Time for some reflection on an experience I had at work when I was the on-call midwife.A woman, having her first baby, booked for a homebirth, had been asked to go into hospital for induction of labour as she was now 11 days past her EDD, expected date of delivery. Previously she had been seen at home and undergone two ‘stretch and sweeps’, on neither occasion was it possible to complete the process as the cervix was long and closed. J had refused to go in to be induced. Her pregnancy had been uneventful and she had no existing medical conditions.This morning I had gone into the office and was told that J was in early labour. The evening before she had called out the on-call who had attended, examined her and found that the cervix was 1 cm dilated, baby’s head was still high and J was having irregular tightenings. The on-call felt that this was very early labour and that it could still be several hours until J was in active labour so having explained this to J and her partner she left. At 1am the on-call was asked by J to attend as the contractions were now more frequent. When the on-call arrived J was in the birthing pool and was experiencing more frequent contractions but they were still quite irregular and short. Eventually J agreed to leave the pool, 1) So the on-call could see how labour was progressing 2) As the midwife felt that J may be using the pool too early and this may be slowing her labour. On palpation the contractions were extremely mild and the baby’s head was still high. An internal examination was performed again and the cervix was found to have thinned and to now be 3 cms dilated but as the head was still so high, and the membranes were bulging it was impossible to determine the position. The midwife was concerned. There had been no descent of the head and this could present a problem in that if the waters break the cord can slip down in front of the head, a cord prolapse. As is usual when a midwife is called out labour ward was contacted, and the shift co-ordinator was briefed on the situation. After involving the obstetric registrar it was decided that J should be ‘invited’ to go in, have the baby monitored and a scan be performed to ascertain why the baby was failing to enter the pelvis. J refused. The on-call midwife was then left sitting downstairs, where the birthing pool was, whilst J and her partner went upstairs to bed, and to sleep. After a couple of hours the on-call advised J that she was going to go into the unit, 5 minutes drive away, catch up with some paperwork, and that J should call when she needed her. 4 am and the call was received, so the on-call returned to their house. Nothing had changed, an examination at 7am revealed that the baby’s head was still high and that the cervix was now 4 cms dilated. J and her partner went back to bed having once again refused to go into the unit and the on-call returned to the hospital to pass care over to me. By now the Consultant was involved, ‘Get her in’ was the message given to me. I phoned J, checked that all was well, labour was still in the early stages and so told her that I would be there in an hour after I had dealt with any outstanding phonecalls and handed my visits over to a helpful colleague. I had a clinic scheduled to start at 1.30pm but I was hopeful I would be able to fulfill that commitment.
I arrived at 10 am. J and her partner seemed quite calm. They were not overly communicative but I suspected that this may be because they were feeling defensive so I avoided all talk of ‘invitations’ and just spent an hour chatting and observing how the labour seemed to be progressing. Gradually I suggested that as it was now 4 hours since the last examination, and the contractions seemed to be sporadic it might be wise to examine J and see how much further along things were. They both agreed, actually seemed quite eager, so I performed an internal examination. I already knew from palpating the abdomen that baby’s head was still high but even so I was surprised by how high it really was. Trying to assess how dilated the cervix was now proved to be quite difficult as it had no firm surface behind it and so with any pressure it moved around, I estimated that it was about 5 cms open. Throughout baby’s heartbeat was textbook at 128-148 bpm, at least baby was a happy chappy. I told the couple what I had found and discussed with them what the findings indicated to me. To me it meant that labour was progressing slowly, but, to be fair, I thought that active labour was only just starting so perhaps a re-examination in a couple of hours to discover if faster progress, and descent, were happening would be the favoured course of action. I explained why the baby’s head remaining high caused us anxiety, why it could be happening and what J could try to encourage descent. J wanted to get back into the pool, I discouraged her from this, the contractions were still quite weak and only coming once in 10 minutes and the pool could slow them down even more. I suggested that J spend some time marching up and down the stairs as this movement sometimes helps an awkwardly positioned baby to ‘sort itself out’ and if we could get baby to move down and press against the cervix this would help dilatation and also improve the ‘feed back’ mechanism encouraging closer and stronger contractions. As J marched up and down the stairs I sat at the bottom and suggested to her that when I re-examined, if there had been little progress, and especially if there had been no descent by baby, then it may be wise to go into the hospital as the best course of action may be to break her waters but that there was no way that I would do that at home with baby’s head bobbing around at the top of her pelvis. J and partner appeared to take this on board and so I went and phoned labour ward to update them on my findings and the agreed plan. ‘Get her in’ was the repeated advise, Hmmm, easier said than done! I looked at my watch, it was now after 12, there was no way I could make the start of my clinic so I asked labour ward to find someone to cover it, difficult request as community were now 2 midwives down, last nights on-call was in bed catching up her sleep and I was stuck in my own personal nightmare. Nightmare? Yes. In someone’s home feeling that I was in a lose, lose situation. I was fairly certain that the next examination would reveal little change, J’s contractions were hardly bothering her at all so she would be quite happy just to carry on, baby was oblivious to everything and really happy, but with every minute I could imagine those membranes bulging more and more and just waiting to pop, with a possible disastrous result.
