Normal birth against all odds

Sometimes birth is not normal. Sometimes there really are complications and problems which need to be dealt with in a hospital setting. Sometimes a medical approach to birth is exactly what’s needed. Sometimes interventions during birth ARE lifesaving. Yesterday was a perfect example of that. I was helping to take care of a woman who was incredibly high risk and had the odds stacked against her in terms of her chance of having a normal, uncomplicated delivery. She was severely anemic, and had been throughout her pregnancy; and not just the usual anemia of pregnancy—no, this was a woman who had a hemoglobin of 6.5 at one point during her 3rd trimester, and a hematocrit of 19%. (To put that in perspective, bear in mind that normal is a Hemoglobin of 12-13 or greater, and a hematocrit of 32-33% or greater.) She had been seen by Hematology several times during her pregnancy and had had numerous anemia work-ups. It all pointed to iron-deficiency anemia, and she was taking iron replacement therapy, but there’s only so much that this can do. At one point during her pregnancy she had been offered a blood transfusion, which she had refused. When she was admitted, her hemoglobin was 7.8 and her hematocrit was 21%—numbers which didn’t demand an immediate transfusion, but which were very concerning given the fact that she was going to give birth, and giving birth means losing blood, and if you’re severely anemic you don’t really have any blood to lose. Our professor used to say that if a woman is severely anemic, she “can’t tolerate” a hemorrhage…which is what…a polite way of saying that she’ll die?

In addition to the severe anemia, she was also preeclamptic. Her baby had oligohydramnios, probably caused by the preeclampsia (unchecked hypertension and poor placental perfusion can lead to intrauterine growth restriction and oligohydramnios, both of which are not good signs). She had protein in her urine, was hyper-reflexive, and was starting to have toxic symptoms (blurry vision, headaches, visual changes, epigastric pain, edema). She was admitted for an induction of labor immediately on account of the oligohydramnios and preeclampsia. To my way of thinking, this was the right call. With preeclampsia, you don’t want a patient sitting around at home with skyrocketing blood pressure—it can lead to siezures if untreated, and the only cure is birth. Similarly, oligohydramnios indicates chronic, long-term insult to the baby, which sadly means that the womb is no longer the best environment for fetal well-being.

This was her second baby. Her cervix was 3 centimers dilated at the start of the induction, so rather than using a cervical ripening agent like cytotec or cervadil, pitocin was started instead. Because she was preeclamptic, she was also started on Magnesium Sulfate, which prevents preeclamptic seizures by causing systemic smooth muscle relaxation. Mag is an awful drug. It makes you weak and hot and sweaty, and it often complicates inductions because it’s hard to induce contractions when a woman is receiving a medication which is causing all of her muscles to relax. Pitocin and magnesium are always at odds with each other. I think a lot of preeclamptic inductions fail because of the magnesium.

Anyway, maybe it was because of the magnesium, maybe it was because her first labor was also a very long, drawn-out labor, but in any case, her progress was very slow. I admitted her on Friday, and she was still in labor when I came back 12 hours later, on Saturday. She hadn’t made much progress; she was only 4 centimeters dilated when the doctor checked her that morning, and was still 4 centimeters when the doctor checked again 3 hours later. Her bag of water was broken by the doctor, an intrauterine pressure catheter was inserted to measure the actual strength of the contractions, and the pitocin was duly increased. And increased, and increased. It got as high as 28 miliunits/min., which was as high as I’ve seen it in a long time. Her contractions were adequte (because of the IUPC, we were counting montivideo units, and yes, they were adequate), but they were always irregular. When I checked her again 3 hours after the IUPC had been placed, she was only 5 centimeters dilated, and it was a tight 5 (I was worried that I was being too generous, and that the doctor would come behind me and check her again and decide that she was still only 4 centimeters, that she hadn’t made any progress, and that she would therefore need a cesarean for failure to progress).

