Plan of care
Due 3rd November 2009 Twin pregnancy
Following a number of discussions held between myself, Katherine, her partner and Leanne Bricker the following plan for labour and birth has been devised.
If gets to 13th October 2009 (37 weeks) can labour on MLU
If labours before then to go to delivery suite but same plan applies.
Wishes to be intermittently monitored and free to mobilise through out labour. Happy for an admission CTG when presents in labour. Wishes to be able to eat and drink in labour.
Happy for vaginal examinations as necessary.
Happy for students.
Is keen to use birthing pool for first stage of labour.
Will get out for 2nd stage. Triggers for getting out will be rectal pressure and / or waters breaking.
Happy for position of twin 2 to be stabilised by staff as twin 1 born.
(Ultrasound scan to be performed if unable to determine presentation abdominally. Can be undertaken on MLU by staff from delivery suite)
Does not want waters breaking for twin 2.
Happy for examination to confirm presentation.
If transverse lie aware will be transferred to delivery suite / theatre
If breech wishes to aim for vaginal birth. To be conducted by Midwife with support from Senior Reg, who should be on MLU during birth if breech.
Aware if Senior Reg unable to attend MLU then will need to be transferred to delivery suite.
Happy for paeds to attend but not in room for birth, only attend to babies if needed. To be present in room if 2nd twin is to be born breech.
Does not want time limit placed on expected birth of twin 2 if fetal heart rate normal.
Happy for active management of 3rd stage.
Not keen on cannula being in situ but may reconsider on the day.
Aware of reasons for transfer to delivery suite.
Abnormal admission CTG or any concerns around fetal heart rates
Meconium liquor
Transverse lie twin 2
Placenta retained
Excessive blood loss
Unavailability of staff that feel confident in caring for her on MLU
(In this instance then shift leader on delivery suite to be contacted and an assessment made of the Midwives that are on duty throughout the unit to determine if there are any Midwives that would feel confident in providing care to Katherine as per this plan of care.)
Katherine will be supported by a doula ?Selina? in labour.
Katherine is very well read on twin birth and aware that this plan of care falls outside the care we would normally provide to women having twins, and the guidelines upon which that usual plan of care is based.
Will be guided by staff, but will question any changes in her plan of care that are suggested.
I have informed Katherine that if available I will provide care to her in labour, but would envisage it being in a supportive role to the Midwives on the MLU.
If I am unable to attend when Katherine presents in labour then I am happy to be contacted by phone to support MLU Midwifes.
Supervisor of Midwives on call to be informed when in established labour. Delivery suite co-ordinator and Senior Registrar also to be informed on admission.
Consultant on call / on delivery suite to be informed of admission and plan of care.
MLU staff to keep shift leader on delivery suite and obstetric staff informed of Katherine?s progress and of any concerns / changes to proposed plan.
These plans have been made prior to labour and over a number of appointments. It would be inappropriate for professionals to make attempts to coerce or attempt to convince Kate to change her plans once in established labour.
Simon Mehigan
Consultant Midwife
There was nothing terribly controversial on the plan. The main issues that people were concerned about were the labouring on MLU, breech delivery of the second in that environment and the intermittent monitoring.
Everything went pretty much to plan. I went into labour after much hilarity with Selina - belly dancing around my front room. She left around 11pm and I went to bed then woke at around 1am with strong but short pains coming every two minutes. We called my mum who came to take the children away and who said she thought it was the real pains given that I was 40+3 and we should call the hospital (she's a doctor). We called Simon (consultant midwife) who said to take our time so we went to Selina's flat to wait for a while, I still wasn't convinced anything was happening as I'd gotten so used to the idea they were late and didn't dare hope! While I was sitting in the car the pains got longer and stronger and further apart but everytime I walked around they got shorter and closer together again!
Selina helped me put on the TENS machine and I was sick in her pan! I knew I was in labour then because I always vomit in labour! When we arrived in MLU Simon had already got there (driving from Nottingham) and showed us to our room. Selina dimmed the lights and got out her pretend candle lights and they did the initial CTG monitoring which was really good so we got the green light for the intermittent monitoring.
I felt myself disappearing into the labour, my BP was a little high so Selina massaged me while the midwife did some more monitoring and it came down nicely. The pains were getting stronger and more regular and I could tell by looking at the increasing strength of the TENS that things were starting to happen. The midwife examined me and I was 4 cm so I went to the pool room and got in the pool.
As soon as I got in the pool I felt the water lift the bump - it was huge and the babies overhung so much I think the water lifted them into a much better position. My contractions got suddenly very strong and after only a few minutes I was fully dilated and had to get out of the pool. I remember Simon saying to me that it wouldn't matter if I accidentally delivered the first in the pool but they'd have to shout at me to get out to deliver the second! I got out though and got onto the bed.
They helped me take off my wet clothes and helped me onto my side and soon after, and with some gas and air, a bit of hand gripping and some mopping of my brow (I had had to take the TENS off to get in the pool) I had pushed Dylan out, he was not very willing to come out of his waters and was partially still inside. They cleaned him off a bit and passed him to me and I thought "ahh, hard work done.... OH NO! TWO BABIES!". Neil took off his shirt and did plenty of skin to skin with Dylan while I got ready for Lily.
I remember thinking "right I'm going to just push her right out" and pushing! They were not sure which way round she was coming (they could feel she was longitudinal) as she had been breech on the last scan but they felt she was head down during labour. I had pushed her right down into my pelvis so they couldn't find her to check her heartbeat which worried them slightly for a bit but they soon found her and she was fine.
A few pushes and she was born, completely intact in her sack of water! That was an amazing sight. They checked the babies Apgar scores but then left us to bond. We stayed in the pool room for a couple of hours and I fed the babies who both latched well and sucked for a whole hour! Then, because the unit wasn't busy, I had a bath in the pool and got dressed and we went to the ward were I had a private room.
I stayed in overnight because they wanted to do some monitoring of the baby's hearts because I have a thyroid problem. All the monitoring was fine, the babies were good feeders and good sleepers and we came home the next day. Now we're at home getting used to each other, my older two are adapting well to the new additions and I'm getting to grips with tandem feeding.
I feel very thankful to all at Liverpool Women's Hospital but especially Dr Bricker and Simon Mehigan who were absolutely fantastic and provided fantastic care! Also very thankful to Selina for having such good ideas and suggesting the Women's in the first place and mumsnet for telling me about doula's too.
Any questions welcome.