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My Daughter's Journey Through Infertility and Childbirth
Hila J. Spear, PhD, RN
My Daughter’s Journey Through Infertility and Childbirth
o
One of the most difficult experiences of my life as a nurse and a daughter was the death of my mother, who died of a rare blood disorder in 1993. She encouraged me to tell her “story” in order to help nurses and those committed to patient care during the death and dying process. Now, almost 11 years later, at the other end of the cycle of life, I have been blessed to wit-
A Nurse and Mother’s Perspective
ness the birth of my first grandchild. Prior to this miraculous event, my daughter had experienced years of primary infertility. Like my mother’s story, I believe that my daughter’s experience of coping with infertility and her eventual pregnancy and childbirth as well as some of my own related observations can serve to encourage other women who have gone through similar circumstances and provide insight for the nurses who care for them. Stories remind nurses of the importance of what they do and of the value and power of nursing practice (Dawes, 2001; Sessler, 1998). The following narrative account is based on conversations that I had with my daughter over the past several years and on journal entries that I made throughout the course of her pregnancy and the birth of her child.
Hope and Acceptance After two years of marriage, my firstborn daughter Katherine and her husband John were ready to begin their family. One year passed and no baby. They rejoiced in the births of nieces and nephews and were happy for their friends who had children. Several years had gone by and Katherine and John still had not conceived. John agreed to be tested and the semen analysis revealed that he was fertile.
(continued on p. 476
480
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Issue 5
Katherine, like many new mothers-to-be, expressed some feelings of anxiety about losing her baby, especially during her first trimester
Katherine graphed her temperature for a designated period and her gynecological examination indicated that she was ovulating and had no obvious cause for infertility. Katherine’s friends encouraged her to consider fertility drugs or invitro fertilization. She and her husband chose not to consider either of these approaches. Because of their religious beliefs, they indicated that if God wanted them to have a child, it would happen. As she approached her 32nd birthday, Katherine decided to seek a more in-depth evaluation to determine if there was any hope for bearing a child. Her blood work was within normal limits. A hysterosalpingogram revealed that her right fallopian tube was blocked and the left tube appeared to be normal and patent. The next step was a laparoscopic surgical procedure to directly visualize and assess both tubes and ovaries. The blocked tube was unsalvageable due to extensive scarring and was removed. A few weeks later, Katherine returned to her obstetrician for her post-op visit. He reported, “You have a 0 to 100 percent chance of ever conceiving. Your best bet would be to try invitro fertilization.” Katherine shared with me that she had faith that God could choose to bless her with a biological child or allow her to minister to other children by becoming a foster or adoptive parent. She and her husband were not interested in pursuing the invitro fertilization option.
Joy Mixed With Anxiety
Hila J. Spear, PhD, RN, is a professor of nursing and director of graduate studies at Liberty University in Lynchburg, VA. DOI: 10.1177/1091592303259575
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AWHONN Lifelines
A few months after the laparoscopy, Katherine took a home pregnancy test. Over the past nine years there had been many false alarms. When the test was positive, she couldn’t believe her eyes. Katherine purchased two more kits and the test results were consistent with the first. She was elated. She made a special trip to tell her father and me the good news face to face. Katherine, like many new mothers-to-be, expressed some feelings of anxiety about losing her baby, especially during her first trimester. I knew the risks and potential for problems but did not want to feed into her fears. However, I did not want to be unrealistic by disregarding a possible loss of the pregnancy. As she voiced her concerns, I shared the following words with her: “Katherine, enjoy this gift that God has given you. If all goes well, you will experi-
ence the birth of a healthy baby in the spring. But regardless of the outcome of your pregnancy, you are already a mother. I am a grandmother. You have a new life inside of you. So enjoy each day of your pregnancy with a sense of peace and wonder. No matter what, you will always rejoice in the sense of amazement and elation that you experienced the day you discovered that you were pregnant. Just take one day at a time.” After breaking the good news to her family, Katherine returned home over the weekend. She called me upon her return, and I could tell that she was anxious by the tone of her voice. Katherine stated that she had received several phone messages from the obstetrician’s office. The nurse stated, “We really need to get in touch with Katherine Bryant.” This message, followed by at least three more similar phone messages caused Katherine to become somewhat alarmed. Maybe something was wrong. Maybe her blood work revealed some serious condition. To allay her fears, I suggested that she call the physician on call to try to determine the nature of the messages. He assured her that it was probably routine—just a follow-up call to give her a basic report about her initial blood work. Katherine called the obstetrician’s office first thing Monday morning. The nurse told her, “Your blood tests were fine but you will need a Rubella vaccine after you deliver, and your blood type is O-negative. We always call new moms to give them a report.” The nurse went on to explain that the report was not at all abnormal and overall routine. Katherine was reassured but thought if it was so routine, why did she receive several messages? During those first few weeks of pregnancy, Katherine asked me many questions. She relayed a variety of physical symptoms such as slight vaginal discharge, being nauseated, not being nauseated, and feeling tired. She was reassured when I told her that what she was experiencing was very normal. She asked, “Mom, you would tell me if something was wrong or abnormal wouldn’t you?” I assured her that I would.
