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I entirely agree Lisa and no offense taken
:-)
Had I NOT been in the hospital situation and
knowing the personality of the particular ob for the day my choice would have
been to send her home, I wish she had not spent the night in hosp at all but by
the time I took over, she had been there 7 hours and was tired and wanting it to
be the real thing. It didn't help that she was wrongly diagnosed
as having SROM'd. Had I seen her earlier in the piece I would have
wanted her to go home, but I don't know that she would have wanted to do
that.
I agree that the ARM was committing her to
delivery, but having told the ob that she was 6-7 cms, - even though I stressed
that this was a true multips os- he was then of the opinion that she needed to
get on with her labour and it took some tact to 'allow' several hours of
non-interference while I tried to get her motivated. She was definitely not
committed to her birth and unwilling to take control of her own labour, so my
path was a compromise of doing what was least intrusive for this woman (i.e.
better that I do the ARM and take things gently than she jump on the medical
machine) and providing her with as good a birth experience as I was able.
I also knew that she would deliver easily and hoped that the ARM would
kick-start her conts and avoid any other interference, I knew that all she
needed was a few really strong conts to get the baby born, she was 8cm by this
time and had made some progress with descent and effacement so it was more an
'augmentation' than an induction. She was asking for an
epidural even though only conts 12-15 minutes apart and
mild/mod.
I would not have done the initial VE had
I been in a home situation, but knew that it was required by the medical model
in which I work - sometimes you can get a better deal with the ob of the day,
and sometimes you can't!
It was a true OP early labour situation but I was
also aware that this woman, while not truly established, was not completely
stopping either and she had had enough.
Shoulder dystocia is not - as you rightly state -
caused by weak contractions, but with a big baby (as I knew this was) weak or
non-existent contractions can certainly delay shoulder rotation and descent,
given that most obs are very uncomfortable with delay between head and body,
this can lead to the 'ER' mentality taking over and merely 'tight' shoulders
being defined as dystocia with the full emergency drill ensuing.
As to utering inertia - well, if I have had a long,
slow labour with contractions far apart, I have found that there can be a lack
of good contraction post birth which can lead to excessive blood loss, if the
conts have ceased for 2nd stage or are far apart I feel synto is not such a bad
thing to have going - she literally only had about 6 synto contractions over 30
minutes to get her to crowning, but as she was going this would have taken
another 2 hours at least and the head/body delay would have been LOOONG, ditto
the shoulder rotation, I think most midwives would be uneasy with 12
minutes each between head/shoulders/body. I would also have been
concerned about PPH with conts only every 12-15 mins. After a discussion
of the options she asked to have the synto drip as she just wanted her baby to
be born by that stage, and I agreed that it would probably be a good
idea.
As I said, this is a typical scenario of the
difference between physiological midwifery care and the medical model in which
most of us work: trying to maintain the best care we can for our women while
working within the system - in which the 'boys' hold the power
cards.
Thanks for your thoughts, I like it when this forum
is used for open, honest discussion and comparison of
opinions/styles/experience. We can all learn so much from each other, and
it's good to support each other - we are all 'with women' in each of our
settings.
Cheers, sue
----- Original Message -----
Sent: Friday, October 06, 2006 5:23
PM
Subject: Re: [ozmidwifery] No
Contractions
Hi Sue,
Without any malicious intent I'm again going to
attempt an opinion.
I don't routinely VE anybody and niggling
backache alone with looking at the women would probably indicate to me that
labour wasn't established. I would encourage her to carry on her normal
routine but rest lots.
I know it's hard and once woman present at the
hospital they sometime feel it's labour and they should get on with it. I am
always kind but say I think your body is preparing but not ready yet and
you'll know when it is.
The next VE you did you said stretchy multips os
6-7cm. Multips os suggests she's not in established labour so when
her waters were broken ( know it was her choice so it's not a criticism of
your practice at all) you tied her into an induction which is essentially what
she ended up with.
Weak infrequent contractions with nothing else
wrong just means her body was taking time getting ready. After the ARM
that's a different ball game.
Shoulder dystocia isn't caused by weak
contractions it's the bony shoulder against the bony pelvis so the shoulders
are unable to move and maybe rotate into the optimal position for birth.
Nothing heightens uterine inertia after birth like an unnecessary ARM and
pushing her body with IV Syntocinon.
Possibly the best way to handle the situation
would have been to send the woman home after the first examination so she was
safely out of any medical intervention.
Lisa Barrett
----- Original Message -----
Sent: Friday, October 06, 2006 6:16
PM
Subject: Re: [ozmidwifery] No
Contractions
Along the theme of slow labours:
I just had a labouring mum with very slow
contractions today. She came in in the night thinking she'd SROM'd but
had not - was niggling all night with backache.
This morning I reassessed and found intact
forewaters and a posterior cervix which was a really stretchy multips os
which could open easily to 6-7 cms. I encouraged food and walking/shower etc
and she very reluctantly walked a bit but wanted to lie down instead despite
the chronic backache. Explained that bub was OP and she needed good
contractions to bring the head down but she was very half-hearted about it.
Even gave her an enema!! (her choice)
After a few hours I re-examined and did an ARM
as she just wanted to get on with it - plus the OB would have come along and
done that soon if I had not! Cx now up to 8cms and better applied, still
OP.
