“Stop that! That’s not in the birth plan!” Jerry nudged aside the nurse focused upon resuscitating his newborn son. Gladys didn’t budge, sweat beaded along her brow line. She resisted Jerry’s pressure while holding the tiny oxygen mask snugly over the infant’s face, gently squeezing the green ambu bag with her other hand … one, two, three.. forcing oxygen into the waxen floppy infant’s lungs.
“I told you, that’s not in the birth plan! The baby needs to be in Donna’s arms!” Jerry continued, standing helplessly at the bedside warmer while watching Gladys work on his son.
Gladys concentrated upon the task before her. She stopped briefly, placing the stethoscope on the baby’s chest to hear the heartbeat, and air movement. The baby was gaining some color, and taking an occasional gasp. She returned to squeezing the oxygen bag with her experienced hands…one, two three… whispering under her breath, “C’mon baby, take a breath now, c’mon, you can do it.”
Only moments before, Donna gave birth this baby. During a long difficult labor, she developed a fever requiring intravenous antibiotics. Her well intentioned, but slightly deranged partner Jerry, had at various times removed the IV tubing from Donna’s arm, and argued with nurses, midwives and physicians about care for Donna’s fever.
Jerry had insisted that antibiotics were delayed until Donna’s fever had lasted for several hours, rather than immediately as medically indicated. He refused to listen when told that such a fever was potentially fatal for Donna and their unborn child. At one worrisome moment when the baby’s heartbeat dropped, he had argued, “I don’t care if the baby dies! This is about my wife’s experience! We have a birth plan!” Susan, the hospital nurse-midwife finally had called in the obstetrician to more forcefully explain the necessity of Donna’s medical treatment during labor.
Susan now listened to commotion surrounding the baby warmer while she focused upon Donna’s perineum. Twelve inches of umbilical cord hung from between Donna’s labia. Blood trickled down. Susan reached her left hand to Donna’s abdomen with a green scrub towel, feeling if the uterus had contracted to release the placenta. She made eye contact with Donna and smiled, “It’ll be OK.” Then looked to see if the intravenous pitocin was running. An infected uterus doesn’t contract well, either to give birth or to prevent excessive blood loss. This uterus needed to contract and release the placenta to control Donna’s bleeding. Intravenous pitocin would help the uterus contract and minimize blood loss.
Birth is a sensory experience. Nursing, midwifery and medical schools teach algorithms of blood pressure, hydration status, medication titration, labor curves. Experienced birth attendants, however, respond viscerally to birth. They know the sounds and scents of a laboring woman, the touch of an effective uterine contraction beneath their palm, the odor of infection, the tone of a healthy postpartum uterus. Even before the first breath, a healthy newborn has a distinct muscle tone and color. The first few breaths may sound a little moist, but they should be effortless. Like a farmer evaluating healthy soil, an experienced birth attendant feels the texture of a healthy placenta and knows if the growing fetus was well-nourished.
Like finely tuned hearing of a blind person, Susan’s senses were heightened at the moment of birth. She’s often thought that birth is her greatest spiritual practice, the Zen of living in the moment. At the moment of birth, she absorbs sensory input and responds accordingly. The analytic brain had integrated didactic information from education, and now responded automatically to surrounding sights, sounds and scents.
Seeing the IV tube empty, Susan asked Fanny, the Registered Nurse, “Please check the IV to be sure it’s running.” With one hand feeling Donna’s abdomen, her other continued gentle traction on the umbilical cord to detect placental detachment. The cord felt hot, even through her latex glove. She thought to herself, “this baby has been baking in a febrile uterus, no wonder it’s too tired to breathe.”
Susan listened to her right, without turning her head, to the baby beneath Gladys’s hands. At last she was relieved to heard the muffled sound of a baby cry beneath the oxygen mask. Donna’s bleeding continued in front of her.
“Fanny, draw a syringe of methergine.” She asked the nurse for an extra medication to manage a hemorrhage. “We’ll also need to culture the placenta and send it to pathology.”
Susan knew that Jerry would object to placental studies to identify the infectious bacteria. Medically, it was important to identify the source and type of pathogen that caused this infection.
Jerry had insisted they bring the placenta home to dry and encapsulate it for deemed natural health benefits. This labor and birth had not gone according to the couple’s carefully designed plan. They would learn soon enough that much of parenting does not go according to plan!
Susan smiled as the IV began to drip its clear fluid into the tubing. Without releasing her hand on the uterus or umbilical cord. Susan then asked Gladys, “How’s it going?” inquiring about the baby.
“He’s beginning to breathe, still retracting though.” The sound of the ambu bag stopped, and Susan knew that the baby must be breathing on his own. She finally relaxed into a full exhale. The baby was breathing, but retractions meant the baby was straining to breathe.
Jerry interjected “Then give the baby to Donna, now!” Susan turned to see the baby still flaccid, with minimal muscle tone. The baby had good color now. Gladys massaged the baby to help it along. “Now!” Jerry demanded, beginning to push Gladys away.
