Monday, March 12, 2018

Thoughts on Labor & Delivery #6: Deceleration

I’ve listened to enough fetal heart rate monitors over the years to develop an ability to hear the difference between normal and abnormal without looking at the screen.  Suddenly, baby girl’s heart rate was noticeably abnormal.  Before I could even ask PIC to look at the screen the room flooded with my nurse, another nurse, two doctors, a random guy who was apparently just “there to help” and probably some more people that I didn’t mentally catalogue because I was too focused on the slow thump-thump-thump-thump.  

PIC was not recruited to help reposition this time but rather elbowed out of the way as I was laid flat on my back by two nurses within a matter of seconds.  My vitals were assessed, and an oxygen mask was placed on my face and cranked up to full blast.  After a short eternity the thump-thump returned to the faster thumpity-thumpity-thumpity and a collective sigh of relief filled the room. 

Drops in fetal heart rate (known as decelerations) are occasionally normal, but when no trigger is known and when the slowing is prolonged it is never a good sign.  It was decided I should remain on my back and keep the oxygen going.  My room remained full of an excess of medical professionals – never reassuring. The gravity of the situation hit me: there was a tiny human being inside of me and she was not ok.  I prayed silently and tried to take deep breaths of the oxygen.  She needed me to breathe deeply and stay calm. 

The obstetrician decided this would be a good time for a cervical exam and declared that I was now officially at 5 centimeters.  (After a mere 18 hours of laboring…) I resigned myself to needing a C-section and a whole new sort of panic set in.  If you have never seen a C-section (but may someday need one) my advice to you is to never ever, ever watch one.   All surgeries seem somewhat barbaric, but of all that I have seen, these are the worst.  After the incision is made wide enough to reach into, the surgeons on opposite sides of the table insert their hands and lean back in order to tear the opening wider and it invariably makes me cringe every time I see it.  This is done because tissue will heal better when torn than when cut, but I think that is far easier to trust when it isn’t your tissue. 

No one else had made the jump to needing a C-section yet. As usual, I was getting ahead of myself and worrying about things that weren’t ready to be worried about. 

Despite minimal exertion, I rapidly became exhausted.  My hands were shaking badly and the oxygen kept sliding off of my face.  PIC noticed first and asked if I was ok.  “I think so, just really shaky.”

This alerted the nurse to my change in status – “Are you just shaky or are you cold?  I could get you a warm blanket and check your temperature.” 

Cold seemed like the wrong answer… I wasn’t cold, so I told her there was no need to check my temperature… but I did want a warm blanket – those are one of the best parts of being in the hospital.  I figured I was shaky due to the adrenaline of what had just happened.  The nurse postulated that maybe I was shaky because I had begun the transition into active labor – meaning I was potentially 6 cm now and likely only had 4-5 hours left before it was time to push! 

Then I was freezing, shivering and shaking uncontrollably.  I definitely was about to throw up. Something was wrong.  My whole body felt terrible and I had a growing sensation of dread.  I could not verbalize what exactly was causing my anxiety so I just repeated over and over “I don’t feel well. No, I really don’t feel good.  Something is wrong.”

At about that time, the OB doctor returned to the room. During labor they monitor both the baby’s heart rate and the mom’s contractions (as well as the rest of mom’s vitals).  My contractions were too rapid – they were occurring one on top of another without any time in between, which is too much stress for the uterus and also bad for the baby.  They turned down the rate of the drug stimulating my uterus to contract and waited. 

No change.

The way in which they monitor the mom’s contractions is with a monitor strapped to the outside of the belly. It allows them to see when the contractions are happening, but (contrary to popular belief) does not give much other information.  (For those of you about to labor, read: size of spike on the monitor does not necessarily correlate to size of contraction… so if you have a really painful one and someone helpfully comments that it was not very big at all, gently remind them of the disconnect between monitor and actual contraction, then, you know, feel free to punch them if it will help).  To monitor the strength of contractions, they need to use an IUPC: intra-uterine pressure catheter.  Just another thing that gets inserted (painlessly, I’m sure) into the uterus.

