To wait or not – that is the question…

Posted on: January 4, 2009

Dec 16th, 2008: Our second mom had been very active till the day of her delivery. In fact, on the night before her labor started, she and her husband went for a movie where she climbed 2 flights of stairs. She was also very good about doing her birth fitness exercises she learned in the Healthy Mother classes, and about walking regularly. Her labor started around 3 am at home, after which she continued to labor at home until her contractions were 5 minutes apart. When she came into the hospital, an internal exam showed that her cervix was long and closed. A CTG showed a flat line (which not a great sign and it means that the baby’s heart rate was not showing the reactivity it should usually show to movements and contractions). Mom was put on CTG monitoring every hour. Thankfully, the next CTG was slightly better, so mom decided to labor further. At 1:30 pm, with contractions coming on strongly, it was recommended that mom try Prostaglandin gel to ripen her cervix, since there was no sign of her cervix thinning or opening.

An hour later her contractions started to intensify – now they were 2 minutes apart and 1 to1½ minutes long. Mom was extremely nauseous and did not want to eat. However, she continued to sip water and drink tender coconut water. After a while she started to vomit, at which point she was given I/V hydration. Once this was done, I worked with mom to help her through this very intense and prolonged active phase of labor. She walked, rocked, went on all-fours, kneeled, did side-lunges, climbed stairs and rested. She managed the contractions with some great Rhythms and Patterned Breathing. But all the while she continued to remain nauseous, and we kept her hydrated with ice-chips. We monitored her with CTGs every 1-2 hours and while some of the results were reactive others were not so good. At 10:30 pm an internal exam revealed that her cervix was 50% effaced and one finger dilated. By now, mom had been in intense, active labor for 8 hours. Since she was getting tired, I advised her to rest and labor alternately for some time in between contractions, while her husband and I alternately gave her rubdown relaxation massages.

By now, it was Dec 17th, and we were still hopeful that some progress would have been made. At 4:30 am, the CTG was flat, and mom was feeling less baby movements. So we decided to move her to the labor observation room, and monitor her more continuously. At 6 am, an internal exam showed that her cervix had still not shown any further progress and was at the same 50% effaced state and 1 finger dilated – this was not what we had hoped for. Further, an abdominal examination showed that the baby’s head was still 4/5ths out of the brim. Amniotomy was not a feasible option because her cervix was only 1 finger dilated. Mom had been in active labor for 16 hours, and was tiring fast, but an epidural was not an option for pain relief, again because of the minimal cervical dilation. Mom was offered Entanox to manage her contractions, which helped her to some extent. Fetal heart rate monitoring every half an hour showed that baby was holding up reasonably, with occasional decelerations of heart rate. At 10:30 am, 27 hours after her labor began, mom was given the choice of laboring on further until baby was doing well, with no more internal exams or to have a C-Section.

However, by 1:00 pm, she decided that she did not want to labor any further. Even with all the comfort measures, continuous labor support and encouragement that we provided, at the end, she was physically too exhausted to continue further. A final cervical exam showed no further progress, and she decided to opt for a C-Section. A healthy baby boy, weighing 3.3 kgs was born via C-Section, 35 hours from start of labor! Slight meconium was found during delivery, which probably explains the variations in heart rate that were found during intra-partum electronic fetal monitoring. After birth, the baby was found to have slight tachycardia and was put on oxygen for half an hour, after which his heart rate stabilized. We had mom and baby nursing within an hour and quarter after birth, and the rest of the recovery progressed well

Lesson learnt: Sometimes, even with a good trial of everything, labor’s progress shows variations. There are situations where even though we might have started out with the intention of supporting mom for a natural childbirth outcome, if she is so tired that she is unable to carry on, her wishes have to be respected. Finally, in retrospect, with the findings of meconium at birth and slight tachycardia in baby it was probably the right time to go in for a C-Section, added to the fact that labor was not making any progress. Not that we knew this in advance, but waiting it out further, may have led to further complications for baby at birth.

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