Belly Tales

Last night was a very strange night. It wasn’t that busy, and yet, somehow, neither the other midwife nor myself were able to take a break. The pace was very steady. We kept expecting it to settle down, but it never did. Just as we were thinking “oh, as soon as this woman is discharged, we’ll be able to rest for awhile”, then another woman would walk through the door.

There were two deliveries. One was a grand multip (G6P5005) who came in 9 centimeters dilated with a bulging bag of waters. The other midwife ruptured her membranes at 3:40 am and she delivered at 3:41 am. I love deliveries like that! It’s always amazing to me how QUICKLY a baby can actually exit the human body, when all the conditions are right. It’s as if they’re on a greased slide, and they just whizz on out. If only all births were so quick and easy.

The woman I delivered was 16 years old, having her first baby. She was newly immigrated, and the father of the baby was back in Santo Domingo. She had her mother and grandmother with her, though, and they were a tremendous support team for her as the contractions were picking up, fanning her face and feeding her ice chips. She progressed remarkably fast for a first baby. We forget, sometimes, that teenager’s bodies are meant to give birth, and probably more so at this age than at any other time in their lives. Even though they might not be emotionally ready, their bodies are, and they often open up through labor as if it were the easiest and most natural thing in the world. This girl was having a labor like that.

When I came on at the start of the night she was 4 centimeters dilated and in a lot of pain. We discussed her pain options, but she didn’t think she needed anything just yet, and carried on with the support from her family. Two hours later, she was ready for something for the pain, and was thinking that she wanted an epidural. However, when I checked her, she was a whopping 8 centimeters dilated, and the head had moved down to zero station. I told her she was a superstar, she was doing amazing work and the birth would be really, really soon. I told her that she could have an epidural if she really wanted one, but that by the time she got it she would probably be fully dilated and ready to push, and that an epidural would just slow down the birth in the long run. She didn’t believe me (I can’t really blame her….the contractions were pretty intense at this point), but her mother and grandmother exchanged a look, and both of them rolled up their sleeves. We coaxed her into a sitting position, and her grandmother went behind her, rubbing her back, while her mother continued to fan her face. Less than half an hour later, she was fully dilated (there is a Russian doctor at our hospital who likes to call this moment “fully delighted”), and was pushing beautifully.

The baby came down quickly and was delivered 11 minutes after she was fully: a beautiful little girl with a really tight nuchal cord which had to ultimately be clamped and cut in order to allow for the birth, and a compound right hand that extended as the baby delivered and unfortunately tore the girl’s left labia, leaving a tender, open gash. The pediatricians were there to check on the baby due to the moderate meconium which had been in her amniotic fluid, but the tracing had been overall reassuring (we’re calling this Category II now…has anyone else moved onto the new NICHD guidelines? Our hospital has finally made the switch officially, despite the fact that these guidelines have been around and endorsed by nearly everyone [ACOG, AMA, ACNM etc. etc.] since 1997, but I must admit, I’m still finding it a bit strange) and the baby came out vigorous and screaming, waving her little pink arms around. An altogether beautiful and uneventful labor and birth, which took less than 5 hours in total. You couldn’t have asked for a nicer first birth than that.

The eventful part came next, unfortunately. Everything was looking good. I was checking her perineum (intact! the only tear was the labial laceration) and waiting for the placenta when there was suddenly a pretty forceful gush of blood. I figured it was a sign that the placenta was starting to seperate, so I gave a gentle tug on the cord, and the placenta quickly began to descend. Instead of coming out with the shiny, fetal-side showing first (Shultz presentation) it came out maternal-side first (Duncan presentation) and I immediately noticed that the membranes had been completely sheared off on one side. There was a thick tendril of trailing membranes which were still firmly attached somewhere up in the uterus, and were taut and unmoving when I tried to gently tease them out by spinning the placenta a bit. Rather than tearing the membranes and losing them, I cut the placenta away and put a ring forceps on the trailing end of the membranes, so that at least we had them. I quickly inspected the placenta and saw that there were hardly any membranes present, only the cotelydons of the placenta, and the cord. Which meant that most of her membranes were still inside, either retained or trailing, I wasn’t sure which yet. And all the while she was gushing blood.

We moved pretty quickly. I called the attending doctor, we asked the family to step out a moment, and started the IV pitocin running. I gave fundal massage and felt absolutely no fundus! I couldn’t find it anywhere (later on, the attending pointed out that that is exactly what an atonic uterus feels like…as if there’s nothing there). The attending began to remove the rest of the membranes by traction, gently teasing and working them down. We administered methergine, then hemabate, and finally 1000 mcg of cytotec rectally. We started a second IV line and used a catheter to help quickly drain her bladder. I was doing firm fundal massage all this time, and finally, after what seemed like quite some time, but was really about 8 minutes, I began to feel a hard, firm fundus balling up under my hand, and the bleeding had slowed down to a trickle. The doctor had managed to extract what looked like the rest of the membranes, and his sonogram later confirmed that the uterus was empty. And then, just as quickly as it had started, the bleeding stopped. The total loss was estimated to be between 800 - 1000 cc. But once the trailing membranes were finally out, and the fundus was finally firm, she was absolutely fine. I repaired the labial laceration, cleaned her up, and helped her breastfeed her beautiful girl.

Her hemoglobin and hematocrit dropped pretty precitously when we checked her CBC four hours later, but it was still in the range of normal (10.0/ 30%), so in the end she didn’t need any kind of blood transfusion. In fact, I’m still kind of astounded by the entire thing. It’s as if a huge emergency had been averted, and yet, at the same time, it felt really routine. We drill our hemorrhage protocol pretty regularly on our unit. It was really nice to see that when push came to shove, we were able to go down the steps of the protocol one by one, and amazingly (or perhaps not), they worked just the way they were supposed to, and lo and behold, the bleeding stopped! Nobody panicked, the nurses were prepared, the doctor was calm. Everyone knew what they were supposed to do, and we just did it.

