Wednesday, December 10, 2008

A not-so-quiet hospital birth

Another birth story from the family physician who wrote A quiet hospital birth. I gave the woman a pseudonym. Besides showing how a woman can be wonderfully supported through a challenging birth in a hospital setting, it also illustrates how a care provider's individual practice style can determine whether or not a birth concludes with surgery. This particular woman was "stuck" for 6 hours at 8 centimeters--something that many providers would have concluded several hours earlier with a cesarean section for Failure to Progress. But, as this story illustrates, there was no reason to suggest surgery just because a certain amount of time had elapsed.

This story also illustrates the importance of one-on-one nursing care as well as the continuous presence of the birth attendant. Some women are fine doing labor and birth mostly on their own, but others require a lot of physical and emotional support to see them through. Unfortunately, many hospitals do not have enough nurses to care for each laboring woman individually. Often one nurse will be in charge of several laboring women simultaneously, leaving her little time to provide this kind of labor support.

The recent discussion of the Dux article "Homework is the mother of prevention" made me think about where the "blame" for the state of U.S. hospital birth lies. Is it the fault of women for not preparing enough, or the fault of providers and a system that promotes unnecessary intervention? The recent birth story I wrote ("A quiet hospital birth") illustrates a very un-intervened hospital birth with a mother who had done her homework and knew what she wanted out of her birth. I thought it would be interesting to share another story, a story of someone who hadn't "done their homework" but had a vague idea of how they wanted things to go, to illustrate how a birth attendant and birthplace can still support someone who isn't as easy as my quietly birthing client to take care of! This story is nearly as long as this labor seemed, at the bedside providing support for someone working hard.

One of my younger clients Laura had a long and difficult pregnancy. From the very start, she seemed more sensitive to the normal discomforts of pregnancy, and frequently had a list of complaints at every visit. Nausea, breast soreness, and abdominal bloating were just the start and were followed by low back pain, cramping, pelvic pain, pubic bone soreness, vaginal discomfort, and more. She usually seemed satisfied with all the self-help tips I could think of to tell her, but she usually brought a written list of complaints to each visit. In the third trimester, she added frequent Braxton-Hicks contractions, some enough to keep her awake all night, and on several trips to labor and delivery she was indeed having regular contractions, but no significant cervical dilation. By 37 weeks, she was fairly miserable with contracting for weeks and ready to meet her baby.

When we discussed her labor plans, she was certain she did not want an epidural, and planned to be unmedicated. I admit to being fairly surprised by this, given how uncomfortable she'd been throughout the pregnancy, but, since this was her plan, I laid out for her my usual description of what we could do in the hospital to help her. I always try to have this conversation beforehand, and to remind my clients that pain medicine is always available, but I will not be repeatedly offering it in labor as I find repeatedly offering pain meds influences people to accept, maybe when they weren't really wanting it. I also remind them that I will not be trying to argue with them in labor either – a request for pain medication will be honored. I always tell my clients, too, that most women who choose ahead of time to avoid pain medication do so successfully in labor, and that they are likely to be able to do so, if that's what they wish.

In addition, there are lots of non-drug things we can do for pain relief and comfort measures. Specifically, we encourage women to find their own comfortable positions; we monitor intermittently unless there is a need for closer monitoring, in which case we can monitor by telemetry or waterproof telemetry; we have tubs in every labor room; we have birth balls and rocking chairs and squat bars; and nurses willing to provide back counter pressure, or cool wash clothes, or hot packs. We encourage laboring women to drink throughout labor, and to eat as they feel up to it, and we encourage them to have the support people of their choice with them throughout. Laura heard all of this before she arrived in labor.

One early morning, when Laura was 38 ½ weeks pregnant, labor and delivery called me early in the morning to say she'd arrived having strong contractions. She'd been woken from sleep around 4:45 am, and arrived to the hospital around 7 am, and was contracting every 2-3 minutes. Her water hadn't broken, and the nurse checked her and found her to be 3-4 cms dilated, 80% effaced, and with a bulging bag of water. The nurse told me on the phone that Laura was working pretty hard with contractions already, breathing and moaning, and was pretty irritable. I hoped that all the prodromal labor she'd had would mean a shorter labor, and hoped the irritability was a good sign.

