I am SO exhausted, what a night.
Poor girl. Wanted to go natural, but very reasonable and flexible patient. They were self-pay, planning to go home in 24 hours, etc.
She was 5cm when my shift started. I kinda had a funny feeling when I first met her, that this wasn't going to be easy. She's short, with short legs and arms, but average size.
SO, la dee da, she's doing it all, birthing ball, tub, standing, walking, etc, no progress, at 2100 we arom, ok fine and dandy.
at 2330 she starts involuntarily pushing while squatting in the bathroom, OK, GREAT this is going well.
at midnight, she's complete, yeah!
at 0100, we've had some variables mom has a temp and hasn't made much progress, despite pushing in all sorts of positions, she's just not relaxing, she's fighting her body.
So, we get an epidural and rest, she has some lates, they resolve, but overall things are "ok"
at 0315, we start pushing again, head has moved, yeah! At this point, ive never checked her, the midwife has been at the bed, almost continuously, so i really dont have a feel for things, other than what I can see, which isn't much other tahn some occasional bulging
I've not eaten other than a half of piece of pizza and a few sips of water, im getting tired!
at 0515, she's still not made much progress, she's squatted, s-s, all fours, every type of pushing I know how, she has a great epidural, she can move, and feel pressure but she's comfortable, still feels tense to me and i finally checked her and it feels like a tight fit and baby feels OP
SOO, at 0545, variables continue, overall reassuring, mom's temp hovering around 100. she's getting exhausted, obviously, doc has seen strip, evalutated things, ok with continuing until 0630.
She really is starting to proress and crown, maybe a smidge.
baby is really decelling more, does'nt l ike mom's back at all but she pushes better on her back.
Doc finally comes in and evaluates again, agrees to try kiwi, but is hesitant, she tries, 2 pulls, baby comes to crowning and just sits there, doesn't budge, 2 popoffs, and baby slides right back up, doc says it's just caput coming down,
FINALLLY AT 0650 we wheeln into the OR and of course it's shift-change and there's not enough help, we need 4 RN's to go into the OR, because there's no tech and we need an assist.
THis poor patient, she's doing good, tho, very stoic, dad is crying she's not said much of anything the whole night.
SO, you'd think this baby would have a nuchal, be big, acyclytic (sp) SOMETHING, but nooo, straight OA, 6-1, no nuchal and the poor midwife, has to work all day today and nearly dislocated her fingers pushing up on the head, there was an audible POP when the suction was released becuase that baby was wedged in there so tight.
mom and babe were fine when I left, but WHEW, I"M POOPED and poor mom just did everythign we asked of her and pushing her little heart out.
Sometimes it's just NOT meant to be
Dec 1, '06
That is when it is so good to be living in this day and age when there is the option of a c/s. I have also had a pt like this. I had to go under and push that head out. She should be so proud of herself for giving it her best, but also happy there was the option of the c/s. I hope she doesn't feel like she failed. I hate that. It really makes my heart go out to these pts.
Dec 1, '06
I always hate when this happens especially when you have tried everything then figure there has to be some explanation and out comes a tiny baby no cord no nothing. Thank god for the option of C/s though. Moms and babies use to die.
Dec 1, '06
There's no chance at all that she would have been allowed to go that long under those conditions where I work. After 2 hours, minimim, with temp and all, I can guarantee you she'd have had a c/section.
I'm all for letting a patient do what she wants, but not at all sure I'd be comfortable with doing it that long with what you've described.
Dec 1, '06
Never would happen where I work. About 3 hours' max is all we go in most cases, and only where there is real progress. This is why I let women "labor down" as much as possible (this makes it necessary for me to fudge dilation to MDs at times, shame on me). But it works in so many cases-----especially in the presence of regional anesthesia. I never have a woman push unless the urge hits her, or the baby is moving down well----unless it's for a trial. And if there is zero progress after 1 hour, I am on the horn to the OB, who comes to evaluate. Fortunately ours are not TOO quick to cut most of the time, and will give the ladies time to deliver vaginally. But 7 hours? THAT is WAY over the top. Can't say I have ever seen this in the hospital----our docs would not allow it to ride that long, even if the moms wanted to.
