Thursday, May 08, 2008

Firsts

I'm still new enough to the doula profession that many births bring me a "first:" first VBAC, first stillbirth, first twins, first delivery out of bed, first hemorrhage, etc. Many firsts have yet to happen in my experience. I am waiting for my first water birth, home birth, breech birth (right!), car birth and birth in an unruptured placenta.

I was already going to write about how my most recent client was my first client to have preeclampsia. She was diagnosed yesterday, nearly 2 weeks past her due date, and promptly admitted to the hospital.

Last night began her induction. She had gotten a gel earlier in the day. Around seven they began cytotec. At 11 she was contracting regularly so they opted not to go another round with cytotec and instead began a low dose pitocin drip.

After all this she remained dilated the same 1-2 centimeters she had been for weeks. They sent her spouse home to sleep, gave her Ambien and a little morphine so she could sleep, and sat back for the pitocin to start its long work.

At 1:00 my client suddenly found herself in serious discomfort and was quickly given the epidural she requested. When the doctor checked her at 4:00 she was complete. She called in her spouse and after less than 1/2 hour of pushing, delivered her healthy baby.

This is what her spouse told me over the phone this morning when he called to say the baby had been born. I assumed the call was for me to come in to the hospital because she was getting uncomfortable with contractions. When I heard a baby crying in the background my heart jumped. I thought her blood pressure must have risen precipitously and they'd had to do an emergency c-section. No.

Everything was okay. She just didn't call me. It was the first birth I've ever missed.

I visited them this morning. It sounds like two things accounted for my full night's rest. First, when things got uncomfortable, they did so quickly. And just as quickly the epidural eased her pain and she rested some more. Her spouse didn't even know she was getting an epidural. He was at home, resting up for the long haul.

Second, my client was very dopey. She said that between the Ambien and the morphine, she had a difficult time even understanding what was going on. She slept when they said sleep and called her spouse when they said it was time to call. No one said call the doula.

Her spouse said this morning that they'd much rather have had this kind of birth than one where they really needed a doula. Indeed, that was the birth we all were anticipating.

I have been replaying the night over and over. Despite their reassurances to the contrary, I can't help but feel like I failed in my job. I saw her at the hospital early yesterday evening, before they started cytotec. At everyone's urging -- the mother's, the doctor's, my own id's -- I went home to rest up.

No one thought this would be a quick birth. I have been an many an induction where the first 24 hours are all sitting and waiting for contractions to even start.

But I do not like leaving clients alone for this very reason. One never knows what will happen. Especially when cytotec, that jackhammer of a drug, is involved. Yes, she could have had 24 hours of cytotec and never responded. I have seen that before. Or she could have done what she did, jump all over it.

I don't think the birth would have gone differently. No one is saying it went poorly. But the thought of my client laboring alone haunts me.

I know this won't be my last missed birth, but I hope it's the last I miss from letting my guard down.

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20 Comments:

Blogger mamaloo said...

I missed my first real doula birth (my first doula birth was my sister's second child and my third labour companion gig overall) which was also my first twin birth. In the excitement to get to the hospital, the clients forgot to call.

They did, however, call a day later when they began having problems with NICU staff and bf'ing. I spent two whole days at the hospital working things out with them and they told me I charged too little :D

I know you'll give this family lost of PP love!

1:15 PM  
Blogger Anne said...

I don't think anyone but another doula could have full sympathy for how hard this must be for you. I've had three such missed births: one had a fast labor and didn't have time to call; one just didn't call for reasons unknown; and one couple said they felt so prepared by our prenatal work that they could go it alone. Either way, it's a shock and a major disappointment for us doulas.

Please take some time to be gentle with yourself and deal with the guilt and disappointment. This is not your fault, but I understand why that's part of the gamut of your feelings. It's similar to the "what could I have done better?" that comes after a bad birth, and although it gets easier over time, it's never fun.

1:43 PM  
Anonymous Anonymous said...

I know it can be hard but remember this isn't about you and your needs, this is about the mom and it sounds like they are happy, so be happy for them.

2:20 PM  
OpenID gorlitsaknits said...

This sounds a lot like my own birth, and I understand the mom not even thinking to call you. In my case, had I had a doula there the drugs could have been avoided and will have one at my next birth.

But remember that the mom did not labor alone. The Dad was there, and that's what really matters.

3:49 PM  
Anonymous Anonymous said...

