A 24 year-old primigravida showed up at our Labor and Delivery one fine afternoon. I was called to evaluate her because she had her prenatal care with one of the OB-GYNs who does not deliver babies at our hospital. She'd been triaged at the other hospital where her doctor has privileges but discovered she didn't like the place, and decided to give our hospital a try.
She was a very pretty young woman, funny and bright during her early labor. "I'm going to do this natural," she announced to me. "I know I can do it."
Why not? I thought to myself. She seemed to be a healthy person, although not of a particularly athletic build, rather one of those quite thin young people who manage to stay slender even though they exist on a diet of potato chips, energy drinks and cigarettes.
As labor progressed, she was quite game to "do it natural." She hadn't attended childbirth class, so the nurses and I took her through Lamaze 101. She learned to breathe through contractions. I had her labor in the bathtub to help her cope through the long stretch of labor before transition. Her soft-spoken boyfriend sat by her side, with the dazed expression of the soon-to-be young father on his face. Still, he was a good support person although he clearly didn't know much about birthin' no babies.
Once she hit transition, things got dramatic. "I can't do it!" she announced. "I'm going to die!" The nurses showed her boyfriend how to rub her back and tried to coach her through transitional labor. "I can't!" she insisted. "I want something for pain."
Fair enough. She already had an IV in, so I ordered some Fentanyl and hoped it would take the edge off transition. Soon she was dozing between contractions and labor looked promising.
When she was completely dilated, she asked, "Do I push now?"
"Do you feel like pushing?" I asked her.
"I don't know," she said. "I don't know how this is supposed to work."
I took one of those deep, inward sighs. I'm a big fan of childbirth education, especially for first-time mothers, and especially for high-strung young women who often benefit from learning how labor often progresses. Knowledge is power, after all. Simply knowing that the intense sensations of labor are normal helps some women cope.
"You can start pushing if you want," I said, "but if you can labor without pushing for a while it might be easier for you. Do you want to get back in the tub?"
"I want this to be OVER!" she bellowed.
That set the tone for the entire second stage. Although she felt she should be pushing, her efforts weren't really effective. I tried to encourage her to change positions--to stand up and rock her hips, or sit on the toilet, or roll onto her hands and knees--anything to get her to connect with the physical sensations she was experiencing. It was a no-go. She preferred to lie in bed, yelling and grimacing as she pushed ineffectively.
I've mentioned before that I prefer to wait until a woman feels a strong urge to push before I start coaching. I think there is a wisdom in the body's holding back from pushing until the fetal head has advanced far enough for its pressure to create an effective signal for a woman to push on her own. However, there is a commonly-held notion that pushing should begin when the cervix is completely dilated. It is really, really hard to disabuse this notion once a woman is in labor.
Because she was already pushing, although not very convincingly, I started coaching her on pushing technique. She was unhappy with being in any other position than semi-recumbent, so I had her put her feet up on a squat bar and pull on hand grips during pushes. Still, she gritted her teeth and made short, exasperated pushes and hollered at the end of each push rather than using the full duration of the contraction to maintain her own expulsive efforts.
The first hour of pushing had already passed, with only a bit of progress. "How much longer?" she asked me, obviously at the end of her rope.
I was still in my calm, warm-and-fuzzy-family-doctor mode. "Well, that's up to you," I told her. "If you push long and strong, like I'm telling you, it will go faster. But if you keep giving up at the end of each push, it will take longer. It's totally up to you."
"Okay, okay, okay," she said peevishly. "I'll try harder."
To her credit, she was trying. For a few pushes she maintained her concentration and pushed for a full eight seconds, which was her best duration. Soon she was lapsing into her previous pattern of grimacing and hollering.
I tried coaching her. I corrected her positioning, told her to pull instead of push on the handgrips, told her not to lift her hips off the bed with her pushes, but to push down and out. I told her to imagine making the biggest bowel movement of all time, a vulgar description of the process of pushing, but vivid and occasionally very helpful. No go to all of the above. She still pushed and cried, pushed and cried, each push lasting a couple of seconds and the crying becoming longer and longer.
I tried to apply posterior pressure while she pushed. In this technique, I place two fingers of my gloved hand into the vagina, behind the fetal head, and push gently downward against the rectum. This accentuates the pressure the fetal head already places in this region and sometimes serves as a more effective "target" for a woman to push toward. It is also a fairly obnoxious thing to do to a woman in labor. I'm trying to reduce the frequency with which I use it, but it really seems to help some women.
