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Old 03-02-2009, 01:24 AM - Thread Starter
 
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The following is the first of my 'birth essays' that I am going to be writing up for DONA when I send in my Certification package(as this one was a cesarean and I am only allowed 1 c-section this one may not be used ...we'll see how the next few births go). The baby was born only 12 hours before i wrote it so it was written when I was still rather raw from the experience with only a few hours of sleep between the 40 hours that I had been awake. While the mom was having her section I found a quiet corner and bawled my eyes out. I felt like such a failure even knowing that I couldn't get inside W's head far enough to change things.

As far as the certification process goes I got a great review from both of the nurses that were with W as well as another from her doctor. It wasn't as hard as I thought it would be to get them to fill out the forms and they were really complimentary on my role and the hard work I had put in. I also collected 13 'active labor' hours which may be what keeps this birth in the running for submission with the certification package.

Quote:


1. Description of the labor

W call me around 8 am on the morning of Friday the 27th of February to let me know that she had been kept awake by contractions the following night and had some show. She had a Doctors Appointment later that morning and would call to let me know what the doctor reported. At 1pm she called to let me know that she was 1cm dilated with show. I told her to try and get some rest and to eat and hydrate herself like normal. At 6 pm she called to let me know that she was experiencing contractions from 5-10 minutes apart and that she was worried that things would progress too fast so would I please come . I arrived at her home just after 7:30 pm to find her pausing to breathe through contractions that were about 5 minutes apart with the help of her mother timing them. She had been laboring with her mother for several hours. Her mother left and for about half an hour the contractions stopped altogether. Within an hour the contractions resumed and over the next four hours they progressed from 5 minutes apart and lasting 1 minute in length to 2-3 minutes apart and lasting 45-85 seconds. W decided it was time to go to the hospital. We arrived at the hospital at 11:30 and W was 2-3 cm dilated and fully effaced. She received at shot of Morphine. She was spilling ketones in her urine and was hooked up to an IV for rehydration. Within three hours she was 4-5 cm dilated. Between 2:30 am and 11:15 am W worked through her contractions without further medication and appeared to progress to 9-10 cm with an anterior lip. Her contractions maintained a spacing of 4-5 minutes throughout but as she appeared to be progressing no augmentation was recommended. Her doctor was called again (she had come at 7 am and confirmed a dilation of 7cm) and checked W only to discover that the intern who had been doing the checks had reported incorrectly. W’s cervix was soft and could easily stretch to 10 cm but the baby’s head had not descended into the cervix in order for her to be ‘dilated’ to 10 cm. She was still only 7cm and the baby was still not coming down. Options were discussed with the clients and it was decided that a therapeutic epidural might help W to relax and the baby to descend. She received an epidural at 2:25 pm with the intent to augment her contractions with oxytocin. Once the epidural was in place W’s contractions increased in frequency without the use of Oxytocin however the baby began to experience several decelerations. W’s doctor was again called in to check progress. At 3:50 pm W was now dilated to 8cm but her cervix had started to swell and stiffen. The doctor did not think the state of the cervix and the babies intolerance of the increased contractions were conducive to a continuing the labor and a cesarean section was recommended. The baby was born at 4:35 by cesarean section due to Relative Cephalopelvic Disproportion and Failure to progress. The baby aspirated blood during the section but pinked up well. The baby was allowed to stay and nurse with W in recovery for an hour before being reassessed by the pediatrician. She was transferred to the Special Care Nursery for a chest X-ray and Observation as her respirations were increased.


2. My role as a doula

My role in this birth was to assist both O and W in whatever capacity they desired. I suggested comfort strategies, changing postions, and massage and acupressure techniques. At home I focused on calming and hydrating W and getting her to think about how her body was built to birth a baby and that what she was experiencing was her body telling her it was working hard to bring her baby out into the world. Once in the hospital O and I worked together over the following 17 hours to keep W coping well through the contractions, using the toilet, hydrated, and changing position regularly.