I'm sorry you missed it. That's never a good feeling, and I always wonder if there was something I could have done differently.

Be careful not to swing to another extreme. If you sit with a woman from the beginning of her induction and her labor starts 36 hours later, you might fail her because you've exhausted yourself unnecessarily.

Sounds like in this case it was beyond your control. Don't kick yourself too much!

4:46 PM  
Blogger Kim said...

I don't really have concrete input to add to your experience, but wanted to thank you for sharing it.

...A fiber jaunt Saturday might make you feel good! wink

7:22 AM  
Anonymous maica preoteasa said...

I had clients call me 13 hours after they went to the hospital. Due to the distance to the hospital, severe weather, and lack of communication on their part, I missed the birth. Felt bad, but what could I do(-ula)? I feel for you.

11:46 AM  
Blogger Firefly Mama said...

Funny how our firsts come so differently for different doulas. My very first doula birth was a home waterbirth, so I got those 2 right away. My first baby I birthed was born partially in the caul, though I'd still like to see one fully intact. I haven't had a successful VBAC yet, or a stillbirth (and hope to never have one). I may have twins due in the fall, but not sure yet.

Haven't missed a birth yet, but know that day will come soon. I'm glad to hear that for your missed birth, at least things seemed to go really well.

1:15 AM  
Blogger Sarahthedoula said...

Missing a birth - no matter what the reason - is an awful feeling. Ugh.

The one birth I missed came after I had been to multiple 'false alarms' in a row, so when my client called me about 10pm, at 37+ weeks, to say she was a bit uncomfortable and going to be checked but didn't really need me yet, I said "Okay. Call me when you know something" By the next morning when I woke up and still hadn't heard from her, I called the hospital to have a very snippy nurse say "No, you can't talk to her. She's having a baby now and obviously didn't need you here!"

The ph in my clients room was broken, so she couldn't call me herself when she wanted to. She didn't have a support person to advocate for her. And it turns out that the only nurse on the floor who doesn't like doulas at all was her nurse, and refused to call me when my client asked her to, saying "There's nothing a doula can do that I can't."

I felt AWFUL!! Because normally I would meet my clients at the local hospital even for a "I'm not sure what's up" check, because sometimes things move FAST. but this time I was really tired out from long false alarms, and decided to wait a bit.

You never forget that sinking feeling of missing a birth..... sorry you had to experience it!

6:43 PM  
Anonymous Stephanie said...

Well, when there isn't time, there isn't time. I wonder why the staff didn't think it was important for the mum to have the people with her that she requested? Doped up stupid with things moving fast and nobody helped her get that together?

You're not upset that you missed a birth, you're upset that you didn't see that coming. She wanted you there, she didn't get help to call you, and dad didn't have time.

Not your fault, but be prepared for the mum to have some stuff to work through over the coming weeks as she realizes what went down.

(PS. If hospital staff want me to go home..I go sleep in the waiting room with my pager.)

12:07 PM  
Blogger Heather Lerner said...

We sent our doula home not ONE night, but TWO nights while we slept in the hospital. The first night while I slept with the cervidil in and the second after they turned off the pitocin drip and my contractions basically stopped. We wanted to be alone together. We wanted to be able to really sleep knowing that someone else was watching the baby's heartbeat after months of waking up every 1-2 hours in terror throughout every night wondering if the baby's heart was still beating. Also, I knew I was going to need a lot of double hip squeezing/lifting and I did NOT want a tired doula! So, even though our doula told us she really wasn't supposed to leave a client after labor started, we insisted. And I'm so glad she listened....we would have told you the same thing if you had been here with us this time.

8:42 PM  
Anonymous Anonymous said...

I'm sorry, but I almost fell over reading this. I have been researching birth in the United States for over a year now and I cannot believe I came across the word cytotec in a context that suggests that it has been recently used! I thought they stopped using this because of the danger it posed. It is specifically stated by the manufacturer as well as the ACOG that is should NOT be used on pregnany women. WAs the mother mentioned in the article given proper information as to the risks of this drug? Is this still widely used?

5:12 PM  
Blogger Firefly Mama said...

Cytotec is still WIDELY used. I attended a birth where it was used just 2 weeks ago, and that was a midwife-attended birth in a fairly progressive hospital. I made sure the mama knew all the risks, but in the end her midwives use it ALL the time so she decided to trust their judgment. Not the decision I would have made...