By the end of the second hour of pushing, the primigravida was hot and exhausted and MAD. "I hate this," she announced, revealing an emotional age of 12 beneath her chronological age of 24. "I hate it, I hate it, I hate it."
I was pretty hot and tired too. Coaching is a lot of work. "I know you do," I said kindly. "Everyone does, but this is how women give birth. You can do it."
"No I CAN'T!" she said, and went back to pushing and crying, pushing and hollering.
By the time we'd reached the two-and-a-half hour mark, she was swearing like a sailor. "I f***ing hate this!" she cried. "This f***ing hurts. I can't f***ing do this."
I had one eye on the clock. I didn't know how much longer she'd be able to push, even once she got the idea and started pushing effectively. I didn't want her to have a C-section for maternal intolerance of labor. The baby's head was descending with each push, but progress was slow and we were all getting tired. My back hurt. My feet hurt. And my HEAD hurt from all her yelling.
"This f***ing HUUUUURTS!" she yelled, mid-push.
Then I lost it. I really did. I looked her right in the eye and said, "Listen, if it f***ing hurts then I want you to f***ing push HARDER. You've got to stop f***ing around and f***ing push like you MEAN it!"
I think I shocked her. She was still crying but at least she said, "You're right. Okay. Just show me how."
I turned on a fan and got down to boot-camp coaching. I used a lot of posterior pressure and started counting out her pushes. "Come on," I told her with each push. "Big push, big push, big push, biiiiiiiiiig puuuuuuuush. Big deep breath, then get right back on it! Push push push push push push puuuuuuuuush."
The nurses got into it too. Suddenly, we were a team and our patient--with tears drying on her cheeks--was revitalized. The baby started to crown. "Oh, you are SO close," I said. "You're doing it! Come one, PUSH."
After the baby was born--a little girl who looked like her mom--the primigravida, now a primipara, thanked me. "You were great," she said. "You are such a great doctor."
I didn't feel great. I went home feeling sore and headachy and really guilty for using the F-word during labor. I'd cussed out a pregnant woman! Obviously I was descending into some kind of medical sadism to cuss out a woman in agony.
The next day, I was the talk of the hospital. "Your patient is telling everyone how awesome you are," the charge nurse told me the next day. "She's telling everyone 'That doctor told me exactly what I needed to hear. She knew exactly what I needed to have my baby.'"
The moral of this story: Nice doesn't always work. Sometimes the F-word is your best friend.
Awesome story! Reminds me a little of the very first patient I saw after completing residency. He was a stubborn little old guy who spoke mostly Russian, and he came in with a chart the thickness of a nice piece of filet mignon. After reading through it, I realized that he had multiple myeloma, but was flat out refusing to admit it. He even threatened to sue me if I said he had that diagnosis!
Well, since I was totally wet-behind-the-ears, I had no clue how to handle this. I tried to be nice and empathetic, like they taught us in residency, but you can guess how successful that was. Finally I just started yelling at him. I told him that he was killing himself and practically shoved the hematology reports in his face. His daughters had come in from California, and they started pressuring him, too! He eventually agreed to an oncology consult, and for the first time ever, he said "Thank you."
I never saw him again. He never made it to the oncology consult; he died before being seen. But I won't forget the experience, since it taught me that sometimes the kid gloves need to come off.
Posted by: Dr. Dredd | July 17, 2008 at 02:59 PM
Wonderful post! So nice to hear about a physician who is supportive of natural birth.
"Maternal intolerance of labor". I am going to have to remember that one.
Posted by: Hilary | July 15, 2008 at 06:22 PM
delighted to read of this event.you are to be congratulated to have waited two and a half hours in second stage.i practise OBGYN with a large Obst client in The Fiji Islands.Sometimes all stratgies need to be applied with different clients with differing backgrounds.Sometimes when we prepare the patient for instrumentation-forceps , invariably the baby is pushed out.Sometimes we get upset with our own stratergies but a healthy baby and a content mother is what counts.
Posted by: neil sharma | July 12, 2008 at 04:09 PM
You spoke her language. I had a midwife who was of the "let it all hang out mentality" and accused me of wanting to be in control and I froze on her until a nurse came in and covered me up and said, "Tea just wants choices! She doesn't need to be in control-- neither of you have it!" Then she gave me choices in little things and I felt listened to.
