Deja Vu

Well friends, it happened again. Just like I told you. I was covering for my friend and fellow midwife yesterday at the hospital from 1pm until 7:30pm. She was moving to a new apartment, I was free for the afternoon and I needed some hours so I thought I would do her a favor. When I got to the hospital there was literally no one on the floor. I finished some charts from the office, chatted with another midwife friend of mine who works with another practice, hung out in jeans and open toed shoes for what seemed like hours. And then 5pm hit. Three, yes three, patients came in all at once. 1 woman at 41.3 wks who was sent in from the office for induction for an IUGR baby, not to mention post dates. Another woman who had been contracting irregularly since the morning, had a non reactive NST in the office but an 8/8 BPP who was now c/o very painful and regular contractions and the last was my own patient from the office who was a 38 yo G2P1 being induced at 41.5 wks. They ALL got to triage at the same time. Got there, in fact while I was upstairs on the postpartum floor seeing a patient that the CNM pp rounder didn’t have a chance to evaluate. One moment it was chill, the next moment it was crazy.

The IUGR induction pt got directly admitted. She was 2/75/-2, soft, midposition. She was started on pit and sat in the rocking chair while her husband knelt on a carpet and prayed over and over and over again.

The woman in spontaneous labor, yes, that’s right, I said spontaneous, was only 3cm (50% and -3) but had three elevated BPs into the 140s over 90s so we kept her. Ran labs, got her a room…her labs were normal, she had no headaches or protein in her urine, basically, she was just hypertensive. She wanted an epidural an hour later when she was 4cm/100/-2. An hour after that, she ruptured on her own to clear fluid.

My own patient from the office was a different story. She had arrived at the hospital for cervical ripening at 7:30 in the morning. But because the hospital was so busy, she got bumped till the afternoon. She had a quick NST, went home, came back a few hours later and still had to wait until 5 to get into triage to be evaluated. When I finally saw her, she looked tired, disenchanted. She’s the kind of person who was cheerful 99% of the time I saw her in the office. Today, she looked heavy. And I could see that she was trying to stay light and stay smiling but her eyes were already glassy like she was just waiting for an opportunity to let go. She was c/o irregular tightening but other than that, no real change from when I saw her in the office the day before. And her cervix hadn’t changed much either. She was a tight 2 cm, posterior and only about 25% effaced. Her last baby was an induction as well and she reported having a really hard time with the “tablet” they gave her. She remembered being sent home and starting to have frequent and painful contractions almost immediately. She was scared and in pain, and didn’t know when to come back to the hospital.

She’d been here all day, I thought. And she does need some ripening. But I didn’t want her to panic more than was necessary or relive an obviously traumatic experience. So, I went with gel. Gel, yes, gel. It’s got a reputation for not working so well. Or at all. One of my preceptors from school used to joke that she thought the gel formulation of ripening agents was just KY jelly disguised in a medical looking syringe.

“I’m gonna give her gel.” I said to another midwife who asked me what I was going to do with my patient.

“Might as well not give her anything at all.” She said back to me.

The thing was, giving this woman gel solved some problems. For one, the patient was less anxious about the ripening process and also, I was able to honestly tell her that this was a way less aggressive form of ripening agent. I was able to look her in the eyes and say, this may not do anything to you at all. You my feel crampy but it’s unlikely that you will have the same experience as you had with the cytotec.

“What if we just didn’t do the gel and we came back tomorrow for the pitocin?” She asked.

“Well,” I said, “If you just come back tomorrow and your cervix is the same, you may have to get a dose of this anyway.”

“Okay,” she said, “Let’s just do it.”

The gel went in and we started the two hours of monitoring you need on this agent at our hospital before a patient can go home. Within 5-10 minutes my patient was contracting every 3 minutes. And then she was contracting every 1 ½ minutes. And they were painful. After an hour and a half of monitoring she was shaking and asking for an epidural. This is the report I got from the triage nurse and I immediately felt disbelief and guilt. Was it really the gel making her contract so wildly? Was it my exam prior to the gel placement? Was the patient mad at me? Was she thinking I lied to her? Did I lie to her? I could barely go back into that room to confront the answers to these questions and to witness her pain. And usually, when it comes to labor pains, I’m kind of a tough guy.

