whitewriter | The episiotomy I should have cut

G2P1, so second baby.
Antenatally well, nil complications.
1st pregnancy 7 years ago, NVB with episiotomy. Supposedly quick birth, listed as 4 hours.
Today, SROM at 04:00, GBS positive so for IVABS and induction.
Next available IOL slot was mine - so I came on the afternoon shift at 13:30 to start the IOL.

13:50 2nd dose of antibiotics given

14:30 VE to commence starting point for IOL: It wasn't an easy one but as I slid posteriorly I found a hole! It felt like I was sliding in the custard, and all of a sudden (imagine I Was feeling a leg wearing panty hose, covered in custard) my finger finds a hole in the panty hose and I can slide my 2 fingers in comfortably. I tried to stretch it a little too whilst I was there. Didn't feel like I could really stretch it, but it was quite thin. I tried also to get baby's position whilst I was there but as far as I could feel the head was quite high. So I did the traditional thing and minused one - it was probably 3cm, but I called it 2cm because that's what we do. However she was a multip (had 1 kid already) so 2 or 3 is moot - it could be 10 at anytime.

The CTG shortly afterwards started to do early declerations.

Dad really wanted mum to try out the bath tub, and so eventually she obliged. I was busy looking at the damn CTG and wondering if my baseline had risen from 145 to 155. It wasn't more than 10% - which it would have been if it hit 160 - but it was still a rise, something to keep an eye on.

I mentioned that if ur in the tub I will need to do your temp every hour to make sure it isn't rising. Dad gets worried the bath will cause a fever. I explain that fever can be caused by lots of things but I didn't want to miss it whilst she was in the tub. The water is kept at 37 degrees. Which is same as normal body temperature.

Looking back on this explanation, it could have been improved. The room temperature is more like 21-26 degrees and that's cooler than body temperature. Humans do well to regulate within this temperature. When entering a warm bath set to 37 degrees; that's the same temperature as human temperature but different to air temperature. This warm, hug feeling from the water is what is said to provide pain relief to mothers during labour. However as it is warmer than being in normal air; I need to check the temperature to ensure mother's body is coping well at this warmer temp, as a method of pain relief.

Does that sound more ... explainatory?

Anyways. (Did I mention how I dislike midwifery because of the amount of explaining and talking we have to do with women and their families that I never had to do in ICU? Communication amongst HCP to HCP is much less taxing than it is to women and their families).

20 mins of the tub and she's not keen anyways.

A warm maternal temp can attribute to a rising baseline in fetal heart rate. I check mums temp once we're out of the tub and the CTG is re-positioned on her.

Her temp is normal.

So. She starts involuntarily pushing. I look at her. Is she pushing? I haven't repeated the VE yet so I don't know if she's fully or what she is. I give her the gas to try to utilise as a mechanism to cope through this period.

I Look at the decelerations on the trace, (down to 120 from 150 for the duration of the contraction: its definatly 15 beats below the baseline for longer than 15 seconds).

The fetal heart rate is getting hard to auscultate via external doppler. I'm finding it actually much lower and lower in the abdomen than initially started.

I decide I should do a VE.

Woman looks much more distressed, CTG is looking crappy, doppler FHRs are lower in the abdomen, it's probably progressed.

This VE felt much more different. I couldn't really find the cervix but I still could feel a barrier- I was thinking 9cm, almost fully. I keep my fingers inside to feel what happens during a contraction, the head comes down a fair bit as she involuntarily pushes.

I get the VE repeated because I want to be doubly sure -- and I use this opportunity to get the senior to also put on an FSE for me since I'm having a horrible time getting the FHR.

It turns out there's pretty much late recovered bradys with each contraction.

My woman is getting more and more distressed.

It's not long before I'm sticking my fingers up there again and I can start to see head on view.

I press the buzzer.
She's on the gas.

She's pushing now (Clearly shes 10 if its head on view)

She's doing great its been 10 mins (not long at all) and she's like at this point last time, they cut me and the baby was out, and I tell her it's not the right time to make a cut yet, babys head is still high.

What she really meant was: I want an episiotomy- and I hope you or someone will do one for me so I don't tear badly. (May I take this opportunity to remind us all that she is in the 2nd stage active labour so communication isn't going to be great from the woman or her family at this stage).

Senior PM is with me. She gets me warm water for the perineum. I explain to the woman that I'll be using warm compresses to help the perineum to stretch (by the way, I think warm compresses are bullshit- but it's part of the PEACHES bundle, I'm new, and it's what we need to do these days. I'd also like to say that episiotomy is part of the PEACHES bundle too).

Fucking bundles.

EH hum. I'll continue.

