The FTPs of caesarean section

Originally published in Birthspirit Midwifery Journal 2009; 4: 25-30. Revised.

The artwork in this post was historically available at http://cesarean-art.com. As the artist did not engage in dialogue, permission was unable to be sought to reproduce this previously freely available work. It is intended that the context in which the illustrations have been reproduced will be seen as honouring the artist’s journey which spoke to my thinking about Nadine (as I call the woman of this post).

WomenAreNotResealableBabyContainers

When Nadine gave birth at home to her second baby, a daughter, she fulfilled a dream of natural childbirth and immediate, uninterrupted in-arms mothering. Her first labour had ended with her son born by caesarean section after she was transferred to hospital from a planned home birth. Nadine’s notes recorded the diagnosis of “dysfunctional uterine activity resulting in failure to progress” as the rationale for caesarean section.

FTP1-3Having worked with numerous women who have been given this Failure To Progress (FTP) label in their previous birthing, my experience has shown that this abbreviation more often than not actually reflects a caregiver’s Failure To be Patient when the notes are perused. While the permanently scarred uterus that results with caesarean section is lifelong, the emotional scarring of the ‘failure to progress’ label is frequently one that never lets go of the woman until she has experienced birth on her own terms. Nadine’s second birth, a waterbirth at home, was accompanied by a noticeable restoration of her faith in her ability to give birth – faith that had been ruptured by her previous experience. Both these births and the issues that impacted on Nadine’s first labour and birth are addressed in this story.

I first met Nadine after a public meeting to celebrate Home Birth Awareness week in New  Zealand at which I had spoken on Giving Birth in a Caesarean Culture. Nadine had approached me afterwards asking if I thought she could give birth at home, despite having had a caesarean. So began the unravelling process of her previous birthing. I explained that it was important to spend time exploring her childbirth history and the physical healing process, going over her notes and weighing up the advantages and disadvantages of both the hospital and home environments for birthing. The latter would help in her decision-making and hearing her story and reading the hospital notes would enable me to answer her question. We arranged to meet in a fortnight and when we did so, she was six weeks pregnant.

Within a very short period of time Nadine determined she would birth at home. She had devoured Artemis Speaks Koehler (1984) and Silent KnifeWainer Cohen & Estner (1983), two valuable classics for women as they come to terms with having had a previous caesarean section. While I fulfilled my obligation in my funding contract and discussed obstetric consultation with Nadine, she did not agree to visit an obstetrician. Her exploration and our discussions meant she understood the nature of the different birth environments and what that meant for her labouring and birthing.

Nadine started labour spontaneously at 40 weeks and five days from a sure last menstrual period date – the same gestation as with her first baby. She gave birth at home just over 48 hours after labour started, after 14 hours of established labour. Her contractions came every 3-6 minutes once it was established and she lost all cervical pain 4 ½ hours before she birthed. Nadine used the shower in labour and then the birth pool for the last 4 ½ hours.

The baby’s head was no longer palpable above the brim 2 ½ hours prior to birth, which is when she started spontaneously pushing with most contractions. Her baby continued to move regularly throughout labour and, when I listened with a Pinard’s stethoscope, the heart beat was always fine. As Nadine started to push, the heart beat was heard centrally, just above her pubic bone. As her labour was progressive throughout there was never a need to examine her vaginally in the 10 hours I attended her – so I didn’t.

Nadine gently birthed her baby with uninstructed pushing after about 2 ½ hours of pushing. She was a woman who smiled and quietly talked to her baby as she birthed and gave me unprompted progress reports about how far down her baby was, when she slid back, when she stopped sliding back and when the full stretch came on her perineum.

She delighted in touching her baby’s head frequently as she was being born.

FTP4-6She gave birth in the pool and lifted her baby up immediately into her arms with that smile for her baby that only a mother can give – and the little ‘hello’.

The placenta came 10 minutes later when Nadine stood up to get out of the pool.

Her baby started breastfeeding within ¼ hour after birth and bed shared with her (and her husband and first child).

Nadine had many quiet smiles in the weeks that followed. This baby weighed 7lb 4oz (3290gm) at birth which was 4.5oz (130gms) heavier than her first. (Both these babies were appropriate for Nadine’s size – she is a tiny woman.) The baby piled on weight and at six weeks weighed 10lb 6oz (4710gms), which amounted to a 47 percent increase on her birth weight.

Nadine’s birth by caesarean section with her first child had transformed her. She told me she had an unremarkable school career and had left school with the feeling that she was “dumb”, and she felt unsupported as she grew up in her family, which extended into her birth choices. Even though her father had been born at home her family did not support home birth. She had, however, gained a real sense of valuing herself through completing an arts course at the Polytechnic and her jewellery making was something at which she excelled. The other thing that she believed she could succeed in doing in her life was giving birth, and she had cared for herself wonderfully in her first pregnancy in preparation for that. Her Caesarean section took that belief away.

So what happened with her first birth?