I was really worried about this woman and this baby. I was worried about a severe hemorrhage. She had so many risk factors leading up to it; she was on magnesium, which relaxes the uterus and makes postpartum uterine atony more likely. She had been on pitocin for almost 24 hours, which tires out the uterus and makes postpartum uterine atony more likely. And because she was severely anemic, she couldn’t hemorrhage. She had no blood to lose. I was worried that after another three hours of little or no progress, she would give birth by cesarean, which means that her blood loss would be at least 800 cc. She didn’t have 800 cc to lose.

At least the tracing was always reassuring. I’m sure that if, at any point the tracing had begun to look anything other than beautiful, there would have been an immediate cesarean. Her urine output was always good, her magnesium levels were always on target (never too high or too low), and all of the medications we were giving her seemed to be doing their jobs. The woman seemed to be taking everything in stride, as well. I was amazed by her strength. She never panicked, even when she first found out that she had preeclampsia and would need to be induced. She had an epidural and was comfortable. She slept for several hours at a time, as did the rest of her family (her partner and grandmother, both in their chairs with their mouths open, snoring). She asked a few questions here and there, but for the most part, she seemed to trust that things would be okay. She must have known something that I didn’t. I was worrying plenty for the both of us.

Three hours after my last exam, I was unsure of what to do. I didn’t want to check her again and have to be the one to discover that she was still only 5 centimetrs dilated, and then have to notify the doctor and watch the entire thing get written off as “failure to progress”. On the other hand, we’re supposed to round on the women we’re taking care of every 2 hours, and I was trying very hard to be on top of things; it was already an hour past when I was supposed to check her and write a note. I called my preceptor on the phone and discussed the situation with her. We decided to write a note on her well-being, lab values and fetal status, but defer the exam for another hour, if possible. I hung up the phone and walked to the room, only to discover that the doctor was already there, and had just checked her. She was fully dilated.

I didn’t even have time to marvel over how she’d managed to go from 5 centimeters to fully in 3 hours…not that this is an impossible thing at all (many 2nd time moms do the entire labor in 3 hours or less), but she had been making such slow progress, and her body was battling the magnesium every step of the way. I was so incredibly, pleasantly surprised! I barely had enough time to get my gloves on before the baby’s head was crowning. He wasn’t a very large baby. She pushed him out in 6 minutes, and he began to scream and wave his arms around. Her partner cut the cord. The pediatricians were there on account of the prolonged magnesium exposure in the baby, but everything was fine.

The placenta came out 4 minutes after the baby, and we began to massage her uterus immediately. It wasn’t firm right away, but it firmed up with massage. We ran 40 units of pitocin in 1 liter of IV fluid (we couldn’t give her methergine because her blood pressure was too high, since methergine can cause a stroke if given to hypertensive women) and…please, no heavy bleeding…please, no hemorrhage…please, let it stop….and it did. She lost blood, but a normal amount. She had a small, first degree laceration which we quickly repaired so that it wouldn’t bleed very much.

And that was it. All of those risk factors, all of those hurdles to overcome, and in spite of it all, a normal birth. Even with the doctor in the room. Even with multiple IV lines, and packed units of red blood cells ready and waiting in case she hemorrhaged. Even with an induction that lasted 28+ hours, and heavy medications competing against each other. Even with a midwife that was worried about so many things that could have potentially gone wrong, which didn’t. Even in high risk situations, with all sorts of complications, even with a prenatal course and labor which is anything but normal….normal birth can and does still occur.

This entry was posted in Birth Stories, Complications, Hospitals, Inductions, Labor and Birth. Bookmark the permalink. Trackbacks are closed, but you can post a comment.

9 Comments

  1. Posted November 26, 2007 at 1:22 pm | Permalink

    that really sucks. I once had a woman with HELLP syndrome and after a failed induction she underwent a cesarean, but her total blood loss was 300cc. It was remarkable. We were grateful because she was a Jehovah’s Witness and refused platelets. She did seize during the induction…and that is always scary to witness.