Twelve Weeks Flew By “Mom, they couldn’t hear the heartbeat, but that turned out to be good because the doctor
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Issue 5
did an ultrasound. I was able to see the baby.” The nurse laughed as she told Katherine, “No wonder we couldn’t hear the heartbeat, your baby is so wiggly.” Katherine told me that her pregnancy seemed even “more real” to her. She said, “The next several months are going to take forever; I want my pregnancy to go fast, but I want to enjoy every minute too.” Katherine stated that she felt that she had reached an important milestone; she had completed that first trimester. We were both thankful.
in utero was an awesome experience for all of us. Near the end of Katherine’s second trimester, she called to talk with me after one of her monthly visits to the obstetrician. She stated, “Mom, it’s so exciting to go to the doctor and to know that I am making progress. Whenever the doctors listen to the baby’s heartbeat, they never offer any
Settling In: The Second Trimester During her second trimester, Katherine called to say, “Next Wednesday I will be 15 weeks along.” She informed me that she had decided not to submit to maternal serum screening for alpha fetoprotein levels or other diagnostic procedures such as an amniocentesis. Katherine said, “I do not want to have these tests done; I plan to continue with my pregnancy no matter what.” I encouraged her to write down any questions she may have for her obstetrician in preparation for her next monthly visit. She discussed her concerns about diagnostic options with the nurse who assured Katherine that she would not have to undergo the testing. It was my privilege to accompany my daughter and her husband to the 20-week ultrasound. The baby was in a breech position, therefore the sex was indeterminable. Since Katherine and John preferred to be surprised about the sex of their baby, they were not disappointed. We all saw the tiny baby stretch, yawn, and kick. A few days before, I had commented to Katherine that her baby would probably be petite with small feet as Katherine is 5′ 2″ with small bone structure. When her baby kicked, one of his or her feet was clearly visible. We all laughed as comments were made about what looked like such a large foot. To actually see the perfectly formed developing baby
October | November 2003
information; I always have to ask. When the nurses listen to the baby’s heartbeat or take my blood pressure, they always tell me what’s going on.” She remarked that although she believed that her doctors were knowledgeable and competent, it was the nurses who made her monthly prenatal visits a positive and encouraging experience.
Final Preparations: The Last Trimester By Katherine’s 34th week of pregnancy, the nursery was fully equipped and ready for occupancy. She remarked to me, “Sometimes it’s hard to believe that I’m actually experiencing this [pregnancy]. I’m ready to have this baby; I just want to know that everything is OK. I can’t wait to hold my baby and to kiss its little hands and feet. How scary, to be a parent. Will I be able to do a good job?” I did my best to reassure Katherine and reminded her that I would always
be available as her mother and as a nurse. Katherine planned to breastfeed and voiced concern when one of her friends was unable to breastfeed due to insufficient milk supply. This same friend gave birth one day after her doctor had informed her that she would probably not deliver any time soon. Katherine and I discussed that even though doctors and nurses are knowledgeable about childbirth and pregnancy and have access to advanced technology, the timing of a birth and how a mother’s body will respond does not always conform to their expectations and predictions. Visits were now every two weeks, and during the last month of pregnancy were every week. One of Katherine’s nurses told her, “You do pregnancy well.” Katherine’s pregnancy progressed normally and she never experienced any significant problems. Her sister and I visited Katherine in her home two weeks before she gave birth. We took some profile pictures of Katherine for future reference; we could imagine the baby inside who was in vertex position, waiting to be born. Katherine stated, “I remember visiting people in the hospital and seeing a new mother being wheeled out to the circle drive with her baby in her arms and thinking, I will never experience that. Now, here I am about to have my baby. It’s really going to happen.”