I arrived around 9 am, and Laura 's water had just broken. She asked for another exam, and was 4-5 cms now, and 85% effaced, with the head at -1 station. By the time I arrived, Laura was breathing hard and frequently yelling through contractions, and pounding on the bed railing. Her boyfriend looked pretty uncertain and was keeping his distance. Laura had eaten some toast and fruit just before I arrived, and that would end up being all she ate the whole day. The nurse encouraged Laura to get out of bed (she'd been trying to encourage her out of bed for some time by this point) and Laura agreed to try the tub. She sat on the toilet and rocked and yelled with contractions while we filled the tub. I really like water for labor and find it relieves a lot pressure. Frequently I'll see a laboring client sink into the water and smile for the first time in hours. This was not to be the case with Laura. Shortly after getting in the tub, she felt too hot and nauseated and weak, and wanted out. We helped her out, and she vomited once, cried for a while, and talked about how frustrated she was that she hurt so much and nothing was helping. At this point, the nurse just asked once if she wanted something for pain, and Laura yelled back that she'd already said no (and a few less printable words!)

After drying off, Laura crawled back into bed, lay on her side, and continued to have frequent, strong contractions. With each one, she'd start to breathe hard, then moan a bit, and then work up to yelling "Ow, Ow, Ow, OWWW! Tell me when it's going away!" and the nurse would tell her as soon as the monitor suggested the contraction had peaked. The nurse tried to encourage her to get out of bed, to sit on the ball, or walk, or at least sit up, but Laura didn't want to move. For a while, in between every contraction she told us over and over that nothing was working, that she just didn't think she could do this, and why couldn't we help her? My nurse did a wonderful job of providing support, without giving in to any "oh, you poor thing" thinking. She'd tell Laura: "You ARE doing this – every contraction gets you closer to baby." She calmly let her know when her contractions were peaking, fanned her with a laminated card, gave her sips of water, and encouraged her to at least roll and change sides every so often. During this time, Laura 's boyfriend started to find his groove as a labor support person too. He pulled his chair next to the bed, wrapped his arms around her, wiped her face with a cool cloth, whispered words of encouragement, and ducked when she'd occasionally pound on the bed railing.

Around 11 am, Laura asked for another exam, wanting so much to be close to done. At this point, she was 8 cms, but the head was still -1 station, and not well applied to the cervix. Still, 8 cms was very encouraging news to Laura, and she got a bit of a second wind. She decided to get out of bed at this point and walked for a few minutes in the room, but quickly decided the contractions were just too intense standing up. She sat down in the rocking chair, then, and rocked through contractions. Laura preferred to have the contraction monitor on, and at the start of each contraction she'd yell for the nurse to tell her as soon as the contraction peaked and was starting to go down. The nurse would hold one hand, while her boyfriend held the other, and Laura continued to yell through contractions, usually some variation of "OW!" until the nurse told her it was going down, and then she'd count out loud until the contraction was done. I took a break to eat lunch at this point, and during lunch I could still hear Laura yelling through her contractions, and the calm voice of her nurse telling her she was doing great, the contraction was almost over, just keep breathing and rocking.

After lunch, the nurse and I switched so she could have her lunch. At this point, the nurse had been in the room pretty steadily for several hours, and she needed a break. Laura continued to cope pretty well in the rocking chair. She would get up every so often to go to the bathroom to urinate and would spend a couple contractions rocking on the toilet. By now, Laura was getting pretty tired and discouraged. During and after every contraction she told me repeatedly that she just couldn't do this, she was too tired, it hurt too much, and the baby wasn't coming, and yet, somehow she made it through every contraction.