Nadine had been well throughout her pregnancy. That labour started with spontaneous rupture of membranes (SRM) in the late afternoon and, when she called her midwife to attend the next morning, Nadine was contracting every four minutes.

Sandra, as I call the midwife, could not palpate the baby’s head at all so she examined her vaginally; Nadine was 8cm dilated with a fully effaced cervix; her baby was cephalic-presenting and had descended to Station 0 at 6.45am. With the arrival of the midwife, Nadine’s labour spaced out and she was given four doses of Caulophyllum in the next half hour.

Three and a half hours later (10.20am), Nadine was encouraged to stimulate labour through movement even though she was shaky and sleepy. At lunchtime (12.20pm) Nadine had an anterior lip of cervix on vaginal examination, which was pushed back over three contractions; it slipped back again. The baby’s head was determined to be at Station 0 to -1. Though the baby was LOA, Nadine was encouraged into a left lateral position and she was given four doses of Gelsemium, (possibly to encourage the remainder of the cervix to retract). One and a half hours later (14.05pm) another vaginal examination showed no change and Nadine was transferred to hospital.

Nadine did not want pain relief – she knew about the effects of drugs on her baby – but she was given an epidural following an ‘informed compliance’ Kirkham (2004); Pilley Edwards (2005) process – and her labour was augmented with an intravenous infusion of Syntocinon. The epidural anaesthetic effect was patchy, but the drug was effective enough to give her a pyrexia of ‘unknown’ origin (37.8°C) within 2 ¼ hours and she was started on intravenous antibiotics.

Nadine had another three vaginal examinations over the next 4 ½ hours by which stage her cervix had closed down to be 7cms dilated as it was oedematous, and a caesarean section was performed. Her baby had a gastric aspirate, blood tests and an arterial gas and cord pH done. That baby weighed 6lbs 15 ½oz (3160gm) at birth.

This all too familiar story of Failure To Progress also had parallel FTPs for the midwife.

Sandra was a new midwife and Feeling Tender in Practice. She had gone immediately into self employed case-loading practice in the community following graduation, which bears testament to the strength of her educational programme.

However, Sandra was not well supported by the profession. She was mentored by a midwife carrying a high caseload; Sandra paid for this mentorship – and excessively. Half of her income went to the midwife which meant Sandra was experiencing Financially Tough Pressure in her ability to maintain an income to support her family while also paying off her considerable student loan. To meet her financial obligations Sandra cared for six women a month.

Sandra was exhausted, not only during this birth but also in her practice. The mentoring midwife was also Sandra’s practice partner and, as her mentor had gone on holiday, Sandra was caring for her mentor’s caseload as well as her own. She had been in self-employed practice for less than a year but she was Far Too Pooped to continue. Sandra had made a decision to stop her caseload and work in the hospital on rostered shifts.

This exhaustion of months was compounded by attending Nadine from early morning until after midnight when the baby was born. Such was the lack of collegial support in the hospital that Sandra received no relief from the hospital staff. It is unknown if she asked for assistance but, in the first decade of direct entry midwifery in New Zealand, midwives who were educated through that means Felt Totally Persecuted when frequently told of the benefits (sic) of the nurse-midwife route to midwifery. Such attitudes may well have placed an additional burden of forced independence onto Sandra’s shoulders, though this lack of collegial support in hospital was also felt by many other self-employed midwives who came to midwifery through the nursing route.

By the time Nadine was transferred to hospital her membranes had been ruptured for 14 hours. At the time of this labour the hospital had an expectation that women would have intravenous antibiotics and an augmentation of labour after 12 hours of SRM. While such guidelines are seldom evidence-informed, midwives can feel unable to avoid this instruction From The Pulpit in obstetric facilities. A motivating force ensuring compliance in these environments frequently comes from the midwife’s heightened Fear of Traumatic Prosecution, which, most commonly, is initiated by hospital authorities. Those midwives that do challenge evidence-lacking guidelines frequently experience Fingers That Point if there is an untoward outcome, despite a lack of causal link. The gossip, rumour, derogatory or denigrating remarks and sarcasm that can result leaves the midwife feeling alone and isolated.

Caesarean recipe

Caesarean recipe

The story of Nadine’s first birth was all too familiar – a whole series of events combined into the ‘perfect storm’ of caesarean section. There were many points within the midwifery care during that birth that would almost certainly have been influential in the end result but perhaps none is likely to have been as potent as the lack of support that this new midwife experienced.

Many midwives readily recognise the circle of support needed for women in labour. But how conscious are we of the importance and influence of the many concentric circles of support needed around the midwife (and woman) that enable healthy childbirth to unfold – the circle of mentoring, the circle of practice partners, the circle of hospital midwifery and, when necessary, the circle of obstetrics?

Perhaps the last of the FTPs of (at least) Nadine’s caesarean section rests with the wider midwifery (and obstetric) community through the Failure To Participate in supporting Sandra, which existed. The lack of engagement in this space had a consequence for Sandra, who actually left the profession within 10 years, when, potentially, because of her age, she could have had many decades of midwifery practice before her.

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