Labor, Delivery and Birth Two days after Katherine’s due date, she called around 9:45 p.m. to say her membranes had ruptured and that she and her husband were getting ready to leave for the hospital. I heard the excitement in her voice and wanted to be with her immediately. She and her husband had invited me to be present for Katherine’s labor and delivery experience. They waited in the triage area for about two hours, and Katherine was admitted to the labor delivery and recovery (LDR) room around
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midnight. Upon admission, she called me and stated, “My water’s definitely broken and I’m not dilated yet. The baby hasn’t dropped, and the doctor said he’s giving me six hours to go into labor on my own. If I don’t, he will induce me.” She ended our conversation with a whisper, “Mom, I don’t like my nurse.” Katherine is not one to complain or to make snap judgments. I assured her that I would be there as soon as I could. By 4:30 a.m., I was at Katherine’s bedside and could tell that she was in active labor. She was using slow chest breathing and experiencing strong contractions about every three to four minutes. It was obvious to me that she was in discomfort, but she did not want to take any medication. Katherine had been ambivalent about epidural anesthesia prior to labor, now she decided that she wanted an epidural as soon as possible. In the meantime, she would manage her pain with her breathing techniques and the support and encouragement of her husband. Katherine said that the doctor was going to perform a vaginal examination around 5:30 a.m. to see if she had made any progress. “I can get an epidural when I’m 4 centimeters.” The nurse entered the LDR room around 5:45 a.m. and performed the vaginal exam, as the physician was unavailable. She reported that Katherine was 4 centimeters, 100 percent effaced, and the baby’s head was at –1 station. The nurse was efficient as she attended to the fetal monitor, the IV infusion pump, and as she recorded her notes on the computer. Other than attending to these tasks, she said little to Katherine, her husband, or to me. It was uncomfortable for all of us when the nurse was in the room, as she did not easily engage in conversation and seemed to be in a hurry. Katherine said that she didn’t want to ask her for anything. After she left the room, Katherine told me that the nurse never intro-
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duced herself and seemed aloof. Katherine said, “She doesn’t check on me that often; is she going to be with me until I deliver?” By 6:15 a.m., with the able technical assistance of the nurse, Katherine received her epidural and in no time was talking and laughing during contractions. Her husband and I both felt relief as well. Her nurse left the room after the epidural was in place and never returned. At 7:15 a.m. a different nurse entered the room. This nurse smiled as she introduced herself to all of us and told Katherine that she would be taking care of her. She carefully explained everything she did as she provided nursing care for Katherine.
She shared in the excitement and anticipation of a new life about to enter the world and personally assessed Katherine at least every 20 minutes prior to the second stage of labor. The nurse said, “Babies being born bring us hope.” We were all pleased that this nurse would be the one who would most likely be present when Katherine’s baby was delivered. Katherine’s obstetrician checked her for dilatation about two hours after the epidural had taken effect and ordered a Pitocin drip to augment her labor. Her contraction pattern was not effective and she had made little progress. He palpated Katherine’s large distended uterus and remarked, “This
baby’s not that big.” By about 12:20 p.m., Katherine’s cervix was completely dilated and the baby had moved to a +1 station. I marveled that the baby’s fetal heart rate was consistently within normal limits and no signs of variable, late or early decelerations were evident. The baby’s heart rate was strong and reactive. At 12:50 p.m., Katherine began the hard work of pushing. With John’s encouragement, along with the nurse’s coaching, Katherine was able to push effectively. After about an hour, we were able to see a few curls of the baby’s dark hair when Katherine pushed. As birth was imminent, another nurse along with the obstetrician entered the LDR room. Finally, after almost two hours of pushing, the baby’s head was delivered. Then what had been a relatively normal labor and delivery experience turned into an uneasy situation as the baby was much bigger than anticipated. The baby’s head retracted on her mother’s perineum and the anterior shoulder was impacted behind the symphysis pubis. The obstetrician calmly instructed one of the nurses to call for special support [intensive care nursery team] as the other nurse used the McRobert’s Maneuver to position Katherine for the treatment of shoulder dystocia. Having worked as a labor and deliver nurse for years, I knew the gravity of the situation. Shoulder dystocia can cause serious injury and, in severe cases, death. My son-in-law asked me, “Is everything OK?” I told him, “They just need to deliver the baby’s shoulders.” It was difficult and stressful to be the mother, grandmother and nurse in this potentially life-threatening situation. Time seemed to stand still, but in about four minutes the physician, assisted by the nurses, was able to deliver my 22 inch long, 8 pound 15 ounce granddaughter. John clapped for joy and was relieved when he saw his new daughter. The special care
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nurses quickly suctioned, administered oxygen, and stimulated the baby. Her one- and five-minute Apgar scores were 5 and 9, respectively. Tears stung our eyes when we heard her first weak cry. Soon after the baby was stabilized, the nurse brought her over to Katherine for a few seconds so that she could see and touch her newborn baby girl. Within an hour of delivery, my precious granddaughter was eagerly nursing at her mother’s breast.