    Have you ever read some of the new research speculating that iron supplementation, esp with synthetic iron, can increase the risk of pre-e? I think it has to do with the physiological blood volume expansion and the response of the synthetic iron to that process. I’ll see if I can find that info for you, if you’re interested.

    xoxo

  2. The Midwife
    Posted November 27, 2007 at 12:08 am | Permalink

    I haven’t read about that. If you could pass on a link, that would be great. Thank you! :-D

    And to my way of thinking, this really didn’t suck at all. It could have been *so* much worse. I’m still amazed and overjoyed that everything turned out as well and as normal as it did.

  3. Posted November 28, 2007 at 12:22 pm | Permalink

    holy!
    Are you a story teller in your other life? You had me hanging off your every word! I was thinking: This is not going to go well at all, at all, at all.

    I was sweating and walking the corridors with you. I chaffed at the constrictions and at the presence of the doctor.

    But fuck! What a potential mess that turned around so wonderfully. And I’m saying this from the stand point of not at all being a hospital, doctor or medication kind of person.

    I shrunk away from the parts of your tale that seemed to say that the interventions were unavoidable. I really do wonder what sorts of thing homeopaths or naturopaths would offer in this sort of situation.

    I really don’t think that the doctor’s approach is the only way. It’s just that their medicine has behaved like a predator eating up recognition of all else. I mean, if pre eclampsia was such a scourge and not at all rare for pregnant wimmin, how did we end up filling the planet with 6 billion people, many of whom don’t have access to hospital care?

    But, I digress!
    You were so amazing! That part where you were stalling, waiting, watching, hoping that nothing would change in any of her data that would set off the doctor and allow for the scheduling of a cesarean? That was intense.

    I can’t help but understand midwives working in hospital environments as dealing with major domination. The doctors function as managerial staff, higher ups who can veto anything. This isn’t a relationship of equals they’ve set up that midwives have agreed to.

    They have final say. That upset me.

    But I saw how you attempted to slow the process even as their model was inexorably dragging that woman towards a horror.

  4. The Midwife
    Posted November 28, 2007 at 4:19 pm | Permalink

    It’s funny…I was talking about it with my preceptor afterwards, and we marvelled over how the really bad hemorrhages are usually the ones you don’t anticipate, the ones where you think everything is going to be just fine, and it’s not. In this case, it was the reverse. We were preparing for the worst, we had all of our hemorrhage meds close at hand, we had packed units of blood on the floor in a little cooler of ice, we had the doctor standing by…and she didn’t bleed. Hallalujah!

    I too wonder what would have happened if alternative methods had been used. Unfortunately, I don’t know much about homeopathy or altnerative therapies yet (I say yet because I really want to learn about all of this, but so far my education has been western medicine, and I haven’t had a chance to start to explore the alternative stuff yet), but I have heard from friends who work with homebirth midwives about how amazing and effective homeopathy can be, especially in stopping hemorrhage. I’m not sure what it can do for preeclampsia, but it certainly bears exploring.

    And yes, you’re right: what have people been doing for centuries (eons) to treat preeclampsia prior to magnesium therapy? There must be other methods for symptom relief, and yet, I do think that untreated preeclampsia is one of the reasons the maternal mortality rate is so high in undeveloped countries, or why childbirth was so dangerous in previous centuries. It’s no joke when it’s severe, as it was in this case. It’s certainly not uncommon, but thankfully, preeclampsia is the exception and not the rule. I think that it was all of those other healthy, totally normal, uncomplicated pregnancies and births which have populated our planet with 6 billion inhabitants. Prior to this century, I think many people died from preeclampsia (otherwise known as toxemia), and I think that many women still do in the poorest countries around the world. I’m all for alternative medicine, but I do think that in some cases (like preeclampsia) the hard science makes a lot of sense, and there is strong evidence backing up the use of magnesium to prevent seizures.