3 hours later and still only contracting
+-12minutely, we discussed synto as she was by now really 'over it' and
refusing to get active. 30 minutes of synto at very low dose and we
had a 9lb baby who rotated to OA in the final few
minutes.
She was drinking and eating as desired but was
not keen to take much of either.
I am not comfortable with weak, infrequent or
no contractions as it heightens the risk of uterine inertia post birth,
shoulder dystocia and a compromised baby - The docs maintain that the fetal
Ph drops (I think) 0.5 per minute sitting at crowning, which they learned at
the obstetric emergencies seminar, so i also know that any of our obs will
get very edgy if there is prolonged crowning. Sometimes you have to
compromise what would be normal physiology with what you know would
happen if obs took over. I wondered how I would have managed this in a
home situaion, probably encouraged her to rest until things were
established, and left alone - but we were not at home! So I
agree with the points raised about hospital midwifery care and empathise
with all who work withing similar restrictions.
How would a homebirth midwife support this sort
of labour?
Sue
-- Original Message -----
Sent: Friday, October 06, 2006 10:10
AM
Subject: Re: [ozmidwifery] No
Contractions
Hi Di,
This reminds me of scenario that a cousin of mine had with her second
bub. Her contractions basically stopped I think when she was fully
and she did end up having some synto to get them going again. But
what had happened was that the midwife (who said she could have bitten her
tongue as soon as she said it!) said to her that she would probably have
to work hard as she had a good size baby on board. My cousin said
that she became really frightened and the contractions just died. I
wonder if there was anything holding your woman back? Although you
said she seemed excited and focussed.
As far as her pushing without contractions, I think if you have a
fetal bradycardia and possibly a compromised bub then it becomes priority
to get the baby out. It might just be head compression, but it might
not.
Cheers
Michelle
diane <[EMAIL PROTECTED]> wrote:
Hi Wise women,
Just want to throw this out there for
comments/suggestions. Had a birth the other night that was a bit
worrying at the time. Good outcome lovely 4200g baby girl. Mum
(primip) had SROM at clinic visit at 830 am then went home and
established at about 1630, came in contracting moderately at 1900hrs was
4-5cm , I took over her care at 2000hrs. Lovely very motivated mum, well
read and attended classes, well supported by partner and mum and mum in
law and sister. Ctx hotted up to 3-4 minutely and stronger, was drinking
well but had a few small vomits, and next UA showed small ketones and SG
1.030, but was still drinking well and ctx remained strong and regular
so didnt want to put in a cannula. VE at 1130 showed an anterior lip,
still a bit thick. Wasnt able to wee again after that but head was well
down.
Was actively pushing with some ctx at 0100
with signs of full dilatation (nice purple line!) Contractions really
started to drop off, became about 4minutely and only about 20secs of
good strength. Mum getting quite tired at this stage but more focussed
and excited than earlier. At this point I did put up some fluids as I
thought with the ctx dropping off combined with her fatigue she might
need some hydration. She pushed babe up to on view (birth stool) but
made little more progress over next 20mins or so. Fluids running in flat
out but no sign of increased ctx. Babes HR started to drop to around 80
which at first had good recovery , so I wasn't too worried but after a
while were staying there for a minute or so each time before climbing
back to 100. At this point with encouragement she managed to push bub up
to almost crowning and that was the last of the contractions!!!
Obviously not easy to get FH at this stage but was quite low and staying
there. She had not much strength left as she had done much of the work
without help of ctx.
With a few position changes she got a
little more head out but then seemed to only move millimeter by
millimeter....colour was ok.... eventually after what seemed like 10
minutes I managed to push the peri back to get a chin...then nothing no
ctx...mum managed to push a little and I got her to move from kneeling
to standing then one leg up on bed....still nothing... went onto bed and
there was some movement with maternal effort (the last of it!) the body
birthed over almost three minutes, it was a pretty tight fit with the
shoulders coming in the lateral position, when a shoulder appeared I
gave it a push with two fingers to the anterior it moved just a little
into the oblique but then was finally out far enough for me to get a
little finger under the arm and finally managed to get her out!
Apgars 7 and 10. but as it was so slow and there were no ctx to assist
with her being a big bub too, It was a bit hairy for a little while.
Lucky she didnt have big enough ears or they might have ended up a
little stretched!! LOL. Second stage was only 1hr 45min but I felt
it was just way too slow birthing that head and those shoulders! Perhaps
I should have been more trusting?? I hesitated in calling the Doc after
an hour of pushing cause was on view at this stage and I thought he
would have been too late by the time he came in. Probably would
have been better to have him on standby just in case, I suppose. I just
felt quite helpless and know that things ended up quite stressful for
everyone in the room. I think I would have prefered to deal with a
shoulder dystocia at least then I would have had a practiced sequence of
events to go through!!
Thought she might get away without a tear
as birthed sooo slowly but peri went with the shoulders, 2nd degree peri
tear (no too big) and a anterior labial that wasnt too bad either.(thank
goodness, was after 3am by then, that time of night where you see
double!) Did have synto at birth but needed to get her to squat to
get placenta and had a constant trickle and (surprise surprise) a
relaxed uterus, which was fine after another shot of Syntometrine (450
loss).
My feelings are I probably should have been
a little more pro active in getting the fluids up, maybe I erred on the
non intervention side a little too long. Any other suggestions, how do
you get a bub out with no Ctx and a tired mum? She did try nipple
stimulation with little effect too.
Cheers
Di
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