Mandy was 29 years old and 39 weeks' pregnant with her second baby. Her previous hospital experiences had not been good and she was more than a little apprehensive and nervous about this delivery.
I first met Mandy and her husband when I came on duty for a routine shift at 7.30 one morning. She had been having Braxton Hicks contractions for a couple of days at home, followed by period-type pains, back ache and then regular contractions every 2-3 minutes, each one lasting about a minute. She had also had a show. But when she arrived at the hospital at 5 a.m. everything stopped, as is so often the case.
When given a vaginal examination by the night staff, she was found to be 2-3 cm dilated. Her membranes were present (or intact, as the midwife would say) and the baby was lying in the favourable OA position. Mandy was placed on a fetal monitor for 20 minutes to measure the strength of her contractions and to check the fetal heart. After breakfast, if nothing was happening, she was going to decide whether or not to go home. At 8.30 a.m. I asked her if she was interested in having some acupuncture, to see whether we could get the contractions going again. She agreed. With her sitting upright on the bed, I began by using four plain 11/2-inch (3.8 cm) needles in BL-31 and 32, and really stimulated them. Then I put needles bilaterally in LI-4 and SP-6, and kept that up for about 40 minutes. The contractions definitely started to become stronger and more regular.
At 9.30 a.m. I took the needles out and placed three small quarter-inch (0.6 cm) needles into Mandy's right ear (either ear would be equally effective). I put them into Uterus, Shenmen and Endocrine, taped them down with some microprobe tape, and attached them by crocodile clips to my Acu-TENS machine. I clipped this to her dressing gown pocket and encouraged her to walk along the corridors for 20 minutes or so, stopping whenever she was having a contraction. It is always better to keep moving so that contractions continue and the fetal head is well applied to the cervix, encouraging it to dilate more efficiently.
After 20 minutes she rested and felt that the TENS was starting to kick in. The contractions were definitely getting stronger. At around 10.30 a.m. I placed some pillows on a chair and suggested Mandy straddle the chair, leaning against the pillows on to the back of the chair. This helped support her during the contractions.
She was experiencing quite a lot of back ache, even though the baby was in the correct OA position. So, still keeping the needles in her ears and with her still straddling the chair, I asked her to point to where the back ache was most intense. Using the second output on my machine, I put two pads low down on either side of her spine, keeping the same frequency on the machine. Her waters were still intact (this is always preferable, as I feel women suffer far less pain when the membrane is allowed to rupture naturally). As part of my duties as a midwife, I recorded her partogram (labour chart) and checked that she had passed urine, enabling the baby's head to descend. She was still happy to chat and eat and drink. Her back ache was quite severe during contractions but she seemed to be coping well with the pain, sitting on the chair during each contraction.
At 11.30 a.m. Mandy's ear needles fell out and had to be reinserted. She was still coping but feeling less inclined to get up and walk around and decided that she would like to have a rest on the bed. Her contractions were now coming every 3-4 minutes and lasting for about a minute. The back ache was still bad, even with the TENS machine in place, and she was finding it hard to find a comfortable position. At this stage it was quite difficult to help her, as each time we tried, a contraction would come. She needed firm yet gentle guiding, but her poor husband could do nothing right!
Mandy then decided she wanted to use the birthing pool. Unfortunately this was already in use, so I got her to kneel on the bed with a bean bag to support her bump and lots of pillows. I also gave her some Entonox (gas and air), and in about 15 minutes she was comfortable and calm again, in a position in which she felt happy and at ease.
It is usually around this point that women ask for pain relief. Mandy was now probably about 5 cm dilated. Her behaviour was very different, much quieter and more passive. She didn't want any contact in between contractions but needed to feel by herself with her own thoughts. The worst thing you can do at this stage is to ask irrelevant questions.
By 1.00 p.m. Mandy was still doing well but asking for something stronger to help with the pain. Having stayed on the bed for 45 minutes, she was now straddling a chair again. She was still using the Entonox between contractions, and the TENS and the needles were still in place.
I gave her a vaginal examination and found she was now 6-7 cm dilated - only three more to go. After the VE she became quite distressed - it is often the case that the contractions feel worse after an examination. By now she was asking for an epidural but I told her how well she was doing and that by the time the epidural came, it would be time to have her baby. I suggested that, as the birthing pool was now free, we should have a go at getting her into the water. I took the TENS and the ear crocodile clips off but kept the ear needles in, and we got her into the water and made her comfortable. It is amazing how quickly women relax once they're in the bath. Mandy kept using the Entonox and seemed to be coping with the pain. The fetal heart was still good.
At around 2.30 p.m. she became very restless and uncomfortable and started to thrash around in the water. She wanted pain relief and felt that she wanted to open her bowels - all typical signs of transition at 10 cm dilated. Because she did not want to deliver in the water, she got out of the pool and on to the bed again. It was difficult to manoeuvre her, as the contractions were very strong and lasting 45-90 seconds.
By 3.30 p.m., she was on the bed and using the Entonox. The needles had now fallen out so I let them be and used no more acupuncture. Mandy was still bearing down and wanting to push. It took about 30 minutes to settle her and reassure her, but the water had refreshed her amazingly. She wanted to stay on the bed, so we helped her to sit upright. By now she was starting to have a much longer break in between contractions and was getting her second wind. She was very relaxed and calm, again indicating that she was almost in the second stage. The baby's heartbeat was fine.
At around 4.00 pm, she began bearing down under her own steam, doing what felt natural to her. After about 15 minutes, her membranes ruptured. The waters were all clear. Although it is normal for there to be a longer gap between contractions at this stage, by 4.30 p.m. I was starting to get concerned that the gap was a bit too long and that she was getting very tired. (As an acupuncturist you can suggest to the midwife alternatives that can help at this stage.) For me the choice was either to use BL-31 and 32 to get things going again (but I didn't want to mess her around and move her off her back) or I could use GB-21 (but again it was a difficult point to get to). I decided to stand her up so that gravity could help and to needle the Bladder and Uterus points in the ear. Was it the acupuncture that got her going again or was it standing her up to allow gravity to work? We will never know. At 5.10 p.m. she delivered a lovely baby girl. At 5.15 p.m. the placenta and membranes were delivered. At 5.30 p.m. I examined her. She had a slight tear that would require a stitch. At 6.00 p.m., when she had had time for a breathing space, I needled BL-17 for blood bilaterally. I also tonified HT-7 for shock.
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