    Still, it’s good to have it pointed out: is it automatically a given that all of these interventions were unavoidable? You do have to think about it, every single time.
    As for the doctor having the ultimate say: it’s always a balancing act in a hospital, like I was describing in my post on Hospital Midwifery. Midwives are the experts in normal pregnancy and birth, but this woman had many complications which made her situation much more high risk, and as a new practitioner and a new midwife, I was more than happy to defer to the doctor’s knowledge and expertise. If this woman had been a totally normal, uncomplicated labor and birth, the doctor wouldn’t have been co-managing. But yes, they do always have the final say. There are certainly days when I feel more like a resident than like a midwife. But still, I think that midwifery care makes a big difference in a hospital setting.

  5. Sophie
    Posted November 29, 2007 at 4:08 am | Permalink

    Thanks for sharing… as a new qualified did you feel you were supported by other midwives? Quite a case to take on…. I qualify in ten months and reading your post makes me feel half inspired and half anxious! Glad your woman got as ‘normal’ birth as possible.

    The other day I cared for a pre-eclamptic woman who was being induced – we came on in the morning at 7.30 and the midwife had examined her an hour before and said she was 3-4cm and contracting well. At 8am, just before the epidural, she suddenly said ‘the baby was coming and she wanted to push’ (1st baby) and sure enough by 8.30 a little boy had arrived. After the birth, my mentor said pre-eclamptics can suddenly ‘just go’ and dilate very quickly – have you noticed this before?

    Anyways, thanks again. Love the site!
    s.x

  6. The Midwife
    Posted November 29, 2007 at 6:35 pm | Permalink

    Hi, Sohpie:

    I actually have seen that before with preeclamptics, during a few deliveries I attended as a nurse (prior to qualifying as a midwife). Sometimes (and espeically if they’re not on magnesium yet) if the woman is in early stages of preeclampsia and her muscles are hyper-reflexive (as in, gearing-up for siezures, but not quite there yet), her uterus contracts extremely powerfully, and the baby comes very quickly. Once you start the Magnesium, though, this tends to disappear.

    I’m guessing you’re in the UK? Do you use Magnesium routinely over there, or only for severe pre-eclamptics?

    And yes, I do feel supported. I feel nervous and anxious most of the time, but I’ve still got a preceptor which I’m always working consistently with, and this makes a huge difference.

    As for not being able to imagine doing this….10 months prior to qualifying, I couldn’t have imagined it either. You do get there, little by little. Guess I have to keep reminding myself of that too. A year from now, I’m sure I’ll feel so much more confident and secure in my skills and management ability, but from where I’m standing now, that still seems pretty far away.

    Thanks for reading!  I’m glad you like the site.

  7. angelagrace
    Posted November 30, 2007 at 10:26 pm | Permalink

    Is what you describe really “normal” birth, though?

    I assure you that I am not trying to be sarcastic or caustic in asking this question….just curious as to what your answer is.

  8. The Midwife
    Posted December 1, 2007 at 11:34 am | Permalink

    Well, in this case I’d say it was a normal birth, with a high risk pregnancy and labor. I guess normal birth to me means spontaneous vaginal delivery without the use of forceps or vacuum, without an episiotomy, where the baby is born by the mother’s own pushing efforts, the Apgars are good, the baby adjusts well to the extrauterine environement, and there are no major complications (like hemorrhage or shoulder dystocia). In this case, everything leading up to this was not so normal, but the actual birth itself was (and there were many points where I thought a cesarean was very likely, so the fact that it turned out to be a vaginal delivery is fantastic!).   Sometimes people mix up “natural” for “normal”.  I don’t think this was a natural birth by any means, but I do think it was normal.

  9. Elizabeth_FutureRN
    Posted December 6, 2007 at 12:22 pm | Permalink

    Hi! I’m a nursing student who wants to be a midwife. I forget how I found your incredible blog but I’ve been reading it raptly for months now.

    I just wanted to say that this entry is awe-inspiring. It brought tears to my eyes. It was beautiful.

    You tell such great stories!

    -Elizabeth

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