Lessons Learned Pregnancy and childbirth after infertility are profound experiences for both the mother and her husband (Burns, 1996). When providing nursing care for women throughout all stages of pregnancy and childbearing, it’s imperative that nurses provide therapeutic communication and unambiguous information (see Box 1 for information resources). Offering information to a pregnant woman that may generate unwarranted feelings of stress and anxiety such as the phone messages my daughter received from the obstetrician’s office serves as a reminder for nurses to carefully consider how the information they relay may be interpreted. A good
Box 1.
Getting All the Facts • American Society for Reproductive Medicine: www.asrm.org • American Infertility Association (AIA): www.americaninfertility.org • InterNational Council on Infertility Information Dissemination, Inc: www.inciid.org • Resolve: The National Infertility Association: www.resolve.org
October | November 2003
example of an approach to insulate the patient and family members from escalating apprehension is the calm and confident manner in which the physician and nurses communicated with my daughter and her husband during the obstetric emergency of shoulder dystocia. They provided reassurance in a tense situation. Effective communication is fundamental to patient satisfaction and quality nursing care (Naish, 1996; Wilcock, Kobayashi, & Murray, 1997). The technically efficient labor and delivery nurse who did not introduce herself failed to communicate a sense of caring or intimacy. She never made a nurse-patient connection with my daughter or her family. With the advent of sophisticated monitoring equipment, it may be tempting to care for the laboring patient from the desk based on what information is available via telemetry. Although technology serves an important function, it should never replace the personal touch and individualized care of the nurse. In contrast, the second nurse who provided care immediately established positive rapport, which led to an intimate nurse-patient connection. Mutual connectedness can meet the holistic needs of patients in a variety of settings (Schubert & Lionberger, 1995). Unlike the technically focused nurse, this nurse was patient-focused. She demonstrated the ability to balance professional competency with a sincere and nurturing approach. It’s important for nurses to periodically evaluate how their verbal and nonverbal communication may be perceived by those entrusted to their care. Though rendering care to mothers during the birth process may become routine for the nurse, it’s never routine for the mother. From a nursing perspective, I was encouraged by how overall nurses made a positive contribution to my daughter’s pregnancy and childbirth
experience by providing encouragement, support and competent care. My daughter was very grateful for the nurses who consistently provided her information about her pregnancy and answered her questions throughout the prenatal period. She felt that the nurses understood and valued her need to be informed. Although her long awaited childbirth experience began with a somewhat negative and one-dimensional nurse-patient relationship, she and her husband were fortunate to experience nursing care from another nurse who exemplified the best side of nursing practice. As nurses, we need to be sensitive to the needs of our patients and treat them with care and genuine concern for not only their physical wellbeing, but we must acknowledge them as unique individuals and attend to their psychological and emotional needs as well. References Burns, L. H. (1996). Pregnancy after infertility. Infertility and Reproductive Medicine of North America, 7(3), 503-520. Dawes, B. S. (2001). Storytelling is not just for children. American Operating Nurse Journal, 74(2), 146, 148. Naish, J. (1996). The route to effective nurse-patient communication. Nursing Times, 92(17), 27-30. Schubert, P. E., & Lionberger, H. J. (1995). Mutual connectedness: A study of client nurse interaction using the grounded theory method. Journal of Holistic Nursing, 13(2), 102-116. Sessler, A. (1998). The stories nurses tell: Using stories to understand nursing practice. On-Call, 1(4), 24-26. Wilcock, A., Kobayashi, L., & Murray, I. (1997, March). Twenty-five years of obstetric patient satisfaction in North America: A review of the literature. Journal of Perinatal & Neonatal Nursing, 19(4), 36-47.
