challenging births 1
sara wickham

This article was originally published in
Midwifery Today.
Republished with permission.


This article is based on the 'Challenging Births' workshop which I lead at Midwifery Today conferences. In this class, I give a clinical scenario to two or three small groups of practitioners, who brainstorm the issues and debate what they would do, what other information they would look for in making decisions with women and the kind of issues this raises for midwives. The small groups then feed back to the larger group, who discuss the scenario and the issues raised. These articles have been written with permission of those who took part in the classes. The words of the participants have been transcribed, with only minor revisions for clarity and to maintain confidentiality. Many thanks to the midwives, aspiring midwives, childbirth educators, obstetricians and others who took part in this class.

Sally has been in labour in the birth center for twelve hours. She requested a vaginal check on arrival and her cervix was 5cm dilated. This is her first baby. She laboured throughout the night with her partner in the bath tub and while walking around the birth center. Her contractions were coming every five minutes and they were moderately strong. You are pretty sure the baby is OA, head engaged and in a good position. Now it is morning and Sally asks to be checked again because she feels she must be nearing second stage. Her cervix is 6 cm dilated. What are the issues for you, and what would you be saying to Sally at this time?

“We have a scenario where we know Sally is 5cm dilated, but we did not know what the consistency of the cervix was, whether it is thin, thick, soft or what… We are just imagining that it were a matter of maybe moderately soft. She laboured in the tub, she did not sleep, next morning she increased one centimetre. My opinion is that she is a primigravida, I am not concerned, once everything is AOK with this mom, fetal heart is alright, her physical condition is alright, her family is satisfied. All the scenario with the normal primigravida is OK because of the position of the baby, I don't get scared about it being just one centimeter dilated because of that water. She stayed in that water throughout the night. And we know water works both ways. So this is my thought, this mom needs hydration, nutrition, rest … and I will give her at least 4 to 5 hours rest, more if possible and then things will go for her.”

“I basically agree … the only concern is that she is now about 20 hours into a labour and we don't know how she is coping - it sounds like she is coping well, that would be the thing I would be watching the most carefully. If she is coping well, we can continue to go on and make sure she is well hydrated and that. If she's starting to not cope well, getting a little anxious, then I would have to be a little aggressive in my situation, maybe with herbs or something. But the contractions are good, I would just tend to wait and encourage her that this is normal and wait.”

“If she is 5cms and I don't see in twelve hours that she is going through transition, I will be checking for stalling … is this a stalled labour for me? And if it is and she passed the whole night walking and awake, you know she must be tired. We will be very aware that she doesn't get exhausted so she can end up with a birth in the birth center. Before morning I will give her something to rest, maybe a cold glass of wine or something so she could rest, her muscles rest and then when she wakes up … usually most of the time they dilate fast and have their babies.”

“I like to explain to moms that there is a rhythm to birth, and during the night is not a high energy time, so mothers tend to rest, even though they are having contractions, things may not be happening. Now it's morning you feed them, you alternate between activity and resting and also re-energise all the people who are in the room and make sure they are energised, rested if need be, fed and refocus all of that energy because it's morning. We agreed that we check and make sure everything is fine and if it's fine just don't worry about it. Then I also do foot reflexology so during the time the mother's going to be resting on the bed (as opposed to in the tub) I would sit on the bed and do reflexology on her feet. I would probably give the dad a warm blanket and let him curl up in the chair and I would sit and massage her feet. And if you don't do reflexology, just massage. But the feet is kind of a non-threatening part of the body and you can sit and do this and talk to her through the contractions if necessary and be absolutely still and quiet in between and make sure that anybody coming into the room is also still and quiet and allow her to regroup and refocus what she is feeling. I also have a friend who does reflexology touching at the shoulders and I would try that, it's reshifting the pelvis, I just learned it and I have tried it a few times, it's part of that refocusing of energy. I think it's important … the mother's going to be disappointed because it's only one centimeter, so you're going to have to deal with that disappointment with the mother and everybody. And really have a good talk to her about how she feels about this labour, why does she think that she's labouring the way she is, because sometimes there are issues which you may not have discovered ahead of time. And let the mother express how she is with this, because there may be some very big issues, or even just small ones, or she just isn't ready to let this baby out yet. And if she's not, that's fine, but maybe she needs to talk to somebody about it.”

“I would also just as a practical thing want to know what her contractions are now because that information wasn't given to us and that's in the back of my mind - is there any labour reason separate from emotional reason? I know myself to be honest I would probably put my hands on her belly again and I wouldn't say to her, 'Oh, wow, what a big baby,' but I there would be a small percent of me that would be wondering is this a CPD kind of scenario. You know how the baby sometimes changes, as labour goes on they seem to get bigger! So in this situation I would have to be honest - I would probably put my hands on again and just in the back of my mind get a new estimated fetal weight to put that into the information that I was going to get over the next five or six hours. And the other thing we were discussing if we were going to take actions is that nipple stimulation may give her more contractions after she rests, this is in addition to what we already said, we agree that she needs to rest, she needs to eat breakfast, she needs to talk about if there are any issues here. I'd also want to know her effacement, because I think someone who's six centimeters probably should be ninety or one hundred percent effaced at this point. Also along with nipple stimulation sometimes if you leave the couple alone for a while and encourage them to be affectionate - that kind of goes with it and her contractions may be stimulated more that way as well.”