The Unexpected, Part IIb (Neil’s Birth Story)

Part I (On getting pregnant in midwifery school)

Part IIa (On the discovery at 39 weeks that our little Tahini was breech!)

We arrived to the labor and delivery unit at 7am. Out of habit, I used my ID badge to swipe in and walked up to the nursing station as if I were about to put my name and pager number on the board. B looked at me and smiled. “You’re cheating,” he said.

“What?” “You’re not the student midwife now, you’re the mama. Mama’s don’t let themselves onto the unit with their ID badges. They press the call button and wait to be buzzed in, like everyone else.” He squeezed my hand affectionately.

Oh. Right. Time to take that hat off and put on the mama hat.

Deep breath.

After getting settled in our room with labs drawn and IV placed, the third year OB resident came and chatted with us about the plan for the day. She also did another ultrasound and surprise, surprise, Tahini was still breech. Other surprise, my amniotic fluid level (AFI) was now reading 4.6, down from 7.0 yesterday.  Not sure how that happened, as I didn’t have any leakage of fluid…but sometimes there can be variation in calculation of this measure. In any case, 4.6 is low, technically considered oligohydramnios (Greek for too little water). As I mentioned in the last post, the risk with oligohydramnios and a version is that the cord doesn’t have as much cushioning, so risk of cord accidents and stillbirth increase quite a bit.

I wasn’t entirely convinced they would even do a version with such a low AFI, but the resident said to sit tight and she’d go consult with the attending, who would be overseeing the version. She had been recommended to me as a skilled and compassionate OB, one who would be happy to work with us to have as calm as possible a cesarean birth if that’s what needed to happen.

We waited around a while for lab results, for the OB’s to finish morning rounds, for the resident to consult. Being an “insider,” I wasn’t alarmed in the least that B and I had over two hours to work through two Tuesday crossword puzzles from our book and for me to take a little nap, along with a visit from the anesthesiology resident who would be performing my spinal/epidural.

The resident returned around 9:30 and sheepishly apologized, noting that three other little ones decided to make an entrance that morning. “No worries,” I smiled. “I know how it is around here.”

“Oh, right,” she said. “You’re a midwifery student. You totally get it. Well, thanks anyway for your patience.”

We then chatted about the plan, which was that the attending felt ok about attempting a version in the OR under spinal, but at the slightest indication of distress, we’d move straight to a cesarean. That felt completely reasonable to me.

And so it was that a little before 10am, I was being prepped for my spinal/epidural. B and I had just a few moments to ourselves to let it sink in that October 1st was the day we’d be meeting Tahini. In just under an hour, he’d be in our arms. We both laughed a little when I asked, “Does it feel real?”

“Nope,” he said. “It won’t feel real until he’s here. And even then…” I nodded. Yup. That was exactly how I was feeling.

P1010082

In the Bair Hugger: a specially designed gown that can attach to a warm air tube in the OR to keep patients warm.

***
The placement of the spinal/epidural went smoothly. Having seen tons of them placed, I knew exactly what to expect: they first wash your back with a cold ChloraPrep solution and then inject you with lidocaine to numb the area. That was the worst part–it stings going in…but after that, all I felt was a strange tugging sensation in my spine. I tried not to think about what the anesthesiologist was doing and just focus on slowing my breath.

Almost immediately, I felt my legs go numb and become heavy. The nurse and anesthesiologist had to help me lie back down and then the team finished the rest of the prep for the version: a pulse oximeter was placed on my finger, a blood pressure cuff on my arm, a nasal cannula (which was super itchy the entire procedure and very distracting!) was placed to provide extra oxygen during the procedure. A foley catheter was placed, as I no longer had control of my bladder. I remember commenting that it felt so strange–I could tell my legs were still there, as the numbness was more tingling than complete lack of sensation…but I couldn’t move a thing.

Someone asked me what music I wanted…I was a bit flustered by the tingling sensation and nasal itching, so I said the first Pandora station I have that I could think of: Django Rheinhardt. It’s often what B and I will play on Saturday mornings while we make a slow, lazy brunch. I instantly breathed a little deeper, mindful that breathing already felt different with the anesthesia in place. I had been told that sometimes, patients have the sensation of being short of breath if the spinal anesthetic flows up the spine…but in general, I should not panic and that it’s a normal sensation. I remember slowing way down and just focusing on each breath.