At last. The marching upstairs had beefed up the contractions, J wanted her TEN’smachine on, she had stopped talking through her contractions, perhaps the next examination would reveal good news, hopefully baby moving in the right direction. 1pm, cervix probably slightly more dilated, but baby’s head still high and not moving down even slightly with the contractions. I went off to the bathroom and allowed the couple to ponder the next move, hopefully they would elect to go to the hospital. J was starting to look tired and I was now starting to worry that she would not have enough energy on to cope with the hard work ahead. No. The decision was that we would all carry on and we would re-assess in another 2 hours. I rang labour ward with the glad tidings and then spoke to my manager for support, life was beginning to feel very lonely. I returned to the labouring couple. J was starting to feel she needed gas and air as the contractions were becoming stronger, I positively skipped to my car to get the gas cylinders, hopefully this was progress. The first cylinder was hissing around the tubing, obviously there was some gas escaping, we fiddled around but it still continued. Not good, it would mean that it would run out very quickly, and it did. The next one was fine but knowing they only last for about half an hour I phoned the unit and asked that the 2nd on-call bring some more cylinders out, she couldn’t as she was in the middle of a clinic! My manger promised me that she would get someone to bring more gas. J then decided that she would get back into the pool. I advised against it for the same reason as before but ultimately had to support their decision as this was her choice. She had the information and, if I hadn’t already told her, she should have read it in the ‘Waterbirth’ book lying on the sofa.
The gas and air ran out but it wasn’t really a problem as the pool had worked it’s ‘magic’, the contractions were back down to 1 every 10 minutes and J was dozing through them. Just after 3pm we discussed the repeat examination, J was eager to find out if there had been any progress, I emphasised to them that if there had been no progress, mainly descent, then I felt that the best option now really was to go into hospital. J was very tired now, baby was still a happy little chappy but I was running out of ideas as to how to keep J out of the pool and maintain adequate contractions. The examination that followed revealed baby’s head still as high, the cervix still ‘floppy’ and ?? 6cms dilated, and the bag of waters bulging (such a temptation to break them). Finally, at 4pm J and her partner agreed to come into the hospital. I phoned Labour Ward and gave them the glad tidings. At 4.30pm I handed their care over to another midwife, said my farewells and breathed a sigh of relief.
Throughout this visit to J’s home I remained as positive as possible. Having facilitated Active Birth classes for several years now I am well aware of the importance of a positive, relaxed approach and it’s effect on the labour hormones. I was finding it difficult in this case as I felt that we were reaching, had reached a point where I should be more directive. The loop playing constantly in my brain was ‘get those contractions going’, if we could just do that I believed baby’s head would descend and labour would progress better. I/we had tried all the methods within my sphere of practice to encourage stronger contractions, J had an oil for labour which contained Clary Sage, she had used her birthing ball, knelt in all-fours, marched up the stairs, snacked on energy rich nibbles, nipple stimulation had been suggested, there had been limited response to these but ultimately, whether due to pool use, baby’s position, or something I still haven’t thought about, it was to no avail.
All was well in the end. The waters were broken, a syntocinon drip was started and at 8.30 pm J gave birth naturally to a little boy. Not the birth experience she wanted but a safe outcome.
What have I learned from this? That even a well-educated, well-informed woman may need to have a directive approach. I was left with the distinct feeling that I was being tolerated and just used as a safety net until they wanted to go into hospital. My feeling was that I might just as well not be there but from what happened with the previous on-call Midwife I knew that, even if I felt I could leave them, they would call me back after about an hour. Anyway, I didn’t feel that I could leave them because of the ‘what if’. What if the waters did break and the cord did come down and I had gone off to do my clinic, I could imagine the backlash, and I believe it would be right. I am pleased that all was well in the end. Perhaps if we had stayed at home we would have got to the same point, eventually. I have my doubts though. J was getting tired, baby’s head was still high and even if we had reached a point where J was feeling the urge to push I believe that I would have taken so long to get there, and then it would have taken so long to push baby out that we would have ended up with an emergency transfer to the hospital rather than the calm drive and arrival that we did have.
At all times I shared my thought processes with the couple, told them the options and allowed them to make the decisions. We were lucky as baby never gave any cause for concern, if I had become worried at any point I would have called in my manager but my feelings were that ‘kid gloves’ were the best way to handle this situation.
J and her partner were pleased they had been able to stay at home for so long, they believe that this enabled them to have a normal birth. They are right, but I do question the use of midwifery resources. It would be wonderful to offer every woman in labour the advantage of staying at home with their own personal midwife keeping them company but with the configuration of the service at the present time it is unrealistic and places strain on the day-to-day service, taking midwifery time from other women and babies.
Would I act differently if this situation arose again. Probably not. Women do have choice in their care. Midwives are often seen as ‘the bad guys’ and complaints about us being non-supportive are rife. What would I have done if J had demanded that I break her waters? I would have refused and if she became insistant I would have called my manager and a Supervisor of Midwives.
What emotion am I left with after this? Disatisfaction.
P.S The gas and air never arrived!