BOMBS Have No Place At A Birth!

I recently had a birth at a satellite hospital in North Forsyth. It was my first birth here. I had hoped it would be a great facility that supported natural birth since some of the doulas with my company have had good births here. The mom had vacillated about moving to a different facility but due to insurance reasons, made the decision to stay the course. She took a childbirth class with friends of mine and felt really prepared.  We had discussed being prepared to have to stand firm in some areas if she wanted the birth she desired.

She started out with on again off again type contractions that had started Sunday and continued into Monday. She had had an exam in the office on Friday. (Vaginal exam 3- she had had two prior to this appointment) Often times labor gets a kick start by having an exam. But sometimes the exam causes a start that is not quite ready to get going and thus leads to an on again off again irritated uterus. The mom had knowledge of the risks.

I was in touch with them on and off.  I met them at the hospital early on Tuesday morning. She was concerned that she was not yet in active labor. And then we met our nurse, Tammy. She came in and announced we were lucky since she was not only a nurse but a previous midwife. She then told my client that if she was wondering if she was in active labor, she most certainly was not. BOMB!

bomb

My client was on the monitor and having her intake done. I reassured her that I thought she was in active labor and that adrenaline was slowing things down- to trust. When the nurse stepped out, my client said she was not sure she liked the nurse. This was a mistake I made as a doula. I teach women to listen to their instinctive voice and yet I dismissed hers. Her husband and I both reminded her that she had only had five minutes with the mom and should consider a bit more time. I should have listened to her instinctive voice.

Tammy finally does an exam (Vaginal exam 4) and finds her to indeed be in active labor, she is dilated 6cm, effaced 70% and the baby is already down to 0 station at 9:13 am. So yes my client was in active labor! But nope Tammy made no apology from her earlier negative remark. After two attempts at placing an IV failed, the third attempt worked.  Tammy then made a comment about my client being a nurse and having the nurse’s curse. BOMB! (She actually tossed this bomb at least three or four times in the whole labor.)

My client went on to recover from these remarks and never said anything more about the nurse- we just tried to avoid much interaction with her. I knew she was throwing bombs and should have asked the mom about her feelings about the nurse, but instead I tried to focus on the work my client was doing instead. I now wish I had brought it up.

My client walked, got in the tub, walked more- got in the tub again. This hospital has nice deep jetted tubs. They used telemetry so unless the monitor slipped, we had little interaction with the bomber.

By noon the nurse said we needed to have an exam (Vaginal exam 5) to see if any progress was being made. I love practices where midwives come in and sit with the mom and access her progress without doing a vaginal exam. Exams are not without risks. The exam showed progress was being made. She was dilated to 8 cm and effaced 80% and the baby remained at 0 station. My client was up and dancing. She returned back in the tub on her hand and knees over the birth ball with the shower spray on her. She remained in the tub for another hour and a half. While in the tub she was really resting well, almost sleeping between contractions.

At 2 pm the doctor was in and convinced my client to rupture her membranes. She felt all that was holding the baby in was a bulging bag. (Vaginal exam 6) My client was completely effaced now and the water was clear, she commented that the mom had plenty of room and the baby was not very big, and she was declared to be completely dilated. 

We used the rebozo for an hour of pushing and then Tammy came in and during pushing did an exam and said she was not fully dilated- but only 8 cm. (Vaginal exam 7)  BOMB! (often times the bag bulging will expand the cervix and then it will reduce down. Sometimes this is due to the position of the baby. No one was telling us that the baby was mal-positioned and the mom was not indicating such via specific pain. 

Tammy informed the doctor and she was back in to place an IUPC (Vaginal exam 8) to determine the strength of the contractions and could not easily get the IUPC in – Tammy said perhaps the baby was too big! BOMB! Wait didn’t the doctor just say an hour ago that there was plenty of room? We realized later that the issue of not being able to get the IUPC in easily was due to it scrapping against the baby’s head- we saw the abrasion after the birth on her head.

