Please see, Don’t Let This Happen To You #25 PART 1
After our conversation about her birth plan and induction, I focused my attention on providing Sarah & John with the support they needed to have a successful, empowering, and fulfilling labor and vaginal birth, despite the less than optimal circumstances.
The first thing I did for Sarah was get her out of that bed! At that time all of the portable telemetry monitors were in use by other patients (unfortunately we only have a few on the floor) so I couldn’t let her walk the halls. But I explained that I could let her go as far as the cords would take her; basically she could sit in a rocking chair, stand at the bedside, and take “unlimited” trips to the bathroom for as long as she wanted (my own personal way of getting around the continuous monitoring.) Sarah said she was most comfortable in the rocking chair since her back was bothering her in bed. (I bet!) She reported at that time that the contractions mostly felt like “bad menstrual cramps.” The next few hours I was in and out of the room since Sarah and John had things pretty much under control and I do believe that couples deserve privacy. They were really cute together I have to admit. While Sarah was rocking John was reading her poetry out of one of her favorite books. It turned out to be the perfect amount of distraction for Sarah. And Sarah did say to me that being in the rocking chair made her feel like she was actually “doing” something, as opposed to “just sitting in bed.” Isn’t it interesting how just getting a mother out of bed can change her perspective for the better!
Over the next few hours I titrated the pitocin up or down depending on how frequent her contractions were coming, how Sarah told me she was feeling, and how strong the contractions felt when I palpated them. Since we had talked extensively about her birth plan, I let Sarah know that Dr. F was planning on coming in around 2:00pm to check on her and break her water and that she had the right to refuse that procedure. I explained to her that it was not an unreasonable request to ask him to wait. I also told her that despite what Dr. F would probably say, it was NOT going to “slow down her labor” if she wanted to wait until she was more active, maybe even 7 or 8 centimeters, or just wait until her water broke on its own. I also told her that I would support her decision and “stick up for her” with Dr. F, but that she was the one that had to tell him what she wanted first. If not, it just makes the nurse look “pushy” and the doctor is less likely to abide.
At 1:30pm, right on schedule, Dr. F came into the room. After some quick small talk he asked Sarah to get into the bed so that he could perform a vaginal exam and break her water.
Sarah: “Umm, I was hoping we could wait a little bit longer to do that, until I am in more active labor.”
Dr. F: “Well, if I break your water it is really going to rev things up and put you into active labor.”
(Side note: Dr. F is just plain wrong. He, like so many mislead obstetricians, was utilizing his own anecdotal evidence instead of scientific research when he made his claim that amniotomy would “rev up” her labor. A 2009 landmark study published by the Cochrane Database of Systematic Reviews concluded (after reviewing 14 studies involving 4893 women),“There was no evidence of any statistical difference in length of first stage of labour [between the amniotomy alone vs. intention to preserve the membranes group]. Amniotomy was associated with an increased risk of delivery by caesarean section. On the basis of the findings of this review, we cannot recommend that amniotomy should be introduced routinely as part of standard labour management and care.” This study hangs in the doctor’s lounge at my hospital and I have actually shown it to quite a few physicians who believe in early and routine amniotomy. And they ignore it and do what they want anyways. It’s infuriating! It’s like they only care about research that supports what they already do and if it goes against their practice, they pretend it doesn’t exist!)
Sarah: “I’d really rather wait.”
Dr. F: (visibly frustrated) “Well I at least have to check you!”
(Oh lord, I love the “have to”!) Dr. F’s exam revealed that Sarah was 4 centimeters! Yay!
After helping Sarah to the bathroom and back to her rocking chair, I stepped out the catch Dr. F at the desk. “Thanks for holding off on the amniotomy, it was really important to her birth plan,” I said, trying to “smooth things over” and (gently) remind him that the patient was in charge! “Yeah well I’ll be back around 4:00pm to check her again and if she hasn’t made any progress I am going to break her water,” he said, grudgingly.
He started to walk towards the elevator but then turned around to me and said:
Dr. F: “You have the pit at 20 right?”
