Gestation period: 15 weeks, G1P0
I first met Lisa in the antenatal clinic. She had come along with her partner, Chris and her mother.
Lisa is of Caucasian origin. At 20 years old, this is her first pregnancy, and also her mother’s first grandchild. Both mother and daughter seemed excited about the pregnancy. I conducted the comprehensive medical history using the obstetrics database. She did not have a medical history. Her blood group is O positive, and antibodies are negative Rubella immune. Furthermore, she tested negative for HIV and Hepatitis, HB 100g/l, BP 98/62 and HR 81bpm. She had never had a pap smear before. Generally, she had a relatively healthy lifestyle and did not smoke.
After the procedure, I explained to Lisa and her mother that I was a midwife student, and I was interested in supporting and observing her closely through her gestation, labor and postnatal periods. Lisa said she had her family’s support and her relationship with her partner was healthy. She had not experienced domestic violence. Lisa’s privacy was respected all through this process of gathering information.
Having been busy dealing with another patient’s first visit, I only met Lisa for the last 5 minutes of her appointment. She had found out that she was carrying a baby girl and was doing very fine. However, she said she had tiny red rashes across her abdomen. The midwife who attended to her had advised her to use Hydocoetisome 1% cream, which could be found in chemists. Furthermore, she was told that if there was no improvement, she should seek medical advice from a specialist. She promised to visit St. Mary, the outreach clinic I was running.
On this day, Lisa is 23/40 through her gestation. She says the fetal movements are good, and her heart rate could easily be detected via the Doppler. She had visited a GP concerning the red rash and was advised to use hydrocortisone cream. We organized a pathology form for Lisa to undertake another FBC and a GCT, both of which she agreed to be done at Barrett and Smith.
Lisa is 27/40 gestation and measuring 27cm fundal height. Lisa reports good fetal movement and heart beat sounds aculeated with good acceleration. Lisa tested negative for gestational diabetes with a BGL 4.1mmol after a 50G loading. The FBC has done at the same time shows 112g/l. During this visit, Chris attends the appointment. We spoke about pain relief options in labor. Lisa said that she did not know what she wanted or what to expect. I advised her to do some research on her own regarding pain relief and maybe talk to her mother about how her labors were.
3/7/12- I did not make the appointment due to residential school.
I got a phone call from birth suite this morning while working in the postnatal ward. Lisa had been taken in at the delivery suite with SROM and contracting 3:10 moderate in tone. Due to the commitments at the postnatal ward, I did not manage to see Lisa at that time.
I managed to see Lisa in her birth suite at 15:30. As I entered the birth room, I found Lisa in tears with her mother by her side. Her partner, Chris, was sitting in the corner watching television, and playing on his phone. Lisa had syntocin 30units in 1000mls n/s running at 4mls hr. The CTG was on monitoring, and Lisa was using the gas N20+02 30:70 throughout her contractions.
I went over to Lisa and asked her how she was doing. She said that she couldn't take the pain and had requested for an epidural. However, since there were a couple of emergencies in the hospital, Lisa was informed that it would be long till they get an anesthetist. I asked her if she wanted a heat pack or if she wanted to change position to help with the pain. She agreed and I also increased the N20+02 to 60:40. I asked Chris if he could help by massaging Lisa’s back or getting some water. He rolled his eyes, huffed and complained that he was trying to watch the television and could not hear because Lisa was making too much noise. I could not believe that Chris was so negative. His partner was in excruciating pain, and his baby daughter was about to be born yet he seemed annoyed that we were distracting him from watching television. I excused myself out the room to get Lisa some water. As soon as I left, Lisa’s mother and josh started fighting. I came back and informed them that we needed to be there for Lisa and the baby and this was not the place to be fighting. Lisa’s mother apologized.
At 16.00, Lisa asked me how to place the epidural. I informed her that the anesthetic will be given to her through an injection of local anesthetic in her lower back. A hollow needle would then be guided between the small bones in her spine. It goes into the space between the layers of tissue in her spinal column called the epidural space. A fine catheter is then taken through the needle. When the tube is in position, the needle is taken away. The tube is taped up the back and over the shoulder and fentanly then local anesthetic infusion will be commenced.
After explaining the procedure, I set up for the epidural and helped position Lisa while the anesthetist undertook the procedure. Once the epidural was placed I undertook 5min Bp for 45min and hourly thereafter. I then inserted an IDC with Lisa’s permission. Then close monitored the baby and Lisa.
At 1700, the IV syntocin was increased to 4mls hr as Lisa’s contractions became less regular. And VE was performed with Lisa’s consent to assess her progress. The VE showed 7cm dilated,-station at -3 and fully effaced. The epidural was working well and Lisa was a lot calmer. Fetal heart was 120-130bpm variable decals. I notified the midwife I was working with who then suggested turning up the IV Hartman and changing Lisa’s position. The O+G registrar was also notified.
1800- Lisa’s OBS remained stable, but the fetal heart was non-reassuring as was having prolonged decals. I informed the midwife straight away who then requested me to do another VE while she notified the O+G. She also prepared for a code one C-section. I undertook another VE with Lisa’s consent which showed Lisa to be fully dilated and baby sitting at +2. The O+G Dr examined Lisa explained that the baby did not show any signs of distress; they needed to quickly get that baby out. They will be putting a cup shape suction device on the baby and help pull it out. Lisa said, “Just do what u have to”. Ligoucaine was placed on the perinea area and an episiotomy was performed. A penthouse cup was placed on the baby’s head. Lisa was told to push when she had a contraction. It took four more contractions for the baby girl, Tiffany, to be born at 18.54; pager score of 9 at 1min and 9 at 5min.
Tiffany was placed skin to skin with Lisa; I asked Chris to cut the cord. He looked shell shocked and replied, “It is an ugly thing, and I did not even want the baby.” I couldn't believe anyone would say such a horrible thing at the birth of their child. I asked Lisa’s mother if she wanted to cut the cord. Unfortunately, she was in tears, and said she was too afraid that she would cut Tiffany as her hands were shaking. I decided to cut the cord. The placenta was delivered with cord contraction following the administration of IMI syntocin.
As soon as baby Tiffany was born, Lisa seemed to get a new boost of energy and forgot all about what just had happened. Tiffany was breastfeeding within 30min. I stayed with Tiffany for the next 2 hours and performed the baby check on her. I had felt very sad for Lisa as Chris was not the supportive partner and father that she and Tiffany needed.
I visited Lisa and Tiffany in the postnatal ward. Her parents and Chris were all there with her. She said she felt great and could not believe Tiffany was here. Chris was holding Tiffany and it was great to see him engage with Tiffany and Lisa. I asked Lisa how breastfeeding was going. She said Tiffany was doing well and that it was amazing that Tiffany just seemed to know what to do instinctively with breastfeeding. Lisa was doing well in her postnatal; all OBS were between the flags, fundal firm and 1cm below the umbilical. I informed Lisa that I would visit her the next day and wished her a good night.
I spent some time with Lisa on the postnatal ward. Lisa was planning to go home today where she lives with her mother, step father and her partner. Lisa said she was ready to go home but was nervous as she felt ill prepared as a mother. I told her that this is a normal feeling and reassured her that she is not alone. Her mother would be with her and that if she was really unsure about anything there is 24- hour new mothers support line she can call. Lisa was discharged later that day.
A phone call
I called Lisa today to check how she was doing, and honestly thanked her for helping me in my CCP. She said it was so good to have me there to support her. I asked how about Tiffany; she said she was still breastfeeding but she was expressing for night feeds as her mother was getting up at night to help feed Tiffany. Lisa said Chris had since moved out and they were working on their relationship.