Someone dimmed the lights. B and one of my midwives, Liz, came in and arranged themselves at my head. I kept my glasses on so I could see what was happening. Everyone paused to confirm we had the right patient, etc., then we got started on the version.

The first attempt lasted about two minutes. I could feel mild tugging and pressure as two residents, overseen by the attending, used their hands to try to move Tahini in a counter clockwise direction. They were able to get him to a transverse (horizontal) position before his heart rate started dropping. In medical terms, this is called a deceleration.

Using the ultrasound during the version to assess Tahini's position. The blanket on my arm was a warm pack, as my IV had been bugging me all morning.

Using the ultrasound during the version to assess Tahini’s position. The blanket on my arm was a warm pack, as my IV had been bugging me all morning.

Normally, baseline fetal heart rate varies between 110 and 160 beats per minute. A variable decel is a random, quick drop in rate with a quick return to baseline. An “early” decel often coincides with a contraction, and is usually a sign of head compression during the pushing stage of labor. And a “late” decel is a drop in heart rate after the contraction, usually a sign of chronic placental insufficiency. A variable decel can be caused by multiple things, but usually, it’s transient cord compression. You can also have a prolonged decel, which is longer than 2 minutes but less than 10.

Tahini’s heart rate dropped down to 80 beats per minute. It wasn’t quite technically a prolonged decel, as it only last one minute, but I vaguely remember the room getting quiet as the residents focused on the screen showing the heart rate.  As a student midwife, I can assure you that one minute of heart rate at 80 can feel like an eternity. B remembers the whole room was completely focused on listening to the heart rate on the monitor. It wasn’t tense, yet, just very, very focused.

At some point, the attending came over and looked into my eyes and said, “We’re just having a decel here…we’re going to give your baby about five minutes to recover before we try again.” I remember thinking, “Five minutes…that must have been some decel.” I didn’t know at the time exactly how low it had been, which was probably a good thing.

After five minutes, the attending was honest: “I’m okay attempting one more time, but your baby didn’t particularly like that first attempt…so if his heart rate dips down again, I’d like to move directly to a section.” That was fine with me. Another dip would confirm that for whatever reason, Tahini wasn’t going to tolerate further attempts, and that potentially, there was an issue with his cord that was impeding the version.

I didn’t have a strong sense of time,  but it seemed like the second attempt was shorter, maybe only 30 seconds. Both residents and the attending had hands on my belly, trying to move Tahini’s head down. B says they were putting quite a bit of force into it, but Tahini wasn’t budging…and his heart rate dipped again. “Doesn’t look like he wants to move further…and he’s really not happy here.” As they spoke, apparently Tahini just slipped back into his former breech position.

The decision was clear: Tahini would be born via a cesarean section..and it was going to happen very soon.

Part IIc to follow

[Friday Wrap Up]: 28

This week: a lovely photo essay and video telling stories about abortion experiences, a reframing of abortion beyond “women’s rights,” questioning the (dreaded) pelvic exam, a new continuing ed opportunity from Evidence Based Birth, revolutionary NICU care, and more on full spectrum doulas from a new blogger!

Abortion: After the Decision

Love this photo essay:

I was surprised when I started talking openly with my friends and colleagues about abortion how many of them had had one themselves. I hadn’t known that 40 percent of American women will have an abortion during their lifetimes. While it’s a personal and private experience, there are 45 million women in America who share in it, and it shouldn’t be a shameful secret. The silence creates a stigma that prevents a meaningful discussion and understanding in the national debate and dialogue.

Not Everyone Who Has an Abortion is a Woman: How to Frame the Abortion Rights Issue

I missed this when it first came out, but was happy to come across it recently. There’s a lot of good stuff here that directly speaks to the kind of inclusive environment of care I hope to create as a nurse-midwife.

We must acknowledge and come to terms with the implicit cissexism in assuming that only women have abortions. Trans men have abortions. People who do not identify as women have abortions. They deserve to be represented in our advocacy and activist framework. Honestly, I am guilty of perpetuating that harmful myth, both in my rhetoric and framing. I often frame abortion restrictions as misogynistic attacks meant to control women’s reproductive lives, and that is true. But abortion restrictions also affect the lives of people who aren’t women, and they hinder trans men and gender-non-conforming people and others who were Designated Female at Birth (DFAB) from accessing abortion care, as well.