3. Mother's Reaction to Labor and Birth

W was afraid of labor from the first time I met her. She was terrified that she wouldn’t be able to cope with the pain and wouldn’t be able to get through labor without medication. She had realized in her Childbirth Education Class that an unmedicated birth was best and had decided to make the attempt while leaving the options open. She was absolutely terrified of having her legs frozen so did not want an epidural and voiced that a shot of morphine or fentanyl would be preferred. During early labor W was suffering more than she should have been constantly down talking herself and ability to cope while at the same time riding through each contraction reasonably well. Once we arrived at the hospital she immediately requested something for the pain and reacted ‘extremely well’ to the morphine/gravol cocktail that she was given. In fact she did not realize that the morphine had worn off several hours later and continued to cope very well through the contractions for several more hours. When her doctor came in to check her in the morning and reported a dilation of 7cm W’s fear of not coping well switched to a fear of pushing. She coped well with contractions for the next 7 hours right up until the doctor reported that after 7 hours of misinformation she had actually made no progress at all. W was exhausted and defeated. She told her doctor to knock her out and get the baby out now because she couldn’t do it anymore. Her doctor recommended augmenting the contractions (which had been 4-5 minutes apart throughout the entire labor in hospital) with oxytocin and recommended W get an epidural to help her relax through the increased contractions instead of jumping onto the Operating room table right away. W was terrified of the epidural but once in place she was extremely relieved. When things progressed as they did from there W was quite ok with it. She felt she had done everything she could to get her baby out vaginally and that a Cesarean Section was her best option.

4. What I learned as the Doula

I learned several big things through this birth. The first is that the mind body connection is bigger than I gave it credit. It was really apparent at several points that it was W’s fear of the process that was holding things back. Especially when the morphine began to wear off and there was no change in her ability to cope. So long as she thought she was being assisted the placebo effect kept her going. The effect of her own fear on her body was also evident when the epidural resulted in increased instead of decreased contractions and increased dilation and fetal descent without any augmentation. It had been W’s fear of labor and pushing that had been holding her 7.5 lb baby back for so many hours. I also saw first hand the effect of ‘multiple hands’ doing the vaginal exams. The interns mistakes cost W and her baby at least 5 hours of laboring energy without progress. Combining the fear and mistakes resulted in what may have been an unnecessary Cesarean Section.


I came home knowing two things for sure. First I did the best I could for W given the circumstances. It was extremely difficult to get her to past the ‘suffering’ that she was experiencing. Labor was an absolutely awful experience for her.. As far as she was concerned the outcome was wonderful and I was a great help to both her and O. Second I realize that when things do not go the way I believe they should I am going to have difficulty separating what I wanted for my clients from what they wanted for themselves. It won’t be impossible for me but I am going to have to shed more than a few tears.
Thank you for taking your time to read this and sharing your thoughts.

Two things to note. We had discussed what might happen if 'multiple hands' did the exams and W had been quite clear in her birth plan that she did not want to be a 'teaching tool' ... however when approached by her doctor with a sweet young intern in tow W was very obliging and quickly forgot her plan. I reminded her after they were gone and she decided that it was ok because the 'intern' was so sweet. It wasn't until after the fiasco that her husband spoke up and asked that only the doctor do the vaginal exams. I am also aware that cervix's change (opening and closing over time)and also that different measurements are obtained by different people. However the intern was corrected on her first check by the Nurse on shift and the Nurse did not correct her for any of the four following checks to avoid doubling up on W's discomfort for every exam. So even knowing that the intern had made a mistake the first time the Nurse never corrected her or double checked. The intern later came and appologized to W and O for 'giving them the wrong #'s' and the nurse appologized for not verifying them ..but by then it was too late to make a difference.

On a personal note our hospital only allows one support person in the OR so only O was allowed to accompany W. While I was waiting in the waiting area the intern saw me and came out to tell me everything had gone well and described the Cesarean to me. It didn't sound accurate to me so I verified it with the nurse and maternity doctor who had both been present. Lets just say that I was right ... her description was inaccurate. She said that he babys head had been wedged tightly into the pelvis and that the OB had had to wrestle her out. The nurse and doc said that her head had not been wedged into the pelvis (and I saw for myself that there was no molding AT ALL) and that the OB had had to wrestle her shoulders out but only because he cuts such a small hole. I was pissed at the time ... even though I kept telling myself this intern was obviously just learning ... why was she allowed to be in the room not even knowing what she was really seeing ... and I had to sit out in the hall waiting and crying by myself.

tireless sewer of teeny little clothes for Bamboletta dolls ...

