Scenario: Planned Hospital Birth with a Labor Support Person
Recently I was called to step in as a labor support person for a client when her Doula had to attend a mandatory engagement. While not super common, occasionally things come up and necessitate such an arrangement, and I am happy to have a support network I can call on, just as I am proud to support others within this community.
The Doula kept me informed of her assessments as the time was drawing near. Upon arrival, I asked to see the contraction app in order to get a picture of recent activity. Contractions were irregular, anywhere from 7-12 minutes apart. I was assured that at some point they were closer together, but knowing they had plans to transport to the hospital to join her OB for a planned VBAC, I knew we first needed to get an established active labor pattern going. As a midwife I am only comfortable attending women in labor when I can listen to fetal heart tones in order to ensure fetal wellbeing. The baby sounded great and mom was handling her labor well.
I suggested laboring in the bathtub with some Epsom salt in order to allow the contractions to regulate. She alternated positions from right side lying to left side lying every few contractions. Within minutes, contractions became more regular and were consistently 7.5 minutes apart. I monitored the baby’s heart rate regularly and we encouraged the mom to drink and take bites of fruit periodically. While the contractions never got closer than 6.5 minutes apart, I noticed the mom sounded “transition-y.” Difficult to describe or quantify, but in my experience there’s certain sounds a mom makes that tell you what point they are at in labor.
I gently assured her and reminded her that, although we had just met this afternoon, I am a midwife and that I could perform a vaginal exam in order to let her know her progress. Remember, upon arrival just after 1pm, contractions had been irregular and now it was about 2pm, after only 1 hour in the bathtub. I shared my thoughts about her contraction pattern versus how she was physically presenting. After the next contraction we helped her out of the tub and to the bed for an exam. The next contraction she experienced was intense; this was the first one out of the tub and she voiced how much better she had been able to cope with them while in the water. With consent and sterile technique I gently performed an internal exam and found her almost complete with only an anterior lip (cervix in the front) and baby at +2 station. I calmly explained what I found and gave her time to process while we started the steps of getting her ready for transport. It was only 2:40pm. She was a trooper!
I followed behind the client in my own vehicle, sterile gloves in my pocket just in case. We had discussed hospital arrival procedure and that I would park and run ahead to get a wheelchair so the mom could be dropped off at the front door and not have to walk much. I was blessed with a parking spot near the front entrance, which almost never happens, and ran ahead as planned to grab a wheelchair from the front. Empty. Nothing.
And, to top it off, because it was Saturday, there were no workers or volunteers at the desk or anywhere to be found. Knowing this mom was ready to deliver at any moment, I couldn’t aimlessly walk around trying to locate someone who could help. Instead I went back out to help support the laboring mother. We labored through a couple contractions while her mother parked the car, and didn’t make much progress before she met up with us and the three of us walked inside. Still nothing or no one to help.
The elevators were fairly close so we figured the best thing was to get there and up to Labor & Delivery. Once there, and it was a slow process, we finally found some help. We went from one to about five nurses and finally a wheelchair. We explained who she was, who her doctor was and what was going on. I was still supporting the mother and helped to ease her back into the wheelchair, which while it was welcome on one hand, was still difficult to do at this point. We quickly made it back to Labor and Delivery and they deduced based on her presentation that we could bypass triage and get a real room. I felt it prudent, because there were no less than seven nurses or staff buzzing about the room and the laboring mother, to let them know my assessment. Normally in this situation I would not advertise that I am a midwife, but I felt I really needed to let them know that I had done an exam and found her almost complete with baby +2.
On top of the myriad of questions they were already asking her, this new revelation threw them and now they assumed, though we were already very clear about who this laboring mother was, who her doctor was, etc., that we were a transport from a home birth situation.
No. That’s not what we said. Yes, I am a midwife. I am her labor support person who was helping her to labor at home until it was time to come to the hospital. She made quick progress and now we are here to meet her OB.
More questions. Multiple times I tried to help and answer what I could for her; however, and this is the tricky part, the hospital staff wants to hear from the patient directly. Now, don’t get me wrong, I get this to some extent. We aren’t talking about possible abuse questions or suspicious injuries, we have a woman in advanced stages of labor, trying her best to birth a human being and we’re getting chatty. STOP IT! I digress.
Now is the point where she is poked and prodded, because apparently those 36 week labs she just had aren’t considered relevant any longer and because the hospital has little to no regard for midwives, they can’t take my word about her internal exam, they need to see for themselves. Her second exam takes place at the hospital and is done by a nurse. She calls her 9 cm and says baby is +1 station. Then when asked by another nurse about this, she adds that there is only cervix in the front. (THAT’S CALLED AN ANTERIOR LIP!) But they don’t like to agree with the midwife. (And station, while subjective, could have changed given the car ride and anxiety the mother was in transporting at this stage of labor and her long walk to the delivery unit.)
Her OB had not yet arrived because while she had called to let her know she had started labor that morning, they forgot to update her. That’s normal. When you are busy laboring, you aren’t thinking about everyone you should update. Instead, we had a hospitalist join the packed room in case the client/patient delivered prior to her OB’s arrival. At some point in this activity, I covered the mother with a light sheet because she wasn’t pushing yet, she was still laboring and I feel was waiting for her husband and then OB to arrive. Step in hospitalist/OB sub who moves the sheet and “needs” to check her again. WAIT, WHAT?!?!
This is the part that continues to baffle me. Why do you allow nurses to do an internal exam if you aren’t going to believe their assessments? Either they are qualified or they are not. Why is this woman or any woman violated repeatedly with little to no regard for consent, all for the sake of routine practice? She had 3 internal exams by 3 different people in a matter of 40 minutes. That is completely unnecessary!
Shortly after, the Doula I had been subbing for arrived and I graciously stepped aside to allow her to continue the role this laboring mother had hired her to perform. I was sad to miss out on the big moment, but I refused to add to the stress or crowd of the moment. By this point, the laboring mother had her husband, her mother, her original labor support person, and the hospital staff was no less than 4-6 people in the room because staff was still in and out. I didn’t want to be the point of contention and create an awkward moment where the soon-to-arrive OB states too many people are present and someone has to go. That would be rude of me; I had just met the couple that day. So, I politely excused myself and went to the waiting room because I knew the birth would be imminent. Roughly 15 minutes later I got the text that the baby had arrived and all was well. Sweet Bliss. Congratulations.
This momma triumphed in so many ways. She did it, and she did more than she originally planned. I hope she looks back on the experience with lots of happiness, joy and maybe even some surprising funny moments that make her laugh out loud.
But, I’m confused. This individual was under the care of an OB throughout her pregnancy. She did everything the system supports. Why, if this was the plan all along, was she questioned countless times by various staff, surrounded by more than a few people and forced to undergo multiple vaginal exams when she was basically complete? I just don’t get it.
The hospitals ask the same questions routinely, do they not? Doctors ask the same questions, do they not? Is there a way for one system to talk to the other prenatally? People register at hospitals prior to delivery, right? Is there some sort of bracelet or barcode the expectant mom could wear (or bring in) that would answer those same questions allowing them to labor as uninterrupted as possible?
Stop the madness. Labor is not the time to get super chatty with a woman who is literally working to bring a human being earth side.
Please tell me you have ideas or you have the ear of someone who can help to change policy or systems. One hospital at a time, that’s all it takes! (It could start with a nurse or charge nurse or OB or hospital administrator…it only takes a spark to light a fire!)