The mother's labor started in textbook fashion at 39 weeks, twelve hours after she had some light bloody show. She spent the day alone, enjoying herself and feeling crampy contractions every ten minutes. When Doula "A" finished work she slowly headed to the woman's home where they had tea and "chilled". Her contractions were becoming slightly more intense but our client was still chatting, making tea, and having a good time.
The textbook went a bit sideways at this point, when our lady decided to have a nap. As she lay down on her side, her waters broke and she felt the urge to push. Doula "B" happened to arrive at that moment and they quickly got into the car and drove to the hospital.
When they arrived at the hospital, they were of course whisked through to a room, and our lady was undressed and invited to get onto the bed. She did so, and continued to push. At this point, the resident tried to find the heart beat for the first time and was unable to. The baby crowned, the resident performed an episiotomy, and a very healthy baby was born.
The medical staff were very angry with the doulas for "letting" our client stay at home for too long. The new mother asked why she had been cut, and was told that the physician was concerned about the heart beat.
She was discharged the next day.
One of the doulas said afterwards:"That would have been a seamless homebirth." Yes.
My question is, what is your take on this?
Should she have come in when her labor started?
Should her doulas have done a vaginal exam? (A rhetorical questions, really, as they are not trained nor allowed to do so).
If she didn't have the support of a doula, then she would probably have come in earlier (here I am trying to convince myself that our services are unnecessary).
Thank you for your time, and appreciating in advance your comments,
Rivka
I’m not sure what the problem is here. The woman was comfortable, and went to the hospital when her water broke. Since doulas aren’t medical professionals, how can it be their job to tell the women when she should go to the hospital?
ReplyDeleteOften a woman will want confirmation from her doula that it is indeed time to go to the hospital, especially if she is a first time mother.
DeleteSounds like the doctor/medical staff resented not having control over the whole process and lashed out on the handiest "victim", the doula. Because, as we know, birth is sooo easy and obvious to control *snort*.
ReplyDeleteBtw, can I have birth like this? Please? LOL
Yes, it would be wonderful to have such a quick and straightforward birth!!!
DeleteThese doulas did a perfect job! This is not a very usual type of birth where someone is chilling, making tea, has the urge to NAP (I've never decided to go off and take a nap in labour!) and then boom, goes into second stage. In fact, had those doulas NOT been there, she wouldn't have made it to the hospital and would have been stuck with an ambulance bill as well as accusations of planning an unassisted birth pinned on her. So the doulas were also instrumental in buffering that a little.
ReplyDeleteI am very sick of medical statements like "why did you let your client (insert crime here)?" Isn't it the hospital itself who tells their patients to stay home until they can't talk through their contractions anymore? Well, some people have it easier. Too bad there was panic and she ended up with an episiotomy. I feel for this poor woman. But this is in no way the doulas' fault. The greater risk was going in in what seemed like early labour, having everything stall, needing pit to pick things up, possibly epidural and all the lovely things that can happen with that. Honestly, if residents could just apprentice with us for a few births, they'd never ask us that stupid question again, "why did you let your client (insert crime here)?" We do not LET or ALLOW our clients do anything, as they are agents of free will. We're guides, not drill sergeants. In fact, the resident should be thanking the doulas for getting her there in time, since hospital birth was her plan. They acted responsibly and ethically.
I had a client recently have contractions every twenty minutes for a few hours. Then for a half hour they got close together. Then she popped out a baby. These things happen. They make great stories. The mom and doulas deserve nothing but praise.
And nah, vag exam wouldn't have proved anything. She could have been two right before she lay down, or she could have been nine and stayed crampy and chatty for another twelve hours. Wouldn't have changed a thing. Doulas don't need to go there. That would just put us into a role we should leave to the clinicians who feel those things are generally important.
Yay, Doulas!
Yay, indeed!!!
DeleteThe thing that comes to my mind: if the baby was crowning, how many seconds did the resident save by cutting that episiotomy? Was the gain in time relevant if the baby indeed had no heart rate? And, finally, it just shows the profound lack of knowledge on the part of the resident that he didn't know that dilation can progress very, very, VERY quickly in some cases, especially after a major change in mother's position.
ReplyDeleteNope, the doulas and the mother did great.
Honestly, I can't think of anything else they could have done. I don't know if I would have felt comfortable driving to the hospital with a mom already pushing (I think I would have called the ambulance rather than risk birthing in the car) - but there just wasn't any warning to go sooner!
ReplyDeleteI agree that the episiotomy was a panic reaction from a resident with lack of experience - hopefully he will learn and realize how useless they really are, for the most part!
One interesting point here - all of us (I got comments on another list as well) - assumed that the resident was a man. I actually don't know whether it was a man or a woman but let's not jump to conclusions. Unfortunately, female residents can make just as many mistakes as male ones. And I've seen gentle, kind and respectful men in the birthing room alongside women.
ReplyDeleteI don't believe that the doulas did anything wrong at all, and I don't believe that the client should have gone to hospital any sooner if she was coping just fine at home. I certainly don't believe the client would have necessarily gone to hospital any earlier if she didn't have a doula - she would have been scared and alone and potentially ended up with an unplanned home birth. Thank goodness she DID have a doula!!
ReplyDeleteThe doulas definitely should NOT be doing vaginal exams as this is not within their scope of practice.
As to the reason she had an episiotomy - maybe the resident panicked. I have performed an episiotomy when needed to expedite delivery when there are valid concerns re fetal heart.
Your story reminds me of a client I had back in the UK when I was student midwife working a hospital night shift..... I had a healthy young primip who had come to hospital in labour. She was examined by a very experienced midwife and found to be 1cm dilated. As she was contracting quite nicely (about every 3-4 mins), she requested to stay in hospital so was made comfortable (this was back in the days before we sent women home). I was sent for my meal break and returned an hour later to find the woman holding her baby! Proof that primips can go unexpectedly fast.
I'm sure there will be a variety of responses. The doulas should be given ample reassurances that what they did was correct. Certainly they are second-guessing through the clarity of the retrospectroscope. She could've pushed for hours!!!
ReplyDeleteResidents are not necessarily skilled in figuring things out - and, in my experience, have no idea how to support a perineum - and they do know how to do episiotomies so they do what they know.
She should not have come in when her labour started - she was waiting until she felt the contractions were strong enough I suspect. I tell patients to come in when they have to stop talking or playing cards during the contractions. This patient sounds like one of the 20% who don't really notice any changes until they are ready to push or their water breaks (as was I, my mother and sister). Her doula was probably looking for the change that was not there.
Should doulas do vag exams? Only if they are trained to do so. And that would move their activities to an entirely different level..........
Unless she has pushing for a long time at home (which it doesn't sound like she was from your email), it doesn't sound as if your doulas did anything wrong - except possibly not calling an ambulance for a woman who felt like pushing. As you said, the water breaking can accelerate labour tremendously. I don't think they should have done a bag exam - that is not their role. If they hadn't been there, the woman would probably have called an ambulance herself. I think that if the doulas were given the space to explain what happened (i.e.: not many contractions and then felt like pushing when the water broke), the medical staff would have understood what happened because they have all seen it themselves.
ReplyDelete