So.
I'm looking at this perineum and it's stretching. And I think its stretching well. The head is descending fine - not slow, but not fast. I'm not putting much pressure on it and it comes down nicely then it stays for a bit: I leave it for one more contraction. Then with the next the head comes through and it must have been the chin that caused the (on later inspection we note) a 3a tear.

I've seen 3a tears sutured in the birth environment but for some reason, atm SSH is taking all 3a tears down to OT.

It separates mother from baby. Mother from father.

It's traumatic. I completely agree.

The registrar talks to the family about the repair. She mentions spinal as aesthetic for the repair. The husband mentions they are against spinal injections. The registrar palms off that discussion to the anesthetics doctor.

I'm busy trying to get notes done before we need to head to OT.

PM incharge says I gotta get an IDC in ( so annoying. Why now. We don't have any anesthetics on board; she's open down there' its gonna be bloody, I won't be able to see -- why not do it in OT right before the repair? I suppose the thing is if there's a delay, then this woman doesn't really have a way to pee right now except right onto her gaping wounds and the 3a tear). Anyways. So I glove up and try. I can't see a thing and its making the bleeding from the trauma worse. I wonder if the bleeding is uterine in nature, and a junior helps me determine no, its not (fundus firm and central) and so-- then the Dad whose face is all up in what we're doing is getting worried. About the bleeding. He wispers in my ear, like I'd have forgotten that she was anemic. I had checked her haemoglobin pre IOL and it was 120+ not terrible. We don't routinely do iron studies so her ferritin stores I don't know what it is.

It didn't look abnormal. It looked due to the trauma of the birth, I explained to the dad that the bleeding whilst looks like a lot, is still a normal amount and the only way to stop it was to go to theaters and do the repair.

(I don't know what he expected, a transfusion or some magic medication to stop bleeding.

OK hold it here. There is a medication that could be utilised but as far as I know, its not part of policy just yet and I don't even know if it's in the cupboard. Its transexamic acid. Honestly I didn't think it was that bad though, but I can get how in a smaller lady, that much blood loss would be a lot for her body side (but this lady wasn't in that category either).

To an outsider, that much blood would always look like a lot.

PM Senior saves the day by coming in whilst bit-less-junior-than-me was also trying to poke the IDC in whatever hole we could see - and somehow got it in one go. PM senior just knew where to aim.

Hats off to the PM Senior - she's fab.

So we run off to theater but not before Dad tells me that he wants me to know that they're both very against spinal injections and if the anesthatist wants to do one that he should be informed for discussion. I explain that I'll call him. Maybe I should have just brought him with me, but routinely, Dad is left with baby in birth unit, I take mum down. Handover to anesthetics, and then go back up stairs to finish off any paperwork then take Dad and baby to the ward.

So I'm in OT and anesthetics is halfway convincing mum to a spinal but she wants Dad involved in the discussion. So I'm on the phone to birth unit -- and before I know it I'm up in birthing, escorting Dad to theaters, to talk to anesthetics.

And I stay there and listen to the discussion and half do my notes whilst I'm listening - emat and all that. It's extensive - and largely based on anectdotal evidence from friends and family that all are against epidurals.

Now. As a midwife, in birth, I've seen epidurals do good and I've seen them do harm.

We're not in birth now. We are in the setting of perineal repair. A spinal/epidural in this setting is actually the best type of anesthetic that they can have - a GA is a terrible idea. A local probably won't cut it and if your here for a really good repair, you need to be VERY STILL. If they thought they could have repaired it with local, the woman should have stayed in the birth unit to get it done - rather than separating the family.

The gist is Dad tells the anestheatist that he's very unhappy that an episiotomy wasn't cut like last time (and almost the anesthatist thinks she's gone to OT for a repair before and therefore would have had a spinal) and I jump in and say no -- she had just an episi, and no repairs in OT.

That this was "one of his concerns about giving birth at SSH" that there wasn't a doctor to cut an episi is what I took from that conversation.

This probably harks back to the media article that says that all the consultants of SSH quit (true, but they do need to give 3 months notice). This is also not related to the episi.

Anyone can cut an episi - all you need is scissors.

I'm just listening to it. Feeling rather shitty and down. But whats done is done. Should I have done an episiotomy, probably should have. Considering she ended up with a 3a tear yes.

But in the moment, it looked like it was stretching well and I hoped we could get away with none. I was expecting a tear, and hoping for a 1st or a 2nd (and not a 3rd).