Afterwards I was waiting for the shaky post-adrenaline terror feeling that often comes after emergencies, but it never came. It made me think about how far I’ve come in my first year as a new midwife. A year ago, this would have probably left me crying or near tears, shaking in the chart room, totally freaked out. Instead, I finished the paperwork, checked her bleeding again (it was fine) and carried on with the rest of the non-stop night. I guess this is what midwives do. They don’t panick, and they stop the bleeding, and that’s that. It was just a hemorrhage kind of night.

As reported by the Daily Kos, a rigorous new poll shows that Measure 11, South Dakota’s latest attempt to ban abortion, might not pass as easily as everyone originally thought.  South Dakota’s initial attempt to ban abortion in 2006 was defeated by 56% to 44%, mainly because the bill included no exceptions for victims of rape and incest, or provisions for the mother’s health.  Now, in 2008, these exceptions have been inserted into the wording of the referendum, but as the Daily Kos points out, these provisions are largely superficial, and offer no real practical exceptions.  The general idea was that as soon as this wording was inserted, the South Dakota abortion ban would pass by a landslide, but thanks to a hard, uphill battle waged mainly by the South Dakota Campaign for Healthy Families, the latest polls show that Measure 11 might be shot down again, just like its 2006 counterpart.  According to the poll, if the vote were today, 44% would vote No, and 42% would vote Yes.  Which is really exciting, encouraging news, although the race is too close for comfort.

Even so, none of this changes the fact that women trying to access reproductive health care in South Dakota face a really tough challenge.  There is only one clinic in South Dakota which performs abortions, and they are done by a rotating staff of doctors who are flown in from neighboring states.  And again, as the Daily Kos has pointed out, the hoops that women in SD have to jump through before actually having the procedure done are incredibly daunting:

The woman must receive state-mandated “counseling.”

The woman must wait at least 24 hours after the state-mandated “counseling” before procedure may be provided.

If the patient is a minor, a parent or guardian of the patient must be notified.

The doctor must offer the woman an opportunity to view a sonogram, and must then record any responses in her permanent medical records.

The doctor must deliver a government-dictated script to women designed to intimidate her and discourage her decision. The mandatory language includes statements of fact which are contrary to all available medical research.

Usually by the time a woman is sitting across from me (a midwife) for her initial prenatal visit, she’s already made up her mind to keep her baby.  But every now and then I come across a woman who’s still conflicted, and we usually have a frank and very difficult discussion about whether she really wants this pregnancy or not, and everything that keeping this pregnancy entails.  This is a hard decision to make in a hospital like mine, sitting across from a provider like me who is resoundingly pro-choice, and is not at all judgemental or discouraging of the woman’s thoughts or decision.  These women are often young, alone, and already scared and intimidated, but if they really don’t feel like they can keep this pregnancy (for whatever reason–and we do talk about the reasons, but only to make sure that she’s thought everything through), I gently refer them to the termination of pregnancy clinic, with compassion and support.  No one is judging them.  Judgement is the LAST thing you should find in your health care provider’s office.

Now, imagine this were South Dakota.  Imagine how much harder it would be to make such a decision if I were legally required to read these women a script containing statements which are medically false and which do nothing but make the woman feel even more intimidated and guilty about her decision.  If I were forced by state regulations to make it very clear that I think abortion is a terrible idea, it would take a very staunch woman indeed to be able to stand up to something like that (and this is not because I’m so terribly persuasive, but only because the power of the white coat is astounding: people automatically trust you a little bit more and believe you’re speaking the truth, just because you’ve got a white coat on.  If you tell them that they need to eat more iron-rich foods because they’re anemic, they generally listen to you.  If you tell them that what they’re doing is wrong, they listen to you too).  And then, to top it off, I’d have to offer these women a sonogram, just so they can see that heart beating some more, and feel even more like a monster for doing what they feel they have to do.  The cruelty of it makes my skin crawl.

In any case, the reproductive rights of the women of South Dakota hang in the balance (and by proxy, the women of the rest of this country too, because if this referendum passes in South Dakota, it’s just opening the door for every other state).  And do not be fooled: the inclusion of exceptions into the wording of the bill in no way changes the fact that this referendum will basically make all abortions in South Dakota illegal, because there is absolutely no practical way to carry out these exceptions, and no doctor willing to test it.  So, what can we do about it?  We can donate money to the South Dakota Campaign for Healthy Families, and we can…(to put a rather neo-conservative spin on it)…pray.

My goodness, it’s been ages.  I do apologize for that.  If it’s any comfort to any of you, I am now quite firmly resolved to pick the blogging baton back up again and give it a twirl, after a very long hiatus.  In my defense, I’ve been a bit busy.  I quickly learned that the demands of being a full-time midwife are much greater than the demands of a midwifery student.  A student has time to procrastinate and ruminate and spend hours reading blogs and writing posts.  A midwife (well, at least this midwife) doesn’t quite have the same amount of time.  Add to that the fact that I was also very busy planning a wedding, and somehow sitting down to my computer to write posts was always the last thing on my exhausted mind at the end of the day.

However, I have since gotten hitched (hands down one of the best days of my life, and well worth all the effort), the wedding planning is now over (hooray!), and I feel like I have more time on my hands again.  What does one do with more time on her hands??  Oh yes! Contemplate all things midwifery-and-women’s-health-care related, and try to write something snappy and insightful about said contemplations.  Excellent!  Hello again, blogosphere!  I have missed you.