Friday, September 05, 2008

Reflecting on a difficult birth

After visiting the new parents and their beautiful baby yesterday afternoon, only 12 hours after his birth, I have felt that I need to reflect carefully and write on this birth. Although I enjoy writing, this is not a simple task. The complexities of life, and of each birth, mean that I have to choose a small aspect of the whole experience and write on it. By reflecting on the experience that I had, within a professional partnership as midwife to this woman and her child, I am using the maieutic mode of enquiry. This is the essence of a midwife's work both as a teacher and as a student: enabling learning through reflection on experience.

The dictionaries explain the connection:

Maieutic = act as midwife. Pertaining to the Socratic method of bringing out ideas latent in the mind. [Webster's]

Gr maieutikos maieuomai = act as a midwife. [Concise Oxford]

In summary, the mother, who I will call M, was a primigravida at 41 weeks plus 3 or 4 days' gestation. For the previous week, and particularly for the past few days, M had been experiencing pre-labour contractions, day and night, every 7 to 10 minutes. Each time we spoke, I encouraged M to trust her body's signs, to rest when she could, and to be ready for the establishing of labour. I saw her on Tuesday, and found that her the baby's head was well engaged, and the cervix very thin. Very good! However, M was becoming discouraged. She did not think she could keep going. She had noted a reduction in fetal movements, and we were not sure of the significance of this.

M had chosen to give birth at the Mercy Hospital for Women in Heidelberg, and had an appointment at the hospital the next day. When offered induction of labour, M agreed to having her waters broken, but wanted to see how she could progress without IV oxytocic. Contractions became more frequent, and labour was underway.

Over the next few hours there was little dilatation of her cervix, and the doctor encouraged M to have the oxytocic. Having no alternative plan, this further step in 'Plan B' was agreed to, with an epidural.

It sounds trite to just say 'with an epidural'. Women who have planned for spontaneous unmedicated birthing, and who understand that an epidural comes with at a cost as well as having the apparent benefit of pain obliteration, express grief at this time. But when they see it as the best option, they make the decision. Well, there's no guarantee, and this epidural did not work, and had to be resited. Even when it was correctly placed, there was a persistent painful area in one of M's legs. The anaesthetist was patient and consistent in trouble-shooting, and eventually achieved the desired pain relief. By this time there were 'non-reassuring' fluctuations in the baby's heart trace.

The hospital midwife told M that it would be best to put a scalp clip on the baby's head, in order to monitor more reliably. M asked me what I thought. We agreed to make a decision after we knew what progress the baby had made, with several hours of oxytocin augmentation. Good news - M had dilated to 'fully'. M declined the scalp clip, and found a sitting position which allowed for better external monitoring.

With a deep anaesthesia from the epidural, M's efforts at pushing were insufficient to get this baby born. The heart rate continued to fluctuate. With M pushing, and the doctor pulling, using the Ventouse vacuum cap, the baby was born in good condition. With the baby came thick, heavily meconium stained liquor. He needed to be born, that's for sure.

When attending a complicated birth, with the increasing possibility of harm to the baby (as indicated by the baby's heart rate and rhythm), it is not possible to predict what may happen. In this case, I do not believe the baby would have been in good condition at birth, able to stay in mummy's arms, if the birth had been delayed much longer.

The matter I want to reflect on, and I hope my readers are also able to ponder, is that decision to move from 'Plan A' to 'Plan B' - in this case, accept induction of labour. Here are a few of the points I am conscious of in this decision:

  • the woman is the one who makes the decision
  • I am committed to being 'with woman' in her birthing
  • I want to give the woman information so that she can make decisions that she believes are best for her
  • obstetric and anaesthetic interventions in birth, although they are common, cannot guarantee good outcomes
  • once we have moved to 'Plan B' we can't go back to 'Plan A'.
My question to myself is, was there something else M could have done, rather than accepting induction of labour? How will I advise a mother in a similar situation next time?

With the wisdom of hindsight in this case, I believe M's decision to accept 'Plan B' was the best option she had. Her body had been trying, for the past week, to get started. She was feeling discouraged, and exhausted. Her baby was showing signs of tiring too.

M asked me what I would have done if we had been planning homebirth. I believe my advice on key decisions would have been the same.


Rebekka said...

I was wondering about a similar scenario recently, after someone I know had regular contractions for three days, was sent home once by the hospital, went back and was given an epidural and IV oxytocic, baby's heart had some 'non-reassuring' fluctuations and she was rushed off for an 'emergency' c-sec.

I was wondering whether an epidural without the IV oxytocic might have allowed her to rest - after three days of pre-labour she was exhausted - and perhaps without the oxytocic the baby's heartrate wouldn't have had 'non-reassuring' decels, and they could have then let the epidural wear off after she'd had a sleep, and she might not have needed the c-sec. I used to read the blog of a family physician in the US (it's not online any more unfortunately) who used epidurals like this, to alleviate maternal exhaustion, without pitocin and the extra risks that come with it.

But it seems, in most cases, to be a case of accept one intervention, accept them all?

Joy Johnston said...

Thanks for this comment Rebekka. The idea of epidural for rest in labour is something that I think a woman would need to negotiate with her own caregivers at the time. When the decision is made to use epidural the level of risk to both mother and baby is increased. Some women are able to continue progressing in labour, while for others there is some physical reason why their bodies are not able at that time to do the work.

David said...

Hi, I'm M's partner and while I'm sure Joy doesn't need any 'fan-mail', I'd just like to say how grateful we are for her calming presence and wealth of experience during the birth, as well as for the professionalism and dedicated care of the staff of the Mercy. I'd also like to add that we were somewhat apprehensive about the Vanteuse procedure, having seen pictures in the ante-natal classes, but it is true, a few days later and you'd never have known our baby had one.