Each day at the start of our shifts we meet in the hub and the Charge runs briefly through the board before assigning staff to patients. The birthing unit I work in has quite a lot of high risk patients and the more red writing on the board next to their name, the more complicated their situation. On this particular morning there was a woman whose entire line on the board seemed to be written in red. She had everything going on: diabetes, high blood pressure, obesity, extreme multiparity, reduced fetal movements, anticipated difficult intubation, unclear scanning, lack of fetal descent, and unsuccessful induction of labour. It was one of those mornings I was thinking Don’t pick me.. please don’t pick me. I didn’t feel like dealing with extreme complications and even just the thought of reading through her mountain of paperwork was daunting in itself. Of course, Murphy’s Law prevailed and I was assigned to this lovely lass – let’s call her Annie. I checked my selfishness, smiled, and walked into the room.
The midwife I was relieving looked… relieved! She gave me the rundown of the clinical situation and a list of things that needed doing on my shift. Annie’s condition was indeed as complicated as it looked, but my job was actually going to be quite simple. I had to monitor a few machines, take some obs, and wait, basically. I introduced myself to Annie and her husband, briefly explained the things I would need to do, asked if they had questions, made sure they were aware they could ask questions at any time, and then sat down to read some notes. Husband soon piped up and asked me a question about the CTG machine. I explained how the machine works, asked if he had further questions and then that was it. I hadn’t done anything extraordinary by my explanation or my discussion with them and I didn’t think anything of it. A few minutes later Annie asked me a question about the progress of her labour and so I reviewed the plan with her again and that was that, too. Just doing my job.
Annie’s clinical situation was complicated in that the medical team needed to induce labour because her health problems were beginning to affect her baby, but they couldn’t do much to induce it because the drugs were negatively affecting her existing conditions. Caesarean would normally be an option in this kind of case but Annie was so overweight that anaesthetics would be difficult to administer and if anything went wrong it would be much harder to fix. The plan when my shift started was to keep the synto going on a low dose and wait for either her contractions to ramp up or her waters to break. The concern with Annie’s waters breaking was that she was now in her tenth pregnancy and her baby was not at all engaged, which means there was plenty of room for the cord to slip down below the baby’s head. If the waters break and the cord comes first it is a major obstetric emergency because when the cord is compressed by the baby’s head during subsequent contractions, the baby gets no oxygen. I explained all of this to Annie and her husband and emphasised the importance of her telling me if her waters broke so I could check that there was no cord.
The next thing I remember is Annie meekly requesting my attention and informing me that her waters had indeed broken. I asked her if I could look down below and felt a little mean for doing so, but sure enough – cord! I feel I need to explain the adrenaline push I got at this point with a little background. Caps lock, italics and bold print are likely to be required: you have been warned.
A major part of midwifery training in NZ (which is a specialised Bachelor’s degree in Health Science – no prior training required) is about what can go wrong in labour and birth. Of course, we need to know all the physiology and normal stuff but that actually takes surprisingly little time to learn. What is most important is that we are able to recognise when the situation is becoming abnormal and then involve the appropriate specialists at the appropriate time. We are the experts in normal birth and obstetricians are the experts in complicated birth. Anyway, at uni we had many a class covering obstetric emergencies and often there is a cascade of treatments you implement in an attempt to manage the situation. You may have 30 minutes or you may only have 5 minutes but you generally have a little time to think.
Cord prolapse is one of the major majors because there’s nothing you can do except push the big red button* and deliver that baby, STAT. If the mother is fully dilated and birth is progressing then you just get the baby out as fast as you can, however you can, within the next two minutes, otherwise you put the woman in this position (head down, bum up), somebody gets on the bed with her and puts their hand up there and pushes the baby’s head back to reduce the pressure on the cord with contractions, and you RUN to the caesarean theatre as fast as you can and give the baby the sunroof option. In our hospital it takes nine minutes for the fastest possible caesarean from go to woah, and if a baby is without oxygen it’s something like nine minutes until severe irreversible brain damage begins to occur. If you factor in the time it takes to decide on a caesarean (rarely ever instantaneous – I’d say in this kind of situation probably 3-5 minutes) then things are looking pretty grim for the baby. I’ve seen some twenty minute caesareans and they are intense. I can’t imagine what a ten minute one is like! A standard ‘emergency’ caesarean usually takes about an hour until the baby is born, but of course it depends on the urgency of the situation.
