Thursday, October 02, 2008

Lady in Waiting

If you’re having a hospital birth, perhaps one of the most challenging parts of labour is the transition from your home to the hospital. Many couples worry about the car ride to the hospital, but it’s amazing to see how most women manage the ride with surprising grace. If the car ride is timed so that it coincides with the trance induced by high levels of endorphins (well past the mid-point of labour), then the whole journey can be manageable.

To illustrate - I vividly remember one client’s ride to BC Women’s from UBC. It was around 4am. She threw a coat over her naked body, somehow managed to run to her car down a long apartment hallway (between contractions), then crawl onto the back seat of her minivan, exposing her bottom to an old man in a trilby hat, who was coincidently walking his little Scotty dog past us at that moment (you should have seen his face!) Bouncing along in the car, this normally private woman laughed and laughed. “That was FUN!” Yes, the trip was uncomfortable, with her husband trying to negotiate hundreds of potholes, but the absurd nature of the trip far outweighed the pain it may have caused.

The stories that result from the car ride can be epic, from the woman riding to the hospital with her head popping out of the sunroof of a Mini, to a recent dad’s call to BCAA: “I locked the keys in my car with the engine running at the Emergency entrance to the hospital!” If you’re lucky, you’ll notice the absurdity in the moment, and laugh.

Now, it’s the hospital assessment room that can be a possible source of stress. If you’re lucky enough to have a midwife who has already completed the assessment at home prior to hospital arrival (which happened last week with one client), you might manage to bypass the assessment room altogether - yahoo! - and go straight to your birthing room. This causes a lot of excitement and very little stress.

The next possibility is that the family doctor will meet you at the front door and do the assessment personally. The continuity of care provided in this scenario is wonderful, and the time spent in the assessment room can be relatively short, provided the hospital can quickly assign you a nurse. There’s also the added bonus of having an additional advocate present to help negotiate the hospital protocols. If I’m lucky, I can coordinate this...but it’s really hit and miss.

If the family doctor is busy with another birth, or en-route, or your primary caregiver is an obstetrician or resident, then we have to hope that the assessment room is not too busy, that all the other women in the assessment room don’t require high levels of care, that the staffing levels aren’t low on this day, and that there’s more than one nurse available to care for the 5 beds in this area. Fingers crossed that the assessment room stay won’t drag into multiple hours, which can easily happen. (I always try to call first, so at least I can alert my clients to the possible delay.)

There are a lot of variables that can increase a woman’s stay in the assessment room. The assessment room nurses (who are amazing, highly qualified, and caring people) do everything in their power to take into account BOTH the triage process and each labouring woman’s needs. There’s a lot of paperwork to be done, protocols to follow, personalities to placate... The assessment room nurse needs 8 arms, two heads, and more than a little wit and understanding, to make it through each shift.

It may appear to clients (husbands especially, since the labouring woman is generally just focused on each contraction) that the nurses are sitting at the desk doing nothing. Often, the people sitting at the nurses desk are not the assessment room nurses, but interns, residents, other doctors, or even a clerk. The supervising nurse in assessment must juggle all her patients to ensure that the woman with the highest care needs can proceed to the next “level”. Granted, the nurse might not be able to explain what she is doing for each woman during the process, but that’s what I try to cover with clients in between contractions. “Yes, it might look like you’re being ignored, but you’re NOT. She’s left the room to negotiate with labour and delivery to have a nurse transfered up to Cedar to be with you, so you don’t have to wait until a Cedar nurse returns from her 45-minute break, etc. etc.” It’s my job to fill in the gaps in information. But, if I need to breathe through the contractions with the woman in labour, the dad will have to wait a bit for my briefing.

Even a 45-minute stay in an assessment bed may seem like an eternity, but it’s about as fast as the system and safety will allow (unless you’re ready to push...then you get to fast forward!) For example, the nurse needs to read a woman’s chart thoroughly to determine her risk status, her drug allergies, her particular needs, and contact her caregiver (and wait for a response). If a nurse is forced to cut corners, a woman could inadvertently be given a contraindicated medication (i.e. fentanyl being given to a woman with an drug allergies), or miss important medical information. I am able to highlight certain important points when I speak personally with the nurse, but she must confirm this by reading through the notes, and then doing a thorough history and assessment herself.

The setting certainly doesn’t make a labouring woman feel safe or calm. The beds are narrow, the space is noisy... But, I ask all clients to imagine that we’re still home, to keep their eyes closed, to focus on a calming hand, the soft pillow, their partner’s voice, my voice. Often I have to talk the woman through each and every contraction, so that she remains calm between each contraction. Yes, she might roar during contractions, but that’s her way of coping. It’s the in-between times that tell us how she’s doing. If she’s able to breathe calmly between contractions, or even say, “Wow! That was intense!” or “I didn’t like THAT one!” then she’s fine. (I try to wangle assessment bed 5...the one with a DOOR!)

As a doula, the assessment room experience is certainly challenging. It takes years of experience to negotiate the process gracefully and diplomatically. Most problems can be prevented creatively. Petty staffing wars can be averted by anticipating them in advance, and steering clear of potentially tense situations (trust me, I’ve seen it happen recently.) Protecting the woman in labour is paramount.

Sounds like it’s better just to stay home until you’re ready to push (which is what one doctor laughingly suggested recently). least you have a doula with you who knows the staff and your caregiver, and can provide the best possible “concierge service” around...

- Jacquie Munro, Vancouver Doula

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