Claiming authority in the delivery room, Susan turned to Jerry, “Jerry, Stop. Let us help Donna and your baby. We support natural childbirth when all is healthy. The hospital provides medical support when necessary. Donna and the baby are sick and need extra help. When things are stable, we will put your precious son into Donna’s arms. We promise!”
Jerry responded, “You’ve gone against everything we wanted in our birth plan!”
Still massaging Donna’s abdomen, and gently holding the umbilical cord, Susan took a deep breath, “Jerry, we explained each variation to you. Complications began before you and Donna arrived here. You’re still together, we’ve kept you informed each step. Donna had an infection. This was not predictable. We don’t want to call security to have you leave. Please, allow to us work for your wife and son. Donna needs your support now.”
Jerry had been pacing the hospital floor for hours, firing a series of nurses, midwives and doctors from his wife’s care. His uncontrolled anxiety manifested by obstructing care for his sick partner and child.
Natural childbirth can be an awe-inspiring experience for a healthy woman and family. As a midwife, that was Susan’s specialty. Susan appreciated this hospital because of their commitment to avoiding unnecessary medical intervention. The high volume and acuity of this setting dictated a careful distribution of resources. Those who need medical intervention or surgery were treated. As a nurse-midwife Susan provided natural support for healthy women, and could likewise assist those with complications
Only patients requiring medical intervention should be treated medically. Healthy women were encouraged to labor naturally without intervention. Susan standardly placed newborn’s directly upon their mother’s belly, delivered in low lighting, delayed cutting the umbilical cord for maximum newborn oxygenation. But when situations demanded otherwise, the high tech skills and experience of this staff could save a woman’s and baby’s life within seconds.
Susan’s thoughts were pulled back as Donna’s vagina gushed more blood, the placenta was beginning to detach. Donna leaned her head back with closed eyes, exhausted and febrile.
Jerry turned to Susan “Let go of that umbilical cord. We don’t want you to pull the placenta out, it needs to come out on its own.”
Fanny picked up the phone, “I’m calling security.” Fanny had patiently worked with this challenging situation for hours. She reached her limit.
Susan sighed thinking that knowledge is a good thing, but too little knowledge can be dangerous.
“The placenta is detaching on its own now. I’m just guiding the placenta out Donna’s vagina, not forcing it.” Susan explained to Jerry. Gently guiding the umbilical cord down and then up, along the angles of Donna’s pelvis, the glistening blue-white of placenta became visible at Donna’s vulva. Jerry stood still and watched..
“The placenta’s coming now. You don’t have to call security.” Susan told Fanny, she removed her hand from Donna’s abdomen to catch the hot organ in her hands. “Please massage her uterus.”
Fanny, exhausted as she was, reached over and massaged Donna’s soft uterus to minimize blood loss. Susan held the abnormally warm placenta in her hands, examining for tears, missing sections, the insertion of the umbilical cord, and presence of the entire amniotic sac.
She held the placenta up with one hand inside, spreading the membranes open, like a wet plastic bag “Here’s your baby’s first house. He was folded up inside this bag. The placenta worked as his liver, lungs and digestion. Now he works for himself. You’ll grow a new placenta for your next pregnancy.”
The excessive heat from the placenta, confirmed the need for special care with this baby. The placenta had good texture she thought, not shredding like that of a chain smoker, or someone with lifelong malnutrition such as placentas of many immigrant women from third world countries. Once the infection is resolved, the baby will be fine, thought Susan to herself.
She wondered if infection could have been avoided if Donna had not waited to come to the hospital until two days after her membranes had been ruptured. Studies show an increased risk of infection to mother and baby if labor does not begin within 24 hours after the amniotic sac ruptures.
In this case, Donna and Jerry stayed home for two days after the water broke, awaiting spontaneous labor. Susan wondered if they had secretly planned to give birth at home, unattended. It was obvious they were well read on the subject of natural childbirth, but unaware of medical complexities.
By the time Donna arrived to the hospital, she was already beginning to develop a fever and had not slept for 2 days. Her body was ill prepared for labor. Donna wasn’t yet infected upon arrival to the hospital, but her risk was high. The obstetric team augmented her labor with pitocin to bring on labor. Even then Jerry had objected to her IV presence interfering with their planned natural birth. Fortunately Donna’s fever spiked close to delivery so was able to continue for a vaginal birth, nearly three days after her membranes had ruptured.
Birth plans for a healthy birth are a good thing, just as are career plans or home remodeling plans. However, all planners must adapt when unanticipated circumstances arise. In this situation, lack of adaption can have fatal consequences.
Susan wondered how can one graciously teach common sense to idealistic young parents in the high emotion climate of labor and birth. Parenthood will be full of many more such unintended surprises and redirections.
“Remember, we will take the placenta home.” said Jerry as he reached for the stainless steel bowl holding the placenta on the delivery table. “We need to encapsulate it to help Donna’s uterus contract and protect from hemorrhage.”
“Jerry, please leave it on the table for now. We’ll discuss it in a moment, let me be sure Donna is stable first.” Jerry pulled his hand back to his side.
Susan felt Donna’s contracted uterus, like a firm grapefruit in her lower abdomen, a good sign. The bleeding slowed to a scant amount. Susan picked up a white gauze pad, holding it up for Donna to see, “This might feel rough, I need to touch you with this gauze to examine for lacerations and see if you need stitches, just warning you.” Donna nodded.