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My Daughter’s Journey Through Infertility and Childbirth
o
One of the most difficult experiences of my life as a nurse and a daughter was the death of my mother, who died of a rare blood disorder in 1993. She encouraged me to tell her “story” in order to help nurses and those committed to patient care during the death and dying process. Now, almost 11 years later, at the other end of the cycle of life, I have been blessed to wit-
A Nurse and Mother’s Perspective
ness the birth of my first grandchild. Prior to this miraculous event, my daughter had experienced years of primary infertility. Like my mother’s story, I believe that my daughter’s experience of coping with infertility and her eventual pregnancy and childbirth as well as some of my own related observations can serve to encourage other women who have gone through similar circumstances and provide insight for the nurses who care for them. Stories remind nurses of the importance of what they do and of the value and power of nursing practice (Dawes, 2001; Sessler, 1998). The following narrative account is based on conversations that I had with my daughter over the past several years and on journal entries that I made throughout the course of her pregnancy and the birth of her child.
Hope and Acceptance After two years of marriage, my firstborn daughter Katherine and her husband John were ready to begin their family. One year passed and no baby. They rejoiced in the births of nieces and nephews and were happy for their friends who had children. Several years had gone by and Katherine and John still had not conceived. John agreed to be tested and the semen analysis revealed that he was fertile.
(continued on p. 476
480
AWHONN Lifelines
Volume 7
Issue 5
Katherine, like many new mothers-to-be, expressed some feelings of anxiety about losing her baby, especially during her first trimester
Katherine graphed her temperature for a designated period and her gynecological examination indicated that she was ovulating and had no obvious cause for infertility. Katherine’s friends encouraged her to consider fertility drugs or invitro fertilization. She and her husband chose not to consider either of these approaches. Because of their religious beliefs, they indicated that if God wanted them to have a child, it would happen. As she approached her 32nd birthday, Katherine decided to seek a more in-depth evaluation to determine if there was any hope for bearing a child. Her blood work was within normal limits. A hysterosalpingogram revealed that her right fallopian tube was blocked and the left tube appeared to be normal and patent. The next step was a laparoscopic surgical procedure to directly visualize and assess both tubes and ovaries. The blocked tube was unsalvageable due to extensive scarring and was removed. A few weeks later, Katherine returned to her obstetrician for her post-op visit. He reported, “You have a 0 to 100 percent chance of ever conceiving. Your best bet would be to try invitro fertilization.” Katherine shared with me that she had faith that God could choose to bless her with a biological child or allow her to minister to other children by becoming a foster or adoptive parent. She and her husband were not interested in pursuing the invitro fertilization option.
Joy Mixed With Anxiety
Hila J. Spear, PhD, RN, is a professor of nursing and director of graduate studies at Liberty University in Lynchburg, VA. DOI: 10.1177/1091592303259575
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A few months after the laparoscopy, Katherine took a home pregnancy test. Over the past nine years there had been many false alarms. When the test was positive, she couldn’t believe her eyes. Katherine purchased two more kits and the test results were consistent with the first. She was elated. She made a special trip to tell her father and me the good news face to face. Katherine, like many new mothers-to-be, expressed some feelings of anxiety about losing her baby, especially during her first trimester. I knew the risks and potential for problems but did not want to feed into her fears. However, I did not want to be unrealistic by disregarding a possible loss of the pregnancy. As she voiced her concerns, I shared the following words with her: “Katherine, enjoy this gift that God has given you. If all goes well, you will experi-
ence the birth of a healthy baby in the spring. But regardless of the outcome of your pregnancy, you are already a mother. I am a grandmother. You have a new life inside of you. So enjoy each day of your pregnancy with a sense of peace and wonder. No matter what, you will always rejoice in the sense of amazement and elation that you experienced the day you discovered that you were pregnant. Just take one day at a time.” After breaking the good news to her family, Katherine returned home over the weekend. She called me upon her return, and I could tell that she was anxious by the tone of her voice. Katherine stated that she had received several phone messages from the obstetrician’s office. The nurse stated, “We really need to get in touch with Katherine Bryant.” This message, followed by at least three more similar phone messages caused Katherine to become somewhat alarmed. Maybe something was wrong. Maybe her blood work revealed some serious condition. To allay her fears, I suggested that she call the physician on call to try to determine the nature of the messages. He assured her that it was probably routine—just a follow-up call to give her a basic report about her initial blood work. Katherine called the obstetrician’s office first thing Monday morning. The nurse told her, “Your blood tests were fine but you will need a Rubella vaccine after you deliver, and your blood type is O-negative. We always call new moms to give them a report.” The nurse went on to explain that the report was not at all abnormal and overall routine. Katherine was reassured but thought if it was so routine, why did she receive several messages? During those first few weeks of pregnancy, Katherine asked me many questions. She relayed a variety of physical symptoms such as slight vaginal discharge, being nauseated, not being nauseated, and feeling tired. She was reassured when I told her that what she was experiencing was very normal. She asked, “Mom, you would tell me if something was wrong or abnormal wouldn’t you?” I assured her that I would.
