The "crap pusher"

[whitewriter]

P4
Obstetric Hx: NVB. NVB. C-section for fetal welfare, NVB. All initiated with IOL (not sure why but Hx GDM, insulin) .
This pregnancy. Refused the OGTT. Perhaps this is why she didn't end up with an IOL booked.

Now 38+5
(Usually we would book for 39+0 so perhaps, we were 2 days out).

Was a booked c-section, but had permission (is this the right terminology??) -- clearance? Had clearance? to labour if she had an NVB before the c-section date came (hadn't yet been assigned but she was on a list somewhere).

C-section was listed for previous (despite the successful VBAC prior) and also for SPD (pelvic pain: Symphysis pubis dysfunction). Some women with SPD use 4ww depending on the severity (In my thoughts, about this idea, is oh the indignity but I suppose what choice would you have? To not walk?).

But also due to the ?LGA due to the refusal of an OGTT.

That's an ethical dilemma there as well. When does the rights of the woman to refuse a test (supposedly, she said she checked her BGLs at home as though she was a GDM as she knew how to in previous pregnancies -- but she would not have been placed in the diabetes clinic to oversee her, therefore the onus is fully on her to do so) at the expense of the fetus --- also putting her at risk for shoulder dystocia ... and my professional self at risk as the accoucher (and an inexperienced one at that) in a small hospital -- (These thoughts did plague me at 02:00).

BIBA due to fear of precipitous birth due to P4 Hx.
So here we are, its 0100 and she's come in labour.
I do the VE.

Man. I so failed that VE. all I could feel was bulging forewaters.
Seriously. I was like either she's 10 or she's more like 5-6.

So I ask the incharge to please reassess cause all I could feel were the forewaters (which I was sorta itching to break but also, if she was going to have a c-section or an epidural for it or an NVB that would be a bad idea...

The senior checked : 5-6.

Okay.

Woman agreed to NVB.

Okay.

Ordered the epidural as requested.

Sped things up as much as possible. The incharge was like you need to settle more (obs, fluids) prior to calling the anesthetist ! (So right but I was a little panic'ed and sleep deprived. I hate seeing people in pain... yeah this is the wrong job for me).

The woman admits to the anesthetist she's had failed epidurals before.

This ends up being the same.

I ask the woman how her other labours went and she informs me she's been told shes a crap pusher by the other midwives. And I'm like ... How is that possible you've had so many NVBs. And she's like thats what they said. I made a face (probably hidden by my mask) and I'm like well. We shall see but don't let that get you down.

Contractions die a little more 2:10 rather than 3:10 (strong though).

She's howling and on the gas. the epidural is 10% effective. Sorta.
I do another VE, I think shes 9cm or anterior lip.

I'm right this time.
O&G review.

Shes 9 and they "stretch her to fully" tell her she has about 30 mins to push -- they'll re-review.

The woman's back is in ++ pain. The incharge tells me to put her in all fours.
It releves it.

We start pushing.

She's terrible at holding her breath in.

So I sorta see what the previous midwife has said.

The O&G re-review. They do some guided pushing with her.

The O&G tells me to continue. They give her til 330am (prior to doing a c-section or a vaccume). Baby looks fine on the CTG. Decels with the contractions (the toco isn't picking them up,.. where in the world am I to have time to write that on the CTG when I'm in sterile gloves focusing on helping the woman to push is beyond me).

I like good guided pushing when an epidural is effective.
but this lady can feel everything I touch so I try the most hands off approach possible.

One finger in the vagina (lol) And I show her how far the baby is (about -- near my thumb, but on my 2nd finger.

Then 15 mins later, after some repositioning. More encouraging her to hold her breath. Her telling her husband to stop patronising her.

I put the
Crying.
Screaming.
Me staring at the clock.

Me thinking fuck me if we are about to go for a c-section my night is going to get longer and shitter with paperwork.
But I focus. Come on. Your doing it. I barely see anything happening in the perineum/anal area.

I warn her I will put the finger in again to check, and it appears the baby has closed the gap to the tip of my finger, halfway. I inform her of this, tell her your progressing. I'm not sure she's encouraged but she doesn't appear discouraged.

The perineum has a sort of scar on it, or rather, it appears her labia, then extends downwards in a line almost straight between her vagina and her anus. I think I should ask if she's had an episiotomy before but it doesn't look like an episi scar. Plus she's trying to focus on pushing (and crying and the tears and the back pain and we took away the gas and told her to not use it cause its reducing focus on pushing)...