Dec 1, '06
Shame that went on for so long. It is kinda obvious from what you wrote that the baby was just too fat to fit. I am also one to let the 'labor down' thing happen, and really use urge to push dictate my actions, rather than announce 'SHE'S COMPLETE' and start pushing without an urge. (just makes for tired mommy and nurse). That baby would've come down on its own if she had a great epidural...and as Smiling BluEyes said, after a while of being complete, and no head coming down..you have to evaluate. If they are really comfy, I may go a bit longer, to give them the old college try...but baby also has to be happy. This baby was getting tired, and I think the head squishing was a bit too much for that long of a period of time. I know this would NEVER happen in my land!!!
Dec 2, '06
Our Ob's will let moms go for that long depending on the situation. If mom is fine and comfortable, baby is doing well it avoids alot of unnecessary csections. We generally wait for mom to have an urge to push, but some never really do get an urge so they start when baby is low. If no progress is made in 2-3 hours then we have then rest for 2 hours. Then they will resume pushing for a couple more hours and that has usually done the trick. If at that point no more progress has been made then the alternatives are consideed. Bear in mind that our ob's are in and out assesing the situation and if mom spikes a temp or baby start to look unhappy it is the end of the line much quicker then that.
Dec 2, '06
Not to change the subject here, but you made the comment about her being SELF PAY so I assume that is part of the reason that she (your pt.) wanted to 'go natural' and 'go home in 24 hrs,' ect.
I have a neighbor who was just had a baby a couple weeks ago and was in the same situation....no insurance and she made (just barely) too much income to qualify for medicaid or any other kind of assistance program. For this reason, she 'nickel and dimed' her prenatal and L&D care, refusing an ultrasound, and other lab tests. She said she was really hoping to be able to make it w/o and epidural b/c she knew they were expensive. She is now stressed about how to pay for the hospital bill - 7,000+ for a normal L&D.
I just don't think it is right....considering how many childbirths are paid for by medicaid. I read that close to 30% (childbirths) here in Colo. are paid for by medicaid. Just not fair.
Dec 6, '06
I'm with you SmilingEyes. I'm glad to see someone else out there believes in "laboring down". This is what I learned a long time ago (when dinosaurs roamed the earth). But where I work now, it's complete - push NOW, can't feel the "spot" 0 too bad- push for 2 hours- then a C/S.
I can't call it pushing, if mom really isn't participating. I too fudge dilation, mostly to the patients, because they learn (from everyone and their sister) that once you're complete, you have to start pushing. Even if I have to wake them up to do it! I believe in mother nature doing most of the work. Pushing is exhausting, whether for 15 minutes or 3 hours.
Most of our MD's are coming around to the "laboring down" theory. They don't like to sit around for 2 hours while their patient is pushing, they get too antsy to get in there and do something, like vaccuum or c/s.
Dec 8, '06
I'm all for laboring down as well, and it's just so weird, cuz everything was going so well with this patient. She went natural and started pushing involuntarily while squatting in the bathroom (using the bar to hold onto) then things just started going down hill, she really wasn't in labor that long, but we started an IV because of the low-grade temp and she seemed dry, even tho she had been drinking fluids all day. After some time of pushing and not much progress, despite pushing in SEVERAL different positions, baby started with d-cels. so we opted for an epidural, and let mom rest, decels continue, temp of 100, uterus getting tired, ctx's not that strong, and irregular, not much progress, start pit, overall reassuring but not a great pattern. She did make progress after resting with the epidural and then began pushing again, i really thought a whiff of pit would do it, but no such luck.
yes she was hoping to avoid the cost. that baby only weighed 6-1, i really hope they aren't too upset with the outcome and aren't too stressed with the cost, I honestly haven't ANY idea what her delivery cost.
I remember hearing it was around $4000 for a SVD with epid? but how much for a c-section?
Dec 9, '06
Gee... sounds like you were the nurse I worked with at the beginning of the week
Short of tying a rope around the baby's head we did everything I could think of for my patient before we called a C Section. She was actually complete for about 8 hrs. After 2.5 hrs of pushing she got a bolus of epidural medicine so she could rest... we started pushing again a few hours later.
Baby never had a decel. Parents are happy that they were allowed to try as long as they did. It is exhausting...