A Little Bit of Everything

When I'm on call, I try to take each situation and file it away in my mental filing cabinet so that I can easily recall what kind of labor management I did so, the next time I have a similar situation, I can just go back to that place in my filing cabinet and do the same thing. The problem is, every time I have a patient in labor, it feels and looks nothing like anything before it. The labor is different, my nurse is different, the entire situation is demanding new things from me. And even if there is one piece of the puzzle that looks the same as another, the rest of the story doesn’t fit. So my management decisions have to be different and my mental filing cabinet is immediately made obsolete. It's a shame actually. Because I try really hard to let one call shift inform the next. But it feels like each time, I am reminded that there are no rules, no black and white, no cookie cutter approach to labor and delivery that can get you through a non-straightforward situation. At least not yet anyway.

I had one patient in labor all day yesterday. She was a young and healthy G1P0 laboring naturally and easily, probably in more control than I had ever seen anyone. She was a role model for natural labor, and for staying on top of each contraction, asking for what she needed and staying open minded and not panicking the entire time. She had SROMed to clear fluid the night before at 10pm, labored at home until she came to the hospital at 4:30 am when she was found to be 5cm. I checked her as soon as I got to the hospital and got report in the morning and she was an anterior lip. So, she labored for another hour and I checked her again. Still an anterior lip. So I tried to reduce it. I gave her cervix a gentle push and the pt bore down at the same time. The cervix, soft and flexible, slipped back behind the baby's head. I kept my hand there and the cervix seemed to stay back. So, we started pushing. Pushing on hands and knees, pushing side-lying, pushing on the toilet. But the contractions space and the woman wasn’t feeling the spontaneous urge to push with each one. So, after 45 minutes, I checked her again. And that lip had come back.

"Well" I told her. "I can try to reduce that cervix again, but if it keeps coming back like this I have to wonder why that is. If it's not ready to stay back, it might just be trying to tell us something." Her back labor and the baby’s complete lack of descent was sort of telling me that the baby might have been in a funky position too...Either way, I did feel like her contractions just needed to be closer together and potentially stronger. But we'd already started pushing, and she originally had that ant lip, and then didn’t and now the lip was back. It just wasn’t straightforward to me. And I have to admit, when something gets "unstraighforward" I start to get “unsecure” about my decision making skills. And maybe it was completely appropriate to ask the doc what she thought at this point. But, I just started thinking, should I be doing more? Should I be more innovative? Should I know how to do sterile water papules for this woman's back labor? Would it make any difference at this point anyway? Should I seek out another practitioner who knows how to do them?

I told the pt to do nipple stim for augmenting her labor while I went to consult with the doc. I knew she needed pit but this was a pt who never got an IV, never got her initial labs drawn, had had zero interventions and minimal exams...i figured, why not let her try the least invasive option first? Plus, it bought me some consult time.

I start to page my doc to give her an update and I see another doc from my practice. "Hey," I say to her, "You have any great ideas for getting rid of a persistent cervical lip?"

"Yeah," she says, "C-section."

"Come on, really." I said

"I'm serious. C section." And she was. She was really really serious.

"Well," I said, "I don’t think her contractions have enough power."

"Well, that may be a different story." She said.

"Yeah,” I continued. “She was an anterior lip, and I reduced it so she was fully and then she pushed for a bit but now that lip is back."

"I've never heard of that." the doctor said.

"Of what?"

"Of a pt being fully and then not fully. She had a lip and then no lip an then a lip again...? That just doesn’t sound right and you’re getting into dangerous territory."

She was making it sound like I didn’t know what I was talking about. Trivializing the situation and the work we had been doing in the room to "lip, no lip, lip." She was making me second guess myself.

But, when the doctor I was on call with got back to me, she agreed that the patient could have some pit to see if that would get her into a better pattern and maybe get rid of that extra bit of cervix. So, we started pit. And though it got to 6 the patient stayed sans epidural amazingly through a wonderful contraction pattern of q 2-3 minutes. I checked her again. Ant lip. I tried to reduce it. It disapeared. But, I wanted a second opinion. The doc checked her. She felt nothing and gave us her blessing to push. So, out loud I said "Great, so maybe that lip has finally stayed back. Good news! The reduction worked! Let's push!" But inside I was crumbling and second guessing: What the hell was that that I felt?? WAS it a lip? Was it...nothing?? Was it there ever? Did I just make this woman go through tons of pit for nothing?? More second guessing.

We pushed for 2 hours. With no descent of the baby’s head. We pushed in every position we could think of, we coached and didn’t coach, and supported and did what we could but the baby just would not budge. If I could actually assess fetal position I could tell you for sure if I thought it was posterior but since I can usually only feel one fontanelle and never have much of a clue which one it is I was in the dark on that.

The doc came in and gave the "I think the best thing would be to have a section" speech and the patient agreed. She was exhausted. And though she was disappointed, she thought there was no sense in continuing.

At this point in my career, when someone disagrees with me (ie. c-section for an ant lip, if my vag exam is off from someone else's etc etc), my knee jerk response is to assume I am in the wrong. I never think, What the hell do they know? That baby was at +2 not +1! Or, A c-section for an ant lip when nothing else is concerning...??!! She is a bitch and I will get someone else's counsel. I can't wait for the day that I could care less what someone else thinks. Or, at least, keep their opinions in perspective, not let a disagreement wreak havoc on my sense of security...

So, we shut the pit off, went over the risks and benefits of section, wheeled the pt into the OR, gave her husband a set of scrubs, got her epidural placed, prepped her belly, brought her husband back to the OR to hold his wife's hand and delivered her baby. Her direct OP baby. And that whole time, before the pt got her epidural of course, she was walking and talking and not in any pain whatsoever. It was as if her labor had just stopped. As if her mind was like, Ok, well, there's no point to continuing like this so, I'm just gonna get out of the contraction mindset. And her uterus was like, Well, you know what? I'm tired anyway, and since I don’t need to help push this baby out anymore I'm just gonna take a ...little...break...zzzzzzz. The resident who was helping the doc out with the section turned to me and said "How far did she get?" "Fully and pushing." I said. "Really? She doesn’t even seem like she's in labor." "I know." I said. "As soon as she knew were going to section, things just kind of stopped."

In the end, the family was happy. I stopped by their room before I left the hospital for the night. They thanked me profusely. Though, still, I can’t put my finger on why. I was so worried the whole time that I was adding bad energy to the room by knowing deep down that there was no progress and not wanting to wait and wait and wait for hours until we were certain she couldn’t deliver vaginally and until everyone was dog tired. I know, I'm human, but I feel like I'm supposed to stay optimistic and positive and enthusiastic. And maybe it's only me that has those expectations. But clearly it's a theme for me, what can I say?

"We thought about it" the patient said, "And we're really happy about the way things turned out. We decided we definitely got our money's worth. We had all natural childbirth basically, and we also got a c-section! We had a doctor AND a midwife! We got a little of everything."

“Yeah,” her husband said. “We really wanted to be part of your “no epidural statistics” but at least the baby and my wife are healthy.”

“You’ll just have to be part of our VBAC stats!” I said. I felt a little better after talking to them but went home emotionally exhausted yet again. At some point I am hoping to quiet some of those self-doubting voices in my brain…I’m just not quite there yet…

I am on call Tuesday night with the doc who resolves anterior lips with c-sections. Already in a mini-panic.