“These contractions hurt!” Patients will say.

“That’s great!” I’ll say. “They are supposed to hurt. Labor is hard work. You’re doing great.”

But with this woman, I couldn’t put on the act. I wanted to immediately take away her pain. I wanted to see her smile again. I wanted to make her comfortable. I did not want her to think badly of me. I relayed her story to the oncoming midwife, who had arrived for her shift at this point.

“You know,” she said, “when you have a personal relationship with someone, when it’s someone you have seen almost every week for the past 2 or 3 months, it’s much harder to watch them be in pain.”

“I know. I know.” I said, “But these contractions…they’re like every 2 minutes…”

“So, the gel is working.” She said.

And yeah, I guess the gel was working as it was supposed to, I just didn’t care. In my head I’m thinking can we give her narcotics in triage? Turb? How can we make this go away. My head was in such a different place. The other CNM and I made a plan to admit her, get her an epidural and pit her as soon as we were able if there was no cervical change at her next exam. Armed with that plan, I was finally able to walk into her triage room. She was drenched with sweat, crying, and looked up at me with eyes that had lost every ounce of her reserves. I put my hands on her shoulders.

“Listen, I’m not going to make you go home.”

“Please, please please don’t. I can’t go home.” She said.

“I promise. You’re going to stay here. We’re going to get you a room and get you some pain relief. And I’m not going to leave until you are comfortable.”

And then the nurse told me it would be at least a half hour until she even got a room. And I bailed on her again. I just couldn’t go back in there and give her what I thought would be horrible news.

“Guess what? I know I just told you you were going to get a room and an epidural but you’re going to have to wait longer, a half hour at the very least longer, before any of that happens. I know you’re having contractions every minute but you’re doing great! Keep it up!”

I just couldn’t have that conversation with her. So the nurse went in, started her IV, drew labs, gave her fluids, basically distracted her, made her feel like things were happening before they actually were. She did get a room. And finally the anesthesiologist came in, took forever to fill out all the paper work because, I’m pretty sure, she was very new. My patient assumed the placement position with her legs dangling off the bed while her “team leader” talked her through every step of the placement. At one point my patient opened her eyes and looked at me hiding behind the curtain that separated the room from the rest of the labor floor. She just stared at me. And I couldn’t read her at all. Mad? Sad? Scared? I kept hiding.

But little by little, she started to feel relief. And her face brightened. And her shoulders softened. And she opened her eyes and looked at me again.

“You’re a saint.” She said. “Thank you so so much.” She was so sweet to say that and it made me feel so relieved. But I was also so embarrassed. A saint for what? For being a coward? For not being able to be a midwife who could sit in a room with a laboring woman who was in pain? Which part made me a saint? I wasn’t sure. But I was happy that she was comfortable. And I was happy that her husband looked like he was having a reprieve from his own stress. We all took a deep breath, they showed me photos of their first child who was 19 months old, and we joked that this labor thing would be so much more fair if the length of it could be determined by how much pain you felt.

“Well, you know what?” I said, “When you have your third child-”

“Um, no.” She said, cutting me off. “This is it. The last one. Snip Snip.” She made a scissors motion with her hand.

I wasn’t sure if she was talking about surgery for her or her husband but I looked at him and he seemed unaware. So, avoiding any more uncomfortable topics for the evening, I kissed her on the check, gave him a hug and finally left the hospital around 10pm.

I stopped in to see her today on the post partum floor. She had an 8lb 6oz baby boy at 5:46am and she was definitely NOT mad at me or disappointed in her care at all. She loved the midwife who took care of her in labor, she was happy she only pushed 3 times and she knew, without a doubt, that the gel was a much better experience than the cytotec.

She lifted her baby up from her lap so he could see me. “Look honey!” She said to him. “Is that your midwife? Who took care of you while you were inside me? Huh? Is that her?”

He just kind of stared at me with unfocused eyes and a trembling chin.

“Yeah,” I said to him as I grabbed his tiny red foot. “It’s me. Here I am. I’m your midwife.”