(Note: The way pitocin is administered for induction in my hospital (and many others) is that you start the pitocin at 2mu/min (or 6mL/hr) and increase by 2mu/min every 15-30 min (or more) to a maximum of 20mu/min (or 60mL/hr) until you obtain an adequate contraction pattern (or, 3-5 contractions in 10 minutes). So what does that mean? That means that you do NOT just crank the pitocin until you get to “max pit,” rather you TITRATE it until you get 3-5 contractions in 10 minutes that are palpable and are causing cervical change. Bottom line is everyone is different. I personally could take a whole box of Benadryl and not so much as yawn while my husband can take one tablet and all but hallucinate! It is no different for pitocin. Some people are extra sensitive and only need a little bit, and others tolerate “max pit” very well. I seem to have this same “fight” with physicians all the time at work. They insist you “keep cranking the pit” when all you are going to do is hyperstimulate the uterus and cause the baby to go into distress. But I digress….)
Me: “No, I have her at 10mu/min.”
Dr. F: (sarcastically) “What!? What are you waiting for?!
Me: (said while biting my lip so I didn’t say something I would regret) “She is contracting every 2-3 min and they are palpating moderate to strong. She has to breathe through them. And the baby is looking good on the monitor. I want to keep it that way!”
Dr. F: “But she’s not going anywhere! You have to keep going up if you want her to progress.”
Me: “But she has changed to 4 centimeters…”
Dr. F: “I was being generous!”
Me: “So you lied…”
Dr. F: (annoyed) “Listen, keep going up on the pit, even if she is contracting every 2-3 min. They aren’t strong enough. Keep going up. If we hyperstimulate her, we can just turn the pit down.” (Note: These were his exact words. I know this because I was so flabbergasted that he said it, I wrote it down in my notebook that very moment! The fact is sometimes the baby is in so much distress after hyperstimulating the uterus that just turning the pitocin down isn’t enough! And it really bothers me when doctors start sentences off with “Listen…” Grrrrr.)
Me: (jaw dropped, completely dumfounded) If I turn the pit up anymore, I am GUARANTEED to hyperstim her.”
Dr. F: “We’ll cross that bridge when we get to it. I’ll be back around 4:00pm.”
By this point I was more than annoyed with Dr. F. I explained the situation to the charge nurse and told her that I would not be cranking the pit on room 11 unless Dr. F wrote me an order that read “Regardless of hyperstimulation or contraction pattern, continue to increase pitocin until the maximum dose is reached.” (By the way, he wouldn’t’ write me that order.) She basically told me to do what I felt was right because it was my license at stake too.
So since I had her blessing, I kept the pitocin at 10mu/min. By this point about a half an hour had passed and I went to go check on Sarah in her room. When I entered I noticed that Sarah was breathing pretty hard during contractions and John was no longer reading poetry. In fact, John looked like a deer in headlights. “The contractions feel so much stronger since the doctor examined me!” said Sarah. “That’s great!” I said reassuringly. “I think I want my epidural now,” she said as she breathed through a contraction. “Where are you feeling the pain the most?” I asked. “In my back, my back is killing me!” she said.
Let me digress for a moment to explain my three rules regarding epidurals:
#1 You can’t ask for an epidural during a contraction.
#2 If you say “I think I want,” we need to try something else first.
#3 You can’t ask for an epidural if you are lying or sitting in bed.
If one of the three circumstances above is present, I have two techniques that I employ:
#1 The 3 Contraction Technique: You have to try at least one position change for three contractions first and then we reevaluate how you feel.
#2 The 15 Minute Technique: You have to try at least one position change for 15 minutes first and then we reevaluate how you feel.
Since Sarah said “I think I want” it was important to try something new first J. I always explain to my patients that epidurals pose higher risk of cesarean section the sooner they are given in labor and I did reiterate this to Sarah. In my opinion epidurals and pain medication should only be a last resort when everything else in my bag of “nonpharmacological comfort” tricks has been tried. She agreed to the “15 Minute Technique” so I (finally) obtained and attached her to a portable monitor, got her on her feet, showed her how to drape her arms over John’s neck as if they were slow dancing, and the showed her how to sway/squat during a contraction. While Sarah and John were “dancing” I was rubbing lavender Bath and Body Works lotion on her back and applying counter pressure to her sacrum to relieve her back pain during a contraction. And guess what…Sarah slow danced for TWO HOURS! She had definitely drifted off to Laborland, where time does not exist and you take life one contraction at a time J.
