"Appropriate care, support and management of atypical labour"

My daughter delivered a healthy baby recently. Unfortunately, prolonged labour may have contributed to a postpartum haemorrhage. My story tells the story of the strength and determination of my daughter to have a natural delivery despite nocturnal, irregular and stalled labour, very similar to her previous birth.

My daughter presented to the Maternal Fetal Assessment Unit (MAFU) at Fiona Stanley Hospital for a term assessment, as requested by her treating obstetric team. She was found to be 3-4 cm dilated and accepted a membrane sweep. Labour commenced at 13:00 hours. For 20 hours my daughter had contractions from 5 mins to 10 minutes apart. We went back to MFAU the following morning, where her contractions again stalled after the sun came up. She was examined and found to be 5 cm dilated with a stretchy cervix. As the birth suite was on bypass and her contractions were stalled, she was sent home and told to ring if she progressed from 'early labour'.

On the following morning at 02:10 hours I contacted MFAU and discussed the current situation, with my daughter experiencing increasing intensity of contractions but still irregular with 3, 5 and 10 minutes frequency. As the hospital was on bypass, the shift coordinator had to contact another hospital to accept. At 02:54 hours the shift coordinator contacted my daughter and said Rockingham Hospital had accepted the transfer. She informed my daughter's partner that we should stay home until the contractions increased, as she was still in 'early labour'.

When we arrived at Rockingham Hospital at 03:30 hours, my daughter's contractions were approximately 10 minutes apart. The midwives were welcoming, caring and friendly, although a little sceptical. The scepticism soon changed when they examined her and found her to be 7 to 8 cm dilated. As she required antibiotics (GBS +ve) and transfer to birth suite there was a bit of a flurry of activity. 

My daughter was calmly breathing through each contraction, and this may have impacted on the initial perspective of the midwives, at both hospitals. Transfer to the birth suite occurred at 0440 hrs and my daughter was still having 10-minute intervals between contractions. My daughter's labour again stalled at 06:25 hours. She went for 24 mins without a contraction, again related to her history of nocturnal labour. Nipple stimulation and rupture of membranes again kickstarted labour at 0650 hrs. The TENS machine significantly supported pain relief, and the midwife got a surprise when the baby's head was on show. 

My grandchild was born in great condition at 08:24 hours after 9 minutes of pushing, however my daughter experienced significant bleeding post-delivery, requiring an emergency response and multiple medication managements.  I feel this is a result of the prolonged, ongoing and under-estimated condition of my daughter's labour during examination and advice calls. If my grandchild was born at home as a result of the conflicting advice received, I would not have managed to stop an immediate postpartum haemorrhage, nor given my grandchild the antibiotics they would have required to prevent a potential life-threatening infection. 

I am writing this Care Opinion to prompt development of learnings for midwives, that each woman is individual and have completely different ways of labouring. For this to have occurred with both labours, it is disappointing, frustrating and anxiety-provoking in times where positivity and calm should be maintained. 

Learnings for consideration:

- A quietly labouring mother is not necessarily a mother in early labour

- Nocturnal, stalled or irregular labour does not indicate the mother is just in early labour; this requires appropriate clinical assessment and proactive management, rather than rushed decisions to free up MFAU and birth suite beds

- The increasing intensity of contractions were demonstrated in the increased strength dialled up on the TENS machine, rather than the way my daughter was managing them

- The ability of mothers to labour outside the norms with focus on themselves, rather than trying to prove they need support and management

- The use of negative language (ie false labour instead of pre-labour)

- The fear of 'being sent home' resulting in second guessing your body's ability to cope

This story has been reviewed and consented for publishing by my daughter.