Continuation of the “Injustice in Maternity Care” Series
My first hour with Jessica & Jason was spent getting to know them, tidying up the room, setting it up the way I like it (I know, sometimes I can be a bit anal about clutter! I don’t know how some nurses can work in so much clutter!!), and turning up the pitocin a couple of times. Around 4:00pm I had left the room to scrounge around for a few more pillows for Jessica. This took me about 10 minutes since pillows are pretty much like gold in the hospital: rare to find and very precious to have!! Haha! Anyways, as I walked into the room Dr. T was leaning over the trash can throwing something away and Jessica was lying flat on her back in bed, spread eagle, completely uncovered, and sitting in a big puddle. It took me a few seconds to piece together what had happened. Turns out Dr. T was throwing away the amniohook he used to BREAK Jessica’s water WITHOUT me being in the room! I quickly stepped towards the bed to raise her head and cover her up. The entire bed was soaked. It was getting harder and harder for me to contain myself and I could feel the blood boiling up into my head.
Me: “What’s going on?” (said in the nicest voice I could muster up)
Dr. T: “Oh, are you taking care of Jessica today?”
Dr. T: “Well, I just got out of the OR and I wanted to check her progress and apparently the residents hadn’t ruptured her yet! So I just did.”
Me: “Oh, well, what nurse came in here with you? I’d like to thank her.” (also said in the nicest voice I could muster up but clearly my sarcasm was piercing through all my attempts to stay calm)
Dr. T: “No, it was just me.”
Me: “Oh really, well you should have come and got me. I would have been more than happy to assist you. It would have liked to lay some more chux pads down under her so that when you broke her water it wouldn’t cause so much of a flood. I’m going to have to change all the sheets now, all of them. And what if the baby had a decel…”
Dr. T: (interrupting me) “Well I couldn’t find you.” (turns towards Jessica) “I’ll come back in a couple of hours to check you.” (turns to walk out of the room and then spins around and turns towards me) “Why is her pit only at 8mu?”
Me: “Jessica didn’t even get to the hospital until 1:30 and policy states we can’t start pitocin until the patient is fully admitted.”
Dr. T: “Well she’s still only 4cm so you are going to have to keep going up on the pit if she is going to get anywhere.” (This statement really takes the patient right out of the equation doesn’t it! Outrageous!)
Me: “What’s the baby’s station? Is the baby still high?”
Dr. T: “Um yes, but the head is now well applied. She’s 4cm/50%/ -3…..maybe -2.”
At this point all I can think of is “Liar, liar, liar!” Dr. T turned to leave the room and after he left I assisted Jessica out of bed to the bathroom so that I could change all of her sheets and help her into a new dry gown.
I need to digress for a moment to explain exactly how outrageous it was for Dr. T to check the patient and rupture her membranes without me or any other nurse in the room.
#1 Although this might seem like a silly thing to be upset about, the fact that he ruptured her membranes without even putting down a few extra chux pads (which were sitting right on the counter) is very rude in my opinion. It’s like saying “You clean up my mess because I am above that.” Honestly it wasn’t that difficult to change the bed over and help the patient into a new gown but it’s the principle of it that bugs me.
#2 It is an unwritten rule at my hospital that a nurse is to accompany any doctor or midwife during a vaginal exam. Even the residents are taught this during orientation. Is a doctor or midwife fully capable of performing a vaginal exam solo…of course they are! But it isn’t about that. It’s mostly about touching base with the nurse first to see how things have been going all shift with the patient. It’s about good communication and team work. And sometimes another vaginal exam isn’t necessary and the nurse can advocate against it!!! I haven’t met one doctor or midwife that attends births at my hospital that has a problem with this arrangement….unless they are trying to do something that they know the nurse will question them on….like performing an early amniotomy on a patient whose baby is still high!! The fact is that that is the ONLY reason Dr. T didn’t come and get me…because he knew that I, and many other nurses, would question the necessity and safety of such an intervention. So he had to SNEAK it. What he did was so SNEAKY and it infuriated me!
#3 The other most important reason to obtain the assistance of the patient’s nurse (or ANY nurse at the desk really) is just in case something bad was to happen. Although something acutely bad is unlikely to happen from just a vaginal exam, the nurse’s role in assisting with the vaginal exam is to maintain the patient’s comfort and protect the patient’s modesty. (As you can see, Dr. T did none of those things, and things like that happen a lot with some of the docs I work with. All of the pregnant readers I know understand how uncomfortable it is to lay flat on your back for any length of time when you are pregnant!) But there ARE acute risks with performing an amniotomy, especially an early or prelabor amniotomy.
