Clinic day #28

Such a short clinic day this week. I am about to go on holidays, so I have no weekly visits. A lovely break.

The day after the dreaded

The day after my shoulder dystocia there was the monthly midwifery meeting and peer review for the midwives at University hospital and another hospital in the area. The main case peer reviewed was a major shoulder dystocia after an assisted delivery that lasted six minutes. (Just to clarify, midwives don't do assisted deliveries, the obstetrician had done it, though I can't remember if it was forceps or vacuum. Lots of maneuvers were done by the obstetrician and midwife, and the midwife ended up getting the baby out). Miraculously, the baby was neurologically normal, though it had a brachial plexus injury. During the presentation of the case, I found myself having to do deep breathing to stay calm and not allow the adrenaline of the previous day's birth to totally consume me.

The dreaded...

If you ask most practitioners what complication they are most afraid of in obstetrics, 9 out of ten will probably say "shoulder dystocia". This is a complication where the baby's head is born and the shoulders are stuck inside. You have a time limit to get the baby out before brain damage sets in (usually 4 minutes), and eventually, if unable to get the baby out in time the baby will die. Often there are birth injuries to the baby and trauma to the mother when involved in these situations as many maneuvers are tried to deliver the baby.

I have a client who has a risk factor for shoulder dystocia (SD), she was obese. Her last baby born at 38 weeks was 9 pounds, and when she went into labour this time she was at 40 weeks. I was anticipating a large baby, but of course, one never knows if a SD is going to happen - I have seen 10- or 12-pound babies fall out, and I have seen a 7-pound baby have a SD. It all depends on the size of the mother's pelvis and to a smaller extent the position of the baby.

In labour, the baby's head was quite high, and also posterior. Then she stalled at 6-7cm. Not a happy sign. The head was quite high, so I wasn't comfortable breaking her water to progress labour, so we tried having her hands-knees again, pelvic rocking, swaying, etc. to try to turn the baby and get it to come down. It didn't work, and then the head midwife offered to do what we call a controlled rupture, letting the fluid out slowly. She did so, and at the same time internally rotated the baby's head to a transverse position, halfway to anterior! There was dark meconium (baby pooped in the water), so that was concerning. The usual protocol at University hospital is to put them on the EFM to monitor constantly, but I knew that if we could get her on the toilet that she would likely progress quite quickly. So we did so. Within a few contractions she was feeling a LOT of pressure and starting to freak out a bit, and a quick exam on the toilet revealed an anterior lip. I had her push, and with my fingers pushed the lip back and in 2 contractions the lip was gone, and wham! the baby's head was showing about 5 cm worth! So, it was then up to the bed, where the baby head proceeded to deliver so, sooo s..l...o...w...l...y. I called for McRoberts position (flat on back with legs flexed way back), and then the head restituted instantly, giving the impression that opening the pelvis wide had given enough room for delivery, so I attempted maneuvers for a normal delivery, then attempted them again. Okay, enough of that, it obviously isn't coming. I put my two fingers in behind the anterior shoulder to try to rotate the shoulder under the pubic bone (to the oblique), with no success. This maneuver has always worked for me in the past. Head midwife started suprapubic pressure and I heard her hit the call bell and ask for neo and assistance for a shoulder dystocia. My mind is racing.... head midwife said to me, "think about what you are going to do", then said to the woman, "take a deep breath, and relax your pelvis". (Afterwards, the woman said that she thought that both those comments were for her). That was exactly what I needed to hear - I decided to go in and locate the posterior arm. So, I climbed on the bed, took a deep breath, in goes my hand, and I'm searching, everything is so snug, there it is, okay, rotate, come on rotate..... finally it rotated around and I was able to extract the posterior arm. Rotate the rest of the baby around, and deliver. Sigh of relief, and neo takes over to resuscitate the baby. The baby needed about a minute of bag and mask to get going breathing, but did very well after that. I look around to incredulously discover that the room is filled with people - I was so focused on trying to get the kid out, that I didn't notice everyone come in! My pants are soaked with fluid/blood and then I start shaking, so much adrenaline going through my system that all of a sudden I don't need... so I decide to let my leg shake and finish my work. I had some trouble capping the cord gasses because of the shaking, though! She needed stitches (not only did a ten-pound baby come out, but my hands were in there too!), so I decided to go change my clothes before attempting that - stitching isn't a job to do when you are shaking!! The rest of the postpartum was uneventful, baby breastfed beautifully and bleeding was within normal limits.

I looked back on the records, and it was listed as three minutes between birth of head and body. Whew.... I don't think it was a full three minutes, likely two and a half. But still, that was enough. I like to say that I don't deliver babies, the mom delivers her baby, and I simply catch. But this one I delivered.

I prefer catching.

Backup butter birth

So my neighbour midwife-colleague went on vacation towards the end of March. She had one mum left to deliver that wasn't delivering, so I ended up taking care of her because neighbour was off. She was overdue and I was to induce her. Well, when I took her in to induce her, her cervix was nowhere near ready (despite a prostaglandin gel insertion), so another consult for another gel, and the OB gave her a 2mg (double dose, as the single dose hadn't changed a thing). The plan was to induce her the following morning. She did start a bit of cramping, but I didn't hear from her all day. The next morning at 3 she paged with good labour, and I went to her home and found she had progressed only one centimetre: she was now two centimetres and the cervix still quite thick, but not as thick as before. My first reaction when feeling that type of cervix was to put her in the bath, but as I listened to baby's heartbeat, her contractions seemed super-strong, and they were coming every 2 to 3 minutes lasting a good minute, so I decided that we should head in. Also, she was GBS+ and I thought if we headed in a little early we'd have time to get the antibiotics in her. Arrived at the hospital, got her admitted, tried to start the IV, and as I poked her, she gave an involuntary push! I took the needle out (I hadn't hit the vein yet), and we delivered a baby! (The student got to assist in the delivery, which was great, she did very well). She went from 2cm to delivery in about an hour! Births that go that well I like to call "butter births" : smooth and yummy.

Catch up... Clinic days #24,25,26,27

I have a lot of blogging to catch up on!!

There were a few births of note in the month that I haven't posted, but clinic has been very routine, really nothing to report, except that I have a client who is a first-time mum and she cannot afford to take childbirth classes, so each prenatal I am giving her a mini-class. I take a different topic each time - one was the birth process (what happens physically), the next coping mechanisms, pushing, etc.... I find that I am enjoying it!