This week, I had a great learning experience that ended with a healthy baby, but a cesarean section, making me sad, and wondering how I could have managed the labor differently. Clinical judgement is just that - judgement. Did I use good judgement? Did the doc? This was the kind of situation that I wish could be replayed with just one thing changed to see if the outcome was the same, or different. That's the thing - even if I had one thing differently, the outcome could have been exactly the same, but I will never be able to find out. Frustrating.
She was a primip (first timer) who presented in active labor around 10 AM. She labored well unmedicated until she reached about 6 cm, then got an epidural. (Epidurals are great for pain relief, but they do slow down labor. Most women don't know that, and many who do, don't care. But they do change the course of labor.) After an hour or so of rest, she was at 7 cm and I decided to rupture her bag of water, which was incredibly easy because it was ready to pop! Baby was low in her pelvis and didn’t seem to like that, showing us by lowering his heart rate to a range that made us nervous for 8-9 minutes. Her cervix changed rapidly after that, reaching at least 9 cm in less than 20 minutes. It was hard to monitor the baby's heart rate, so I put an internal monitor onto the baby's head, and still we had a difficult time keeping the baby’s HR on the monitor, probably because the baby had some head swelling. I also put in an internal pressure monitor because it was hard to monitor her contractions from the outside, and we added some saline solution to see if fluid around the baby would help his heart rate recover back up to his normal range. The nurse then called in the OB (without waiting to find out if we midwives wanted her to), and he pretty quickly decided to do a cesarean section.
As I said above, I wish I could have a “re-do.” I’d love to rewind and see what would have happened if I’d let her bag rupture on its own. I wish I had been more assertive, and seen if pushing could have helped bring the baby down. Yes, she was “only 9” cm, but that cervix was so thin, not all the way around the head, and that head was so low, so much already through it, that I think pushing may have just finished it off, and brought the baby down. She was a strong girl . . . but the baby's heart rate decelerations were making everyone nervous.
The baby came out screaming and had Apgars of 8/9 (10 is the highest!). Breastfeeding is going well. Mom is having some bleeding from her wound that we're watching closely. She's not all that upset about her cesarean, definitely not as upset as I am. Mostly, I’m beating myself up for not being more assertive and giving her a chance to see if pushing worked, and the baby tolerated it.
I did get to assist on the cesarean section, and remove the placenta. That part was cool.
No comments:
Post a Comment