Another time my doctor said that if he gave me another shot that we'd narc my baby up, but I was in EXTREME pain. He seemed to have relented when he said that he was giving me another shot when I later found out that it was saline being injected into my saline bag-- but it had the effect that I needed.
I think that what you describe is where the ART in medical arts comes in!
Posted by: Tea | July 11, 2008 at 02:44 AM
If she was going around saying "Can you believe that doctor cussed me out!?!" you'd have a problem. She's not ..she's saying "She knew exactly what I needed." your instincts guideded you ...
you did great!
Posted by: Peggikaye | July 08, 2008 at 06:17 PM
She was right. You told her what she needed to hear when she needed to hear it.
You brought her focus back.
Maybe it was a bit unorthodox, but a healthy woman gave birth to a healthy baby because you cared enough not to take the path of least resistance (C-section).
You, my friend, rock! : )
Posted by: Kim | July 08, 2008 at 12:48 PM
Excellent description. :)
Well, in rural India it is not a common practice for deliveries to be conducted under a male physician, most of the deliveries occur under the guidance of a female attendant. This attendant is a Dai/a midwife/a nurse or a lady doctor.
In many a primary health centers manning a male physicians, nurses are there to support. Women would like to be deliver their babies in their home than under the guidance of a male physician.
But, things are changing and for good. Educated families are now visiting male physicians for common OBG problems.
Posted by: Rural Physician | July 07, 2008 at 01:19 AM
Awesome!! Gotta love that transitional stage as well...
Posted by: Dragonfly | July 05, 2008 at 08:39 PM
Thanks for stopping by, everyone!
Glad to know I'm not alone out there in the boot-camp philosophy of the second stage!
TBTAM, I'm glad to get an OB's endorsement on laboring down rather than pushing the moment complete dilation is attained. As for epidurals--we don't have dedicated OB anesthesia, so most of the time I can't get one for our patients. I do intrathecals, however. Much better for the second stage, imho.
Posted by: Theresa | July 04, 2008 at 07:24 AM
f***ing awesome post!
I totally agree, BTW, that women should be left to wait to push. Until you feel it, it's next to impossible. Epidurals, however, take all the sensation away, so I guess it doesn't matter much anymore.
Posted by: TBTAM | July 04, 2008 at 05:45 AM
I 100% understand. I had a client with whom I was cajoling, humorous, stern, frustrated, begging, instructing, physically interactive and ultimately resigned that were moving into the hospital from her wished-for homebirth.
In the hospital, the nurse was a total b*&^h and told her, "We aren't nice here like those (almost spitting the word out) midwives you have. We get babies out."
The baby was +2 and hadn't moved from when we began pushing 2 hours earlier.
But that nurse - and the incredible anger of another nurse - propelled my client to FINALLY push the baby out.
In talking to the client afterwards, we realized she was used to the anger and yelling aspects - she'd been in the military. All my methods were for nothing. She needed someone to get mad at her. I could never have done that. Frustrated as all get out, yes. Angry? Never.
Your post outlines perfectly how every woman is different and different women need different "prompts" to get their babies out. Some women need the Hypnobirthing prompt - to "breathe" their babies down. Other women don't do anything until there are fingers in the vagina pressing, pressing, pressing... "Push HERE! Feel it? Right THERE." Still others barely need three good 3 x 10 count pushes and the babes' in their arms.
I think the mark of a good (great!) provider is one who is flexible and understanding of the variety of possibilities that might be needed and utilized.
I think you were fantastic.
Posted by: Navelgazing Midwife | July 03, 2008 at 12:01 PM
Wow, what a great story!
(Hi! I'm Xavier! I just found your blog through Liana at Med Valley High).
I'm considering rural family medicine actually, so I'm really enjoying catching up on your archives! I'll be back :)
Posted by: Xavier Emmanuelle | July 03, 2008 at 09:02 AM
Hahahaha!! Great job! That was a funny story, and you handled the situation soooo well. And at least she didn't mind the cursing!
Posted by: Mary | July 03, 2008 at 07:34 AM
Great, very funny story!
You followed your instincts - sometimes nonconventional is the way to go.
Posted by: Dr. Smak | July 03, 2008 at 06:29 AM
Great story. I think you did the right thing in that context - and more importantly, the patient knows you did. I, however, feel less interested in becoming pregnant than ever before. :)
Posted by: Dr. Val | July 03, 2008 at 06:26 AM