AROM - what could I have done differently?

[robinia]

For DD's birth I was a lot better prepared than for DS's birth, and I was able to resist a lot of intervention that was pushed heavily at me. But it ended up not being as positive or peaceful as I had worked towards and in fact I have happier memories of DS's induction!

My waters broke around 3 am and by 3 pm, I was about 6-7 cm. (Kind of irritated that I know this, since I had asked for minimal internal exams.) Contractions were slowing down and spacing out from the late morning. The midwives were saying that labour had stalled and that the likely reason was that the membrane had not fully ruptured and that they should do AROM. I resisted this and did a few (exhausting) hours of bouncing on the ball, walking up and down stairs, changing position, acupressure etc. At about 8 pm I agreed to AROM. The experienced doula I had with me agreed too, which in retrospect surprises me. I was still about 6-7 cm. I went straight into very painful contractions and was deeply upset and panicky because the midwife cut DD's head while rupturing the membranes, and told the doula so, in my hearing. (You could see the scar for months until DD's hair grew.) She was born quickly and painfully after that.

I have a lot of issues about the birth, including how unhelpful the doula was, but I guess the main question is - what should I have done in this situation? I didn't know anything about AROM or when/if it is needed and would really value some more information. Thanks in advance.

[Kidzaplenty]

I am a bit confused. Your water broke at 3am but you had AROM 12 hours later? I am guessing that it was broke again?

[MsBlack]

I don't really much believe in 'stalled labor'. Some labors go 'straight from A to B', gradually increasing in intensity and length of contrax, never slowing down--or starting out fairly easy for some hours, and then jumping pretty fast to hard labor that soon brings baby. And many NORMAL labors have plateaus or slowing down periods. There is nothing particularly necessary in the great majority of cases for speeding up labor, or for fearing such a plateau/slow-down.

What I most likely would have recommended, if baby and you were otherwise fine anyway, is that you REST with that slow-down--and possibly EAT. Your water broke at 3am, you labored well for 12 hrs--you were probably tired from less-than-normal sleep time before all that work. You were likely hungry, in need of real sustenance and not just fluids. Quite possibly baby needed more time to get into perfect descent position, head-moulding, stuff like that. Not to forget the natural rythms that most women have--that time of day (3pm) may have been a normal 'low point' in your energy that would shift in another few hours were you emotionally and physically supported during that time (rather than induced to worry, and to work harder, in resistance to that rythm. In other words, when I hear of your labor's pattern, I can only think--THIS IS ALL NORMAL, IME.

So, simply taking advantage of that plateau by sleeping between contrax, eating some protein/complex carbs, getting as comfortable as possible position-and-pillow-support-wise, everyone else getting a rest too, would have worked it's magic in time.

It's also true that while upright positions and moving/bouncing is helpful to some moms' labors, it is really not helpful to all of us; for some it actually slows things down while wearing us out. Sometimes, adopting a more relaxed/passive mode--such as sidelying--actually brings on labor harder and faster.

IMO, AROM was NOT called for--and I think it only RARELY is called for. There was not a thing wrong with your labor--the problem was care providers who didn't understand the things I mentioned above, who were needlessly worried and burdened you with that worry, and who felt that 'something had to be done'. Naturally, we all wish for shorter labors, and care providers want to minimize a mother's intensity and duration of pain if they can. Yet moving in a supportive way through such a plateau, utilizing rest and nourishment instead of trying to 'overcome' it, can also make for a less lengthy and painful birth. I have seen many a mom launch into a short intense final phase of labor when we took a few hours to help her rest and eat and accept the situation as normal (again, assuming she and baby were showing all good signs).

In future, perhaps staying home longer (or having a homebirth) would help you avoid interventions. Or at least, being firm about avoiding methods to 'speed up' labor, including AROM, unless there is some reason for urgency.

