Monday, October 19, 2009

Even Grand Multips can Get Big Cervical Lips

I'm sitting at our little table in our cozy studio, just finished a bowl of chicken and vegetable soup. Sounds strange to be eating that here in the South Pacific, eh? Well, today is the perfect recovery day as it is gray and rainy outside and I was at the hospital into the wee hours of the morning, so needless to say, it's a slow morning. Filled perfectly by homemade chicken soup.

A busy night at the hospital last night. It started with the phone ringing in the maternity ward, which I have gradually acquired the confidence to answer as my Bislama has improved. “There is a lady coming” was all that the voice said. In walked a young woman teetering on active labor with her first babe. I checked her and her cervix was very favorable for labor: 3cm, very thin, with a well-applied head that was nicely engaged in her pelvis. After checking the babe’s heart rate and monitoring her contractions, all the while rubbing her back and offering reassurance as best we could, we made her a bed and encouraged her to walkabout, drink plenty, and eat if she liked and to tell us when she felt like pushing.

Then before we were even finished cleaning up the Admission room, in walked another woman in early labor. This woman falls into the category of grand multip (as many women here in Vanuatu do since it’s so common to have lots of babies), pregnant with her 5th babe. She reported some bloody show the night before and that morning and said she recently started feeling some mild pains. I checked her and found that her cervix was very soft and stretchy, but only 2cm dilated, at least 1cm thick, and the babe was well engaged. Now if the first time mom who had come in had had a cervix like that we probably would have sent her home to continue laboring and thin and dilate the cervix since that’s a lot of the work of early labor (unless she lives far away), but with a multip, a grand multip at that, that would be a big mistake for things can move very quickly, even with a cervix that is thick and not very dilated. And so as this mom laid on the exam table while we did a tracing of the babe’s heartbeat, she had 5 good strong contractions . I thought, yes, grand multips, they keep you on your toes. Never assume anything and trust the mom's instincts. This mom knew today was the day.

After we encouraged the experienced mom to walkabout and provided her with a bed in the antenatal room, I went to the tea room to have some dinner and watch some French soap operas I'm not a big TV person in general (on second thought, perhaps that is an understatement, being that I haven't had a television for over 10 years now), and I can't understand French, but it's interesting to try to pick up what I can from the body language and intonation. Never a shortage of those soaps on the little TV that plays continuously, 24 hours per day. As I walked back to the front desk, a woman greeted me and pointed down the hall saying she’s ready. I thought she was pointing to the first time mom, but then noticed a new belly in the hall, and blood dripping all over the floor. Oh no, I thought, this does not look good. Too much blood before the baby has arrived.

We took her right into the birthing theatre, she climbed up onto the table and her dress was soaked in blood, blood stained the insides of both her legs. It all happened so fast that we got her name, that this was her second baby, but didn’t have time to pull her chart. I asked one of the baby docs with me to check in on the babe’s heartrate while I gloved up to do an exam. To my surprise and relief, the babe’s heart rate was pleasantly beating away in the 140’s. I checked the mom’s pulse to be sure we weren’t just picking up her heartbeat- 120. Okay, I thought, where is all this blood coming from? Placental abruption (separation)? Placenta Previa (low-lying)? Hmmmm...... Large clots of blood passed my fingers as I started the exam. Inside there was no cervix, she was completely dilated and she had a bulging bag of water. I couldn't feel any placenta either, luckily. I debated, to rupture her membranes or not….. I considered this situation with all the bleeding and decided I wanted to know what color the fluid was. So we ruptured her waters (or “released” the membranes as some prefer) and not surprisingly, it was bloody. Well, little more information that provided, but the babe’s heartrate continued beating away without any decelerations. It’s interesting to observe how when some women are complete there is no stopping their urge to push, while others seem to have no urge, and still others have the dreaded premature urge to push before the cervix is fully dilated. This mom fell into the second category, so we coached her on pushing when her belly was sore. She pushed and pushed with all her might, and slowly, slowly the head made it’s way down. And I do mean slowly, as she would take a deep breath, hold it while pushing for 15 or 20 seconds and the head would move millimeters. And it appeared to me that she had had some sort of repair after her first birth because the tissue just inside the vaginal opening was very tight- unnaturally unable to stretch. Finally the baby started crowning and I saw his little face, pale and void, followed by a pale, limp body. To see a babe’s face as he is crowning in a woman laying flat on her back means that her baby was born face-up, or posterior, or face-to-pubes as they call it here. I like to fondly refer to these babies as star-gazers. This position however, generally makes for a more difficult labor, or at least a longer pushing stage in my experience, hence the slow, slow descent.