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Old 03-02-2009, 06:08 AM
 
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What an experience! I do feel you did your best. You'll know more next time, but people do set themselves up for the kind of situation they're going to have whether they realize it or not.

I too have been the victim of a "wrong #" but by a well experienced OB who was just trying to prove a point. I got a second opinion because I didn't trust the man and guess which of us was right? I have nothing against medicine when used appropriately, but I HATE it when medical personnel push their agendas on others or won't take responsibility for their actions (okay, that applies to way more than just medical personnel...).

One thing I've learned from your experience: It really is necessary to get an idea of what a mother's personality is like before the labor starts...might give a heads up atleast that something of this nature could happen.

Thanks for sharing and keep up the good work!
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Old 03-02-2009, 11:44 AM
 
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Jes,
There is only so much a doula can do.

The client brought her personality and how she copes from a lifetime of experiences, she seemed to function in fear and more than the usual self-doubt women have when doing something unknown. This is the crux of labor and ppdoula work, we talk people through doing something unknown to them.
Giving birth and breastfeeding is hugely unknown in our culture!

I could be reading into it, but it seemed as if her fearfulness and self doubt were in her personality when you met her, so it was beyond the ability of a doula to help her resolve these life issues. As a doula you can help a client examine them prenatally, but you cannot resolve them with her if they are deeply seated fears beyond giving birth.

Maybe having a professional resource to refer for hypobirthing or a Birth Counselor might of helped her with her self doubt talk.

Just between doulas, I question why she choose the environment she did to give birth, it certainly sounded as if the typical way a hospital functions contributed and fed her fears instead of calming and reassuring her, the hospital experience dug her deeper into fear and doubt. Many clients feel emotionally safer in hospitals that is their comfort level, she did not seem to go into this with that feeling. Again I could be reading more into it.

In the end it became a typical textbook hospital birth, combined with W's fears and the incompetence of the intern this all fed into W's doubt of her ability to birth her baby, it was a perfect storm for a cesarean.

It's likely she is glad to finally had the Cesarean, the feeling of "suffering" in labor is so horrific that having the cesarean is a huge relief to takeaway that suffering feeling.

So be very mindful how you talk aobut the cesarean to her!
Thisis her birth, her life!
Not everyone needs ICAN, or is disempowered by a cesarean.
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Old 03-02-2009, 06:12 PM - Thread Starter
 
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I agree that hypnobirthing or at least professional counseling would have gone a long way to help her ... and you're right I should have noticed this in her personality beforehand (and did to some extent). She was always self deprecating but we would talk about the natural process and how miraculous the human body was etc and she would come around.

By the time she called me to come over she was already exhausted and convinced that she had been in labor since 2:30 am (I arrived at her home at 7:30 pm) ... prelabor contractions started waking her every ten minutes around 2:30 am ... they had stopped in the morning but even with my reminding her to get some rest, stay hydrated, and eat like normal she did none of those things. She was spilling ketones when I arrived (I could smell them on her breath) and would only accept small sips of water sporadically between contractions and refused all food. she had dug herself a hole and while I could reach in and touch her I wasn't strong enough to pull her out and she wasn't willing /able to help.

I was thinking of taking the hypnobirthing course down the road and am now even more inclined to do so. I just need to find one that's actually within a reasonable distance.

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Old 03-02-2009, 09:18 PM
 
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Jes,
You did the best you could with the tools and experience you had as a novice doula. You did good. Your non-judgemental loving intention and kindness towards her goes a very long way, and you sound like you have that.

And your client did the best she could with the "life experience/ baggage" she brought to her birth. I'm always intrigued by clients who never follow any of the doulas suggestions to avoid simple complications if they went to the bathroom, ate, hydrate and then pumping if they are separated at birth from the baby.

I think the Hypobirthing might be a home study course.
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Old 03-02-2009, 09:32 PM
 
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