Friday, March 14, 2008

Ten Centimeters. Push!

Last week I found myself in one of my favorite positions -- Leaning over a hospital bed, rubbing the back of a laboring mother.

Over all, the labor wasn't bad.

I went in with a positive attitude, hopeful of seeing a good birth. I liked the obstetrician - she was an extremely nice woman with a great personality, and seemed to genuinely be enjoying her job. She was very supportive of the mother's desire to have no epidural if possible. Although medical reasons made the obstetrician decide that induction of labor was appropriate, she respected the mother's wishes to keep the Pitocin drip at a minimum and not turn it up once she started contractions.

The mother had given birth in the same hospital twice previously and was well prepared for labor. Her husband was supportive and as helpful as possible.

As labor progressed and the Pitocin induced contractions became more and more unbearable and on top of each other, the nurses were awesome. They provided one-on-one care, basically having someone in the room with us constantly. They, along with the father and I, encouraged the mother to try all sorts of positions - standing, hands and knees, sitting on the birth ball, rocking, etc.

I was even more impressed when the nurses got into whatever positions they had to to continue to monitor the baby's heart rate. It seemed that whenever the mother was in an upright position, the electronic fetal monitor (EFM) just wasn't tracing the heartbeat very well. So, the nurse had to stand there for several hours continuously holding the doppler in place to maintain a tracing. There was absolutely no "I'm really busy. You'll just have to lay in bed so we can get a decent tracing" or any, "I'm sorry this isn't working. We're going to have to put in a fetal scalp electrode." (The obstetrician wanted constant monitoring because of an increased risk of fetal distress with the Pitocin induction.) Care was all focused around what the mother wanted and needed and what made her most comfortable.

I was also impressed with the information that they provided the parents with before taking any action. The mother got vaginal exams when she wanted them, not every two hours or according to any set protocol. The father and mother both didn't want her water broken early in labor. The hospital staff respected their decision and didn't do it till near the end, when the mother requested it.

As I massaged the mother's shoulders and gave the father suggestions for new ways he could support her and asked the nurses to better explain the progress to the couple, I found myself thinking, "This birth isn't bad. It's about as good as hospital birth gets."

Of course, the Pitocin made things miserable for the mother, and more than once she just burst into tears and cried, "I just can't do this anymore!" But every time she got to that point, we managed to re-focus her on dealing with this contraction and just getting through right now. Her obstetrician poked her head into the room at just such a moment, and very quietly, almost reverently watched her experiencing an intense contraction. "Wow," she whispered. "You just never see women willing to do this any more. I'm so impressed."

Ten centimeters came as the sun came up. The shift would be changing soon, but these nurses were excited that they would get to see the fruit of this labor before they left. The doctor was summoned. Mother got back into bed and was positioned in a semi-sitting position. The bed was broke down, and her legs were spread apart while the overhead lights were turned onto the site of action. The doctor gowned and gloved. Two nurses held one leg (since the stirrups were uncomfortable) and I held the other. Sterile drapes were placed everywhere, leaving only the vaginal opening exposed. The father, nervous and excited at the same time, held her hand, and reassured his exhausted, tearful wife that she was almost done. She was so tired, and kept saying, "I don't think I have the energy to push. I can't."

We all assured her over and over that she could and would get her baby out. The doctor leaned in close to her face and looked her in the eyes, "Just listen to me and do what I tell you. Just follow my instructions closely and you'll be just fine."

The mother nodded through her tears, and the father whispered, "Honey, you can do it. Just listen to the doctor."

"Okay, on the next contraction...." The doctor began to explain the process of letting the contraction build, then taking a deep breath and holding it while pushing as hard as possible while the nurses count to ten.

I sighed to myself. Purple pushing. Why do all doctors think that this is the only way to get a baby out? I knew they'd do this. Why do I even hope that this time will be different?

("Purple pushing" is the above described technique, termed such by many doulas and midwives because the mother has so little time to breathe and exerts herself so intensely that she often starts to turn purple and even burst the blood vessels in her eyes. It has been employed at nearly every hospital birth I've ever attended. It barrels a baby a baby out faster than any other method of pushing. A first time mother who might take an hour to push a baby out when allowed to do it at her own pace, will usually push a baby out in less the 20 minutes with this incredibly intense way of pushing. I personally think that purple pushing can be necessary and effective if a baby is in fetal distress and there is a good reason to get the baby out as quickly as possible. If there is not medically indicated reason, I think it just traumatizes the mother's body [tissues don't have much time to stretch and she's more likely to tear, etc.] more than necessary, not to mention that she thinks of pushing as one of the hardest, most exhausting things she's ever done.)

So, the pushing began. "Take a deep breath. Hold it! PUSH!! One.... two..... three..... four.... no, no, don't take a breath yet! Keep pushing down and out as hard as you can!... five.... six... that's a girl!... seven.... eight... nine... TEN! Good push! Now, quick, quick, another deep breath, and down and out! One.... two.... three.... "

(Mother falls back exhausted. "I can't! I have to catch my breath! I can't breathe! Just let me catch my breath!")

