challenging births 2
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.
Elisa is in labour at home with her third baby and is coping well with strong contractions. Her other babies were born vaginally, the first in a hospital and the second in a birth center. She appears to be making steady progress, although she has decided she does not want to be checked vaginally unless this is absolutely vital. The baby's heartbeat has been strong, variable and accelerative throughout labour. As her water breaks, you notine that there is meconium in the liquor. It appears to be old, but you cannot be sure. What issues does this raise for you, and what would you be saying to Elisa at this time?
“Given this setting, we were not very worried, because we don't know how much meconium and what exactly this looks like - is it massive black clumping stuff, or is it just a touch of old green stuff?! But assuming that somebody thinks it's old, we're not sure, but it doesn't sound like it's very massive here and the heart rate is good, she's apparently making good progress, we're basically not all that worried about this, well not at all worried about this. We would certainly maybe want to keep a closer eye on her, maybe listen a little longer every time we listen, to be sure that the baby keeps on being happy. We would also want to discuss with Elisa the significance of this so that she doesn't get alarmed and she is reassured that we are following up and if it were to be worrying we would act on it but right now we're not worried. We talked a little bit about moving her to the water because birth in water when there's meconium might be a good idea so the baby doesn't breathe immediately, also the water will dilute the meconium. There's none of us saying we're going to do deep suction here, but maybe a bulb syringe afterwards. We would assess the baby and see if we felt that was a necessary deal. And also we would be checking whether the meconium situation was something we would have to take action on. We also talked about watching the baby afterwards, are we going to watch the baby particularly closer because we were worried that there's going to be meconium aspiration syndrome or is that a bit of a non-issue? Are we going to discuss it with the mum, or just leave her be? That depended a little bit on our backgrounds what we felt we were going to do about that. Maybe it's because I haven't been burnt yet, but I personally from what I have read and heard and felt that meconium aspiration syndrome is a bit of an unknown, is it caused more by the deep suction than by just the presence of meconium, how real of an item is it? All these times they send the baby to the NICU and they do these x-rays and they are looking for something, they always say they see this shadow… I don't know, it seems a little questionable to me and I would not want to start getting the mother worked up and worried about something that I wasn't sure how much I needed to be worried myself. Although I don't know whether that's responsible because you should of course include the mother and make it her choice to a certain extent but as I'm not sure how worried I want to be I don't know whether I would bring it up. I would make sure I was there promptly, make sure I gave good postnatal instructions about looking at the baby and then come promptly the next day on my follow up visit. My friend was saying that she was a little more concerned than that and she would probably stay a little longer after the birth to keep an eye on the baby for a little longer than she normally would. So we were not in exact agreement on that.”
“All three of us agreed on what we would do. We would first explain to her what it was and what the implications were, that type of thing. I don't think going on about meconium aspiration syndrome and all that but just what it meant and what we would like to do. The first thing we would want to do is do a vaginal exam, find out what stage of the labour she was in, and that would sort of determine our actions from there. And if we thought she was still very early in labour then we would discuss with her the possibility of maybe going in. If we thought that she was close to delivery then we would be very happy with that. Because the baby's heart beat has been good, she's been making progress and there have been accelerations. So really we weren't going to worry a lot, unless it was really very early in labor and then maybe we would think about something else. And once she looked like she would continue to progress and give birth, then what we would do is, once the baby's head is out, but not before the body is out, just suck out whatever meconium is in the mouth and the back of the nose, just to take that out of there so that when the baby was born and they did breathe it would reduce the possibility of anything going down. My colleague uses homeopathic medication so she would give the baby something like that after birth to just make sure that the breathing was OK. I don't, so I would just watch the baby closely afterwards, and I do think that the period you would have to watch would have to be right after, not the next day or so, but immediately after, for maybe a couple of hours after to make sure that the breathing was OK.”
“Is there a specific homeopathic remedy that you would give, or would it depend on how the baby was?”
“It depends on how the baby was. If the baby is not really alright, then I give lachesis - this is a kind of snake poison! I generally give it to the babies when they have the cord on their neck, after the birth I give routinely - sorry, but I give it routinely! Whenever it occurs again in his life that something is taking his breath then the baby will not suffer again. That is when the cord is around his neck. But when meconium is there then it's for the first four breaths, that feeling, whenever it occurs again in your life, it shouldn't block you. Homeopathy works for happy breathing.”
“I would also be concerned to know what the baby's gestational age is. Because you can expect meconium if the baby is post-dates or past term.”