Risks related to amniotomy that have emergent consequences include:
1) Umbilical cord prolapse
2) Fetal heart rate decelerations related to umbilical cord compression
3) Change in presenting part
Let me give you an example. One time I had a doctor that ruptured a patient with polyhydramnios and a high presenting part. (That means, the baby’s head was not well engaged into the pelvis and was still “floating”.) After the gush of water flooded the bed, the baby started to have pretty serious heart rate decelerations with every contraction related to compression of the umbilical cord. When the doctor did a vaginal exam to check her dilation, he found that he was no longer feeling a head, but a HAND. Since the baby was high and floating in a large amount of fluid and the head was not well engaged when he ruptured her membranes, the first thing to rush out was the baby’s hand. The doctor was unsuccessful at moving the hand back. And that woman, a grandmultip (G6P5) who had had FIVE previous spontaneous normal vaginal deliveries ended up with an emergency cesarean section. And it was VERY IMPORTANT that I was in the room when all of this happened since I was the one who ended up almost single handedly assisting her into knee chest, throwing on some oxygen, and wheeling her down to the OR as the doctor rushed to scrub in. Yes, emergencies can happen that fast. (This one however was almost completely avoidable!!) Please know that I am not telling this story to scare anyone. But the LESS interventions you have, the significantly LESS chance you have of that kind of emergency happening. And if a physician or midwife is going to take the chance with any intervention like amniotomy, it is very important that he or she has assistance from a nurse in the room.
Okay, thanks for letting me rant there for a minute. Back to the story…
So after I helped Jessica clean up I offered to help her out of bed into any position she liked. After all, it’s important to use gravity to help you and not work against you! Jessica decided that she wanted to get up into a rocking chair. I continued to titrate the pitocin to obtain an “adequate” contraction pattern. Jessica’s body was actually pretty resistant to the pitocin so I ended up eventually getting all the way up to “max pit,” or 20mu/min, around 6:00pm. Jessica was contracting about every 2 ½ -3 minutes each lasting for about 40-60 seconds. Jessica complained most about her back pain and so we tried a variety of positions to ease this for her including using the rocking chair, standing at bedside, birthing ball, back rubs, slow dancing etc. Jason was an excellent birth coach and the two of them really worked well together. Jessica did not feel comfortable walking in the halls (some women prefer a bit more privacy and I can’t really blame them!) so she did a lot of pacing in the room. Around 6:45pm, Jessica was getting really tired and asked if she could get back in bed. We tried a few positions in bed (side lying, kneeling, etc.) but the back pain was too intense.
I wished at that moment we could have gotten her into the Jacuzzi but despite what some other people might tell you, trying to continuously monitor a patient in the Jacuzzi is almost impossible, especially since there are no monitors in the tub room at my hospital so I cannot see or hear what the baby’s heart rate is doing when I am in there manually holding the monitor to her belly so the bubbles don’t knock it off. This is yet another reason why back door inductions frustrate me. If she was in true labor and not on pitocin, I could have done intermittent auscultation which is very compatible with using the Jacuzzi. Some women think they can have it all (for example their induction and the Jacuzzi). But fact of the matter is that agreeing to an unnecessary induction automatically makes a natural birth plan harder, NOT impossible, but harder.
Turns out the only position that Jessica liked at that time was sitting straight up in bed, leaning forward on the squatting bar, with the foot of the bed lowered so the bed looked like a “chair.” She was moving and breathing very well in this position with Jason and me as her coaches, and she seemed to start to drift off into “Laborland.” At 7:00pm Dr. T came into the room and stated he was going to do a vaginal exam to check for progress. Jessica had started to complain of some intermittent rectal pressure so I had assumed that the baby had moved down some. Turns out she was 5cm/100% effaced/-1 station!! “This is great!,” I said to Jessica, “You are doing such a great job! Not only are you 5cm now but you have thinned all the way out AND you have moved the baby down a lot!! You are doing so well!!”
Both Jessica and Jason seemed excited about the progress which is great because I was afraid that Dr. T would say something annoying like “Oh bummer, you are only 5 cm.” But the truth is that in order for your cervix to dilate you have to thin out first and therefore progress in effacement and station are also signs of great progress, not just dilation. “Do you want anything for pain?,” asked Dr. T. “No, not yet, I want to try to go longer,” she replied. Jessica spent the next two hours sitting straight up in bed, leaning over the squat bar, with the bed in the “chair” position. Jason was standing beside her rubbing her lower back while I was helping her to stay focused on her breathing. She had a couple mini “freak outs” like “I can’t do this anymore!,” “This is it, I can’t take one more contraction!” “How much longer is this going to be?!” What is important to remember is that these “freak outs” are NORMAL and it doesn’t mean you are weak or a wimp. Far from it! Labor is one of the most intensely physical experiences of your entire life. It is comprised of sensations that are unlike any others you have felt before. And that is why positive encouragement is so important. I know it is hard to see someone you love in pain but Jessica had said she did not want any pain medication or an epidural at this point so providing her with unconditional support was what was needed.