I've known many midwives, even homebirth midwives, claim that part of our job is to help shorten labor where we can--out of kindness to the mom. "We have the skills of AROM, and manual internal rotation of OP baby, etc, we should USE THEM!" But I just don't see that there is any real benefit to this for mom and baby in the great majority of births. We just can't improve on birth's natural rythms most of the time! And there are too often 'side effects' of messing with the process--whether 'small issues' like your baby's cut scalp (well, a cut is a small issue unless it becomes infected with the virulent germs that grow only in hospitals), or larger ones of all sorts.

BTW--Congrats on your birth! Maybe next time, you will make different choices, but this time you still did a great job with the info and help that you had.

[robinia]

Thank you, this is really helpful.

Yes, my waters broke before 3 am - it seemed to me that it was full-on, I had been having pre-labour contractions for some hours before and went into much harder contractions for a few hours afterwards - but the midwives suggested it had been a hindwater leak and that that was why the membranes needed to be ruptured again.

But despite on the one hand saying that the membranes needed to be ruptured, they were also saying that they'd induce by 24 hours after the original rupture, and the usual nonsense about how I'd be too tired to push if I let it go on, which I did disregard but I thought that AROM would be preferable to induction (at this point I'd been fighting off monitoring, internal exams, unnecessary IV antibiotics, gas etc for hours and was running out of steam to resist an induction - all in my birth plan of course, but they just took that as an annoyance). I had no idea that AROM would be so painful, throw me off balance so much and speed things up so dramatically. I think maybe they didn't either because she was born very soon afterwards and they didn't believe me when I was saying she was on her way - transition hit pretty much as soon as it was done. I only just managed to scrape through without drugs.

So it seems like my instincts at the time, which were actually to relax and stay calm until things progressed, were correct. I had no desire to do all that activity but the doula was pushing me to do it. Both DD and I were perfectly fine all through that day - in fact the midwife seemed positively irritated that her heart rate was stable throughout - and I think that everyone was getting bored with waiting for the troublemaker to give birth!

It's true, I did go to the hospital too soon, though that was only clear afterwards and there were a number of factors that led up to it.

Thanks again for your input, it's taken me a long time to feel calm enough to ask. There probably won't be a next time (for fertility reasons) but it's nice to understand the process better.

[rnchrista]

Originally Posted by robinia

Thank you, this is really helpful.


So it seems like my instincts at the time, which were actually to relax and stay calm until things progressed, were correct. I had no desire to do all that activity but the doula was pushing me to do it. .

It's a possibility that your doula was having you do things to get labor to progress because of hospital time-line policies after your water broke. While I totally agree with what Ms Black said, it's an unfortunate fact that sometimes hospital policies make it difficult to accomodate labor patterns that don't continually show signs of progress. At home, I wait. As long as mom and baby are doing fine, I wait. I am way more likely to encourage things to slow down so Mom can get some rest (or whatever it is that she needs) at home then I am to encourage things to speed up. However, when I doula in the hospital, sometimes it can be a different story, and I need to take into account what time lines and interventions they are going to impose if things don't change.

If you're unhappy with your doula, I always recommend that you talk to her about it. She may have an explanation like above....or maybe she won't, maybe she's more medically based. But it's really hard to say unless you've talked to her directly. I just know that sometimes it can be a hard balance for me, between what I know and believe about birth and how I'd do things at home, and knowing that I may not have the luxury of truely honoring the normal birth process in the hospital because of their restrictive protocols.

[MsBlack]

rnchrista makes some good points for sure, concerning hospital policies w/respect to ruptured membranes and 'being on the clock'--and just the general medical need for labor to constantly progress (for their own sense of rightness about it).

But I have noticed that not all birth pros realize these 2 things: that in most normal cases moms don't really 'stall', but many do 'plateau/rest/slow down'--sometimes briefly, sometimes for hours. And also, that upright-and-mobile does NOT work for everyone--sometimes 'laying-down-and-still' is best.

My rule of thumb, btw, about trying things to speed up labor is that an hour will tell you if it's going to help. If there's no noticeable change within an hour, then usually it's rest time, or on to something else. I don't generally see situations where things have to 'tried', though--following the lead of mom's/baby's signs, with plenty of basic physical/emotional support as needed in the form of food, fluids, rest, encouragement, most always means birth happens without any need for special applications/efforts.