Questioning the Pelvic Exam

I know I’m not alone in wondering what the heck the point of this annual exam is…in fact, I was thrilled last year to read Feminist Midwife’s questions about it, too. This week, the NYT’s Jane Brody writes about a growing number of gynecologists who are starting to question the purpose of this exam.

These experts say that for women who are well, a routine bimanual exam is not supported by medical evidence, increases the costs of medical care and discourages some women, especially adolescents, from seeking needed care.

Moreover, the exam sometimes reveals benign conditions that lead to follow-up procedures, including surgery, that do not improve a woman’s health but instead cause anxiety, lost time from work, potential complications and unnecessary costs.

And even more stunning, yet not surprising:

How important is this exam to a doctor’s income? Slightly more than half of those surveyed ranked “ensuring adequate compensation” as very important or moderately important.

One of the most vexing problems in medicine today is the fact that doctors get paid only for performing procedures, not for the time they spend talking with patients to discuss issues of possible medical importance.

Giving Birth Based on Best Evidence

Rebecca Dekker, PhD, RN, APRN, over at Evidence Based Birth, is starting an online continuing Ed series, beginning with a class on “Big Babies.” Be sure to check the giveaway!!

NICU program that gives parents charge of baby’s care cuts stress

This is an awesome, awesome new movement in NICU care: giving parents more responsibility in the care of their newborns.

“With family integrated care, we have done something quite different,” explains Dr. Shoo Lee, pediatrician-in-chief and director of the Maternal-Infant Care Research Centre.

“What we’ve done is to say that for all babies in the NICU, the parents should be the primary caregivers, not the nurses. And the nurses are really teachers to the parents.”

The program was instituted following a 2011-2012 pilot project in which the parents of 40 newborns were asked to spend a minimum of eight hours a day in the NICU and tasked with the overall management of their child’s care.

That included bathing and changing diapers, monitoring the infant’s vital signs, and recording feedings and weight gain on their medical chart. Nurses were responsible for the medical side of care — looking after feeding tubes, adjusting ventilation apparatus and administering medications.

The babies’ progress was compared with those whose care was primarily provided by nurses, and Lee says “the results were phenomenal.”

Full Spectrum Doulaa new blog!

A friend and fellow doula has started this awesome blog about full spectrum doula work…here’s an excerpt from her first post, The Politics of Pain, Part 1

I am very much in favor of a movement that reclaims abortion as a complex matter of the heart, just like birth. Birth and Abortion are the yin and yang of reproductive power. I know that abortion will never be a happy event in the way that birth usually is… but I know it is a powerful experience and I think even in our most “pro-choice” enclaves, we are still blowing it. We are often working to hard to “rescue” people from their circumstances, thereby failing to embrace the growth and change that come with going through something.

Informed “Consent”

Consent.

I kinda hate that term, actually. It implies that there’s someone in power and someone in a more subservient role. It doesn’t have to be that way. But so often, it is…especially in the world of health care. Apparently, there are standards and protocols among various medical associations for what informed consent looks like, but I have to say, as a doula who’s attended almost 30 births, I’ve seen some pretty wild variation in what patients are told or not told before “consenting” to various medical procedures.

It’s even worse when the patient does not speak English as their first language.

Let’s start with the ACOG description of informed consent, found on their website:

Although informed consent has both legal and ethical implications, its purpose is primarily ethical in nature. As an ethical doctrine, informed consent is a process of communication whereby a patient is enabled to make an informed and voluntary decision about accepting or declining medical care. There are important legal aspects to informed consent that should not be overlooked. It is critical for physicians to document the contents of this conversation as part of the permanent medical record. A signed consent document, however, does not ensure that the process of informed consent has taken place in a meaningful way or that the ethical requirements have been met (ACOG Committee on Ethics, August 2009).

I’ve been hearing some folks use the term “informed choice” rather than informed consent. A brief internet search yielded this short article by Dr. George Spaeth, an ophthalmologist in Philadelphia, making the case for a shift to using the principles of “informed choice” instead:

In healthcare, distinguishing between “choice” and “consent” is important, as choice encourages autonomy while consent discourages it. Fundamental to proper patient care is enhancing a patient’s autonomy and helping the patient take charge of his own life, especially as it relates to health. This is essential not only for philosophical and legal reasons, but also because self-care is pivotal to achieving a consistent state of health, which is, of course, the ultimate goal of therapy. To speak of “informed choice” rather than “informed consent” would help eliminate paternalism in medicine without detracting from healthcare professionals’ intent to be helpful or decrease in any way their ability to be beneficial. To speak of “informed choice” rather than “informed consent” will emphasize the importance of patient autonomy in making proactive health care decisions.