Everyone smiled as the baby finally released a lusty, but crackly, cry. Only five minutes had passed since birth. It seemed like an eternity.
Susan turned her head, briefly making eye contact with Gladys, “Good job, as always! Thank you.” Gladys and Susan quietly chuckled, as they both signed with relief. “We must stop meeting like this.” smiled Susan. This birth came uncomfortably close to a bad outcome.
Returning to her task at hand, Susan said, “Donna, you don’t need any stitches. You pushed well, and your skin stretched perfectly. Your bleeding is under control. I’ll just wash you off, then you can breastfeed your son.”
Gladys brought the baby to Donna’s extended arms. “Your son is beautiful. Congratulations.” smiled Gladys as she gently placed the newborn into his parents’ arms. Jerry and Donna gazed at their new son in their arms, with fatigued amazement and adoration. They had waited months for this moment.
Fanny said “Let’s remove your gown so you can hold your baby skin to skin. That’s the best for both of you.” Susan washed Donna’s bottom, then turned to put away her instruments. Fanny and Gladys made their medical notes.
“Why isn’t he breastfeeding yet?” demanded Jerry.
Susan sighed, “He’ll have a sucking reflex within the next 30 minutes or so. He’s really tired and still learning to breathe. He’ll breastfeed soon.”
Gladys added, “Because the baby and Donna were infected, after he nurses, we’ll have to bring him to the Neonatal Intensive Care nursery for observation and evaluation. We know that’s not in your plan, but infection wasn’t in the plan either. We’ll wait about an hour now before bringing him up. Breastfeeding is important; we do everything we can to support it. Donna will have free access to breastfeed even while the baby is in the NICU.”
Jerry looked to Susan, Susan nodded to confirm Gladys’s words. Susan thought once again how much she appreciated this hospital. Bonding and breastfeeding time is valued here; even a sick baby, if stable, has time with his parents before being brought to the nursery. Not all hospitals make such an effort.
Fanny placed the placenta into a container for the pathology studies. Susan decided to delay informing Jerry of the need to evaluate the placenta. Allow them this quiet time, thought Susan; we can burst this bubble in another hour.
Donna, as the infected laboring woman, had been amenable to changes as her labor proceeded outside of normal. Jerry vehemently resisted his loss of control throughout. Allow them this uninterrupted time to settle with their new babe could calm the unrest.
Outside at the nurses station, Susan documented details in Donna’s chart. Lydia, another nurse, began rubbing Susan’s shoulders. “Oh, thank you!” said Susan as her shoulders relaxed.
“You worked hard for that one!” responded Lydia.
On the postpartum order sheet, Susan scribbled for a social worker evaluation for Donna, knowing that controlling partners can often be abusive. Susan wished she could order a psychologist for Jerry.
When Susan finished writing, Lydia stopped the shoulder massage to ask, “The woman in room 5 is requesting an exam, she wants to know if she’s progressing. Shall I check her or would you prefer to?”
Susan responded, “Thanks for asking, Lydia. As the bedside nurse, you are more aware of her progress than me. Please would you check cervical dilation and let me know your exam. I need to stop for a breather.”
Deanna, another nurse handed the phone to Susan, “It’s for you. Triage asked to speak with you.”
Susan took the phone and heard, “ We have a woman in active labor for you. She’s having her 6th baby, with a history of fast labors. She’s 6 centimeters dilated now, appears to be moving fast.” Susan felt her adrenalin rise as she heard this news. The voice on the phone continued, “She had limited prenatal care and a history of cocaine use during the pregnancy. Her blood pressure is elevated.”
Susan sighed, “I’m coming now.”
The triage nurse continued, “And we also have a Cantonese speaking woman with ruptured membranes in early labor. She’s a normal midwife patient except for history of a previous cesarean section in China.”
Susan walked around the nursing station desk toward the triage area and nearly bumped into Teresa and Sean as they exited the operating suites. “Did you section the triplets?” Susan asked the obstetricians.
“Yes” Sean responded, “all went well.”
“Whew! How much did they weigh?” Susan asked, knowing they were very premature.
“We don’t know yet.” Sean responded, “But they’re breathing well and on their way upstairs to the NICU. The third one was so small I held her in my palm. She looked up and blinked at me. Amazing.”
Teresa interjected, “Did the infected woman in room 8 deliver?”
“Yes, all is well. Her husband has a lot to learn about priorities.”
Teresa raised her right palm for a high-five. “Good job! We really wanted to avoid having them in the O.R.!”
“No kidding! We aim to please” Susan slapped Teresa’s raised hand while walking past. “I’ve got to admit a couple in triage now. I’ve got it handled. Maybe we can catch up for coffee later?”
Sean walked down the hall, “I”m headed to the postpartum unit.”
“Call me if you need me.” Teresa said as Susan walked away.
“You know I will!” Susan called back over her shoulder.
Alisha looked up as Susan entered the triage area, “Sorry to have more for you, I know this has been a rough day.”
“Hey, no worries. Job security is a beautiful thing!”