Tuesday, February 23, 2010

No C/S for Me

I had an interesting situation recently. I spoke with a woman, having her first baby, at the beginning of my call. She had been contracting all night. She opted to go into the office when it opened for a labor check. She was found to be 5-6cms so wanted to come to the hospital. Her plans were for natural childbirth.

On arrival, Nurse Crappy checked her and found her to be 6-7cms. My thinking was 'great, it's gonna be an awesome labor and birth!' Little did I know what was to come.

She was handling the contractions well. The baby didn't look too hot on the monitor but wasn't bad either. I felt the strip was reasonable enough for her to just have intermittent auscultation. I wanted her to be able to get in the tub, walk, etc. Her contractions were kinda irregular. She decided on getting in the tub with lots of bubbles to keep herself covered. She seemed to be very modest. She was very comfy in the tub and was sleeping so i headed over to the office to see a couple patients, do rounds, etc. I told her to have the nurse call me when she got more active again and I would come back.

I returned to the hospital around 3pm which was good timing as the patient was asking for me. She wanted to be checked, which I did. She was 7/80/-2 with a bulging bag of waters (BBOW). She was a little disappointed that she had not changed in that 5 hours. I recommended that she keep doing what she was doing (positions changes, nipple stim, walking, etc) and possibly consider breaking her water. Her husband and mother were present and doing a nice job of labor support.

Around 6pm she wanted to be checked and have her water broken if no change. She was still the same, although her cervix felt slightly swollen to me at this time. I broke her water (light meconium) and figured that would get her progressing again. She did start to contract a bit more but the intensity didn't seem to be changing based on how she was behaving. Then the contractions went back to their previous irregular pattern.

At 9:30pm, I checked her and she had not changed other than the cervix was definitely starting to feel like it was swelling. The baby had lots of molding but was no lower in the pelvis. I'm concerned at this point as she has made almost no progress in almost 12 hours now. She's also exhausted - has been in labor for just about 24 hours now. I start making pitocin noises. She declines. I encourage her to continue with rest breaks alternating with various activities.

Shortly after that, she is lying on a mattress pad on the floor, feeling pressure in her lower back and butt. I have suspected that the baby is OP, but not really sure. She's had a lot of back labor. Her mother tells her to go ahead and push. I say no as I had to just checked her shortly before and she was still 7cms. I suspect that the mother had been encouraging the patient to push when I was not in the room, which was the likely cause of the cervical swelling.

About 11:30pm she's practically a zombie. And she wants to be checked due to the pressure she's feeling. She's still 7cms, head no lower, and cervix swollen. She's starting to get agitated. I again discuss pitocin and pain management with her. She again declines.

Shortly before 1am, she again wants to be checked. We had been using the peanut so I thought we would check her before flipping her to the other side. No change. I recommend an epidural and pitocin. The patients mother wants a second opinion. She tells me "I thought you were supposed to be about natural" or something to that effect. I explain that 15 hours at 7cms with a swollen cervix wasn't normal. The epidural would stop her from pushing against that cervix (which mom was probably coaching her daughter to do). The pt's mother wants to see a doctor. She says "There must be a doctor here in the hospital or the doctor you spoke with should come in". I had consulted with my back-up and shared that info with them. I told her there was no one but a resident around. She wanted me to get this resident and have them check her daughter and offer a second opinion.

I went out to talk to the resident. I'm pretty irritated at this point. Little did I know this resident was a dipsh*t. I was told after my convo with her that she was an idiot. I explain the situation to Dr Dipsht and ask if she could help me out. She looks at me and says "Maybe. I ahve some patients in triage to see after I finish writing this note". Seriously? Maybe? I tell her to forget it. I'm thinking she better not ever ask for advice from me on management of her patients as I will just tell her 'maybe'.

I get my back-up to call and speak with the family. The patient then consents to the epidural and pitocin. The mother sits in the corner and pouts.

