!Not-knowing
---
agk's diary
27 July 2022 @ 18:18 UTC
---
written on GPD Win 1 lying on floor
while my kid plays with a pencil
---
"I'm not dilating. I'm not going to dilate," the
woman told me. I had sanitized my hands, knocked,
and was meeting her as night shift turned to day.
> I invent composite patients based on details
> from enough individuals none can be identified.
Her oxytocin ran fast at 23 ffter being titrated up
over 36 hours since her post-term induction. It did
what it was supposed to do. She had a 60-90 second
contraction every 2-3 minutes with relaxed uterine
tone between them.
The midwife ruptured her membranes late the night
before. Her amniotic fluid had been nice and clear.
At an 0500 vaginal exam , her cervix was only
dilated 4-5 cm (of a possible 10), effaced 70%,
and her son's head hadn't moved down from 0
station, right between the ischial spines of her
pelvis.
She can't push her baby out til her cervix ripens
to 10cm dilated and 100% effaced. The baby's head's
pressure on the cervix causes the hormonal changes
that ripen it, but he's occiput posterior, eyes
front, leading with the flat top of his head, not
the pointy apex at the back of his skull. It would
be so nice if he would spin to face her spine and
ram her cervix with the apex of his skull with
every contraction. It probably would have been
easier when he still had an amniotic fluid cushion.
"I never should have induced. My body doesn't work.
Something's wrong with my baby. Something's wrong
with me. Something's wrong. My body doesn't work."
She was so exhausted, so dispirited, so anxious.
Her husband, a factory worker, had left to get
breakfast. Her mother had her and her siblings so
easily at home in Africa. Why was her body unable
to do as her mother's had?
Every few contractions for the last day and a half
electronic fetal monitoring showed variable decel-
erations of the fetal heart rate---quick drops more
than 15 bpm that quick returned to baseline. Vari-
ables indicate transient cord compression, breaks
in fetal oxygenation. Her baby had good reserve so
weathered them well, and bounced back to his base-
line heart rate. Cord compression wasn't surprising
with such a big baby in such a little lady.
We helped her sit up in bed to labor, eat clear
liquids, (lemon ice, clear broth), turn radically
to her right with a calf in the stirrup and the
peanut ball betweenn her legs. I sat, listened,
breathed with her, encouraged, learned about her
life, her job, her family, her rethinking of small
decisions in light of the enormity of subsequent
events.
I encouraged her to press the button under the
flashing green light to deliver epidural pain
control with her PCA pump. "It doesn't work any-
more," she said, and cried. I called the anesthesi-
ologist, who asked her consent to replace it. She
said, "It won't work. There's no point." She'd been
awake and in labor for 40 hours.
I met her mother, baby brother, church friend, as
each visited and left again. We breathed through
contractions. I showed her the fetal heart rate,
assured her: her son was definitely not dead. We
talked about what happens in a c-section and what
would lead her midwife to recommend one.
My shift neared its end. She reported increasing,
almost unbearable pain. We helped her change pos-
ition but it didn't help. I messaged the midwife,
who checked her cervix. Still 4-5 cm, 70% effaced,
0 station. "Oh, God!" shr cried in despair, then
suddenly "Oh, God!" in sharp pain. We all heard her
son's heart rate on the ultrasound drop from 150
BPM to 70 and stay there. Her husband arrived.
"I think the ultrasound slipped," I said. "That's
her heartrate."
"No," said the midwife. "No, that's the baby's
heartrate." Suddenly we were all in motion. Oxy-
tocin off, oxygen mask on, midwife got consent,
reached in her vagina and screwed a spiral elect-
rode into baby's scalp. The muffled lub-dub of the
ultrasound fetal heart rate was replaced with sharp
beep beep as midwife and nurse got the woman onto
knees and elbows in bed, ungowned bottom up in the
air.
I encouraged her husband to hold her hand, got him
water, told him she got some sleep when he was gone
and he'd come back at exactly the right time. A
nurse gave her a shot. My shift ended.