“Just speaking about what you tell the mothers… I had a mother recently who had meconium and she was so worried because of what she had read ahead of time and she was just afraid the meconium was going to kill her baby because it was going to get aspiration when the baby came out. And I spent the next few hours trying to reassure her and it didn't work. She worried herself into a c-section. She got to 5 centimeters and she stayed there. Simply because of what she had known from ahead of time. You know this informed consent is a two-edged sword.”
“The guys who said you would do a vaginal exam and check her and if she was close to delivery you'd all be happy, but then what did you say you would do if she was not close to delivery?”
“If she was still very early in labour, depending on the other things and after our discussions with her, but a consideration would be to think about transferring her. But, again, all the other things would have to be taken into consideration and one of the things that I forgot to mention is the gestational age. If it were post-dates then we would also worry less.”
“We have a birthing center and we have labour and delivery - she could not be at home in my area. If she called with meconium she would not be allowed in the birthing center, she would have to go to L and D and we could follow her as a midwife over in L and D as long as we don't have a patient in the birth center. If I have a patient in the birth center I have to give her up to the doctors just because she has meconium.”
“We are required to do an amnioinfusion even if it's light meconium. And peads have to be present at every delivery even if it's light meconium.”
“Post dates aside, one of the things that I learned was that when the women are not afraid, when they trust birth, it's OK. I'm not surprised your women had a section if she was so worried - when the mother says, 'oh, shit', the baby goes, 'oh, mec'.”
“The midwives in one area looked back at their records and they had very little instance of meconium, but every time they saw a mother whose baby had meconium, there was always an issue involving fear going on, or a problem in the relationship with the woman and her partner.”
“If it's old meconium and she doesn't want to be checked (vaginally) I would feel OK. It is her third baby, I will check on fetal heartbeats between contractions and during contractions, to rule out the possibility of a prolapsed cord, if I don't see it in the introitus but if everything is fine in that, I will check on the heart tones very closely and the baby but stay in there with her because old meconium I have never had a problem with. Just suction and it's fine, not a big issue for me.”
“I just though it would be interesting to go over the things that we were different about and why we were different and whether they were things that would matter. The vaginal exams, we didn't address at all, we just went, oh, she doesn't want vaginal exams, OK, you know, so what! But then I guess maybe it's not 'so what', I don't know. Then the maturity thing we didn't address at all either, and I just don't know how significant these things are, but then the whole question is 'how significant is meconium anyway?' I mean if you had these huge clumps of it, you've all seen those really nasty ones, then however laid back you are you just cannot be laid back anymore, is my feeling. But when it's not like that I don't know how much attention to pay it at all, or even whether it's the woman … this fear thing we were talking about. What would the vaginal exam tell you? Why would you transport her if it's early on? It's not like I'm really questioning, I just didn't understand, it didn't seem like particularly relevant information to me at that point.”
“We considered that {transporting} because we weren't really sure what the meconium was, because the scenario said it looked like it may have been old and we weren't sure about some other things, and so that's why we just said one of the possibilities … we sort of said, well this is the range of possibilities, these are the things that we may do. A vaginal exam would give us a better clue as to where she was in the labour so we could make a better decision because we did not have the other information.”
“Old thick meconium can be worse than fresh meconium because fresh meconium can easily come from a sudden constriction of the cord which by the movement goes away. And also if it's the beginning of labour then you might think of the baby as not having a lot of reserve energy. If the meconium is old then you should think of maybe the baby is not having enough reserves and if it is early then I would take her to the hospital. Later I would not. But fresh meconium is not like that, because then the baby has the reserves.”
“Would you estimate reserves according to the fetal heartbeat?”
“I would consider whether the baby has reserves from the fetal heart tones. Or the CTG / fetal monitor, although you then have to judge whether that it accurate or not.”
“Isn't it interesting that in the UK and the US it's actually the other way around - we are far less likely to be worried about old meconium than we are about fresh meconium? You're looking from completely the opposite perspective - old meconium might be more of a problem, which is really interesting to think about.”
“The other thing I've noticed about meconium is that if you let the labour progress it sometimes changes to the point where at the time of birth it almost seems that the new fluid that's coming out is clear, so then you wouldn't even need to think about suctioning or anything. Something I heard a speaker say was that if you attempt to aspirate meconium the baby's reflexes go to suck in by the stimulation of the bulb, so that she really doesn't like suctioning even if there's meconium.”
“She said if you hold the baby so the head is down, then you let the secretions drain out naturally.”
“The key is whether the baby has lack of oxygen or not, because if it has lack of oxygen then he will try to breathe the minute he can, which is aspiration, even before getting out. But if it doesn't have a lack of oxygen then he will not aspirate.”