The pitocin gets started about 2:30am and I decide to go home. I haven't had dinner and am tired. I eat, start taking my clothes off and the pager goes off. It's 3:30am. I have another patient who's 7-8cms. I turn around and head back in. I'm almost there when I get a call from the nurse who says she got up to four of pit, then the baby had a 15 minute decel. *sigh* She still hasn't changed although the cervix isn't as swollen now. I order terb and they get the baby stabilized by the time I arrive. However, the pt's mother wants to see the doctor. She wants to know why he isn't there if there's fetal distress. She wants a resident to look at the strip. She's ticked cuz we never got her a resident when she asked before. I have the nurse call my back-up and tell him to come in and see these people and evaluate the situation. he calls for a section in 30 minutes and heads on in. I know that there's a very real possibility that these people won't consent to a section. Fortunately the baby looks better when I arrive a few minutes later.

At this point, I kinda wish these people would just fire us and I could hand them over to the resident :P

My back-up arrives and has a long convo about section versus expectant management after checking her. She is 8-9cms and cervix is less swollen. The baby has a lot of caput now as well as molding. The caput is at 0 station. He doesn't mention any of this until we are back out of the room. He just wanted to section her and be done with it. Frankly I was feeling the same way. The patient informed us she would only consent to a section if the heart tones were down and don't come back up. She couldn't clarify to us how long she would wait. She very much felt that the pitocin was the cause of the decel, even though the baby continued to have some decels with no pit and no contraction.

So no section. We watched and waited. At 7am, we turned the whole situation over to the next shift. I wished the patient the best of luck, hoped she would birth a healthy baby vaginally.

I touched base with the midwife who followed me - the patient delivered vaginally 5 hours later with 9&9 apgars. Go figure.


AtYourCervix said...

It just makes you wonder sometimes.........do we wait too long for a vaginal birth? Do we call a c/s too soon? When is it "enough" time? Many docs and CNMs I work with would have convinced her to have a c-section after just a few hours stalled at 7cm.

Glad she had a vaginal birth though. I imagine she must have had to really fight for it (it sounds like she did fight pretty hard for it)

Ciarin said...

It was definitely one of those tough situations. In hindsight, it's easy to wonder if we were jumping the gun...I like to think we weren't pushing for the section too soon (and there were no attempts to strongarm her - just a very frank conversation). Our 6% section rate shows that we don't do a lot of unnecessary sections.

M.G. said...

I attempted my last VBAC for 66 hours before I asked for the cesarean. None of the medical professionals even mentioned it & I had been stalled at 5 for over 24 hours! I thank God that they were not pushy and allowed my body to attempt what it was naturally made to do, not enough medical staff do this. If I were in your shoes I'd be greatful that the woman was so strong & I'd praise her for doing everything possible to birth her baby as nature intended. In the end her body did what was meant to be!

Ciarin said...

M.G. - sorry to hear about your experience. I'm glad that you were given more than ample time to attempt the VBAC. As long as baby looks good, it's not really an issue to me. However, when a baby has a 15 minute decel followed by large decels throughout the remainder of the labor, with meconium present....well, its personally not a decision I would have made for myself. I would have consented to the section and I don't think that would have made me a weaker person (which you imply by saying she was so strong to refuse a section). But I am biased....I have a child with mental retardation and would not be interested in risking having another one (as much as I love my child). To me, it was a gamble and I always put the well-being of my child before my own preferences and wishes. If that makes me weak, then so be it. I am very happy that everything seems to have worked out for her - please don't get me wrong. But it's certainly a difficult decision and not the same for everyone. We would also be remiss to not offer a section for failure to progress and fetal distress.

Anonymous said...

This case was a hard call. In hindsight it sounds like this woman's body just needed more time to accommodate delivery of her baby. Sometimes you can wait it out and other times you can't. I wonder what accels and variability looked like? Was there a cord pH done?

Recently I had a pt who also had a nasty strip...prior to me coming on shift pt had prolonged decelerations and pitocin was stopped and then restarted over 6 hours later...long story...anyway the pt went on to have a completely uneventful delivery, no more decels eventhough the pitocin was back to the mU that led to fhr shenanigans earlier...go figure.

Anonymous said...

...and if she hadn't swollen her cervix by untimely pushing, she might not have been so tired, either. Doncha wish we could boot out support people who are actively hampering the process??

Pattie, RN

Ciarin said...

Patti - yes!

sara said...

At least the story had a happy ending :) That's really good to hear.