facility. We went to the general, and the OB said that she wanted to induce my client, because in her words, "the lungs are already developed, so what are we waiting for?" Full term, maybe?! Don't get me wrong, induction after 34 weeks for when the water breaks is an acceptable plan of management, medically speaking, but so is waiting (with antibiotics to prevent infection). The clients were informed and wanted to wait. So, we went to a Catholic hospital close to University hospital where I don't have privileges. She would be a transfer of care in any situation, so it didn't make much difference where we went. So they gave her antibiotics, and admitted her. The next day, the OB that was on wanted to induce. They declined. Then the next day, a wonderful resident sat down with them and talked out the risks and benefits, and really addressed some of their concerns. They decided to induce.

At 10am on Dec 31st they called saying that they were being induced, and were just waiting until the husband and I could get there. So I went and we waited until 10pm, when the board was empty enough that they could start her. Apparantly they had quite a few people walk in either in labour or "I think I'm in labour, please induce me". So, the race was on for a New Year's baby.

So the IV got started, and the oxytocin turned on at 11pm. This woman has never taken longer than 3 hours of active labour, so the possibility was definitely there for the New Year's baby. Unfortunately, the nurse forgot to come in a couple times to turn up the pump and so it ended up being a 2am baby instead of probably closer to 1am. The baby did really well, and this hospital was so breastfeeding friendly that he was in the room with mother by 6 hours postpartum (he did initially have some grunting to work out of his system), which would definitely not have been the case at University hospital. So the baby is off to a good start. I think sometimes things happen for a reason. I'm glad that U hospital was full, because in the end this baby got a good start with breastfeeding.

All in all, a wonderful New Years.