Reflection 2.4 Amy, Bess and Claire

Establishing boundaries

Amy 

Amy first texts on Thursday at 9 pm. She reports "very strong" contractions that are happening about every 3-9 minutes and lasting from 30 seconds - 2 minutes long.
She texts again at 1 am saying contractions are even stronger now and happening about every 5 minutes and lasting 45 seconds long.
She calls on Friday morning at 6 am reporting contractions every 5 minutes and 50-60 seconds long.

You arrive at Amy's on Friday at 7 am
Her BP is 130/80, pulse 90, temp 98.6
FHTs are in the 130s-140s before, during, and after a contraction
Leopold's ROP
SVE: 2 cm/100%/0
Struggling with contractions, needs lots of labor support

  

 

 My first thought about this prompt was Amy is 18.  This flags me and makes me take notice of the fact that they have probably been infantilized as a pregnant teenager, and I need to be aware of the language used in conversation with them (Fleming et al., 2015).  However, due to their age, I decided to go and do what I like to call a morale check, where I go and visit and, if they want it, assess them.  I do this because, in the past, I have learned that a good pep talk can go a long way with clients.  I also, in truth, would feel very protective of this client because of their age as well, having had a daughter pregnant at 18 and birthing at 19 myself and watching how her providers often dismissed her.

            After arriving at Amy's and with consent examining them, I would talk with them and remind them that early labor can take a good bit of time. Lots of encouragement.  If they have a doula, I would ask them to consider keeping in touch with them often.  After some therapeutic rest, I would encourage a few positions to help rotate the baby, like some inversions; depending on the time of the year, a swim or visit to the beach would be great, but I would also remind them to do life as much as possible. I would remind them they can reach out whenever they need to and that I am there and ready to serve.

            I would then leave and wait for them to call when labor has progressed a bit.  I may even check in a bit myself.  Hopefully, Amy has a doula who can work with them as well to keep them motivated and to ensure they are taking care of themselves by eating, drinking, and emptying their bladder often.  This can help shorten labor (Ciardulli et al., 2017).

Bess G1P2

Bess's first contact is a text on Thursday at 9 pm reporting contractions that feel "a little different" than they have before. She also reports some bloody show and loose stools throughout that day.
Her next contact is a phone call from her wife on Friday at 1 am reporting contractions q4m and 90s. You can hear her moaning quietly in the background.

You arrive at Bess's home on Friday at 1:30 am
BP 120/70, pulse 70, temp 98.6
FHTs 120s
Leopold's LOA
SVE: 6cm/90%/-1
Breathes heavily and moans lightly during contractions, walking around 

    

Her first text is excellent; it lets me know to get all of my ducks in a row.  The prompt is very indicative of what we experience the most at the practice I work with.  Often my preceptor will relay this information so that we can all be ready to leave.  Multips can move pretty quickly at times (King, 2018).

    After this assessment, I would call my student midwife and or birth assistant, depending on what is going on with my practice at the time.  I would also have the partner start filling the tub.  This labor could be a few more hours or 15 minutes; you never know with a multip (King, 2018).

We would set up the birth tray and start doing FHT every 15 minutes until we feel like they have moved into transition, where we will do them every 5 minutes (Alfirevic et al., 2017). A complete set of vitals once an hour until transition, where they will go every half hour.

In the meantime, I would encourage movement and maybe even a session on the toilet backward with the door shut so she can shut the world out.  The reason I like clients to labor on the toilet is that in past experiences, this has really helped progress labor.  I would also consider hanging a rebozo on one of the doors so the client could dangle (-1 station) to help bring the baby down (Ondeck, 2019). Considering I don’t know the outcome, I am not ready to reflect on what I would do differently.

 

Claire contacts you by phone call on Friday night at 9 pm. She says it's definitely not active labor, but she just wanted to give you a heads up.
She plans to go to bed and you make a plan to touch base in the morning.
You call her Friday morning and learn the contractions stopped overnight while she was sleeping.
You hear from her again on Sunday right after midnight when she calls to report contractions q3m/60 seconds. She stops talking every few minutes but is not vocalizing.

You arrive at Claire's Sunday at 1 am
BP 110/60, pulse 70, temp 98.6
FHTs 130, decrease to 116 at peak of contraction, increases to 140s at end of contraction, and return to baseline of 130s after 60 seconds post UC
Leopold's OA

Declines SVE
Very quiet and still during contractions, returns to normal conversation after they end

I would head to Claire's immediately.  I would also call my team before heading out.  As soon as we got there, I would have my team set up and if Claire wants a water birth attempt to get the tub filled and ready, however, the baby FHT shows me that this birth may be pretty imminent as the vagus nerve is being stimulated during the contractions which shows the baby is very low.  Since we did not do n SVE, this would be my prediction based on experience and how labor progresses (Xodo & Londero, 2022).

FHT every 15 minutes until we feel like they have moved into transition, where we will do them every 5 minutes (Alfirevic et al., 2017). A full set of vitals once an hour until transition where they will go to every half hour. 

Once the tub was filled up, I would encourage them to get in.  Water can really help 1, shorten labor, 2 relax the birthing person and help them better cope with the discomfort of labor, 3 lower the risk of perineal tears, and 4 increase satisfaction with their birth (Gonçalves et al., 2018).

Based on past experiences I would be surprised if I even made it to the birth, however, that could be because I live an hour away from my practice.  I would have liked a heads up on Friday when things started happening and would probably go spend the weekend with my mother since she is only 2o minutes from the birth suite and or the Virginia Beach area.

 Resources

Alfirevic, Z., Gyte, G. M., Cuthbert, A., & Devane, D. (2017). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews, 2019(5). https://doi.org/10.1002/14651858.cd006066.pub3

Ciardulli, A., Saccone, G., Anastasio, H., & Berghella, V. (2017). Less-Restrictive food intake during labor in Low-Risk singleton pregnancies. Obstetrics &Amp; Gynecology, 129(3), 473–480. https://doi.org/10.1097/aog.0000000000001898

Fleming, N., O’Driscoll, T., Becker, G., Spitzer, R. F., Allen, L., Millar, D., Brain, P., Dalziel, N., Dubuc, E., Hakim, J., Murphy, D., & Spitzer, R. (2015). Adolescent pregnancy guidelines. Journal of Obstetrics and Gynaecology Canada, 37(8), 740–756. https://doi.org/10.1016/s1701-2163(15)30180-8

Gonçalves, M., Coutinho, E., Pareira, V., Nelas, P., Chaves, C., & Duarte, J. (2018). Woman’s satisfaction with her water birth experience. Advances in Intelligent Systems and Computing, 255–265. https://doi.org/10.1007/978-3-030-01406-3_22

King, T. L. (2018). Varney’s Midwifery. Jones & Bartlett Publishers.

Ondeck, M. (2019). Healthy birth practice #2: Walk, move around, and change positions throughout labor. The Journal of Perinatal Education, 28(2), 81–87. https://doi.org/10.1891/1058-1243.28.2.81

Xodo, S., & Londero, A. P. (2022). Is it time to redefine fetal decelerations in cardiotocography? Journal of Personalized Medicine, 12(10), 1552. https://doi.org/10.3390/jpm12101552