Twelve Weeks Flew By “Mom, they couldn’t hear the heartbeat, but that turned out to be good because the doctor
Volume 7
Issue 5
did an ultrasound. I was able to see the baby.” The nurse laughed as she told Katherine, “No wonder we couldn’t hear the heartbeat, your baby is so wiggly.” Katherine told me that her pregnancy seemed even “more real” to her. She said, “The next several months are going to take forever; I want my pregnancy to go fast, but I want to enjoy every minute too.” Katherine stated that she felt that she had reached an important milestone; she had completed that first trimester. We were both thankful.
in utero was an awesome experience for all of us. Near the end of Katherine’s second trimester, she called to talk with me after one of her monthly visits to the obstetrician. She stated, “Mom, it’s so exciting to go to the doctor and to know that I am making progress. Whenever the doctors listen to the baby’s heartbeat, they never offer any
Settling In: The Second Trimester During her second trimester, Katherine called to say, “Next Wednesday I will be 15 weeks along.” She informed me that she had decided not to submit to maternal serum screening for alpha fetoprotein levels or other diagnostic procedures such as an amniocentesis. Katherine said, “I do not want to have these tests done; I plan to continue with my pregnancy no matter what.” I encouraged her to write down any questions she may have for her obstetrician in preparation for her next monthly visit. She discussed her concerns about diagnostic options with the nurse who assured Katherine that she would not have to undergo the testing. It was my privilege to accompany my daughter and her husband to the 20-week ultrasound. The baby was in a breech position, therefore the sex was indeterminable. Since Katherine and John preferred to be surprised about the sex of their baby, they were not disappointed. We all saw the tiny baby stretch, yawn, and kick. A few days before, I had commented to Katherine that her baby would probably be petite with small feet as Katherine is 5′ 2″ with small bone structure. When her baby kicked, one of his or her feet was clearly visible. We all laughed as comments were made about what looked like such a large foot. To actually see the perfectly formed developing baby
October | November 2003
information; I always have to ask. When the nurses listen to the baby’s heartbeat or take my blood pressure, they always tell me what’s going on.” She remarked that although she believed that her doctors were knowledgeable and competent, it was the nurses who made her monthly prenatal visits a positive and encouraging experience.
Final Preparations: The Last Trimester By Katherine’s 34th week of pregnancy, the nursery was fully equipped and ready for occupancy. She remarked to me, “Sometimes it’s hard to believe that I’m actually experiencing this [pregnancy]. I’m ready to have this baby; I just want to know that everything is OK. I can’t wait to hold my baby and to kiss its little hands and feet. How scary, to be a parent. Will I be able to do a good job?” I did my best to reassure Katherine and reminded her that I would always
be available as her mother and as a nurse. Katherine planned to breastfeed and voiced concern when one of her friends was unable to breastfeed due to insufficient milk supply. This same friend gave birth one day after her doctor had informed her that she would probably not deliver any time soon. Katherine and I discussed that even though doctors and nurses are knowledgeable about childbirth and pregnancy and have access to advanced technology, the timing of a birth and how a mother’s body will respond does not always conform to their expectations and predictions. Visits were now every two weeks, and during the last month of pregnancy were every week. One of Katherine’s nurses told her, “You do pregnancy well.” Katherine’s pregnancy progressed normally and she never experienced any significant problems. Her sister and I visited Katherine in her home two weeks before she gave birth. We took some profile pictures of Katherine for future reference; we could imagine the baby inside who was in vertex position, waiting to be born. Katherine stated, “I remember visiting people in the hospital and seeing a new mother being wheeled out to the circle drive with her baby in her arms and thinking, I will never experience that. Now, here I am about to have my baby. It’s really going to happen.”
