midwife's muse

Ten days ago my friend and colleague,V , reached the date her first baby was due. We had been planning a homebirth but her blood pressure going up had seen the end of that plan so she readjusted her expectations, and we waited. Then the Consultant decided that induction was necessary. Super calm V was rattled by this, she had been told that baby had a large head, and so she started questioning why baby was late. If it was due to the size of baby's head then was being induced going to get her anywhere, or would she just have hours waiting for her cervix to allow the waters to be broken, difficult breaking of the waters, a day on a drip, and then a nasty forceps delivery, with her perineum looking like a 'car crash', or an emergency section. She put this to the Consultant who felt that we should give it a go anyway. V was doubtful so said that she would go along with the plan, but that if, at any point, things stopped progressing normally, then go straight for section.

The induction process was started on Friday afternoon, by Saturday morning she was ready for her waters to be broken (ARM). I was contacted and in I went. Labour Ward was full, so having called me at 7.30am we then had to wait around until 10.30 before we could get down there and start the process. Thank heavens it was an easy ARM, her cervix was about 2cms dilated, the baby's head was not too high, and the litres of fluid that drained were clear. A swab in pregnancy had detected Group B Strep so she had to have IV antibiotics so I started these running, whilst giving her body a chance to start the contractions by itself. An hour and a half later and nothing had started so the syntocinon drip was put up and V was strapped to the CTG. Luckily the machine was picking up a good reading, so she didn't have to be confined to bed and could stand or use the birthing ball.

After 4 hours of contractions, the last two hours of which had been strong with 4-5 in a ten minute period, I did an internal. Not good news, the cervix was only slightly more dilated, although it had thinned out, but the real down side was that there was caput (swelling) on baby's head. We discussed the situation, my take was that as V and baby were fine at present and there had been slight progress lets continue. V was happy with this, so on we went. Gradually the contractions became far more intense, they were lasting so long that there was hardly a break between then. Baby indicated its displeasure by dropping its heartrate and then increasing it. I watched the monitor, the fast heart rate continued, and continued, the contractions were too intense, I turned the drip off and went in search of the Registrar.

The Registrar looked at the trace, she was not overly concerned, but decided to examine V anyway. It was 2 hours since the last examination, and the news was disappointing, no progress, the caput was increasing. V was very unhappy by this, we all were. Then the doc surprised me, lets get an epidural going so that V can't feel the contractions, which even with the drip off were still practically continuous, and then start the drip again. V agreed, reluctantly. Whilst we waited for the anaesthetist I ran through the next dose of I.V antibiotics, and then the anaesthetist arrived and sited the epidural. It took quite a time to do and by the time he had finished I was watching the trace with growing anxiety, it was totally unreactive, there was hardly any variation in the beats, this is a worrying sign. Whilst I was making V comfortable after the epidural, which was showing no signs of working, another midwife came in to retrieve a piece of equipment, I asked her to invite the Reg back in to look at the trace.

By the time the Reg attended, it was a new one now, the night staff were arriving, it was 2 hours since the last review. She shared my concern about the trace so did another internal, no change. Her view was lets get the epidural sorted, and continue, cautiously. I waited until she had left the room, sat down with V, held her Hubby's hand and started, 'You asked me to be your midwife, that means that I am also your advocate. Before all this started you told me your worst fears, think about this V. If you were the midwife in this scenario, how would you think it was going to end? It's now 9.30 at night, you have made no progress, baby is starting to show that it is unhappy, do you want to carry on or shall I speak to the on-call Consultant? I'm going outside for 5 minutes, tell me your decision when I come back in and we will go from there.' I didn't make it out of the door, ' I want a section, please.'

When I got to the phone the Reg was already on the phone updating the Consultant about the happenings on Labour Ward, I didn't get to speak to him, he had told the Registrar to discuss a Caesarian with V and her Husband, if they agreed!!!! he would come in to do it. A huge weight was lifted, I was practically ecstatic, so was V's Hubby, V was more restrained, just cuddling me and crying, happily.

Conclusion, one 8lb baby boy. He gave us a few scary moments initially as he decided breathing was not on the agenda, but a whiff of oxygen and a couple of sharp foot slaps and he announced his presence. What you can't really tell from the photo is quite how much caput and moulding his poor little head had endured, I'm not exagerrating when I say he has a head like E.T.

I got home at 1am, shattered, but thanking my lucky stars for a happy outcome. In October my friend expects her baby, she already has problems, placenta over the cervix, cholestasis, irritable uterus, I shall see this baby out and then, apart from daughters pregnancies and births, I shall confine myself to only my caseload.

7.8.06 11:50