A quick story…
When I used to run cross country in high school we would often have “distance days” were our workout consisted of running a 13-18 mile long run. We would start right after school and often not get back until it was dusk. Those runs were grueling especially since we lived in a very hilly town. I remember thinking or saying things like “I can’t do this anymore!” or “No, just go on without me!” I remember feeling so many times during those runs like I wanted to “quit” and walk. But I knew that if I did, it was just going to take me that much longer to get home. And one of the things that kept me going the most was the support from my teammates. “Just run until that phone pole” then “just run to that fire hydrant” then “just run to that stop sign.” I got through it because I took it one small stretch at a time. When I thought about how much farther I had to go, when I thought about the whole run as a whole, the task at hand seemed overwhelming and insurmountable. But when I took it “one phone pole at a time” I felt like I could handle it. There was no other way to get home but to run. And it hurt. And the cramps in my sides made it hard to breathe. And sometimes I would have to lean over into the woods and throw up. Every bone and muscle ached, from my ears to my toes. I remember my knees stinging with each footstep. But there was no other way to get home but to run…. And when I finally crossed onto the track at the high school to run the last stretch I felt like I could do anything. I did it!
I am not trying to claim that running a long run is exactly like labor. For one I was only running for a few hours, not hours and hours and hours. And I knew exactly how much I had left, unlike moms in labor. And genital pain was not involved at all! Haha! But the point is that a great mix of positive encouragement from my teammates, self determination, and the technique of taking it one step at a time was the reason I succeeded. If my teammates just left me in the dust every time I said “Just go on without me! I have to walk” then I wouldn’t have been as successful and I wouldn’t have gotten as much out of the run. So ladies, it’s NORMAL to “freak out” a bit, which is why surrounding yourself with positive, helpful, and supportive coaches (not just “specators”) is so important, ESPECIALLY in a hospital birth.
Jessica labored like this for about two more hours. She was definitely in Laborland, kinda spacey, like she was in a trance. At around 9:00pm Jessica said that she was feeling a lot more rectal pressure and wanted an epidural so I went out to the desk to page a resident. Lucky me Dr. T happened to be sitting at the main desk chatting with another doctor. I told him that Jessica would like to be checked to see how far along she was because she was considering an epidural. He came into the room and low and behold, she was 6cm/100% effaced/ 0 station. Woohoo! Jessica stated she wanted the epidural so I proceeded to get things set up so that we would be ready when anesthesia came in. I had already reviewed with her the risks and benefits of an epidural earlier on (when she was more comfortable), so now I just had to explain to her what to expect from the procedure.
After setting up the room I walked out to the desk to see how long it would take anesthesia to see her. Turns out that anesthesia was tied up in a cesarean section so Jessica would have to wait. (Unfortunately, even in a hospital that has 24/7 anesthesia like mine, they are not always available for epidurals. So if this is your only reason for deciding to have your baby at a high-risk hospital, I would make sure you review all of your options. And if your only labor preparation is deciding you want an epidural, it is imperative that you prepare for the possibility of not getting one!) When I was at the desk, I checked the orders to make sure Dr. T had written for the epidural. And that’s when I found his progress note:
S: Complains of more pain, wants relief
O: Cervix 6 cm dilated, completely effaced, 0 station
EFM shows Ctx every 3 min x 60, baseline 140, +accels, Æ decels, moderate variability
A: Active phase labor with unsatisfactory progress
P: Anesthesia notified for epidural
Recheck in one hour, if no significant progress, anticipate primary cesarean section for arrest of dilatation
I was floored. I couldn’t believe he was basically already throwing in the towel for Jessica. It was her first baby for goodness sakes! Babies come in their own time! I mean, she hadn’t even gotten the epidural yet and the pitocin has to be shut off for the epidural so by the time the “hour” was up, it would have been completely unfair to expect her to have made any “progress.” And what does that mean anyways? So I called him out on it:
Me: “Dr. T. You are already throwing in the towel for her!? Why does the plan even mention a cesarean at this point?!”
Dr. T: “You’re kidding right, she has only changed 2cm in the last 7 hours.”
Me: “Well that’s not really true because I didn’t even get her contractions into an adequate pattern until about 6pm. And it’s her first baby.”