Labor, Delivery and Birth Two days after Katherine’s due date, she called around 9:45 p.m. to say her membranes had ruptured and that she and her husband were getting ready to leave for the hospital. I heard the excitement in her voice and wanted to be with her immediately. She and her husband had invited me to be present for Katherine’s labor and delivery experience. They waited in the triage area for about two hours, and Katherine was admitted to the labor delivery and recovery (LDR) room around
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midnight. Upon admission, she called me and stated, “My water’s definitely broken and I’m not dilated yet. The baby hasn’t dropped, and the doctor said he’s giving me six hours to go into labor on my own. If I don’t, he will induce me.” She ended our conversation with a whisper, “Mom, I don’t like my nurse.” Katherine is not one to complain or to make snap judgments. I assured her that I would be there as soon as I could. By 4:30 a.m., I was at Katherine’s bedside and could tell that she was in active labor. She was using slow chest breathing and experiencing strong contractions about every three to four minutes. It was obvious to me that she was in discomfort, but she did not want to take any medication. Katherine had been ambivalent about epidural anesthesia prior to labor, now she decided that she wanted an epidural as soon as possible. In the meantime, she would manage her pain with her breathing techniques and the support and encouragement of her husband. Katherine said that the doctor was going to perform a vaginal examination around 5:30 a.m. to see if she had made any progress. “I can get an epidural when I’m 4 centimeters.” The nurse entered the LDR room around 5:45 a.m. and performed the vaginal exam, as the physician was unavailable. She reported that Katherine was 4 centimeters, 100 percent effaced, and the baby’s head was at –1 station. The nurse was efficient as she attended to the fetal monitor, the IV infusion pump, and as she recorded her notes on the computer. Other than attending to these tasks, she said little to Katherine, her husband, or to me. It was uncomfortable for all of us when the nurse was in the room, as she did not easily engage in conversation and seemed to be in a hurry. Katherine said that she didn’t want to ask her for anything. After she left the room, Katherine told me that the nurse never intro-
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duced herself and seemed aloof. Katherine said, “She doesn’t check on me that often; is she going to be with me until I deliver?” By 6:15 a.m., with the able technical assistance of the nurse, Katherine received her epidural and in no time was talking and laughing during contractions. Her husband and I both felt relief as well. Her nurse left the room after the epidural was in place and never returned. At 7:15 a.m. a different nurse entered the room. This nurse smiled as she introduced herself to all of us and told Katherine that she would be taking care of her. She carefully explained everything she did as she provided nursing care for Katherine.
She shared in the excitement and anticipation of a new life about to enter the world and personally assessed Katherine at least every 20 minutes prior to the second stage of labor. The nurse said, “Babies being born bring us hope.” We were all pleased that this nurse would be the one who would most likely be present when Katherine’s baby was delivered. Katherine’s obstetrician checked her for dilatation about two hours after the epidural had taken effect and ordered a Pitocin drip to augment her labor. Her contraction pattern was not effective and she had made little progress. He palpated Katherine’s large distended uterus and remarked, “This
baby’s not that big.” By about 12:20 p.m., Katherine’s cervix was completely dilated and the baby had moved to a +1 station. I marveled that the baby’s fetal heart rate was consistently within normal limits and no signs of variable, late or early decelerations were evident. The baby’s heart rate was strong and reactive. At 12:50 p.m., Katherine began the hard work of pushing. With John’s encouragement, along with the nurse’s coaching, Katherine was able to push effectively. After about an hour, we were able to see a few curls of the baby’s dark hair when Katherine pushed. As birth was imminent, another nurse along with the obstetrician entered the LDR room. Finally, after almost two hours of pushing, the baby’s head was delivered. Then what had been a relatively normal labor and delivery experience turned into an uneasy situation as the baby was much bigger than anticipated. The baby’s head retracted on her mother’s perineum and the anterior shoulder was impacted behind the symphysis pubis. The obstetrician calmly instructed one of the nurses to call for special support [intensive care nursery team] as the other nurse used the McRobert’s Maneuver to position Katherine for the treatment of shoulder dystocia. Having worked as a labor and deliver nurse for years, I knew the gravity of the situation. Shoulder dystocia can cause serious injury and, in severe cases, death. My son-in-law asked me, “Is everything OK?” I told him, “They just need to deliver the baby’s shoulders.” It was difficult and stressful to be the mother, grandmother and nurse in this potentially life-threatening situation. Time seemed to stand still, but in about four minutes the physician, assisted by the nurses, was able to deliver my 22 inch long, 8 pound 15 ounce granddaughter. John clapped for joy and was relieved when he saw his new daughter. The special care
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nurses quickly suctioned, administered oxygen, and stimulated the baby. Her one- and five-minute Apgar scores were 5 and 9, respectively. Tears stung our eyes when we heard her first weak cry. Soon after the baby was stabilized, the nurse brought her over to Katherine for a few seconds so that she could see and touch her newborn baby girl. Within an hour of delivery, my precious granddaughter was eagerly nursing at her mother’s breast.