Around 2 pm (the nurse had long since returned and taken over primary support) Laura wanted to be checked again. Her contractions had spaced out to more like every 4 minutes, but were stronger and longer. She felt like she had a lot of pressure in her bottom, and in fact had taken to running back to the bathroom with almost every contraction, although usually she wasn't able to actually pee and she'd tried for some time to move her bowels without success and we'd told her we thought the pressure was just the baby. I checked her again, and she was still just the same, 8 cms, about 90% effaced, with the head not well applied to the cervix. This was one of those times I was sorry we'd done an exam, as Laura was pretty crushed by this news when she'd hoped she'd be about to have a baby.

At this point, I offered 2 options. To begin with, Laura and the baby were doing just fine. Although she was tired, and frustrated, and fairly miserable, Laura was coping pretty well, and the baby was tolerating labor perfectly, and I explained there was no real need to do anything. One option was to just carry on with labor, as nobody was in trouble and there was no emergency. The other option was to try adding some Pitocin to see if that would encourage her cervix to dilate. Laura had been 8 cms for at least 3 hours at this point, past the medical definition of failure to progress, although it's been studied that merely waiting 4 hours instead of 2 can reduce the cesarean rate for failure to progress by 50%. Laura was tired, and hurting, and frustrated, and wanted anything that might speed things up. Her choice was to start Pitocin.

The nurse hooked up Pitocin, and we slowly titrated it up over the next hour, and Laura 's contractions got closer together again, coming every 2-3 minutes. For a while, she lay in bed on her side again, and yelled her way through some more contractions. After an hour or so, the nurse checked her again, and found her to still be 8 cms, with the baby's head still not descending well to the cervix. She talked Laura into sitting upright for a while, in a chair position in the bed, hoping that would help the baby descend. Then Laura decided she needed another trip to the bathroom, and since she was more comfortable there, we encouraged her to stay sitting on the toilet for a while. We put a pillow behind her head so she could lean back between contractions, and her boyfriend wiped her face with a cool cloth. During contractions she'd rock and sway and yell, and in between she'd flop back on her pillow and close her eyes. Around 4 pm, Laura informed me she was really done, she just couldn't take it anymore, and she knew she had to be ready to push. She flopped back down on the bed in tears, and demanded to be checked again. You guessed it: still 8 cms. Now, however, more of the cervix seemed to be in the front, the baby was lower, and the cervix was very soft and stretchy. Laura was really disappointed to hear this, but I tried to emphasize the positive changes (softer, stretchier, head lower) and within a few minutes she went from crying hard to asking if there was anything else that might move this along. I suggested she try hands and knees, thinking maybe that might help move the cervix that was mostly in the front.

Within a few minutes, the nurse had helped Laura turn around in bed, so she was kneeling on the bed with her arms draped over the back of the bed that we had cranked all the way up. During a contraction, she'd kneel even more upright and sway back and forth, and she went back to pounding her fists, this time on the back of the bed. At the start of each contraction, she'd sort of wail the nurse's name at the top of her lungs, and then yell "Tell me when it's going down!" In this upright position, we couldn't actually pick up her contractions on the monitor, so we had to go with educated guesses on when the contractions were peaking, leading to a few times the nurse saying "It's going down!" and Laura wailing "Oh no it's not!" In between, she'd sometimes rest, and sometimes repeat over and over "I just can't do this!" Close to 5 pm, Laura said "This is IT!" and flopped her self back over on her back. She grabbed my hand and said "I'm done. I just want a c-section. That's possible, isn't it?" I had noticed that she had grunted a bit with the peak of the last couple contractions, and I hoped that meant she was close to pushing at last. I talked her into an exam instead of an instant cesarean, and was disappointed to find that same 8 cm cervix, although still it was very stretchy and low. At this point, she'd been 8 cms for 6 hours, and the baby was still doing very well, but she was obviously emotionally at the end of her rope. On a gut feeling, I suggested she just try pushing a couple times and see what would happen. Worst case scenario, I figured nothing would change and we'd be right back where we'd been. With Laura 's permission, I did an exam during her next contraction, and encouraged her to push hard. To my surprise, I could feel the cervix just melt away as she pushed, and the baby surged lower. By the end of her second contraction, she was fully dilated. (And then I wondered what would have happened if I'd tried that 4 hours earlier – but it was only in the last few minutes that she'd started having some spontaneous pushing urge, so likely 4 hours earlier it wouldn't have done anything.)