I stimulated him and was conscious of not cutting his cord right away, knowing that he was still getting some oxygen from the placenta, so long as the cord was still pulsing. (In the States as midwives we generally always do delayed cord clamping, waiting until the pulsation stops, but not so here.) After close to a minute, with no grimace, no effort to breathe, no tone, and no color, I clamped and cut the cord so we could take his little body over to the warmer and work on getting him to breathe. The midwife suctioned him and I grabbed the bag to help inflate his little lungs. I could feel a good heart rate through his chest, confirmed by the little rhythmic beatings I heard with the stethoscope. Still no breath. A few inflation breaths made his little chest rise and shortly thereafter he started breathing, shallowly. His eyes were still closed, and overall he appeared to be teetering in and out of his body. Come into your body little one, tell us about how hard that was with a nice good cry, I thought. We put him under the plastic head box with oxygen and slowly, slowly, over the course of 20 minutes or so, he came into his body. His eyes shifted slowly this way and that. His heart rate remained good and his color improved. The last to improve was his tone. His APGAR scores were 2 at 1 minute, 7 at 5 minutes, and 8 at 10 minutes. Not great, but alive, and improving with time. He weighed 2.6kg. When put to the breast he sucked weakly a few times, then he’d go back to sleep. He seemed oh so sleepy. Clearly a difficult transition for him. This was one baby that I wanted to hear wail and scream, who never let us hear his little voice. It wasn’t until later that I scanned the mother's chart and found that her due date was not until 27 November (although due dates are to be taken with a grain of salt here as they can be imprecise), so it’s possible that this guy was just early and therefore his lungs and sucking muscles were not quite developed.

We never did find out where all the blood came from. The placenta was completely normal and came out Schultz (whereas a low-lying placenta ha a greater chance of coming out Duncan- fancy words describing which side of the placenta is showing when it comes out). Maybe her cervix dilated so quickly that all the cervical capillaries just burst? Not sure, but that was a lot of blood, whatever it was...

Due to the nature of the tight tissues, this mom ended up with a ragged second degree tear that included a pocket just inside her vagina and a lateral vaginal/perineal split, which I actually thought was a third degree because I saw a little piece of the famous shiny anal sphincter. The midwife stepped in and sewed her up, which was fine because meanwhile our first time mom was grunting next door.

She gave birth with ease and I sutured her bottom while her big healthy girl with a strong pair of lungs reminded us of how quiet the little guy next door was.

Meanwhile, we had another first time mom come in in early labor so we admitted her and sat down to get caught up on all the paperwork.

As the night continued the grand multip made some more noise and her eldest daughter who was continually rubbing her back and giving her water said it was time. I checked her and was surprised to feel just how much cervix was left….. she was 7 cm and the front part of the cervix was thicker than the sides or the back. This mom was really feeling it in her back, so I thought, hmmm, maybe this is a night of posterior babies. Based on my experience here with grand multips, I have had a few moms that wanted to push and they were 8cms or so, and with just one or two good pushes, the cervix was gone and the baby's head was on the perineum. I asked her to give a good push just to see what happened, but the cervix did not give. At this point it was about 9:45pm. She had progressed 5 cms in just over 3 hours- great progress. So I encouraged her to breathe through the contractions and to walkabout. An hour later, she wanted to push again, so I checked her and she was essentially the same, although the front part of her cervix was slightly larger than during the last exam. I encouraged her to lay on her side for a few contractions, then switch to her other side, hoping that would help with her cervix. Another hour, another strong urge to push.... another exam, essentially the same dilation, with an even thicker anterior cervix. Where is my homeopathic Arnica, I wondered.... in my first aid kit 2 blocks away. DARN! Once again, I encouraged her to push and she if I could hold the cervix back over the babe's head. No luck. We ruptured her membranes to see if the head could be better applied and waited another hour. Still the same, however, the front of the cervix had swollen to something like a thin sausage. I had never felt such an anterior lip and it was really something. This is why the premature urge to push can be disastrous because the cervix can swell to the point that it can't be pushed back and if it gets really bad the blood supply can get cut off and the cervix can be shed. Well I hoped we weren't heading down that road, so I called the midwife in and she also tried to reduce the lip. No luck, it was too big. We turned the mom on her side and once again encouraged her to breathe through the contractions to try to prevent further swelling. We decided to call the OB on call. It was 1am and this wasn't an OB we were particularly thrilled about, but we were out of ideas between the 3 of us. Meanwhile the mom was unable to control her urge to push and was wildly pushing with each contraction, still laying on her side. Just after hanging up the phone with the OB, we checked her again and low and behold, that big fat cervix was nowhere to be found. Amazing. Sidelying pushing had done it. We quickly rang the OB and told her not to come and within 5 minutes she pushed her baby out, not posterior (at least not at this point). A 3.4kg baby girl, with healthy lungs and a loud cry swam out of her mama all at once. This placenta was the largest that I had seen here. Pretty flat, but just huge- like the largest of large pizzas you've seen. It must have covered a good portion of her uterus inside! No suturing needed, but I did see a big purple bulge further up in her vagina- the swollen cervix, congested with blood. Luckily she had minimal bleeding so even her cervix appeared intact.

A lesson learned, grand multips keep you on your toes for lots of reasons- always a higher risk for hemorrhage, labors can be quick and unpredictable, or apparently longer and plateauing. And surprisingly to me, even the grand multips cervix can swell, into an anterior lip beyond any anterior lip I had ever felt before. And in the end, a combination of position and the mother following her uncontrollable instinct to push was what got her babe past that hurdle and into her arms. Whew!

I cleaned up and ran home to a quick shower and tumbled into bed exhausted, reminded of the many late nights I had kept during my training in Seattle. But also honored by the beauty of seeing a woman through the entirety of her birthing process, the challenges and the joys, and welcoming a few more little Ni-Vans into the world.

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