"No, honey. Not till this contraction is done." (Pulling her forward) "Take a deep breath right now, and hold it. Hold it while I count to ten... (more insistently) ONE! TWO! THREE! FOUR...."

Ten minutes have passed. We're seeing a baby's head. The doctor comments on all the hair. Mother is gasping for air between pushes and saying she needs to slow down. The Pitocin drip is still going, and the contractions are coming right on top of another.

"No, not till your baby's here. Keep going!"
The nurses get in her face to help her stay with the pushing a little longer. I want to tell her she can take a 10 second break, but that is obviously not the opinion of the doctor.

I tell myself that this is ridiculous, but determine to keep my mouth shut. I'm the doula, not the obstetrician. The doc keeps taking sideways glances at the monitor. The baby's heart rate shows no sign of compromise. It's plugging away with nice short and long term variability around 140, even during contractions with head compression. Wow! The doctor smiles, "Your baby is doing great! Let's hurry up and get him out!"

The contraction ends. Mom falls back on her pillow and sobs and gasps for air. "Just... just let me rest for a minute..." I'm happy to see that the contraction is over and baby is wonderful. Surely they will let her rest till the next contraction hits. The father looks slightly concerned, torn between wanting to help his wife get what she says she needs, and wanting to follow the doctor's orders for the safety of the baby.

But, no, rest is not an option. The doctor wants to get this kid OUT! "You're almost crowning! You can't stop pushing now till your baby's head is out," she says firmly. The mother wearily sits forward, clutches her thighs again and pushes.

"No, harder, longer. Take a deep breath. Hold it while we count...." And again.... and again.

Finally a head emerges.

I breathe a sigh of relief. Finally the mother will get to inhale once without holding her breath for the count to ten.

I wait for the doctor to feel for cord around the neck. Instead she graps the baby's head firmly, locking her fingers under it's jaw line on both sides, braces her feet against the base of the hospital bed, and leans back, pulling for all she's worth. "PUSH!" she shouts at the dazed mother.

I watch with horror. The baby hasn't even rotated! How does she expect to pull the little guy out without allowing his shoulders to properly spiral through the pelvis?

The baby doesn't pop loose. Her eyes register panic. I see "lawsuit!" flashing through her mind. She yanks a little harder on the head. Still no baby. "Stuck baby!" the doctor half whispers severely to the nurses. The father has realized that the doctor is frightened and something is dead wrong. Tears squeeze out of his eyes.

"Supra-pubic pressure!" the doctor shouts in the direction of the nurse at her right shoulder. There are four nurses and a respiratory therapist standing by. Three of the nurses dive for the mother's stomach. (Supra-pubic pressure is usually applied with the palm of the hand, pressing down hard on the top of the pubic bone, trying to help the baby's shoulder "pop" out from underneath. It's a maneuver used for shoulder dystocia.)

One nurse lays the bed back flat with one swift maneuver. The other three pile onto the mother, leaning all of their weight into her stomach. She screams. "PUSH!" everyone yells together. "HARDER! HARDER! You've got to get this kid out!" The mother again grips her thighs, now having her knees almost to her ears and pushes with every ounce of strength she has left.
The doctor leans back and with all of her 200 pounds, pulls on the baby as if her life depended on it.

The baby pops out. It's been less then 15 seconds since the head emerged. The doctor quickly grabs a hold of the pink, squirming body of a crying baby and suctions and cuts the cord while uttering a sigh of relief. All that scare and an APGAR of 10. The nurses straighten up, slightly shaky. The parents can't stop crying and shaking. Their little boy is here, but his arrival was the worst minute of their life.

I stand there, still holding the mother's trembling leg and rubbing it and thinking...
About how this birth happened. About how it could have happened differently, if only some common sense had been used and everybody hadn't been in such a rush.

I replay every move over and over. It wasn't a shoulder dystocia. It was a little 6 lb. baby, being pushed out by a woman with a more than ample pelvis. If the baby would have been given another 30 seconds to rotate and line up the rest of his body, he would have slid out with the next push.

I shake my head, feeling sorry for the obstetrician who created her own emergency and is still shaking about the "close call" she had.

I feel most sorry for the mother and father who just went through some of the scariest moments of their life as they welcomed their baby.

The obstetrician tugs on the still pulsing cord, pulling out the placenta and throws it into a basin for pathology to inspect. She asks the nurse to turn the Pitocin up (to keep the mother from bleeding), and then inspects for tearing.

Seeing none, she looks pleased. It's been almost 5 minutes since the baby was born. He is wailing in his little warmer next to the bed. The mother is too exhausted to want to hold him right now, so the nurses are playing with him. The doctor pats her patient on the leg and says, "You look great! You'll be a little sore. Just use ice packs for a couple days. Congratulations! You have a beautiful baby!" She breezes out the door, to deliver the next patient.

I like her. She's a nice, caring woman. She's sweet and friendly. The nurses were great.

But now I know why I don't want a hospital birth. Sometimes I forget.
I'll remember this one for awhile.