At first, pushing gave Laura a big second wind. Briefly, she became much less irritable, and even talked about how glad she was not to have a c-section after all. She was quite tired, and at this point, she wanted only to try pushing in a semi-sitting position. Over the next half hour, though, she started to get discouraged again, and to tell us again and again that she was sure she just couldn't do it, that the baby wasn't coming, and that it was all just too much. We encouraged her to try a different position, and to see if she could get a little more strength behind her pushes. She agreed to try the squat bar, and she pushed in the full squat for a while. In between, her boyfriend continued to give her drinks, wipe her face, kiss her cheek, her arm, and her knee, and tell her she could do it – and she would tell him no way, she definitely couldn't do it! After a while, she was too tired to stay squatting, and she moved back to semi-sitting. By now, with each push we could see just a tiny sliver of the top of the baby's head. For a few pushes, hearing that we could see the baby's head encouraged Laura, and she pushed hard and merely rested in between, but when the baby still wasn't out, she started to be more discouraged again. The nurse encouraged her to keep going, and helped her up to squat again for a while, then gave her a sheet to tug-of-war with while she pushed. Finally, a little bit more of baby's head appeared with each push, and even Laura could feel that the baby was moving, although as the baby slid back out of sight in between each contraction, she yell and pound the bed "Don't go back IN!!!" and she kept asking us when the baby was ever going to come.

Like the rest of her active labor, crowning took quite a while. For the last 5 contractions, I was sure each time that this would be the one. But, although the baby didn't slide back any longer, he just moved a millimeter at a time and slowly, slowly, slowly a little bit more and then a little bit more, and then even a little bit more of the head stretched the perineum. Finally, when it seemed there was no way more head could be out and the baby not be born, the baby's forehead, and then eyebrows, and then one eye, then the other, the nose, and baby's mouth slowly slid out. Once the head came, the whole baby tumbled out quickly, wrapped tightly once in the cord around the neck, which I unwrapped as he tumbled out. Laura didn't want the baby immediately on her chest–she somehow managed to gasp out a reminder while the baby crowned that she wanted him dried and cleaned off first. I don't like to cut the cord immediately, so the second nurse brought a couple receiving blankets, and we held the baby level with mom's belly and dried him and wiped off all the blood. Baby was immediately pink and had wonderful tone, and let out a yell. The first nurse (the one who'd been there all day) encouraged Laura to look at her baby, and asked her if she thought he was clean enough to put on her belly, and Laura agreed. We laid the baby on his mother, and she wrapped her arms around him.

After 20 minutes or so, the placenta separated and Laura had more cramping and pushed it out. She had a small 1st degree skin tear, but it was on the outside of the perineum, where they often sting quite a lot without suturing, so I offered sutures and Laura agreed. Fortunately, after all her hard work, she barely felt even the local anesthesia going in, and the sutures were quickly done. This baby turned out to be very calm and alert, and he latched as soon as his mom shifted him near the breast. He was born at 6:43 pm, nearly 8 hours after the first time Laura had been 8 cms. He was 7 lbs and 2 oz, with dark hair, dark grey eyes, and long slender toes. Once the baby arrived, as I'd seen so many times, Laura perked up and all the frustration and discouragement disappeared into the joy of holding her new baby.

