Since my last post, when I was ready to quit midwifery school were it not for the spraypaint-gold handcuffs of debt (I just made that one up. Really. Pretty good, huh?) things have gotten better.
But first they had to get worse.
Saturday morning I was paged at 4am. This was especially disconcerting as I’d gone to bed at 1:30am — my preceptor had introduced me to Extras, the other Ricky Gervais BBC comedy, and I’d found it necessary to watch 5 in a row.
So: at 4am the phone rings and my head is thick and dark and the nurse is saying things to me like “Blood pressure 140/89″ and “+4 proteinuria” and “late decels.”
And what would I like to do?
I stumble out of bed. “Right,” I say.
“Labs?” the nurse prompts.
“Yes, yes, labs.” My mind clears somewhat. “Order the liver function panel.”
“We don’t have a liver panel,” she tells me. “You need to tell name each one.”
Looking back, it seems like some kind of a joke. But there I was, scrambling in the dark for my SOGC (that’s ACOG to any yankees out there) guidelines while muttering “ummm…ALT…Creatinine…Platelets….”
So, to translate more fully: we had a first-time mom not yet in active labor who had high blood pressure, protein in her urine, and whose baby was showing heart decelerations with slow recovery during contractions.
High blood pressure (we look at the bottom number in pregnancy, and anything over 90 is cause for an obstetrical consult) + proteinuria = pre-eclampsia.
Pre-eclampsia is very, very bad. Should it develop into eclampsia –and there’s not usually an obvious dotted line that one can follow to know that’s happening –the mother can seize. She and her baby can die.
Midwives do not manage pre-eclampsia. We are vigilant for any signs & symptoms, and should any develop in our clients we refer immediately to an obstetrican. The hospital I am currently working at is a small semi-rural hospital. We don’t have any OBs or any pediatricians, and we don’t have the drug management for pre-eclampsia.
I arrived at the hospital and met with the client. She was still in early labour, and remained calm as I explained that we might be transferring her to a hospital in Edmonton.
Then I took a look at the strip. The nurse had said 4 late decels. I saw 1, and nothing concerning since then.
The proteinuria was worrisome. The BP was still below 90 for diastolic, but we didn’t want it creeping up. My preceptor suggested waiting for the lab results. By 6 am the labs had arrived–flawless. Pre-eclampsia can cause multi-organ failure, and liver enzymes in the blood are one of the signs of this. With more information in hand, I again paged my preceptor.
She suggested I call the OB on-call at one of the Edmonton hospitals. It was an interesting chat. Here I am, a student midwife thinking: Creeping BP! Proteinuria! Oh, and I was pretty sure I’d felt clonus, a completely bizarre symptom which is detected only be bending a woman’s foot all the way back and then letting go. If it jerks in quick beats rather than simply falling forward it indicates neurological system damage.
But OBs see this kind of thing all the time. She noted the good labs, the BP still below 90, and the blood in the urine which could account for the proteinuria. (For the record: I’d thought of getting a clean-catch catheter sample, but no one else had wanted it.) She basically dismissed my account of clonus. “Keep her,” she told me, carefully underlining what I should look for and what would warrant transfer.
All right then. Keep her.
We did keep her, until 9:21 that evening when she delivered a beautiful baby boy.
Just in case you’d lost track: I was paged at 4am. The baby was born at 9:21 pm. I did get breaks during the day and 2 quick, completely tensed-up naps (has anyone ever slept well on a hospital bed without the aid of drugs? Ever?), but it was a slog.
Add that to the list: birth can be beautiful and it can be dark. And sometimes, it can simply be a slog.
This baby was posterior, which means it’s not in the best position and so slows things down to an extreme. But it also meant it was a real midwifery birth: we used all the midwifery tricks to help turn a baby. So many c-sections happen at births like this one. Progress is slow. An epidural is put in place. The pelvic floor relaxes and the woman can no longer move and that baby is now not going to turn. Things go on and on. Sometimes surgery is ordered just for slow progress, other times they wait until the baby stops being able to tolerate each contraction. Either way, the writing is on the wall for hours.
(And no, I’m not anti-epidural so don’t get all worked up. Epidurals can be amazing, and sometimes they can even help a posterior baby. But do women realize that epidural = IV, electronic fetal monitoring, catheter, likely oxytocin augment, increase in operative delivery (forceps & vacuum), increase in surgical delivery, and increase in tears? When you put it all together, that whole knee-jerk “Natural birth=pain, Epidural = comfort” equation doesn’t add up.)
Where was I? After all was said and done the new mom & dad started singing my praises. Which was, well, lovely, although it was the awesome midwife who got us all going on the posterior-positions, the dad who provided incredible support to his wife, and, most important, the mother herself who coped like a superstar through it all.
Every job has long, hard days. Every job has slogs. Not every job gives the satisfaction of passing a newborn baby to its mama and watching the wonder & amazement of that first meeting.
And then yesterday. Well, this is getting too long to be blog-worthy but yesterday I arrived to a birth just in time, literally, to glove and catch a lovely baby girl, and then had another birth where I had only 1/2 hour to wait before handing mom her baby.
(“Show me the vagina!” that woman said. It was her 4th birth, and she already has 3 boys. We helped her pull back the blankets. [We midwifery-types never announce the baby's sex, leaving it for the parents to discover.] A boy.)
It’s always a nice surprise when the paperwork takes longer than the births.
Plus, I got a lovely lunch in Edmonton with my friends, and a first-rate game of hide & seek with their adorable 3-year-old son, Timothy, who does that hilarious kid thing of not only always hiding in the same spot, but also hiding completely out in the open with a blanket 1/2 covering his body.