12:22 AM  
Blogger doulicia said...

I agree. Cytotec is the drug of choice at both local hospitals for the thick, firm cervix. That goes for the CNMs as well as the MDs.

I was NOT aware of any official warnings against its use, either by the drugs manufacturer or ACOG. Do you happen to have links to either?

9:07 AM  
Blogger Firefly Mama said...

FDA Warning link:

http://www.fda.gov/Cder/drug/infopage/misoprostol/default.htm

I'm not aware of an ACOG warning. Actually, when I googled it I found this article by Ina May:

http://www.mothering.com/articles/pregnancy_birth/birth_preparation/cytotech.html

And the really terrifying part of her article is ACOG's action described here:

On August 23, 2000, spurred by a large lawsuit brought by an Oregon man whose wife died after a Cytotec induction, G. D. Searle Corporation mailed a letter to 200,000 healthcare practitioners, warning that off-label use of Cytotec has resulted in the death of mothers and infants, uterine rupture, hysterectomy, retained placenta, severe vaginal bleeding, shock, and pelvic pain. According to an informal poll cited by Mother Jones, this warning was heeded by an estimated one-third of US hospitals, which forbade further use of Cytotec for the induction of labor.

Searle's letter clearly upset some obstetricians who had come to depend upon Cytotec's efficacy in labor induction. Some angrily petitioned ACOG to take action against the impending death of their favorite induction drug. On November 1, 2000, ACOG submitted what it called a "citizen petition" to the FDA requesting that the agency require Searle to withdraw its letter warning of Cytotec's potential dangers when used for labor induction.

The FDA has yet to comply with this request.

In my doula practice, I try very hard to inform the parents of the significant risks here. This is one of those issues I have a hard time NOT telling them what to do...I just KNOW they would be (of course) devastated if the cycotec causes uterine rupture, even in an uncut uterus, and leads to death or hysterectomy.

10:33 AM  
Anonymous Anonymous said...

I'm sorry, the ACOG has NOT issued a warning- quite the contrary; however almost every other organization has:
U.S. Food and Drug Administration
Best scientific opinion—Cochrane Database
Searle (manufacturer of Cytotec)
Society of Obstetricians and Gynaecologists of Canada
British Royal College of Obstetricians and Gynecologists
All obstetric organizations in Scandinavia
FIGO (International Federation of Gynecology and Obstetrics)
World Health Organization
Obstetric organizations and drug regulatory agencies in many other countries
(http://www.midwiferytoday.com/articles/cytotec.asp)

I have been researching a book for over a year now on misogyny in america and I wanted to include a chapter on birth trauma due to the horrible treatment women are receiving when they go into labor. Almost everything I have read insinuate that cytotec is a thing of the past; but obviously it isn't.

I do not mean to offend anyone here but, in my opinion and with all the information out about this drug being used on pregnant women, any health professional who still uses it is not fit to practice medicine. They are playing Russian Roulette with people's lives.

4:53 PM  
Blogger Firefly Mama said...

I absolutely agree. It seriously broke my heart when my last client decided to go ahead with the cytotec, despite all I had given her about how dangerous it is.

6:05 PM  
Anonymous Anonymous said...

Not to go off on a tangent, but I am really enjoying speaking to all of you. Does anyone find it extremely strange that in a society that is terrified of pain during childbirth, that it is common practice to give women medication that enhances their pain? Women are conditioned to dread childbirth, television is a particularly influential medium that seems to make childbirth look like sudden death, and the medical community seems to make the whole thing worse. I would love to hear anyone thoughts on that- agree/ disagree.

7:08 PM  
Anonymous Anonymous said...

Firefly Mama- I can totally understand how that could totally make you feel hopeless to say the least, and baffled as well.

I wonder what the woman's thought process was. I would guess its the old, "well the doctor knows best" idea. I think that's what gets us into a lot of trouble to begin with.

7:10 PM  
Blogger Firefly Mama said...

It wasn't just "doctor knows best" cause she was seeing midwives. CNMs. I think there is an overwhelming perception that CNMs are midwives and therefore always take the most gentle approach, but people forget...they attend NURSING school. There is a lot of medical model training there, and CNMs that attend hospital births have supervising OBs whose rules they must follow. Some CNMs are great, don't get me wrong. But I do not agree with their continued use of cytotec.

10:37 PM  

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