I did tell the dad this. He earlier also asked what makes someone to get a tear? Partially it is based on the anatomy of the woman I explained, some nationalities have shorter perineum's compared to others. It's not entirely always the case though. Maybe in that moment I once again, didn't explain myself well. A tear occurs due to many factors -- the descent of the baby, if its fast or slow, is there adequate time to stretch down there, the anatomy of the woman also plays a factor, how big the baby is... smaller babies would tear less, slower descent maybe more controlled and give the tissue time to stretch... (and that warm compress is a bullshit in my opinion still).

If you should or not, is a mix of : clinical judgement, personal preference of the woman, personal preference of the midwife, clinical experience of the midwife, the amount of support a junior midwife has with them in the moment.

It all boils down to those factors in a melting pot of what actually happens for your situation.

Anyhow he felt, the 3a tear was something that could have been avoided.

I wasn't entirely certain ( you can have an episi and still tear - btw).

Back in birth unit, at the midwifery station, with PM senior there, he asks about the episiotomy and how to ensure that they get one "next time". The PM senior tries to reason with him that yes the 3a tear will be documented and it will be noted, and taken into consideration with regards to the next birth, however having an episiotomy doesn't gaurentee that a tear doesn't happen ; not all women need an episiotomy - that usually with the 2nd baby things stretch better than the 1st time and it ends up being avoided.

In the end the Dad lets it go.

On my way home I start to think about his statement "this is why we had concerns giving birth in SSH". Which is not something I probed about at the time. I wonder if they read the bad press on SSH recently, and were concerned there were a lack of doctors and so forth.

In their first birth, it was largely medically driven. In India, this is the norm.

In Australia, whilst we are increasingly medicalised we do have a good midwifery service.

I really do want to go oversease and experience more midwifery.

It'll be uncomfortable. I've heard some interesting stories where white nurses have gone overseas on tours, and albiet not midwives (and considering that RN training in Australia can skip all women/pregnancy/birth/neonatal and paediatric training) and been forced to perform VEs or help review pregnant women because they have "status as a white person" in a 3rd world country.

Which is one reason why I wanted to do proper midwifery first before attempting any overseas work (I always felt like half an RN without a solid background in pregnancy/birth/children etc). The only way to bridge this knowledge gap in Australia is to either: do a double degree (only some states have it) or to train up post your RNs (what I chose to do -- very grateful to NSW Health for continuing the program. It's state run, its called midstart. You basically get paid to learn. 1 year intensive.)

I take the Dad and baby up to the ward; and Dad immediatly complains the room he's allocated smells and is dirty. I'm wearing a mask and can't tell - but also can't smell anything.

I handover privately in the nurses (? midwifery?) station (giving an account of my not so great afternoon) at the postnatal ward -- and then we go to the room, and the midwife agrees it smells and changes them to another room.

At the end of all of that, whilst the dad is trying to get us to call OT for an update on his wife- I bid him good luck, explain that his wife did wonderfully, and wished them well. He did thank me for my hard work.

What I would have liked to have said; if I wasn't so starved from having had no dinner and still feeling terribly about the episiotomy I didn't cut - was that he did a good job as advocate for his wife.

It's not easy; when your not one of us; who see this kind of thing every day. It's stressful when your worried about your loved one. She is important to you, and I can see that. Sometimes I feel in Western culture we are very ; individualised in our choices. Like, if there's something I wanted to do or needed -- like say, an epidural. It would be considered fully my choice and my body, and say, if a consequence was to occur due to it, then I would bear this consequence wholy - albiet although my partner; may also suffer say due to my loss of income or reduction in my mobility or ability to care for myself -- that the decision wouldn't ordinarily involve the other person as it was my body.

Whilst in other cultures; the decision may fall harder on the potential caregiver of the person.
In this case, the husband, as he would be the wife's carer from then on, should this be the case that a negative consequence occurred and therefore he was fully in the discussion of what type of anaesthetic for the woman to have.

So I did want to thank him for being an advocate for his wife. He was in no way rude to me, he was in no way condescending or malicious. He was being genuine, and spoke very well in an educated manner and in some ways I wished my communication skills were as good as his were.

Or indeed as well as the PM Seniors. She was a bomb. Love her. Even if she'll come to a birth room and ask what I'm doing if I'm doing guided pushing with a lady ("why is your finger up there?" lol.)

I left resolved to ensure I cut an episiotomy for all Indian women who had had one before and it being a term baby. It just seems like the right thing to do from now on.

I also knew I'd be up until 2am thinking about the episiotomy that I didn't cut.

That the consequences of the 3a tear - meant repair in OT which also meant:
- Mum and baby were separated
- Could be for a long enough period that the baby will be given formula
- That the experience itself is traumatic for the the couple.
- They won't forget this "negative experience"
- Now they've lost faith in midwives to ensure good outcomes at birth.