Читать книгу Better Births - Anna Brown - Страница 19

Fiona*’s birth story: To me, midwifery‐led care is about being with woman – not just in the physical sense, but holistically engaging with her, understanding her story and actively listening. I feel extremely privileged, within the National Health Service (NHS), to work in a home birth team, case‐loading and providing community to our clients. Through this level of continuity, I feel I have been able to give the best care of my career, because for the first time I am getting to know the women we care for. As a team we care for mothers throughout their pregnancy, and spend time understanding them as an individual. What motivates her? What are her fears? What are her preferences and why? What does she find supportive and obstructive? Listen carefully to a mother and she will tell you her story; engage with her and you will understand it.

One evening I was first on call, about five months into my career with the team, and about 18 months post qualification. I received a phone call from Fiona, a term mother, at about 9 p.m. to say her waters had broken. This mother was someone I had booked under the team's care when she transferred to us in the third trimester from another location. She had a previous home birth elsewhere and was incredibly calm as a person. Her first birth had been straightforward and had been the quicker side of ‘normal’. I confirmed her waters were clear, and baby was moving well. Fiona reported feeling very comfortable, with just a few ‘niggles’ so far. Guided by this information and her relaxed manner on the phone, I suggested she rest and call back when things changed or if she had any concerns.

A few hours passed, and I received another phone call. Still calm and relaxed, Fiona told me that she was now having two contractions every 10 minutes. She felt they were mild to moderate in strength but could feel they were beginning to spread from previously being low and crampy to now up and across her abdomen. They were lasting about 40 seconds. By textbook definition, I knew that this indicated that Fiona was not in ‘active’ labour, as her contractions were not yet regular or occurring 3 : 10 lasting 60 seconds. But on hearing her pause and breathe through a contraction on the phone, I felt that I should make my way to her.

When I arrived, Fiona was quietly pacing in her room using a TENS machine and listening to a relaxation track. I checked my kit and quietly set up my resuscitation equipment – the family had a full discussion with us at a 36 weeks antenatal appointment and knew what kit would be present. So this was not alarming. I completed a full assessment – observations, abdominal palpation, began regular auscultations and then sat back and observed her. Liquor remained clear, and baby was still moving well; all was well. We do not routinely perform vaginal examinations, unless requested or unless there are any deviations from normal, for at least the first four hours – within which time many mothers have birthed or are close to birthing.

Fiona continued to pace, and I observed as she paused to breathe through each contraction. I noticed she was now contracting about three times in every 10 minutes, but reflected on how on an average triage shift, a mother as stoic as her would likely have midwives saying ‘she's not in labour’ ‘she can't be in labour’ – and yet here she was, and signs implied otherwise. In hospital, perhaps a vaginal examination may have surprised a midwife. But in reality, that information would not change this picture at all. What was important was that Fiona was contracting regularly – she required midwifery support, it didn't matter if she was 4 or 8 cm. With no interruptions to her hormonal and physiological progress in labour, I knew her dilation was likely to be advancing rapidly, especially as a multiparous mother. Her partner, Rob inflated the birthing pool and began to fill it.

Occasionally, I reminded Fiona to stay hydrated and she began sipping water after contractions. I asked when she last passed urine, and she thought it had been a few hours. She mobilised to the bathroom. I documented and phoned my second midwife to attend – I knew her drive was a bit further than mine and felt the mother was so calm and stoic we could be having a baby here soon. Shortly after coming off the phone, I heard a quiet ‘grunt’ from behind the bathroom door. I asked to enter the bathroom and found Fiona beginning to spontaneously push at the height of her contraction. With Rob speedily filling the pool, which was just about 20 cm deep, I suggested we move off the toilet and make her more comfortable. I was now auscultating baby central and low, where we had previously been listening in at the left occipito anterior (LOA) position. A steady 130–135 bpm baseline remained post contraction. This implied that the baby was progressing down through the mechanisms of labour and was ready to be born. As Fiona moved back into the bedroom, she spontaneously knelt on her bedroom floor, leaning on the bed, and I placed pillows under her knees.

As the next contraction came, there was a forewater rupture and vertex was visible. I grabbed my ‘delivery kit’ – a small zip‐lock bag with cord clamps, sterile scissors, swabs and, if needed, syntometrine. (We carry full delivery kits, but this is an easy grab bag when baby comes quickly.) I began five‐minute fetal heart (FH) auscultation and told Rob to stop filling the pool – the baby was coming! I asked instead for a bowl of the pool warm water and used this for my warm compress to protect Fiona's perineum, with consent, as baby advanced. I reassured her that everything was progressing well and to keep listening to her body. At this moment, her son woke up and came into the room – Rob quickly reassured him, and I greeted a hello as we had met throughout her pregnancy. The child sat excitedly with his father and supported the mother – even clapping hands in excitement! As Fiona's baby's head crowned I reminded her to blow and control her breathing, as we had discussed at the 36 weeks antenatal appointment, to allow baby's head to birth slowly – she calmly blew long breaths as baby delivered – head then body within three minutes of vertex being visible. I passed Fiona's baby through her legs and she held her close to her chest maintaining skin to skin whilst I rubbed baby and covered them both in a warm towel. The second midwife arrived shortly afterwards, and Fiona went on to have a physiological birth of the placenta also.

On reflection, I was relieved I had attended at the time I did, despite the fact that, at the time, Fiona was reporting mild to moderate tightening. Fiona's labour was not typical as she was so stoic throughout; I'm not sure she would have ever sounded like a textbook ‘actively labouring’ mother over the phone. In hindsight, knowing the mother as I did, meant I had an understanding of her nature, and knew she would likely be incredibly calm in labour. This had a huge influence on my decision making, based on my relationship with Fiona and knowing her as an individual, which I intuitively considered when attending to her and providing care as her midwife.