*This is the emergency bell. When you push it, everybody in the ward who is not absolutely essential in their current location is supposed to come running, even those in the tea room or in the toilet. Then one of the people to come calls the emergency phone number (often something like 777 or 888), tells the operator what’s happening in a keyword like ‘neonatal resus’ or ‘obstetric cardiac arrest’, then more specialists are paged and they come running too. Within about two minutes there should be at least a dozen very specialised people in the room managing the emergency. Pushing the emergency bell is adrenaline enough usually because of the significance of the action.
So this information was all very much at the forefront of my mind that morning, but up until this point the atmosphere in the room had been a sleepy one filled with the quiet sound of baby’s heartbeat from the CTG, the soft dawn light coming through the window, and the expectation of another long day of waiting. The medical staff were gathering in the hub for their handover and Annie and her husband were hopeful that they would come up with some additional plan to coax baby out. When I checked and saw the cord, all of that changed in an instant. I breathlessly informed Annie that there was cord and reached for the emergency bell, knowing full well that the dozen people sitting just a few steps away would come crashing through our door in a matter of seconds.
And crash they did. First the charge midwife, then the night obstetrician, the morning obstetrician, all the obs and gynae registrars, spare midwives, nurses and medical students; almost tumbling over one another in their haste. Everybody knew the basics of Annie’s story and they all knew this bell meant cord prolapse. Someone did an examination and informed the room that Annie was only three centimeters dilated, which means caesarean, except: except! This was her tenth baby. At this moment the intensity and the focus in the room was extreme. Everybody was poised, ready for action, but it all depended on whether Annie would be able to push her baby out. Do we call for a caesarean or don’t we? How is the baby looking on the CTG? What about Annie’s physical incompatibility with surgery? Can she push it out?
It is quite incredible to observe at these moments how calmly a midwife or doctor can converse with a labouring woman and her family, and how all the others present who are poised for action just kind of stand there like statues. I’ve been in both pairs of shoes and the moment is allAtOnce and somewhat eternal both at the same time. There is such a need for understanding of the situation by the woman and trust in the staff that they know what they are doing. Because Annie and her husband were on this journey and had conversations like the ones between us that morning they knew. They understood what cord prolapse was, how significant it was, what it meant for their baby, and the course of action that would need to be taken.
When the obstetrician asked Annie if she could push her baby out in the next contraction she just nodded and set her jaw. I don’t know if I’ll ever understand the physics of this kind of cervical dilation, or if it is even to be understood – was it her determination? a hormonal surge? her cervix being that stretchy? Whatever it was, less than a minute later a little boy was born, and he yelled at the indignation. He needed a little assistance to breathe because of his extremely rapid birth, but he was fine.
Soon enough everybody else had left the room and it was just me again with Annie and her husband and their newest baby boy. I was carrying out my usual postpartum checks and helping them with the baby as needed when Husband piped up and asked me what my name was. I thought this was kind of an odd question because I had two nametags on, but told him anyway. Then he said, “I’m naming my son after you.” Whaaaat?! After I picked my jaw up off the ground I asked him why. Didn’t he have someone more worthy he wanted to give that honour to? Who they had known for more than an hour? Who perhaps had helped them significantly along the way? He informed me that I was that person because I had listened to them and taken the time to explain things to them and prepare them in a way that nobody else had done. I was amazed at this and grateful that I was able to be that person for them, and rendered speechless. When I could think straight again I thanked him for the honour and suggested that he at least use the masculine form of my name for his son’s sake! So, world: meet Michael.
Note: I have absolutely no intention of being a proper writer, but this took me way, way longer to type out than I anticipated. Because I have read over it and changed it so many times it’s kind of gobbeldy gook to me now. If you feel like giving me any editing advice I’d be extremely grateful. Did I miss any major bits out? Does it jump around too much? Did I start to explain something but not finish it? Did I leave loose ends? I want it to be a good reading experience. Please try to keep things nice if you can, and thank you very much.