The nurse and I, however, were fairly exhausted. Watching someone work that hard and need so much constant encouragement for so long is really draining. The nurse commented that she didn't think she could hear "I can't" one more time and stay sane. But Laura intended to birth her baby without pain meds or an epidural, and with a lot of encouragement (and some questionably useful help of Pitocin augmentation) she did just that. Of course in a home setting, we may well have not known about the long pause at 8 cms, and she may well have started to push spontaneously, and the fact that she dilated from 8 to 10 with her first 2 pushes may well have never been known. But even in a hospital setting, with a more medical approach, a client who hasn't done any research or have any knowledge about how things are supposed to go (and some interventions which may or may not have been helpful) can be supported in her wishes to get through labor without an epidural – even if she herself is sure a lot of the time that she can't do it!


  1. That's awesome... everyone should have people/persons to support them during labor/delivery regardless if they need hands on like Laura did or hands off like your quietly birthing client. More women would be empowered to birth in a way they can remember fondly (with or without meds) if there were more people to support like this... thanks for sharing such a beautiful story.


  2. That's so, soooo awesome! How I wish wish WISH that my hospital had been that way when I had my son, I might have one less scar on my belly...

  3. I want a referral to this Dr.

  4. This perspective could have saved me from the scar.

    Thanks for posting this!
    ~ Kimberly

  5. All the more reason NOT to do VEs and just let the woman do her own thing ! Had she *not* known she wasn't 'complete', ie not at 10cm, and had she simply been encourgaed to tune into her OWN body and the sensations she was feeling, or had she been encouraged to give a few light, "grunty" pushes, I am willing to bet that that eight-hour lull would not have lasted nearly so long.
    Oh, well. A lovely story of support, just the same.

  6. I think all birth workers would do well by their clients to read this :

  7. Emma, I would argue that the woman WAS doing her own thing. If you read the story closely, the woman asked for the vaginal exams; they weren't forced upon her by the staff or done as a routine. Of course, as the physician telling the story mentioned, having exams can be a mixed blessing because the number you hear can make you very happy or very discouraged, depending on the situation.

  8. As the author - I was hoping someone would bring up something like "that's why we shouldn't do vaginal exams"! I am content to attend a labor and do no exams, and do in fact have that happen from time to time. Most of my clients, however, are not willing to labor for hours and hours with no clue as to their progress. Most have not taken any childbirth preparation or read any books (despite repeated urging by myself - all my clients are given a handout at their first visit with a list of good books, and I have a big lending library, but that just isn't the way most of my clients operate.) Most of my clients have only "The Baby Story" and their friends and families's horror stories to go on. Frequently, I also have a grandma or auntie standing over the client in labor bugging me every 10 minutes to do another exam - and not buying my reasons to limit them. This particular client was particularly wanting to know her cervical dilation like every 15 minutes - and was put off a bunch of times. I tend not to give a lot of direction to a client unless they are asking me what to do - if a client starts pushing spontaneously, or grunting a bit with the peak of contractions, we go with it. Her nurse did tell her repeatedly to listen to her body, and push a little or grunt with contractions if she thought it would help, and she did not until the very end of the 6 hour pause.
    It would certainly be an option to do no exams and just wait out labor, but sometimes clients want to know, and sometimes they welcome any intervention that might speed up labor. Not how I approached my own labors, or how some of my more naturally-minded clients approach their labors, but some clients are really looking for me to be doing things!

  9. I think it would make a huge difference if nurses could be 1:1 with labor patients. Unfortunately, the accountants dont see it that way.

    ANd some L&D nurses are better at labor support than others. I think it is a shame that labor support is not really being taught to new L&d nurses. Often they will come to the desk and tell me "This patient needs an epidural." I will say "did she ask for one?" ANd the nurse often will say "well no but she is in so much pain I hate to see her suffer." I will ask "How many centimeters is she?" Often I will hear 2 cm. I will ask if she got in the tub? No. Did you offer her pain meds? NO. Did you do the hips squeeze? To that folks look at me and say what on gods green earth is the hip squeeze.

    Sorry I digress. I liked your story.

  10. Encouraging story. Good for her boyfriend for getting in there with her, and good for you and the nurse for supporting her all the way! We seriously need more healthcare providers like you two. :)


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