Monday, September 7, 2009

The labor from hell

So the labor from hell was miserable, especially for the patient of course!

I had come in at 7am because I was scheduled to first assist for a section. I had told the off-going midwife the night before not to worry about calling me early as I would need to be there anyway. Well, she never called me at all so I assumed there were no labor patients there. Wrong! This patient, someone I had spent a lot of time in the office with and a young girl at that, had come in around 2 or 3 am. She had done the walking thing and had changed her cervix to 4/90/-2. She was planning natural childbirth. So she was admitted for expectant management.

When I arrived, the night shift nurse had just checked her because her water broke - calling her 6/90/-1. So off we go, me thionking she's gonna have her baby by lunchtime. Boy was I wrong. Even after her water breaking, she never really would contract more than every 4-6 minutes. They felt strong but progress came to a standstill. And the patient was doing a wonderful job of staying relaxed and breathing with her contractions. WTF?

I go do my section then come back to do labor support. At 10ish, I recheck her because she's feeling pressure and shaking a bit. She's the same (well, actually I would have called her 5/100/-1). That sucks. But onward and forward. We continue to try different positions, the tub, etc. At lunchtime, I have to go do another section so leave her for a bit.

After the section, come to find out the nurse had checked her and she was...any guesses? 6-7/90/-1 per the nurse. So I am feeling a little aggravated because I don't know if this is change or just the nurse feeling the same exam but calling it a little differently. I would rather have been the one to check her but the nurse said she felt like she needed to push (the patient, not the nurse) and she didn't know how long I would be in the OR. Jeez, you could have come asked me - it's not like you had to go to another part of the hospital to find me and the patient is a primip for gawdsake! My favorit expression - it ain't gonna fall out!

So more labor support, more time goes by. I blow off office hours to stay with her thinking we will have a baby in the afternoon. The patient continues to do very well (now I start questioning how well she's doing - probably because things aren't progressing!) and contractions do palp strong.

Around 5pm, I decide to check her and she's what I would call 6/90/-1 with a bag! So we break her water, again. And we continue on, thinking this will do the trick. Her contractions get a little closer together for awhile (every 3-4min) but then gradually space back out to 4-5 min. They palp strong, patient is coping well. WTF??

I start thinking about pyschological blocks. That's the only thing I can think of. Her pelvis, while a touch on the small side still feels roomy enough to birth a #6.8 baby (which is what I am estimating).

Around 6:30pm, the patient is starting to struggle to work through her contractions. We have continued to try multiple positions and the tub. I can look at her and tell she's losing it. The exam is unchanged.

I pull the patient's momma out to the hallway to chat for a bit. The patient is underage and I need to know her momma's thoughts on where to go from here. I am of the opinion that the patient needs an epidural and pitocin at this point. She hadn't wanted pitocin earlier when I suggested - not because she didn't want the interference but because she just didn't want to hurt more and she knew pit would make her hurt more. Her and her mother didn't want an epidural because they had heard too many bad stories, not because they were worried about the effects of epidural on birth. So, I talk to mom for a bit...she's not happy with the thought of an epidural but willing to consent for it if its what her daughter wants.

We go back in the room where my patient is definitely starting to lose her ability to cope. She wants the epidural. So that gets done. The nurse checks her after putting her catheter in. She's the same. Pitocin gets started and the patient is instructed to go to sleep for a bit.

We fight with the pitocin and her contraction pattern for awhile. Her contractions just didn't want to pick up. Her body was just fighting this process??

Around 11pm, I finally recheck her, thinking I will put in a IUPC because her contractions continue to be dysfunctional looking. And that's kinda my ward or good luck charm. I'll say lets go put in an IUPC and then discover the patient is too close to delivery and doesn't need it. Sure enough, the patient is 9/100/0 with a touch of caput. Woohoo!!!!!

So we wait some this time I am absolutely exhausted but a friend brings me coffee which helps. Finally, around 1am, the patient is feeling a lot of pressure and feels like she needs to push. I check her and she's 10/100/+2 and the caput is crowning :p We start pushing. It only takes about 10 minutes to get the hang of it. She pushes for about an hour, finally delivering an adorable baby over a couple little dings in her bottom.

We had long crowning so the baby came out floppy initially and the labor nurse panicked (well, I think she did but she doesn't think she did) and called for nursery without taking a minute to assess and mess with the baby herself. This kinda irked me and we had some discussion about it later. She's a new nurse (maybe been doing this for about a year now) and she hasn't learned how to truly assess babies yet. I knew the baby was stunned and needed a chance to get going. Our apgars were 2 and 9, with just blow-by and stimulation to get the kid going.


Joy said...

You weren't lying when you said it was a labor from hell! Oh I feel so awful for that girl. Glad the baby ended up doing okay, too.

And was that nurse completely batty or something? Based on the story she didn't seem very reliable.

Ciarin said...

Actually she's a decent nurse but just young....doesn't know how much she doesn't know. They get cocky sometimes around that one to one and half year mark until something happens to remind them how much they don't know.

Jamie said...

That is very close to what happened to my client in March.

She progressed quickly to 6cm, then stalled for four hours. Since she was a primip I was pleasantly surprised. Her midwife and I were sure she was in transition, since she was not coping well (even in the tub) and contractions were very strong and close together.

A vaginal exam showed baby's head was OP. I ask certain questions of my clients prenatally to see where baby is situated and how their abdominal muscles and fascia are. I had suspected baby was OP since her baby had been moving from side to side in the last few months of pregnancy. Often those babies settle OP for labor.

I think when babies are OP dilation can stall until baby rotates, typically around 5-7cm. Sometimes that's the only sign you'll have. My client didn't report any back pain at all. She got an epidural and pushed baby out OA after two hours.

It sucks doesn't it? Oh well. :(

Ciarin said...

I think she was initially OP but we seemed to resolve that - Based on where the baby's back was and mother's report of relief of back pain. And still, no labor progress over hours and hours.

I think we were dealing with pyschological issues (I think she was just scared of birthing the baby even though she denied this when we chatted).