[robinia]

Yes, I'm sure that she was encouraging me to do those things to avoid further intervention. The hospital's timeline was fixed for inducing 24 hours after the waters originally broke so rnchrista's point is perfectly valid, and indeed that's exactly why I agreed to AROM, to avoid induction.

There were other issues with the doula, so I couldn't resist the snippy remarks! - but I understand how and why those arose. I did have to have a chuckle about the suggestion of discussing it with her, since she came round for a postnatal home visit and told me all about exactly what I'd done wrong in labour - not a big help with those post partum emotions.

Looking back, if someone had said to me, if we do this be prepared for labour to progress hard and fast, that actually would have been enough to make the experience better.

Thanks very much for your input.

[MsBlack]

Originally Posted by robinia

Yes, I'm sure that she was encouraging me to do those things to avoid further intervention. The hospital's timeline was fixed for inducing 24 hours after the waters originally broke so rnchrista's point is perfectly valid, and indeed that's exactly why I agreed to AROM, to avoid induction.

There were other issues with the doula, so I couldn't resist the snippy remarks! - but I understand how and why those arose. I did have to have a chuckle about the suggestion of discussing it with her, since she came round for a postnatal home visit and told me all about exactly what I'd done wrong in labour - not a big help with those post partum emotions.

Looking back, if someone had said to me, if we do this be prepared for labour to progress hard and fast, that actually would have been enough to make the experience better.

Thanks very much for your input.

Yeah, hospital timelines...sigh. Thing is, usually what I see is that with rest, things pick up on their own! Thus very likely to put you holding your baby well before the 24hr deadline. But they are not so prepared to trust and wait.

As for the doula and her 'what you did wrong' remarks...oy. Sorry you had to hear that--really not so helpful, especially soon after birth. Maybe much later, maybe when preparing for your next birth/ttc, when those pp emotions and the experience of the last birth is more safely in the past...

And yes, it really does help to be forewarned! AROM doesn't always bring on things hard and fast...but often it does. Sometimes caregivers forget things like that in the moment--your comment is a good reminder to us birth pros to be mindful of that issue.

[robinia]

Thank you very much MsBlack for your kind and helpful remarks! This is really helping me to process this experience.

Do you mind if I ask another question? A little background - until about a week before the birth I was booked in for a caesarean due to placenta praevia, even though hoping and preparing for the placenta to migrate so I could have a vaginal birth, so in asking a 'when to go to the hospital' question I'm not at all saying that hospital is better, just that in my situation it seemed to me personally a step too far to prepare for a home birth. The home birth climate where I live is also a little different from where you are.

Anyway, the hospital's policy was that you should make your way in, not in a rush, but fairly promptly after rupture of membranes. I went in over three hours later, after three hours of strong and regular contractions which had increased in frequency to 4 minutes etc, which was their other recommendation for when to go in. (And was told off for waiting so long.)

I see people suggesting to wait for a longer time after membranes have ruptured but it always seems to be associated with a recommendation to lie to the hospital about when membranes ruptured, and that doesn't sit well with me.

I would have gone in at that time anyway because there were other factors (the road between my house and the hospital was due to close later in the morning, and my MIL had arrived to look after DS and I was not comfortable labouring with her there), but out of interest, how long is it reasonable to wait after rupture of membranes before going in? - it only seemed obvious in retrospect that it was too early.

Another way of asking the same question, perhaps - if you were at a home birth, would you have any timeframe in mind for when you would like to see delivery after rupture of membranes?

Thanks again.

[MsBlack]

Robinia--given the 'rest of the story', especially contrax at 4min, strong for 3hrs, I can see why you went in when you did. And of course, can see why you planned a hospital birth in the first place w/previa consideration. So--sounds to me like you did just the right things (um, 'what I would likely have done myself' ) under the circumstances.