Case in point: 

I was called in to a birth as a volunteer doula earlier this week. This mama didn’t speak much English at all, nor did her family members in the room with her. When I got there, the charge nurse told me she was 5 cm and baby was OP. The mama started asking about an epidural once I got settled in, so the nurse got a translator over the phone and had the anesthesiologist come in to do the informed consent.

What happened next would be laughable, really, if it weren’t so freaking sad. His speech went like this:

“I’ll insert a catheter into your back and it will administer medicine to make the pain go away. It won’t harm you or the baby and it will wear off about an hour after birth.”

Yup. That’s it. Now, granted, I’ve seen pretty lousy consent processes even in situations when the patient does speak English as a first language…but this one floored me.

There was nothing at all about the process, the types of pain medication, or the possible side effects, nor the inability to move freely and likelihood of needing a urinary catheter (until after she asked). That’s right: nothing about risk of spinal headaches, itchiness, or the whole damn thing just not working, or only working on one side.

This mama was a bit smarter than that and started asking lots of questions. After a particularly rough contraction, she agreed to have the epidural (after changing her mind twice, much to the annoyance of the anesthesiologist). He left to prep, and the midwife, who had just attended another birth, came in to do a cervical check. The mama had made some progress, but this is not what the midwife emphasized.

Instead, with the translator still on the phone, the midwife very calmly looked straight into the her eyes, smiled, and said,

“You know, you are making good progress. I know this labor is hard, but I also know you can do it. I think that if you get in the tub right now, you’ll feel a lot better. It’s safe for you and the baby. You are working so hard, and I know you can do this without the epidural if you don’t want to have one.”

The mama relaxed, closed her eyes and nodded, leaning back into my hands that were massaging her back. After that, there was no turning back. She got in the tub. Maybe 20 minutes later, she turned to me, eyes wide, and said, “I can feel the baby’s head!” 20 intense minutes after that, with the nurses scurrying the whole time to get the mama out of the tub and into the bed (despite the midwife’s assurances that an upright birth would have been just fine), a beautiful, healthy baby was born.

So, total time from when she first said she wanted an epidural to time of birth was less than an hour. All she really needed as a calm, confident midwife who believed in her inherent strength to birth this baby. I cringe to think what might have happened if the had walked in 15 minutes later.  This mama wouldn’t have been consenting in an informed, empowered way to anything but the sparse information bordering on opinion that the anesthesiologist was giving her.

As ACOG Committee on Ethics notes:

It [informed consent] is a means not only to the responsible participation by patients in their own medical care but also to a relationship between physician (or any medical caregiver) and patient. From this perspective, it is possible to see the contradictions inherent in an approach to informed consent that would, for example:

  • Lead a physician (or anyone else) to say of a patient, “I consented the patient”
  • Assume that informed consent is achieved simply by the signing of a document
  • Consider informed consent primarily as a safeguard for physicians against professional liability

I was so deeply disappointed in the treatment this mama received as a non-native English speaker…and it has me all fired up and thinking about how I would have done things differently had I been in the anesthesiologist’s shoes.

A few thoughts:

  • For starters, I would not have spoken to her during contractions and would have asked the translator to pause as well. Who the heck thinks that you can meaningfully “consent” to anything in the middle of a whopping contraction that’s making you want pain meds in the first place?!
  • I would have clearly and simply described the process of getting an epidural and its intended affects (numbing of sensation), as well as the type of medication used.
  • I would have outlined the top potential risks/complications and their rates.
  • I would have described the other interventions/consequences that come with an epidural: continuous monitoring, blood pressure checks, immobility, urinary catheters.
  • And I would have described alternative comfort measures, both pharmacological and otherwise.
  • And yes, I would have done all these things, even though with a translator, it may have taken longer.

I’m curious to hear other folks’ experiences with informed consent for those who do not speak English as a first language. Whether as a doula or midwife, how do you see your role? Does anything change in your need or desire to advocate for the patient?