Tuesday, January 20, 2009

Faith and patience.

Okay, the story forthcoming could have had a variety of endings, and here lately we've seen alot of different ones, but this mommy had faith in her body and its ability to birth and it ended just the way she had hoped.

I went into work one evening and was given a patient who had come in early that am for PROM (we seem to be having a run on these the last few months!). When she arrived she refused pitocin, although it had already been four hours since her membranes ruptured and she wasn't having any contractions. The midwife on call for her primary midwife (primary midwife is out of town)was okay with this and told her to do some walking, sit on the birth ball and see if things will get going. Well, by the afternoon not much had happened so the mommy agreed to some pitocin. At this point it had been over 12 hours since ROM and her vag exam was essentially the same as when she had arrived at the hospital that am (thick cervix, fingertip dilated and ballottable fetus....not very promising). At this point the midwife had to consult with the MD on call who came in and check the mommy, got consent for an IUPC and placed it then went on to tell the mommy that they would give her two hours and if she hadn't changed then they needed to have a cesarean section.
After the doc left the room the patient and her husband talked and then told the nurse that they didn't want that doctor to care for them and essentially fired him at that point. So, another midwife in the practice came in to talk to them and discussed the possibility of infection and putting mommy and baby at risk and agreeing with the MD that if things didn't start moving along they would have to consider the possibility of a cesarean. At this point mommy decided she wanted an epidural so the midwife said that was fine and she could have one and instructed the nurse to start the IV fluid bolus, at this point the dad pipes up and says that they want the epidural right now. The midwife tried to explain that it would take a few minutes since she needed the fluids beforehand, dad got a bit huffy and told the midwife to just leave. Well, the midwife did just that and at that point called another MD with the practice and asked him to come in and care for them because they had fired the other MD and she would not care for them at this point.
All of this drama happened within the 30 minutes before my shift began. So, I came in and introduced myself and immediately got the patient in position for her epidural placement. After her epidural they were very calm and got settled in then the new physician came in and spoke with them.....he was wonderful and they liked him immediately. He explained to them how the first stage of labor is the longest and sometimes requires a great deal of patience, and that he was fine with us monitoring her throughout the night, titrating the pitocin as needed and would re-evaluate in the am. But, he was very clear that if she started to get a fever, the baby showed any signs of distress at all or if she had not made significant change by the am that they would have to have a serious discussion about a cesarean. The couple was fine with this and the MD went home to sleep.
She was very comfortable with her epidural, I turned her side to side hourly and checked her vital signs. She had agreed to start some antibiotics to head off any infection so we did that. I monitored the strength of her contractions and actually ended up turning the pitocin down twice during the night. By 1am she was 4cm, and I am pretty sure the baby was straight OP....this would explain the dysfunctional start to labor. We continued with the side to side turnings and by the end of my shift she was 7cm.
After my nap I called to check up on her and found that she birthed her baby vaginally around noon after a very long pushing stage and being ruptured for 36hrs.
Unfortunately, things don't usually turn out this well in this type of situation. Health care providers seem to lack a great amount of patience for a generally slow process and a little bit of faith in how the process works.
I am glad this couple got the type of birth they wanted, I just think the whole situation could have been handled so much better, on both sides.
We seem to be having a run on PROM these days and gals being in labor for a long time before finally giving birth.
Honestly, I have noticed that alot of the health care providers that had gotten away from the weekly in office vag exams starting at 37wks seems to be going back to that.......sad, and I think that has alot to do with PROM.


Sarah said...

I was ruptured for nearly 41 hours before I had my VBAC baby. I didn't allow any vag exams until 30 hours had passed and we were discussing using a castor oil-verbena-apricot juice-almond butter cocktail. If I had been planning to birth at the hospital, I would have been sliced. As it was, I had a short labour once it got kicking and my little boy was born peacefully in the water at home.

Ciarin said...

Wow - interesting story. I question the wisdom of getting an epidural at FT and thick. It's a good thing you provided diligent nursing care by keeping her moving all night! Was the baby born OP?

RN2CNM said...

Ciarin, fortunately for her the baby was not born OP. I think it must have finally turned sometime after I checked her at 1am when she was 4cm and when I left at 7am because by 10am she was complete. It took 30 hours for her to dilate to 4cm and then only another 6 to go complete.