After a flurry of births we don’t have any more women due until June 30th, which means that, although I’m on-call another 24 hrs, it’s unlikely I’ll attend another birth in Stony Plain.
So I’ve been doing some exploring: chowed down on gravy & fries at the local diner; hunted for junk as a massive antique/garage-sale store (bought the juice glasses of my dreams, though they still have to survive 4 flights before they’ll be tucked into my kitchen cabinet); and have a date with Gillian to lay in the sun at Alberta Beach and tour the Spruce Grove Grain Elevator:
I’ve also been reflecting a bit, thinking through what I’ve learned these last 6 weeks. I take it for granted now that I’ll manage a birth on my own, consulting with a midwife when I think it’s in order. I also call the midwife when the woman is close to pushing, but generally she’ll just lurk in the background, there if I need her but otherwise out of the way.
I know where I still need to improve. For instance, I feel comfortable with the actual manuevers of suturing, but still struggle to visualize that post-partum perineum: what goes where, and how.
(Did you just unconsciously cross your legs reading that? I did writing it.)
A less cringe-worthy skill: navigating fetal position from the suture line & fontanelles. Definitely still a serious work-on.
Then there are the emergencies.
As frightening as the post-partum hemmorhage was, the drugs stopped it fast.
(“Get me the misoprostal!” my preceptor called out, and thank goodness I’d noted where it was stored, and knew the dose. What I hadn’t noticed: each 200mcg pill was sealed tight in its own plastic baggie. We needed 800mcg, so that was 4 tiny and seemingly rip-resistant plastic bags to pry open while this woman bled. My feedback from that episode: keep an 800mcg dose ready. I heard yesterday that they now had tiny envelopes with 4 pills each. So look at that, I’ve even changed hospital protocal.)
But shoulder dystocia can’t be stopped with a drug. And even more than PPH, it flat-out terrifies me.
Of course emergencies are frightening for a reason, and it’d be fool-hardy for any practicioner, no matter how experienced, to feel bold about them. (Have I ever said ‘fool-hardy’ before?)
But then there are those gray areas. Ruptured membranes with a GBS- woman: do you wait for labour to begin, or crank up the oxy, and if the former, is your limit 12 hrs? 18hrs? 24hrs? Labour dystocia: do you augment? Rupture membranes? Will positions help, and, if so, which ones? Post-dates: do we wait or get labour going? Fetal heart rate decelerations in 2nd stage (pushing): is it just the baby coming around the pelvic bones, or is it time to demand aggressive pushing and call for a vaccuum?
Perhaps it all boils down to: When should we be hands-off and when should we be hands-on? When do we watch, and when do we act?
In some ways, gaining confidence managing those gray areas is the most difficult. We look to the research literature to guide our recommendations, but quality research isn’t always available or applicable. At those times, a practicioner needs to act on her own experience and intuition. And experience & intuition is just what we newbies lack.
So that’s where I’m at right now. But I’ll end this post with a great birth story, which happens, conveniently enough, to be about the last birth I attended.
Gillian was the primary on-call midwife, and I was playing the role of nurse/”2nd midwife.” (At a home birth, there are always 2 midwives.) The 2nd midwife takes fetal heart tones after every contraction or every 5 minutes (whichever is more frequent) during the 2nd stage of labour, documents, notes the time of delivery, gives the oxytocin injection if active management is chosen, assesses the baby and initiates resuscitation if necessary, notes the time of delivery of the placenta, assesses the placenta to ensure it’s intact, and just generally assists the primary midwife–following orders as needed.
(Any questions? Everything mentioned there is explained elsewhere on the blog. So, if you’ve been reading closely….)
So. We had two women in labour: a multip and a nullip, both at 6cm when I arrived.
15 minutes after I arrived, the multip reported an urge to push. Gillian and I got into our respective roles, but after a few contractions Gillian checked her and found her to be just 7cm dilated with a posterior babe. Meantime, our nullip was getting pushy. So we left the multip with the nurse and headed into the other room.
Nearly 2 hours later, our lovely first time mom was getting very close to delivering her baby when the nurse knocked on our door to say that our other mom was now wanting to push. I had gotten so involved in my role as 2nd attendant at the nullip labour that my preceptor had to say, “Ilana, aren’t you going?” before I realized that I should go take the primary role next door.
I walked in to find the client in the tub, with her husband, sister, mother-in-law, and mother gathered around.
Remember my first birth in Stony Plain, when I was told the dad would catch and had to pull aside another student to ask how I was supposed to make that happen?
Well, this time I asked, “Whose catching this baby?”
There was a moment of surprised silence, and then the mother of the labouring woman stepped forward.
“I would love to,” she whispered.
I had her sit beside me, and told her what we’d be doing.
“Do I need gloves?” she asked, motioning towards mine.
“Nope,” I said. “It’s your grandchild.”
A few contractions later (and 7 minutes after a boy was born next door), I placed my hands over the grandmother’s and together we guided the baby out and up onto its mother’s chest.
There was a collective cry of joy & relief. Then the mother asked, “What is it?” pawing at the blanket to see what make & model of babe she had.
I peeled back the blanket and she took a look. A girl.
Everyone screamed and shrieked and laughed and stomped and hollered. The dad’s face was wet–actually wet–with tears.
It was the first girl to be born to his side of the family in 50 years.
What a priviledge to share in that moment.
So, so long Stony Plain, and thank you to the women who let me into their lives & labours.
One final local picture:
Who knew, but the first sheriff of Stony Plain, commemorated on the mural above and by a statue outside the old railway station, was none other than a Mr. Israel Umbach. I’m thinking he was MOT, for sure.