Friday, March 07, 2008

Decision Points

The other evening a healthy baby boy was born vba2c to Julie (not her real name). For those who don't understand the abbreviation, that's vaginal birth after two caesareans. Words can't express the elation that we all felt as Julie held her new baby in her arms.

This birth took place in a private hospital, and I worked with an obstetrician and several shifts of hospital midwives in the labour. It was not a highly medicalised birth - Julie had stipulated in her birth plan that she did not want anyone to offer pain killing drugs, and at no time did she seem to be looking for medical pain relief. Electronic fetal monitoring (EFM) was used - the hospital's new telemetry monitor was put into use, enabling Julie to move freely, and spend all the time she wanted to in the bath. Julie's doctor had agreed to her plans with the understanding that if she did not progress in labour there would be no artificial stimulation of contractions. Julie was not asked to have an IV cannula in her vein.

Many of my stories are about women who give birth without any complications, in as close as we can to an 'undisturbed' state. The use of EFM is a disturbance, no matter how up to date and wonderful the gadgets are. But Julie had agreed to that disturbance, and was able to labour without letting it bother her. Julie's previous births had both been by emergency caesarean, early in the labours, when both babies had showed clear signs of distress.

Julie and I agreed to approach this birth with the intention of 'normal until proved otherwise'. I explained decision points - any time when a decision could be made. The 'default' decision was that Julie was giving birth. Plan A. At any time an alternative plan may be considered, if a valid reason for interference had arisen. This is the same basic plan that I encourage every woman to adopt.

It was not a simple journey from the first signs of labour to the birth, two days later. We reached several unexpected decision points, and each time, after careful consideration, agreed that Plan A was good. There was the high and very mobile head which did not engage until the second day. There was the vaginal loss, clear at first, then apparently meconium stained. There were subsequent concerns about infection and fetal distress. I called the loss a hindwater leak - the obstetrician disagreed. He did agree that the forewaters were intact, so as long as Julie's temperature remained normal, no treatment was required. At the end of the first day Julie was having contractions but not dilated, and the baby's head was still high. We assessed that she was not in labour; Julie agreed to stay in the hospital; the monitor was removed, and I went home to bed.

Julie's husband called me back to the hospital the next morning, as her contractions were becoming stronger. On palpation I was pleased to discover that the baby's head was engaged. Julie had not slept much, and was now putting all her focus into working with the labour. A dilute mixture of juice and water kept her well hydrated, with a little ready energy. By midday we were all delighted that Julie had progressed to 5-6cm dilatation, more advanced than she had been in either of her previous labours. Another decision point was reached in the afternoon, when the waters were broken artificially. The baby's head was still quite high. I was still concerned enough about that baby's high head that I wondered if we would have a caesarean at that late stage.

However, shortly after, Julie began pushing. Each step had been taken, and we all sensed the birth was near.

The baby's heart rate became very slow in second stage, and the doctor was consulted. Julie's baby's birth was assisted with the Ventouse cap - she pushed and the doctor pulled, for just one contraction. He went straight to Julie's abdomen, and I dried his body as he started to take some breaths then give out a strong cry.

I won't attempt to tell the story from Julie's perspective, or from her partner's. The midwifery lesson from this birth is that patience and consistent decision making enabled the mother to come into spontaneous labour, and to work through her own birthing journey. She can rightly say "We did it ourselves".



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