A Reflection on a Whitenedded Birth
CCP number 1, Rachel, a primite G1P0, was presented to delivery suit in labour at 0300. Rachel had tested negative to group B streptococcus (GBS) on the lower vaginal swab taken at 36 weeks gestation. During earlier antenatal visits we had dicussed pain relief options such as massage, warm baths, showers, heatpack, change of positions through out the labour, gas, morphine and epiduruals.
The partogram of Rachel's labour was commenced at 03.30. A vaginal examination (VE) was attended by the midwife with the consent of Rachel’s. The VE which was recorded on the partogram indicated that Rachel was 4cm dilated, fully effaced and the baby’s station was -2 at spines. An initial CTG was instiu showing baby baseline fetal heart rate was 125-135bpm with good variabilty. Abdominal palpatation indicated an occipital-posterior position.
At 5am Rachel’s pain intensified and so did her contractions, then at 4:10 moderate in tone. Rachel requsted a warm bath. Shortly after the bath had been drawn Rachel requested more painreilf. Nitrous oxide: oxygen (Na02:02) was set to the ratio of 40:60 and Rachel was instructed on how to effectively use the gas. Whilst in the bath, a waterproof Doppler was used to ausculate the baby’s heart rate every 15minutes.
Whilst in the bath, Rachel’s partner Tom was encouraging her by massaging her and whispering encouraging wisdom to her. Around and about 6 am Rachel became more distressed regarding increased pain and frustration as it felt like the baby was never going to come. N02:02 had been turned up to 50:50 at this stage. Rachel insisted on morphine s/c. In line with the hospital policy on giving morphine, Rachel had to get out of the bath in order to have the morphine. Before the morphine was given Rachel was informed that if it was given within 2 hours of the baby’s birth the neonatal intensive care doctor would have to be present as the baby could have a depressed respiratory rate due to the morphine. 10mg of s/c morphine was given as per Rachel’s request.
At 7AM a new midwife came on to shift and took over the watch on Rachel. Since it had been over 4 hours from the last VE and the new nurse wanted to check her progress, Rachel consented to another VE. The examination revealed that Rachel was now 8cm dilated, fully effaced and -2 to spines with bulging fore-waters. Not long after the VE Rachel’s membranes ruptured with copious clear liquor. Rachel requested an epidural l but the midwife explained that she did not think she was far off from having the baby and by the time the anesthesist placed the epidrual the baby would be out. Baby’s fetal heart rate which was intermittently auscultated remained at a stable baseline of 130-135 with good variability, accelerations, and no decelerations. Rachel’s vital signs remained stable.
As Rachel’s pain increased it was suggested that she might like to stand up and move around the room to help move the baby down. Rachel tried this position for about 10 minutes but declared that this too was uncomfortable, stating that she just wanted to lie down again. At 10.35 Rachel was very distressed and said she felt like pushing. The midwife attended another VE showing Rachel to be 10cm dilated. The midwife suggested for us to wait a little longer before actively pushing, since the baby’s head was still high.
At 10.55 Rachel started actively pushing while in supine position having 3; 10 strong contractions. Rachel remained pushing in this position for the next hour. A CTG was placed on Rachel as the fetal heart base rate increased to 150bpm. Doctors and the incharge midwife on the shift were informed and they reviewed the baby. Rachel was encouraged to move into a different position, in particular, on all fours. However, Rachel said she was too tired to push anymore. She become increasingly upset and baby was having decelerations on the CTG. The doctor was asked to review again. The review indicated that Rachel was to tired to push anymore and baby was becoming increasing distressed.
The doctor explained to Rachel very poorly that he was going to perform a venturous birth. Rachel asked me to explain in English what he just said. I explained that baby was showing signs of distress and that they needed to get baby out faster so they were going to put a cup shaped sunction device on the baby and pull. Rachel said, “Just do what u have to”. Ligoucaine was placed on the perineal area and an episiotomy was performed. A ventouse cup was placed on the baby’s head and Rachel was instructed to push when she felt a contraction. It took four more contractions for the baby girl to be born at 12.53, apgar score of 9 at 1min and 9 at 5min and was placed skin to skin with mother.
Rachel’s third stage was active and 10 IU of syntocinon was given IMI with the birth of the baby’s anterior shoulder. The uterus was guarded whilst controlled cord traction was applied after signs of separation were evident. The placenta was delivered at 12.59 with the fundus firm and centred at the umbilicus. Blood loss was less than 500m. The episiotomy was sutured with 2.0 vicryl.