Dr. T: “Jeeze, you call that progress?! I can’t be here all night you know…”
(YES he really did say that. This is also the doctor that told me once to tell a multip who was 8cm and feeling pushy to “Not push” because he wanted to finish the ice cream he had just ordered with his wife and kids. I mean, I’m all for him spending time with his kids but he was ON CALL and this was a third time mom who was feeling RECTAL PRESSURE and was 8 CM! There is NO telling her “Don’t push!” It’s called the fetal ejection reflex for goodness sake! And guess what, not only did he missed the delivery, but he then chewed me and the resident out for it. I’m not making this up…In fact I can’t make this stuff up!)
Me: (getting pretty upset but trying not to scream at him) “Are you kidding me! She wasn’t even in labor when she got here! If she was, you wouldn’t have started her on pitocin. She wasn’t even in labor! You didn’t have to be here at ALL but YOU were the one who sent her in for induction.”
Dr. T: (smirking) “Induction! She was 4cm!”
Me: “But she couldn’t feel any of her contractions! And now you are just going to cut her without at least seeing if the epidural helps?! This is her first baby! This delivery has consequences for the rest of her life!”
I was afraid I was going to strangle him at this point so I just left the desk to go back into the room. Anesthesia didn’t show up until 10:30pm and at 11:00 pm Penny, the night nurse, came in to take over. I stayed until the epidural was finished and tucked her in. The next day I got the full scoop on what happened from Penny and the patient’s chart.
Apparently Jessica got great relief from the epidural and slept like a rock for 2 hours. Luckily the baby tolerated the epidural well and remained happy on the monitors. Dr. T must have fallen asleep in his call room or gotten distracted because he never came back to check her. At 1:30am Jessica woke up feeling a lot more rectal pressure. Penny called the resident to check her and her exam revealed she was fully dilated (HOORAY!!) but that the baby was still at a 0 station. Since the resident was busy with other patients she agreed, per Penny’s request, to NOT call Dr. T and wake him up but rather to shut off the epidural, allowing it to wear off a bit, and use passive descent to help get the baby down more before they started pushing. (Although Jessica was feeling more rectal pressure, a practice push revealed that she could not feel her bottom enough to push. If she had started to push at that time, she would have just tired herself out). Also, Penny knew that Dr. T was notorious for only “letting” patients push for about an hour (even if they can’t feel their bottom) and then if the baby isn’t out he performs a cesarean for “failure to descent.” Phooey!
One hour later at 2:30am Jessica was feeling an uncontrollable urge to push and a vaginal exam by the resident revealed that she was 10cm/100%/ +2 station!! Yay!! Penny said that she felt it was best not to make Jessica wait for Dr. T to rise and shine so she instructed Penny to push whenever she felt she needed too. She said that Dr. T didn’t even make it into the room until about 10 min before Jessica pushed out her 8lb, 6oz baby boy at 3:05am after only approximately 30 minutes of pushing!!!! The baby was also found to be in an occiput posterior position, which explains all that back pain Jessica was experiencing and perhaps the length of her labor as well. Dr. T did cut an episiotomy but the baby delivered before he could get his hands on a vacuum J. According to Penny, baby Christopher James nursed like a champ and stayed skin to skin with mom for almost a whole two hours!
Fortunately for all those involved, Jessica and Jason’s story had a wonderful ending! However, despite the fact that Jessica’s birth did not end in a cesarean section doesn’t mean that there were not many injustices in the way her care was managed by her birth attendant. Stories like this always get me thinking…what if? What if Jessica had been sent home from the office instead of sent in for a back door induction? Would the baby have eventually turned around so that he was no longer occiput posterior? Would her natural contractions been easier to handle and therefore would she still have opted for the epidural? If she was not induced with pitocin and therefore not required to be on continuous monitoring, would the freedom to move around more in labor and the ability to use the Jacuzzi tub helped to alleviate her back pain if the baby stayed occiput posterior? What if she had had a different nurse that encouraged her to get the epidural earlier on? What if Dr. T had gotten his way and started to make the patient push before she had regained use of her legs and feeling in her bottom? What if Dr. T had kept her membranes intact until much later in the labor? What if Dr. T had checked her one hour after she was found to be 6cm and she hadn’t made “satisfactory progress”….would she have been given a cesarean for “failure to progress?”
In summary, I would just like to say that unlike what many OBGYNs, nurses, friends, family members, moms, journalists, etc will tell you, the journey matters just as much as the outcome. The fact is that women truly amaze me no matter how they give birth. Whether it is a natural home birth or a scheduled cesarean section, the bottom line is that women have superpowers! They can grow people inside of them after all!! And my greatest wish is that all women will feel in control of the decisions regarding their birth and in the end feel empowered no matter the mode of delivery. But as a society we have to be more conscious of how our overly medicalized maternity care system affects the thoughts, feelings, and emotions of our patients and families as well as their outcomes.