“I’m starting to feel more pressure in my bottom like I have to poop,” she said. What a great sign! I explained to Sarah that eventually that pressure would not only be felt during contractions but between them as well. Sarah was getting tired so we tried some kneeling on the bed for about a half an hour while John rubbed her back. Around 5:00pm Dr. F sauntered on in to check Sarah and as he had said he would earlier. All that hard work certainly paid off, Sarah was 6-7 centimeters dilated!! “I need an epidural now!” Sarah assertively told Dr. F. “Okay sure! I’ll write the order. But first I am going to break your water,” he replied. So I took a deep breath and with my best impression of an adorable puppy dog I cheerfully asked, “Could we please wait until she has the epidural in place first before you rupture her Dr. F? That way she won’t be leaking all over herself as she is hunched over for the epidural?” (Sometimes you gotta do what you gotta do!) Surprisingly he agreed and after he left the room I helped Sarah to the bathroom to pee.
However, it turned out that at that time, another patient was in the operating room for a cesarean section and there were two other patients “in line” for epidurals before my patient was. And since we only have one anesthesiologist in house and no others were available to come in, Sarah would have to wait. I explained all of this to her and showered her with support and encouragement regarding how far she had come, how much work she had done, and how she could make it any amount of time longer until she got her epidural because she was a strong woman! I don’t know how much of it she bought at that point in time because she was really really uncomfortable but regardless I couldn’t get her an epidural “now” so she would have to wait anyhow!
The next two hours or so (yup, the cesarean ran long and with two other epidurals in line, it took anesthesia two hours to get to Sarah) were spent walking around the room, hands and knees, side lying, kneeling, hunching over the counter, etc etc etc. By this point Sarah was almost at her breaking point so I offered up one final suggestion: Let’s sit on the toilet. Although skeptical at first, Sarah finally agreed to give it a chance and for the last 20 minutes before anesthesia arrived Sarah sat on the toilet, rocking back and forth. (Turns out skeptical Sarah actually liked sitting on the toilet. I asked for her to just give it “three contractions” and then we could get back to bed. After three contractions she asked if she could just stay there until anesthesia came! Hmmm, maybe this L&D nurse actually does know a thing or two J)
By this point it was 7:00 pm. The anesthesiologist had to poke Sarah twice to get the epidural in the right place, (Which happens a lot! That’s another risk! They are working blind after all!) and so we were not completely done with the epidural until 7:45-8:00pm. I propped Sarah up on her side with a bunch of pillows, put the baby back on the monitor, shut off all the light and tucked her in. She was snoring before I could leave the room. At least she can take a little nap before she has to push, I thought to myself. But what do you know, about 15 minutes later Dr. F came barreling down the hall. I saw him coming so I jumped from the desk and said “Are you going into room 11? She just JUST feel asleep. Please can we let her sleep for a bit?!” No luck. “What?! No, I HAVE to break her water. This is getting ridiculous now, its 8:00 for goodness sake!” he barked. So I hung my head like Charlie Brown and followed him into the room. He flipped on all the lights (is that really necessary) and Sarah sprung up from her sleep. The good news however was that Sarah was 8 centimeters!! I reluctantly passed the amniohook to Dr. F and he ruptured Sarah’s membranes. Clear fluid…good! I took the opportunity to change all the bedpads under Sarah and turn her to her other side. “I’ll be back in a hour to check you again”, said Dr. F as he brushed out of the room. I encouraged Sarah to take the next hour to try to rest as much as possible (no TV or talking on the cell phone!!) and went back out to the desk.
