30 January, 2009

reading labor

I'm fairly perplexed that experienced Obstetra interns in Peru (and OB nurses in the States) have no ability to assess a woman's labor pattern via observation. Even some of the matriarchal Technicas (kind of a cross between a nurse and an orderly) haven't a clue.

A woman having her first baby got up out of bed to urinate. She was contracting every 4-5 minutes and very much still "here"; i.e. her level of consciousness had not altered appreciably. Still, once she became vertical, one of the interns alarmedly inquired if she needed to push.

Another woman lay in bed having back-to-back, strong contractions which required all of her energy and focus. She appeared to be in transition. She was not holding her breath nor was there any catch in her throat during contractions. Interns abruptly questioned her desire to push during her time of deepest work and most expansive opening.

Then there's ignorance of the period of quiescence. Often a woman's labor will crescendo as she opens, then pause before the expulsive phase begins. I witnessed this very pattern here one night. As the woman's formerly intense, frequent contractions became more widely spaced apart, the Obstetra lectured her interns on Friedman's curve and ordered an IV bolus of pitocin to speed things along. Oh, if only they had been more patient! The laboring mother was gathering her strength, rounding the peak, and about to accelerate once more.

I've witnessed nurses in the US ask women "Oh are you having one?" (a contraction; really, they can't tell?) and attempt to complete medical and social histories right in the middle of seriously surging concentration. Overreliance on external fetal monitors creates an inability to trust one's own senses.

It's so simple. You just observe with all your senses wide open. There are several external signs that a woman is completely dilated: the reddish purple line extending from anus to sacrum, the rise of her fundus to meet the sternum, the open point on the top of her head, the other open points on the bottom of her feet, and the horizontal crease running across her low abdomen. Some birth attendants can actually smell a change in the labor, or feel their own cervixes opening. When I accompany a laboring woman to the bathroom, I stand outside the door and listen. Is her breath even or is she holding it at all? Is she grunting or throaty? What noises are splashing into the toilet?

it's so simple,
except when it isn't.

Last night I was working with a young woman having her first baby. Her contractions came in rapid succession, with tremulous vibrations rocking her entire body. She wanted to urinate and defecate but could not. As I squeezed her aching hips I could feel them pulsing open. So I added up all the signs and thought the baby's head was descending and she was probably in transition, about 8-9 centimeters dilated. Imagine my surprise to find her cervix 4-5 centimeters and the head very high in her pelvis.

Checked myself. Make no assumptions. Stay open. Stay humble.

1 comment:

Kelly said...

I have really enjoyed reading your blogs and would love to see you when you come back!