Yesterday I worked a 24 hour call shift at PIMC. This was the 3rd shift in a row Ramona (one of the midwives) and I were working together. The last 2 had been rather slow, and no births. Saturday morning started out slow as well, and we twiddled our thumbs, praying someone would walk through the door in labor.
The first one (let's call her Shawna) to walk up the to nurse's station in OB Triage (OBT), wasn't really in labor yet, although she was having some scattered contractions and had started to dilate. So, we sent her out to walk for a couple hours, telling her to return around 11am (or sooner if contractions were stronger, her bag of water broke, etc.).
Next one to come was Sandra, 25 years old, 41 weeks, G5P3 and here in OBT for her scheduled NST/AFI (Those check the baby's reactivity on an electronic fetal monitor (EFM) and the amount of amniotic fluid surrounded the baby.) I had seen her in clinic on Wednesday and this woman was ready to have her baby, except for one minor detail: she wasn't in labor. I had stripped her membranes, scheduled her for the NST/AFI, and told her it would be great if she decided to have her baby Saturday while I was on :-) . When Sandra walked up to OBT, it was obvious she wasn't laboring yet; she looked to happy. So we did her NST/AFI, and she was pretty much begging us to induce her. Well, we didn't really want to, but then her AFI came up a bit low, so we didn't have much choice. We admitted her to labor & delivery and started Pitocin.
Our 3rd woman, Andrea, walked in before we finished Sandra's AFI. She is 19 years old and this is her first pregnancy. She looked the most serious of the bunch about being in labor, and was actually having some decent contractions. I did a vaginal exam and found she was 4-5cm dilated--another candidate for admission! Ramona and I were getting excited now. Maybe we would actually have a couple of babies soon.
So Andrea's in room 44 and Sandra's in 42. We figure it could be a close race, since Andrea was a first-timer, and usually they take a bit longer than the women who've had a few babies. Well, both of them ended up taking a bit longer than we had figured. Andrea's dilation progressed fairly well for a few hours, then slowed down as we recognized her contractions just weren't going to be adequate to get this baby out. So we started Pitocin on her as well. Meanwhile, Sandra, her mom, and sister were lounging in 44, looking altogether too comfortable for someone whose labor is being induced.
Andrea's main problem from her pregnancy was that she probably had gestational diabetes, but had never been followed up for it or given any medicine. She was a big girl already, and the baby looked like it was going to be at least 9lbs. So, we prepared for a shoulder dystocia (when the head delivers but the shoulders get stuck behind the pubic bone). Sure enough, she was finally ready to push around 6:30pm (just before the nurses change shift), but we were ready with our action plan for a dystocia if needed (it is a very scary situation). She pushed well, slowly and evenly, but it wasn't long before we saw the turtle sign: a head that comes almost out of the perineum, then recedes back into the birth canal. This is a pretty sure sign the shoulders are getting stuck. Finally, the head delivered, and we reached to deliver the rest of the body too, but it just wasn't coming. Quickly, Ramona and I changed sides, the nurse and I pushed Andrea's legs up as close to her chest as possible, and put some pressure above her pubic bone, hoping to push the anterior shoulder down and under the bone while Ramona worked on tugging. To no avail, so Ramona goes in for the posterior shoulder, trying to tug it down and out. Just was we managed to get some other staff in to help, Ramon frees the shoulders and delivered a very large baby boy onto his mother's abdomen at 7:08pm. Phew! There was an audible sigh of relief, although the work wasn't quite done. Baby Jacob needed a bit of resuscitation, but soon perked up quite well, and weighed in at 9lbs 4oz. Andrea didn't need stitches for tears, and soon we were able to leave them alone to rest. When I checked on her this morning both her and Jacob seemed to be doing well.
Meanwhile, Sandra is taking her sweet time about progressing in room 44. The nurse keeps upping the Pitocin and we broke her bag of water just before the drama with Andrea nextdoor. Well, things finally started moving, and we asked Sandra if she wanted the epidural. (On admission, when we asked her about pain meds, she firmly asserted "Of course. I figure they didn't make 'em for me not to use!") But, she's changed her mind. She figures the pain isn't too bad yet. Well, 4o minutes later, dilated to 8cm, she decides she wants the epidural, and we told her its too late--its almost time to have this baby! At 10:30pm or so, she easily pushed out an 8lb 14oz baby girl--long and beautiful just like her 5'11" mom. That was a nice birth to end the evening on, and after cleaning things up, we congratulated Sandra and went to bed.
2 hours later, Janice, the OBT nurse comes knocking on my door saying there's a woman in labor. I thought, oh, maybe Shawna--who had never come back after walking--finally decided to show up, 12 hours late. No, it wasn't her, but Danielle, a 26 year old, G7P5, 4o weeker with no prenatal records, except a visit to OBT in January when she had fainted at a casino. She was positive for illicit drug use too. I woke up Ramona, and before we had really made a decision about whether or not to admit her (contractions were pretty far apart), the nurses had called admitting and lab. So we admitted her. (Well, we also were a bit concered about her EFM strip, and she had progressed from 4cm to 6cm in an hour). Well, she wanted an epidural right away, which of course slowed down her contractions to next to nothing. We started Pitocin on her, and went to bed. I got up 2 hours later, and was pleased to find she had progressed to 8cm. Back to bed. Up at 6:15 to check on her again. This time the nurse tells us she's febrile (103.2) and she's got the shakes. Dilation is complete and baby is almost out (+3 station), but Danielle still can't feel any pressure and has no urge to push. We started triple antibiotics to cover an infection (we were suspecting chorioamnionitis) and after the first 2 were in, we knew we had to get the baby out. So we got Danielle pushing, and by 7:08am she had a baby girl! No problems there, except that the baby had a bad fever too (which we expected), and was whisked off to the nursery for an IV and some antibiotics. Well, now we had to get the placenta out (because that was where we expected the infection to be). The placenta was stubborn though and would not come! 35 minutes after delivery, still no placenta. Ramona went in to try a manual extraction (where you sweep the uterus with your hand to pull the placenta out, but to no avail. So we called in the MD (who had just finished a c-section). It took him 2 long and persevering tries, but finally the placenta was out and we were able to let mom rest. Placenta got sent for cultures.
By this time Ramona and I were exhausted, and more than happy to turn things over to Linda, our replacement. What a night!
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