The doctor mentioned needing an IUPC to determine why my uterus had suddenly kicked into overdrive. (Paraphrased).  The nurse took my temperature: 97.70 F.  “That’s not right.” I helpfully informed her.  Given my current near-death appearance, she hadn’t handed me the thermometer and instead held it herself… barely between my lips.    “We can try it again if you want” she said, rather skeptically. 

We did.  It was 102.40F.

I now had a fever and a rapid heart rate. Two of my vital signs had changed and unfortunately, the baby’s heart rate was starting to increase beyond the normal range too.  Signs of infection during a delivery are usually considered chorioamnionitis (a medical way of saying an infection inside the uterus).  Often mom will show signs but baby will not, which is less concerning.  Once baby is effected, the whole situation becomes more serious.  In a former life as a pediatrics intern, I had been paged to multiple deliveries where mom was diagnosed with chorio, but baby had not ever shown symptoms… since we were already passed that, I assumed the pediatrics team would be present at the time of delivery… likely a million hours from now. 

The OB-GYN doctor prepped to place the IUPC, but stopped quickly upon reaching inside the missile silo.  “We won’t be needing this.  You’re 10 cm and completely effaced.  It is time to push.” 

Um, excuse me? “I was 5 cm… like an hour ago”

“Yeah, it’s no wonder you feel so crappy. You were progressing rather rapidly.  It’s time to have a baby.”

I took mental stock of myself: still nauseated, chilly and exhausted.  If I had ever felt that I could push a baby out of my hoo-ha, I most certainly did not feel that way now. I was sure that I was going to push for a bit, pass out and then need a C-section.  (I didn’t know it then, but the OB was also fairly convinced that I would end up requiring a C-section, but bless her professionalism, she remained positive and encouraging.)

The room got busy.  Many people busied themselves bringing in a sterile table covered in what looked like mid-evil torture devices that were modernized into blue plastic forms, a few more played transformer with my bed so that I was further reclined with my legs elevated in handy leg holders up nice and high so I couldn’t run away even if I could summon the strength to my lower half. 

“Pediatrics will be here, right? I mean if it is chorio, they should be here.”  After some discussion that I tuned out while trying to focus on keeping myself alive and fully mentally present it was decided that they should be present. 

The doctor, having removed her brutus the buckeye name badge holster and put on gloves, had done all that was required of her to prepare for the delivery.  She kept one eye on the chaos of preparations around her and the other on ground zero while we chatted about where she was from in Ohio, which Honolulu bars showed the Ohio State games and how non-ohioans simply didn’t get it. 

As preparations were finalized, a nurse helpfully reminded me that the normal pushing time for first time moms is anywhere from 1-3 hours.  I looked at the clock to assess if the kitchen would still be serving dinner at the end of 1-3 hours.  It would not. 

Mentally I told myself that I was getting this baby out in under an hour.  I had no reason to believe that this ‘first time mom’ statistic would break for me when none of the others had, but what can I say, blind optimism is apparently deeply engrained in who I am. “I don’t think I can push for that long… I really don’t feel okay.”

PIC assured me that I could.  My doctor informed me that in the past 10 minutes I had gone from 1+ to 2+ (the baby had moved further down in the birth canal without me doing any pushing… a good sign that my uterus was ready to evict even if I couldn’t push).  She told me “I can see her hair.”  

For as long as I can remember, my rule for any significant other in the delivery room was that they could be present but had to stay “behind the 50-yard line”.  I couldn’t imagine wanting anyone to see the disaster that would certainly be my bottom half during that time.  … I also couldn’t imagine them wanting to see it, but in the off chance that they did, I was sure my dignity would override their wishes.  So when PIC asked if he could look to see this theoretical baby’s hair, I surprised even myself when I consented. (Also, a million bonus points to him for asking… even in that situation.  It was his baby about to make her way into the world and I was distracted enough that I likely wouldn’t have noticed even if he hadn’t asked. Goodness knows there were plenty of other people doing far more than looking at this point! But, he respected my wishes and asked permission first anyways – a quality that I will highly value as he helps me raise our daughter.) He confirmed that he could see her hair and did not comment on anything else he may have seen.  Further bonus points. 

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