Monday, January 28, 2008

ANGRY MOTHERS

A friend recently sent me a rant from an email list, in which someone told the story of a recent birth in country Victoria. In almost every paragraph, as the story unfolded interspersed with the cyber-chat language of that generation, there was anger expressed toward the obstetrician, the other doctors, the hospital system, and the caesarean surgery. The comment by the writer was “Wasn't sure where to put this, but need somewhere to get angry! LOL.”

The story was that M (the mother-to-be) went to hospital when her waters broke one morning: she was at 40 weeks and 5 days’ gestation. Labour was beginning, but after a couple of hours the decision was made to augment labour with a drip (Intravenous Syntocinon).

After “travelling really well”, labouring without drugs, a “student obstetrician” (possibly a junior doctor, the hospital resident) told her she was fully dilated and could start pushing. M tried to comply, without success. The consultant obstetrician then examined her, and told her she was only 5cm dilated – had a long way to go.

At this point M “loses hope and asks for an epidural”. But the epidural does not work properly – one side of her body is numb, and the other side is in pain. At 2am the “Ob decides it is time to C-Sec because he needs to get home to bed. M is beyond it by this stage and kinda agrees. So they spend half an hour taking off her freaking toe nail polish and to allow the epi to wear off so they can do a spinal. Which also doesn't work so they give her a G.A.”

M woke up when her baby was two hours old, and was told that the baby was born with a low apgar score – 2 at one minute, and 5 at five minutes. “M is kinda happy she didn't see all the slapping around that has traumatised her DH.”

“… She feels like a failure. Was told by the Ob that on top of that she will HAVE to have C-secs with all subsequent births because her pelvis is too small (oh gagf!) and besides her uterus will definitely rupture if she even tries for a vaginal birth.”

What can I say? Unfortunately this story is all too common.

The obvious question is, could things have been done differently? Could this mother and her baby have somehow progressed safely to a normal vaginal birth?

In labour and birth there is a sequence of decisions that need to be made, but can only be made in relation to what is happening at that time. There is no turning back. Decision points in labour are times when the decision is made to either continue with the natural process, or to intervene. Once an intervention has taken place, such as induction or augmentation of labour, it is no longer ‘natural’ labour, and subsequent care may become more and more medical. This is often referred to as the ‘cascade of interventions.’

In this case some of the key decisions that were made were to go to hospital, to augment labour, to assess progress, to have epidural anaesthesia, to perform caesarean surgery under general anaesthesia. I will go through these decisions in reverse order, and comment where I consider it useful in understanding how a sequence of events like this one is likely to unfold.

Decision point 5: Caesarean surgery under general anaesthetic

By the time the baby was taken from the mother, the baby’s condition was poor – she needed to be born and start breathing on her own, and she was given expert resuscitation immediately. It appears from the account that the baby recovered well.

Attempts had been made to give firstly epidural then spinal anaesthesia, without success, so the only alternative at that point in time was a general anaesthetic. During the interval when the anaesthetist was attempting to achieve anaesthesia (numbness) there would have been observations made of the baby’s heart sounds, and it is likely, in view of the baby’s poor condition at birth, that the baby was becoming distressed. It can be assumed from the account that the caesarean surgery was life-saving for this baby.

The obvious question is, therefore, could this baby have been safely born vaginally? The previous decision points may throw some light on the matter.

Decision point 4: to use epidural anaesthesia

As this case exemplifies, epidural anaesthesia is not necessarily a passport to pain-free birth. The treatment in itself may bring problems – in this case the torture of being numb and unable to move down one side of the body, and the pain of labour down the other side. In addition, the natural pain-relieving substances, endorphins, that build up in a woman’s body during unmedicated labour, are quickly rendered ineffective when medical management of pain is commenced. I do not have a physiological explanation for this – production of hormones and action on pain receptor cells is beyond my personal knowledge base - but I know it happens.

If the epidural had been successful, and the labour could have continued for several hours, a different conclusion could have been reached. The epidural in established labour will not, of itself, reduce the chance of vaginal birth.

We may wonder why some epidurals are ineffective. The skill of the anaesthetist is an obvious question. Also there may be some women whose inter-vertebral spaces make it easier for epidural to be administered than others.

There are serious risks to the epidural such as paralysis and infection. These, thankfully, are rare. However there is also the ‘minor’ morbidity which is probably under-estimated, and under-reported. Physiotherapists often see women with chronic lower back pain as a symptom after epidural in childbirth.

I cannot argue against the use of regional (epidural or spinal) anaesthetic in labour, because I know there will be some women who are not able to tolerate the pain for reasons such as obstructed labour. The only alternative management of severe pain is repeated doses of opiates, which also have unwanted consequences. Without regional anaesthesia the only surgical alternative is the general anaesthetic, which has potentially serious consequences for mother and baby.

It appears that in this case the decision to use epidural was made by the mother in response to her disappointment over being ‘only 5’ centimetres dilated, after having been told she was fully dilated. It is truly discouraging when a mistake like this is made. Yet the decision to ask for epidural was probably the point in this labour at which the cascade of interventions became overwhelming to the mother.

The lesson to women contemplating birth, and to midwives providing care for these women, is surely to value unmedicated birth, and to do all we can to protect and support the natural processes in birth.

Decision Point 3: to assess progress

The decision to assess progress is a standard protocol in maternity services. The people providing the care are responsible to assess and record the condition of the mother and baby, and this includes progress in labour. Yet the woman is the person who gives permission for the observation or assessment to be made. I can’t even take your pulse without permission, let alone put my fingers in your vagina and reach up to make contact with your baby’s head, and cervix.

We must not overlook any assessment or recording of observations as a point at which decisions need to be made.

The skill of the person who makes an internal assessment of dilatation is crucial. It seems that in this case there was an error made by the junior doctor: not an unexpected event in teaching hospitals.

My comment to midwives is to challenge any assessment that seems unbelievable. The midwife who was at that hospital must surely have doubted the doctor’s assessment.

My comment to mothers is also to challenge – to remain sceptical. If you don’t feel like pushing and someone tells you to push, ask them to convince you as to why that’s the best thing to do.

Decision Point 2: to augment labour

Augmentation is a decision that is often used in medically managed maternity care, with the rationale being the need to progress before the labouring woman and her baby become exhausted. This is particularly the case with primiparous (first baby) women. When the membranes have ruptured, as in this case, there is the additional consideration of increasing risk of infection being passed from the mother’s vagina to her baby. M was in early labour, with her first baby, with ruptured membranes.

Decision Point 1: to go to hospital

It is usual for women to go to hospital, or to be seen by their midwife, when their membranes rupture. Had M been able to stay at home, unobserved and active, it is likely that her labour would have progressed well. It is clear from the story that the baby was well until the later stages of labour. M would have been aware of her baby’s movements and the tone of her baby’s body, and this would have given her confidence to go on.


Where’s the midwife?

I can’t argue that women ought to know this; and somehow be a DIY midwife. The woman’s midwife is the person who is missing from the story. The midwife could have spoken to M on the phone; could have ascertained that all was well with the labour; could have visited her at home, and encouraged her without taking over or interrupting in any way. The midwife would have assessed progress at an appropriate time for M, rather than the junior doctor learning from his/her mistakes. The midwife who acts to protect and support the healthy natural processes in birthing has skills that obstetricians and other doctors do not have.

The midwife also recognises complications, and refers the woman to an appropriate care provides when complications arise. M may have needed medical support in birthing her baby: we don’t know. But without the partnership of a trusted and competent midwife, M did not have much chance at all to attempt normal birth.

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