Why did the baby's head stay high? Could I have done anything else?

The woman seemed to progress quite well in labour until about 3 or 4 thismorning. I had palpated her abdomen prior to going to hospital, and the baby's head was high and mobile then.

It was important to her that we go to hospital. Her experience of labour with the previous two children had been inductions for high blood pressure, and she thought that she would feel better in the hospital. Her little boy, not 2 years old yet, who sleeps in her bed and nurses frequently, was very upset about his mother not being available to him. He could not understand that mum did not want to hold him. He cried and pointed to the bed. It was very late, and even his dad could not comfort him. It was obviously a difficult separation for both the mother and her child.

So the woman called her parents to come and stay with the children, and we went to the hospital.

After a few hours I expected the sounds and behaviours of transition. The woman told me that she felt pressure on her bowel, consistent with a bulging bag of waters. The night wore on, and the woman became less active, needing to conserve her energy. Her husband and I also struggled with our own tiredness. There was nothing we could do. The woman did not need her back to be rubbed, or hot packs, or any of the other little helps we often use. I wished we had a tub of water for her to rest in. But a hospital room, no matter how nicely set out, with double bed and homely décor and spacious bathroom, is a very limited space. There was no-where for her to walk, and she was too tired for that anyway. We waited, trusting that the change would come.

I turned over in my mind the thought that perhaps I should ask the woman if I could check her internally. I do not routinely perform vaginal examinations on women in labour. I decided against it. The doctor would be coming in the morning, and there was no indication for me to intervene. The baby's heart sounds were excellent, and the woman was coping well.

It was no great surprise to me when the doctor examined the woman, to find an empty pelvis. The head was floating above. The doctor asked the woman's permission to break the waters. She looked to me, and said "what do you think, Joy?". I said "I don't know what else you can do.", and the woman agreed.

I applied supra-pubic pressure in an attempt to slow the release of water. It gushed. The doctor commented "I've got something else here", and indicated for the emergency buzzer to be pushed. Quietly he explained cord prolapse, and the woman understood. I helped her over into the knee-chest position, quietly prayed with her, and the doctor maintained pressure on the baby's head. "There's no pressure on the cord" he said.

The room filled with people, and the woman was helped onto a bed. A midwife took over the digital pressure, and we headed off to the operating theatre. I picked up my camera, and instructed the father to stay close. At the operating room the doctor was scrubbing. I thrust my camera in the hand of one of the staff, and said "She wants pictures of the baby".

Within about 7 or 8 minutes of the cord prolapsing, a healthy baby boy was born.

24 hours later:

I have had time to reflect, sleep, question, grieve, be angry and be thankful.

I have visited the woman and her child. The baby was snuggled near his mother's left breast. He was awake. He did not like having his nappy changed, as I wiped the sticky meconium from his bottom. Then he nursed quietly and was content. The woman told me she has peace in her heart. My overwhelming emotion is thankfulness - for the baby's life, and the quick and appropriate action taken. We had prayed for safety and peace.

I have visited the doctor. The doctor had gone home asking the same questions as I had. Why didn't the head descend into the pelvis? Was there anything else that could have been done?

This woman has had a previous caesarean, and I wanted to know what effect that long and ineffective labour had had on her uterus. Was the lower segment continuing to be taken up? Was there a Bandl's Ring from the retraction? Was there excessive strain on the old scar. I really wanted to know if my failure to intervene earlier the labour put the woman at any risk.

The doctor welcomed the opportunity to critically reflect on yesterday's events. He felt that the only other course of action would have been a caesarean without breaking the waters. He did not want to walk away from a labouring multi, whose labours had been very efficient, with the possibility of spontaneous rupture of the membranes, and cord prolapse. With reference to the old scar, he reassured me that there was no sign of dehiscence, and the lower segment looked good. This situation was very different from obstruction.

My role as midwife continues as the woman takes up the role of mothering this child. The woman is experiencing a mysterious and repeated phenomenon; that the love she has for each of her children is not diminished by the birth of another. Mother-love is multiplied and enlarged.