Wednesday, April 25, 2007

Henci,

Could you share some research wisdom on fetal scalp sampling-- its efficacy, etc...I was recently the doula for a woman who had an emergency cesarean.  I am not sure that it was unecessary or could have been avoided.  She chose a midwife, whereas her previous births had been with an OB-- thus, they naturally wonder-- maybe we should have asked the doctor to come in earlier? (He basically came in, did a last ditch attempt to vacuum, and went to c-section under general).  I am trying to tell them that if anything, he probably would have just sectioned sooner.

However, Devil's Advocate thinking here-- although the decels on the monitor looked pretty bad, maybe the baby was not in all that bad a shape and could have passed a fetal scalp sample (not that the MW could not technically have done that)-- thus my question to you regarding how reliable they really are. 

Moreover, the baby's Apgar's were 4/8 which would indicate that he was truly very distressed, whereupon one midwife I know suggested that the general may have done it.  Do you know of any research on general anesthesia for c/s reaching babies?  Is this a real possibility?  Is it possible he was OK?

Thanks for taking the time!

- Shayna 

I'm not sure that the research on fetal scalp sampling is relevant to this case. It is intended for confirming whether abnormal fetal heart rate patterns indicate fetal distress in labor, but as you describe it, the baby was low enough to try a vacuum extraction, which means the problem occurred late in second stage (the pushing phase). In such a case, the goal would be to get a baby in trouble out as quickly as possible, not to take a blood sample and wait around until the blood sample could be analyzed. I suppose the obstetrician might have tried scalp stimulation. If the heart rate responds by increasing, you can be reasonably confident that the baby is ok, at least for the moment. At best, that might have allowed for avoiding general anesthesia, seeing as the attempt at vaginal instrumental delivery had failed. It would be foolish to second-guess the obstetrician's judgment, though, when faced with severely abnormal fetal heart tones and a baby neither the mother nor the obstetrician could deliver vaginally. I would also add that when the obstetrician got called in doesn't seem to be the factor here.

If I may make a suggestion, you, as her doula, are in a good position to listen nonjudgmentally to this couple and to validate their feelings, especially the mother's. In other quarters, she is likely to be hearing, "But the most important thing is a healthy baby." Of course, that is true, but it isn't the only thing. She may well be experiencing negative emotions around this birth such as anger, disappointment, frustration, regret, and she may need to hear that those feelings are legitimate as well.   

-- Henci

P.S. It would not surprise me if the woman, her partner, or you are experiencing symptoms of post-traumatic stress disorder as a result of this birth. The primary trigger is feeling helpless and terrified that you or someone you care about is in danger of severe harm or death, which certainly describes this birth. This is not my area of expertise, although I have a friend in mental health who specializes in perinatal mood disorders. I know that PTSD symptoms include nightmares, flashbacks, hypervigilance--being on "high alert" all the time. PTSD is subjective; one's perception of the event is the reality. It is possible to be fine after an experience that others think is horrific and traumatized by experiences that others see as no big deal. If any of you are experiencing symptoms, get back to me, and I will ask my friend for advice on what might help the healing process.    

Thanks, Henci, for your wise words.  Interestingly, the mother seems to be accepting of what happened-- although still curious to understand why, especially since she wants more children and not interested in any more surgeries.  It is actually those around her who are shocked and hurt and worried about her recovery-- legitimately so as she has 4 small children to care for. 

I am sure that there is some level of trauma for all of us, but the questions are more from a place of curiosity and wishing to prevent future repeat scenarios.  Emotionally, I think we are pretty much OK.  We just wish we could put our finger on why this baby would not come out (the others did) and why he went into distress with no cord around his neck, no Pitocin, etc...  Maybe we'll never know.

Many Thanks,

Shayna

One question that might be asked is "What was the baby's position?" If the woman had not had difficulties birthing her other children, perhaps this baby was malpositioned in some way. Malpositioned babies--occiput posterior (looking toward the mother's belly), asynclitic (head tipped toward one shoulder), nuchal arm (hand up by the head or "telephone" baby)--are strongly associated with c/secs. As to why the distress in the absence of obvious cause, my best guess would be occult cord prolapse; the cord was being pinched in some way that didn't show up. I am not a clinician, though. Perhaps, since the mother is wondering if this could repeat, she might want to talk things over with her midwife, the ob, or both and get their take on it.

-- Henci

Yes, Henci, the baby was most likely posterior (in the dr.'s own words)-- and possibly acynclitic as well (but are'nt most posterior babies?).  I had actually tried to shift the baby the night before, and I think I was partially successful b/c she went into labor 8 hours later-- although I have also had the haunting thought that perhaps my shifting techniques resulted in deflexing the head or in some way contributing to the problem.  I essentially did what Penny Simkin and various midwives teach-- invert to bring baby up, hands and knees to bring baby front, and semi-prone Left to get baby settled in anteriorly.  When I arrived the next morning to find her in labor, I believed that the baby had moved somewhat back to his posterior position, and decided that he must like to be that way due to cord reasons, etc... and did not persuade him any more-- assuming he would rotate with the force of the contractions-- afterwards I wished I had done more.  Damned if I do, damned if I don't.  \

I think the premise of an occult cord prolapse is  very plausible.  Does this have anything to do with a thin cord or poor nutrition or something that we can educate women about?  Or just bad luck?

Thanks,

Shayna

If you look at it logically, I don't see how you possibly could have done any harm. All you did was use positioning of the mother to try to coax the baby into a better position. If there was something constraining the baby into a malposition, changing the mother's position would be too gentle a persuasion to change that, and, in fact, it didn't. As for inadvertently causing a cord problem--and we don't even know that cord compression was the problem--if repositioning the mother the night before had caused it, it seems to me that abnormal fetal heart rate patterns would have shown up earlier in the labor. Finally, if it was occult prolapse, I am not aware of anything other than rupture of membranes while the head was still high or bad luck that could have caused it.

-- Henci  

The abnormal FH patterns started about 45 min. after SROM at full dilation and 0 station.  Does that sound like an occult proplapse to you-- or would it have been faster?  I think it might have been b/c after much hard pushing, mom got the baby down to +1 and the problem worsened considerably-- b/c of more descent-- or b/c of mother's breath-holding/ expulsion efforts?-- My guess is probably both. 

Thanks for your reassurance.

Best,

Shayna

Keeping in mind that I am not a clinician, it sure sounds like the cord was getting pinched to me. It might have helped if the woman had not been doing purple pushing, but with the malposition, it doesn't sound like she was getting anywhere even with it. I think this should all be chalked up to really bad luck and an example of the benefits of appropriate use of obstetric intervention.

-- Henci