Lessons Learned Pregnancy and childbirth after infertility are profound experiences for both the mother and her husband (Burns, 1996). When providing nursing care for women throughout all stages of pregnancy and childbearing, it’s imperative that nurses provide therapeutic communication and unambiguous information (see Box 1 for information resources). Offering information to a pregnant woman that may generate unwarranted feelings of stress and anxiety such as the phone messages my daughter received from the obstetrician’s office serves as a reminder for nurses to carefully consider how the information they relay may be interpreted. A good
Box 1.
Getting All the Facts • American Society for Reproductive Medicine: www.asrm.org • American Infertility Association (AIA): www.americaninfertility.org • InterNational Council on Infertility Information Dissemination, Inc: www.inciid.org • Resolve: The National Infertility Association: www.resolve.org
October | November 2003
example of an approach to insulate the patient and family members from escalating apprehension is the calm and confident manner in which the physician and nurses communicated with my daughter and her husband during the obstetric emergency of shoulder dystocia. They provided reassurance in a tense situation. Effective communication is fundamental to patient satisfaction and quality nursing care (Naish, 1996; Wilcock, Kobayashi, & Murray, 1997). The technically efficient labor and delivery nurse who did not introduce herself failed to communicate a sense of caring or intimacy. She never made a nurse-patient connection with my daughter or her family. With the advent of sophisticated monitoring equipment, it may be tempting to care for the laboring patient from the desk based on what information is available via telemetry. Although technology serves an important function, it should never replace the personal touch and individualized care of the nurse. In contrast, the second nurse who provided care immediately established positive rapport, which led to an intimate nurse-patient connection. Mutual connectedness can meet the holistic needs of patients in a variety of settings (Schubert & Lionberger, 1995). Unlike the technically focused nurse, this nurse was patient-focused. She demonstrated the ability to balance professional competency with a sincere and nurturing approach. It’s important for nurses to periodically evaluate how their verbal and nonverbal communication may be perceived by those entrusted to their care. Though rendering care to mothers during the birth process may become routine for the nurse, it’s never routine for the mother. From a nursing perspective, I was encouraged by how overall nurses made a positive contribution to my daughter’s pregnancy and childbirth
experience by providing encouragement, support and competent care. My daughter was very grateful for the nurses who consistently provided her information about her pregnancy and answered her questions throughout the prenatal period. She felt that the nurses understood and valued her need to be informed. Although her long awaited childbirth experience began with a somewhat negative and one-dimensional nurse-patient relationship, she and her husband were fortunate to experience nursing care from another nurse who exemplified the best side of nursing practice. As nurses, we need to be sensitive to the needs of our patients and treat them with care and genuine concern for not only their physical wellbeing, but we must acknowledge them as unique individuals and attend to their psychological and emotional needs as well. References Burns, L. H. (1996). Pregnancy after infertility. Infertility and Reproductive Medicine of North America, 7(3), 503-520. Dawes, B. S. (2001). Storytelling is not just for children. American Operating Nurse Journal, 74(2), 146, 148. Naish, J. (1996). The route to effective nurse-patient communication. Nursing Times, 92(17), 27-30. Schubert, P. E., & Lionberger, H. J. (1995). Mutual connectedness: A study of client nurse interaction using the grounded theory method. Journal of Holistic Nursing, 13(2), 102-116. Sessler, A. (1998). The stories nurses tell: Using stories to understand nursing practice. On-Call, 1(4), 24-26. Wilcock, A., Kobayashi, L., & Murray, I. (1997, March). Twenty-five years of obstetric patient satisfaction in North America: A review of the literature. Journal of Perinatal & Neonatal Nursing, 19(4), 36-47.
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