As 9:00pm approached, I started to get a pit in my stomach. I had a gut feeling that Sarah was probably going to be fully dilated when Dr. F came back and I was worried that because he wanted to get home (Sarah was his only patient on the floor) he would rush her into pushing before she could feel her bottom and we would end up with a cesarean section for “failure to descent.” So at 10 minutes to 9:00pm I took a chance, went into Sarah’s room, and said the following:
“I remember reading in your birth plan that even if you are fully dilated you would like to wait until you feel the urge to push before you start the pushing phase. Is this still true? (Both Sarah and John answered yes.) Okay, how are you feeling right now? Do you feel the urge to push when you have contractions? (Sarah told me that she couldn’t feel much of anything and did not have the urge to push). Okay, so basically what I am trying to say is that I think it is a totally reasonable request to want to wait until you can feel the urge to push. So when Dr. F comes to check you, if you are fully dilated it is okay to ask him to shut off the epidural and give you some time to start to feel the urge to push. You don’t have to start pushing right away. In fact, if you do, you will probably push for WAY longer than you have too. I will back you up. I know it sounds scary to shut off the epidural but trust me, pushing isn’t going to be so scary because you can actually DO something about all these contractions and pushing when you can feel the urge is a lot easier.”
Both Sarah and John agreed. I had said my peace and turned to leave the room but at that time in came Dr. F. He checked her and what do ya know, she was fully dilated!!! (But still at a zero station). “Okay, let’s start pushing!” he said as he pulled over the delivery table. “Umm, I don’t really feel anything yet so can I wait until I can before we start?” My whole face lit up with excitement; I was SO proud of Sarah for advocating for her birth plan! So then I chimed in, “It’s part of her birth plan, Dr. F, can we shut off the epidural and give her at least an hour before you check her again?” “Well let’s see how she does first,” he said annoyed, and asked Sarah to give him a “practice push.” Thankfully this convinced him that she certainly could not feel her bottom and he agreed to come back in an hour.
The best part was that after Dr. F left the room John turned to me and said “Wow, did you call that one or what!” I have to say it made me feel better that someone noticed how predictable doctors can be J.
I shut off the epidural and for the next hour sat with Sarah and John and coached them through transition. Although nauseous Sarah never threw up, but the pressure in her rectum was certainly getting more intense for her. We worked on breathing for about 30-40 minutes and the last 20 minutes I showed her how to grunt during contractions and do little baby pushes to relieve some of the pressure she was feeling. And then she said the magic words “I think the baby is coming!” Those words ring like a choir of angels to my ears! As I was leaning towards the call bell to page Dr. F into the room, the door opened and it was him. He checked her and with a look of surprise said “Wow! You are a plus 2 station now! You have done a lot of work in here!!” I was smiling so big I thought my cheeks were going to explode!
Sarah felt more comfortable pushing on her left side so John supported her right let while I supported her neck, applied cold washcloths to her forehead, and offered sips of cold water.
At 10:45pm after only 37 minutes of pushing, Sarah (a first time momma) gave birth vaginally to Elizabeth Joy, weighing in at 9lbs 1 oz!! She had a second degree perineal tear that required only a couple small stitches and never required an episiotomy, forceps, or vacuum extractor. Sarah spent the first hour skin to skin with Elizabeth and got a great start with breastfeeding. I only wished that I didn’t have to leave at 11:30pm and could have gotten to spend the whole 2 hour recovery time with them. I left the hospital that night exhausted but empowered, drained but excited, and so incredibly proud of Sarah and John for sticking to their convictions and advocating for their birth experience. I must have said to her a million times through my tears of joy, “You did it! You did it! You did it!”
It is such a shame that it takes so much energy to fight for your right to your own birth experience during a hospital birth. I think the mix between Sarah, John, & I was a great one, yet it still took a lot of effort on everyone’s part to avert unnecessary interventions and protect their birth plan. And unfortunately, it was all made much more difficult starting from the very beginning when Sarah was scheduled for an UNNECESSARY LABOR INDUCTIION. I thank God that Sarah ended up with a rewarding and empowering vaginal birth but things could have taken a turn towards CesareanTown at any point along the way, NOT related to natural labor, but related to INTERVENTIONS.
The morals to the story are this:
1) Remember LABOR & BIRTH are natural, INTERVENTIONS are risky, NOT the other way around.
2) Even if you are planning on an epidural, uncontrollable circumstances may require you to labor without one for longer than you thought and therefore labor and birth preparation, whether it be reading books, taking a class, hiring a doula, or talking with other moms, is just as important if you are planning for an epidural as if you were planning for a natural birth.
3) If you have had a healthy, uneventful, normal pregnancy up until your 37th week and your baby has a reactive non-stress test it is important to seriously question your doctor or midwife if they are suggesting, offering, or pushing a labor induction for you.