The IUPC was showing only minimal contractions and there was the need the doctor felt for a little Pitocin being added. Sometimes with a long labor- and the prodromal labor that began things- the uterus gets tired and a little Pitocin is successful in helping the uterus. The mom asked me later, what if she had waited. With the IUPC in place, it meant we could not get her back in the tub. She would not be walking outside the room any more. She would be able to be up and dancing but she was really getting tired now. But before the medication to accelerate contractions was added, there was a lengthy discussion. The doctor and Tammy were convinced it was what was needed. The mom agreed to move forward with the low dose Pitocin. It never went above 4 and was even turned down to 2 near the end. So very little was needed.

With the addition of the Pitocin and the fatigue, the mom asked about getting a mild narcotic to get some relief from the now more active contractions. No longer would she be getting in the tub where she was able to relax so beautifully. So at 4:50 pm she received a dose of Fetanyl. Tammy then shared about her daughter wanting an epidural right away when she becomes pregnant and how she has promised her daughter to have the anesthesiologist waiting for her! BOMB! And the nurse’s curse again was mentioned BOMB! And Tammy said she wondered if my client would be able to stay out of the OR BOMB! (and yes she shared this with my client!)

At 6:20 pm there was an epidural decision made. I was made to leave and I returned to the room at 7:30 pm. I am not sure why they took an hour to get the epidural in and her stabilized since my client said everything went smooth. I am also disappointed that the protocol is to separate her from her paid support person or choose between me and her husband since I am allowed to stay if an epidural is chosen in most facilities.

The next exam showed my client is completely dilated and the baby is down to +1 station at 7:25 pm. (Vaginal exam 8) So somehow this epidural was either doing magic in thirty minutes or she was fully dilated on her own and the need for it was not really needed. This is where I feel if she had had a supportive nurse, the undermining of her ability to do this would not have been going on all afternoon. Now the mom was not only dealing with fatigue and Pitocin accelerated contractions but also the underlying message of this being a big baby and her perhaps having to have a cesarean looming over her.

The baby started having some decelerations now. And soon the doom and gloom Tammy talks about 99.4 being a fever BOMB! We have a new nurse who is so supportive and wonderful with us now but for some reason Tammy wants to linger to throw more bombs. She tells us that the baby is being tachycardia due to the fever BOMB!– (this temperature  is not even classified as a fever yet.) She starts talking about an infection. BOMB! She sits down in a chair she has pulled up between me and her my client’s husband and my client, holding her hand. Our new nurse picks up on the negative vibe immediately and goes and tells the charge nurse we only really need one nurse and Tammy gets the boot. Did I mention this nurse is an angel? This southern red head is named Laurie!

angel

The doc arrived just as Tammy was leaving and the mom gave birth at 8:15 pm. There was meconium at the very end that did cause the baby to get an APGAR of 6 initially since they were trying to not stimulate the baby initially. She weighed in at 6#2.8 ounces, certainly not the big baby that Tammy had projected. 

The mom struggled a bit with not having the ideal birth she desired. She of course is happy with the outcome but realizes that her instinctive voice was right- the bomb tossing Tammy was not a good fit. We should have listened to her initially. I will not make the mistake again even if the mom feels that in only minutes of a interaction with a nurse. And later the placenta pathology was reported to show acute chorioamnionotis and acute funisitis. My client being a nurse did some research and everything she could find showed this is typically caused by vaginal exams during pregnancy and labor. (She had had 8 total exams, in 12 hours at the hospital she had had 5) So she is guessing that is why she had a fever….(She was GBS-).

So I learned to really give full merit to a mom’s instinctive voice no matter if it is within minutes of meeting a staff member. I have learned to ask the mom if she is feeling supported by a bomb dropping staff member and is wanting to have them replaced. I have learned to encourage even more in spite of the experts saying she really needs medication- and ask what the mom wants and if she just needs a bit more time – trusting the process even in spite of others not trusting it. The mom’s level of vulnerability is very high during labor. A doula or a husband are not able to erase others who may undermine her. This makes me sad. I realize this would have been a very different birth experience if the bomb tossing Tammy had been replaced in those first few minutes of her arrival at the hospital. If Laurie had been there all along I feel the birth experience would have been very different!

I struggled with using this nurse’s name but feel she needs to learn the impact she can make on a laboring woman’s outcome. A doula can not “protect” a mom but I should have supported her instinctive voice from the beginning. I have learned to listen more intently and helped her act on it.