And all of a sudden at 0314 I see a sliver of baby scalp and my hope is renewed.
All of a sudden all her pushes are amazing. And perfect. And she's doing it. And I'm legit positive as fuck.
And then the head's coming (thank god) and it's a freaking big fat head looking at me.
The peri is stretching like a large rubber (so good).
It comes.
Then 2 of the longest minutes ever as I grapple with the head to encourage the shoulders.
I try to stick my pinky in the armpit and it just doesn't go cause its tight.
I put my left hand just under her pubis seeing if there's space. There is. The baby coughs.

I think well it breathes that's a start.
The girl thats come to help me has pressed the assist cause I'm like why is the shoulder not fully coming.
One more push and its out. Incharge is here.
But Baby is out.
03:17.

Three minutes.
Felt longer.

I tell the woman later that she's not a crap pusher.

Someone has to right that wrong there. It was 4.2kg and not a peri tear or a vaginal tear in sight.

I've seen crap pushers in my time but never would I tell that to their face.

Remember the woman that begged for a vacuume delivery and then wanted to go home right after? I didn't tell her she was a crap pusher. I did tell her that due to the vacuume delivery we would have to admit her for one night and that she had to have the 40U syntocinon infusion which meant the IDC needed to stay until the morning ... all of which hampers one's ability to feel "Free"? post an NVB (you can go home 4 hours post if all is well and you feel confident with the newborn).

Why tell someone something that reduces their confidence in their own body's abilities?




We're now being told we need to ask for consent prior to obtaining a CTG.
I thought thats nuts. What happened to implied consent, same as how someone offers their arm to us when we motion with a blood pressure cuff.

We take ECGs.... they let us bare their chest for it, it then be considered implied consent. If a woman allows us to attach the monitors to her belly, is that not implied consent?

But I suppose the real discussion here is to know, if a woman understands the meaning of her consent. As in, CTG is a tool. It is not a be all and end all of all clinical decisions. However, it does play an important role in deciding for example, if we need to do a c-section for fetal welfare, if we need to call for an induction to end the pregnancy early due to concerns of fetal welfare (say if the woman was on anti-hypertensive medications). -- This becomes more dodgy when there's say reduced fetal movement (something we can't say for the woman)--- the CTG has these markings on it that show movement, however, we aren't asked to look at those at all. Even if a woman says the baby isn't moving at all and the CTG looks fine --- is this a gap? why don't we get trained to look at it? (The doctors look at that line though, I must say. So really, I haven't really payed attention to it).

I've had women come in for an episode of what they said was reduced fetal movement -- and then, it moves fine during the CTG and they're happy. But then the doctor has to review them because they had a risk factor (these include, first time mother, low socioeconomic status --- low education, seriously. How are we to ask the women if they are these, we are meant to just deduce them?! By appearances and history and story? Judgement again.)And so the doctor gives them a form to get an ultrasound done. Its Friday at like 430 pm. I thought they'd do an inhouse ultrasound but no, its just a form. So she has to pay for it, externally. The woman starts ringing around ultra sound places and none have a spot for 2 weeks! So then she comes back and tells the doctors theres no spaces for the weekend, not even a week (lol but when its reduced fetal movement we tell people to come right in, as per policy) --- and the doc says thats fine, just get it when you can get it ...

And it makes you wonder if they're getting taken seriously if thats the case.

So the CTG is reassurance in this situation. The ultrasound, is some "action" taken. Sort of like, instead of feeding or comforting a fussy baby, shoving a pacifier in their mouth to soothe briefly until it either falls asleep or gets angrier and refuses the pacifier.

I get that having a CTG done could increase one's chance of outcomes they may not want to have (say, a c-section). Just as how agreeing to have your blood pressure taken may put you on the path to being diagnosed with hypertension which could lead to life-long medications (which you. may or may not take appropriately, or may not actually help-- depending on how proactive you are about health markers).

Do we ever inform a woman that a CTG can increase the likelihood that adverse outcomes may be diagnosed? Same like those people who want to have ultrasounds all throughout the pregnancy just to "see the baby" or "check it out". If the morphology is considered normal (aka. the baby grew until 20 weeks and it has all aspects functioning normally, in what way would that fail later on down the track provided all else is normal?). Other than outright refusing to give them a form for an ultrasound (although they can go to the GP and try asking again) explaining that it's not necessary-- We leave that sort of information to be self discovered by the woman herself. Advocacy for one's body. For one's privacy. To have that "my body, my choice" -- which was funny, when the husband of the aforementioned woman in today's post-- mentioned when she was trying to push (literally) and she told him to shut up.

"My body my choice" : is that an accurate statement intrapartum in a SSH?

I'm not so certain.