I have a patient who is living in her obstetrical past. She is a wonderful woman, very intelligent, with a pleasant sense of humor. I very much enjoy seeing her prenatally. But...
She's living in the past as far as labor and birth is concerned. No matter what I say to her, she can't seem to move out of the past. I would love and appreciate some words of wisdom on how to handle this!
Her second baby came rather precipitously after laboring all day and only being slightly dilated when the midwife checked her. So the midwife goes home. The patient delivers 90 minutes later unattended. Was the midwife correct in her assessment of cervical dilation or did the patient really gor from almost nothing to delivered in 90 minutes? I don't know.
Her third baby was a long torturtous back labor and pushing out of an OP (posterior) baby. She very much hopes to avoid that again (I don't blame her!). So, every week at the office I feel for the baby's position via Leopolds.....and the remains OA. I tell her this, showing her exactly where the baby's parts are, etc. Still she is fixated on the fear of an OP labor and birth.
She came in recently for a cervical check due to contracting all day. She does not love close to the hospital at all. She's worried that if she cmes in she will just get sent home and the same thing will happen as baby #2 because these contractions feel the same way. I reassure her that the nurses don't decide when she gets to go home, and that I won't send her home without waiting for a bit. Turns out false alarm....
What do I say to her?
9 comments:
To avoid fears about repeat of #3, can you share with her some fetal mapping or "optimal fetal positioning" literature or websites to give her the knowledge (and thus, the power) to deal with these things herself, rather than having to rely on you? And for fear of repeat #2, can she check her own cervix?
My SIL said that she could tell that she dilated from 5-10 in one contraction. The nurse had just checked her and found her to be at 5, and then she had a major double-peaking contraction, and she felt her cervix fully dilate. So, she said, "Um, I think you need to check me again, because I think I just dilated all the way." The nurse was skeptical but she did it, and found her to indeed be complete. [I've never "felt" my cervix dilate, so I don't know what it feels like.] So, yes, it is entirely possible for the midwife's assessment to have been correct.
Tough call, though...
-Kathy
Kathy - good idea on the positioning stuff! Will do :) As far as the vaginal exam stuff - I am highly skeptical of a woman doing her own cervical exam. It typically takes a L&D nurse a good 6 months to become very proficient at checking a cervix. I'm sure it's doable but frankly I internally roll my eyes a bit when I hear about moms (and dads!!!) checking the cervix during labor. The midwife could have been correct in her exam...or maybe not. I am well aware that a woman can dilate from 2 or 3 or 4 cms to complete in a rapid amount of time...seen that many times. But also have had experienced nurses tell me a patient is 8 or 9 or whatever, only to find she's 5 when I check her. So mistakes in exams happen (and I've been on the mistaking end of things as well :p). So anyway, don't know about the feasibility of her checking her own cervix if she wasn't already familiar with what her cervix feels like and where it is prior to labor.
Yeah, it always sounds a little far-out to me to be able to check your own cervix while heavily pregnant. And in labor. I've only ever checked my cervix as part of fertility awareness, so not sure if it would even be physically possible for me to do so while 9 months pregnant. However, if a woman can feel her cervix at all, there is surely some difference between "slightly dilated" and mostly or fully dilated, that even a novice could feel? [Although I'm thinking of midwife Peggy Vincent in "Baby-Catcher", when she didn't realize that her not being able to feel her own cervix in labor was because she was fully dilated -- she thought it was her positioning and her pregnant belly. :-)]
I've also read in one of Ina May Gaskin's books that she has witnessed a regression in cervical dilation. The time she told was of a woman who had dilated to 7-9, and then a gruff doctor came in and roughly assessed her, found her to be a 5, and berated Ina May for bothering him when she wasn't more fully dilated. Ina May rechecked the woman and found her to indeed be a 5, whereas moments before, the woman had been about 8 cm. Weird, huh?
Plus, there are all the cases of women being tight and closed at a prenatal visit, then having a quick labor later that day; and other cases of women walking around dilated to 5 for weeks prior to labor ensuing. So (as you know), dilation is not a hard-and-fast rule. :-) But probably better not to tell the mom this, unless you think it would help.
-Kathy (using my Google Acct because my WP acct keeps saying there's an Open ID error)
www.spinningbabies.com is an excellent resource for avoiding another OP baby.
I wonder if her precipitous delivery was due to an OP baby that rotated and then dilated her cervix?
If she was not overly concerned with that it would be something else. You just smile and nod. Listen to the concerns actively. No it is not going to happen now that she is worried about it. Birth tends to throw us curve balls, doesn't it?
I think all pregnant women have something to fixate on that causes them anxiety and alarm. I have met a lot of them. I think I will start asking each woman what her major concern is. I will get a litany of different concerns I am sure. I am starting to think it is just normal go through pregnancy stuff.
I was scared sh1tless about labor when I was pregnant with number one. Number two, I was scared that he might come out mentally retarded. Nothing could quell my fears. So my action plan is to just smile and listen. That is it. It is like a cold that just has to run it's course, I think.
Our main practice has a contract with the health dept in the next county and it's 60+ miles away... sometimes if the moms are sent home in possible latent labor and they are nervous about it changing to active labor and "not making it" (or wanting it to hurry up so they CAN come back and be ready to have baby), we have suggested everything from mall walking at our local mall for a while, to staying at the hotel in front of the hospital. I have had more than one pt decide to stay at the hotel (and use the pool to help get more comfortable :)
and yeah occasionally there's the one that changes at lightening speed.... I've had them change so fast that I didn't even get out of the room from SVE #1, hand washing, walk to the door "uh, I think you should check me again...." ... from 4-10, etc.
I've only had one with "regressing"... it was when I still had a preceptor... she (OB RN for like 25 years) BOTH totally thought the lady was like 9-10, called the MD who came in and said she was 5, we rechecked and sure enough she was 5. Never quite figured that one out. I haven't had another one "regress" more than a centimeter or two (which I always figure may be positional, etc.) ... not saying it's not possible... just my experience...
Pt always want concrete answers and I always tell them that 'the only thing predictable in OB is that it's unpredictable'.... part of the fun of it I guess :)
Just a follow-up on this lady....when she finally went into labor, it was loooooongggg, took forever to deliver.
I had such a fast labor with my first (nearly unassisted at home by accident) that next time I am planning on homebirthing with a midwife, but I will be doing lots of research on what to do if I end up delivering even faster and with no one there.
I think a lot of it has to do with personality types- when I almost had my daughter at home I was irritated afterwards that we even went to the hospital...whereas someone else might be afraid that they Wouldn't Make It to the hospital next time. My experience has made me research even more, whereas other people might be just scared from it. It's interesting how nearly the same experience can produce two totally different reactions in people.
I went from zero to baby with my second daughter in 52 minutes. So, yes. It's totally possible.
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