Risk of infection after rupture of membranes (ROM) rises 24 hrs after first vag exam. I've known women to walk around for days with a small leak--no vag insertions of any kind, drink plenty of fluids, watch for any sign of infection but otherwise don't worry. This is a bit different if there is a large leak--usually the initial rupture helps baby move down, shuts leak off or mostly off (tiny trickles), and we feel pretty ok that baby's presenting part is down in pelvis far enough to preclude cord prolapse. IF this does not occur and presenting part stays high (continuing sizable gushes of fluid), I'm more vigilant because cord prolapse becomes more likely (not 'common', but still more likely). I believe the risk of cord prolapse with, or soon following ROM is why hossies want you in right away.

So, my policy with PROM (PRELABOR rupture of membranes) is to observe and wait, observe some more, continue waiting if all is well. Most women start labor within 12 hrs, many more within 24hrs. A few walk around leaking for days--as long as all mother/baby signs are well, I'm content to wait. I've had a few clients request transfer from home to hosp. for induction because *they* were not content to wait...but that is informed consent in action.

The more I hear, the more I think you did a great job of navigating things, given a couple of curve balls tossed at you! Seems to boil down to the supposed stall, what would have been the 'best' thing to do--that and your shock at what happened by way of rapidly ascending intensity following AROM.

I don't know....we just can't predict or plan for everything in life or birth, no matter how hard we try. You can certainly mourn any loss of your plan or dignity or power you experienced--and I think lots of women would feel those things (me included) given your story. Yet I hope you also claim the love wisdom and power that you accessed and put to use for yourself and baby, throughout your pregnancy and birth. Especially in a hospital setting, sounds to me like you actually kicked a$$ pretty much (in that really positive way ) for yourself and baby. And that is to be admired....give yourself due credit!

[robinia]

Wow, thank you so much. I'm feeling a bit teary reading your response! It's so nice to have finally worked out that my choices weren't really so bad (and my instincts were better) - after I spent that day being told that pretty much everything I wanted was wrong, and then felt that I had let DD down despite all the fighting. You know, I think that your reference to "shock" is spot on - there was so much adrenaline that the oxytocin didn't stand a chance. And all this in a situation where there wasn't even a hint of an emergency - no wonder so many mothers don't stand a chance of natural birth. Thank you!

[MsBlack]

You are most welcome

I hate for women to feel that they've made bad choices. Especially when it is so easy for us to feel that we have let our LOs down somehow, when birth does not go as we'd hoped. It is so not true....on the contrary: whatever difficult feelings of yours that your baby felt during that labor and following, your DD was 'aware'...in that nonrational, heart-to-heart way... that all you were doing was loving her with all your might. That love and protective instinct comes through loud and clear, I believe--and is far more powerful a teacher to your baby (about you, about her own safety and welcomeness with you) than your passing feelings of fear and disappointment. Our babies know when they are being well-loved, even when times are tough and our feelings may not be entirely 'positive'.

Have you considered talking to your doula--or writing her a letter anyway--about how NOT helpful it is to be told what you did wrong? She needs to know how important it is to choose words wisely when discussing a birth with a postpartum mom!

I had a doula for only one of my births--and a good thing, since it was my one csec after 5 homebirths, during a very stressful time of my life--and she was fantastic. Right down to the birth story she wrote for me afterward, where she cast every one of my decisions in the positive light of my love for my baby and my birthing wisdom in difficult straits. How I loved her for that--it was a time when it was so easy to feel I'd failed in numerous ways, felt a lot of self-doubt. But reading her story helped me tremendously--because even though it would be 'true' to cast my choices in actions in a more negative light, it was *just as true* to view them through the lens of love. Your doula needs to know that her rational, judging/assessing view needs to be well-balanced with that loving view, and with the understanding of the positive foundation at the base of mothers' choices during pregnancy/birth/beyond.

[rnchrista]

Rather then try to respond to what MsBlack has already said so eloquently, I'm just gonna say that she (MsBlack) is right on the mark. About everything

[robinia]

Thank you MsBlack, you are a wise and kind person.

[MsBlack]