Saturday, September 29, 2007

Personally speaking

Nothing much to report personally. Been under the weather the last couple days. I really feel at a loss for words...hmmm...

Oh, I know, work sucks...kinda. It looks like we are going to lose two students from my class. One for major attendance issues - which is a shame because I can see her being a great nurse, when she shows up. The other - I can't imagine her being a good nurse so it may be just as well if she gets tossed out. She's on strict probation for numerous issues that I won't go into here because it's really rather boring. The boss seems to be in a crabby mood lately so no one can do right - or at least this is the way I am feeling. I am finishing grading the first assignment, which was a culture paper. It's depressing - some write well but then don't address all of the criteria so they lose points. Others write almost as well as my 12 -year-old but at least address all the criteria requested. Grrr. I can't win.

What's still good about work? We are getting closer and closer to OB!!!!! Meanwhile, clinicals are going well for OB and peds. I can't wait to show students the Gentle Birth Choices DVD I got recently. I'm reminding them frequently that birth is not always like what they see in the hospital (it's a county hospital which should tell you a lot about the experiences they are getting). That birth can be very different...and of course, I am always reminding them about being sensitive to the needs of the patients. They are a good group of students and are so excited to be there :)

Tuesday, September 18, 2007

Another shift

I worked another shift yesterday. Funny, I get cancelled then they call back at 0830 requesting me by name. Not sure if that's good or bad.

The charge nurse says "Do you wanna do postpartum? It's the easiest".

I say "sure, whatever". Normally I hate postpartum but I'm tired and she tells me its the easiest...ok...whatever.

I have no ass left...I worked it all off running with a full load of couplets (mom/baby). Grrr.

Heavy Breather

One of my new officemates is a heavy breather.

If you'll recall myself and three others get the new office to share. One of those three is part-time and only there when I am not, which is why we were paired up. Works good for me. The third officemate is funny at times and boring at other times...she talks a lot but is an incredibly intelligent woman. The third...

She is the one who is completely computer illiterate...she is the culprit also for heavy breathing.

And it's not even regular heavy's not sighing. If it was regular, maybe I could stand it. When I have my mp3 player, it's not an issue. An atomic bomb could go off and I wouldn't hear it when I'm playing the music. But I forgot my music today...grrr....

So, everybody's in the office, it's quiet. Then big heavy breath. Then silence. Then big heavy breath.

AAAAAAAAAGGGGGGHHHHHHHHHHH! *banging my head against the wall and suppressing the urge to tell her to stop breathing*

Sunday, September 16, 2007

New (to me anyway) trick for back labor and/or pain

I learned a new trick yesterday that I thought I would share...

When someone is having back pain or back labor try this...

Have them lie down flat with their knees bent. Push on their knees just below the kneecap. The midwife I worked with yesterday tried on me and on a patient. I thought it felt great (I have a lot of arthritis for a youngin' - autoimmune junk). The patient, who was having back labor, also said it helped during the contractions. Neat!


While at the hospital yesterday I noticed signs here and there talking about different illnesses and encouraging handwashing. Ok, so that's pretty normal. But then I saw the sign for coronavirus...

CORONAVIRUS - my definition
-a debilitating illness following a night of drinking coronas excessively

The real definition from Wikipedia
-Coronaviruses primarily infect the upper respiratory and gastrointestinal tract of mammals and birds. Four to five different currently known strains of coronaviruses infect humans. The most publicized human coronavirus, SARS-CoV which causes SARS, has a unique pathogenesis because it causes both upper and lower respiratory tract infections and can also cause gastroenteritis. Coronaviruses are believed to cause a significant percentage of all common colds in human adults. Coronaviruses cause colds in humans primarily in the winter and early spring seasons.

A day in the life of a labor and delivery nurse

So I worked a labor and delivery shift yesterday...what a crazy day.

The unit where I worked is the same place I did my midwifery clinicals. I jumped at the chance to go back there for a couple of reasons. The first - I know for the most part how things work there - it's a familiar environment. The second reason - it's so cool to go back and see people I really liked (especially the midwives). Now, you have to understand soemthing - the nursing staff in some cases are just warm bodies. This means there are some nurses that hav no clue when it comes to caring for laboring patients. When I was there as a student midwife, I often had to be the midwife AND the nurse for my patients. For example, you couldn't count on the nurse to notify you if your patient was having lates (a type of deceleration in the baby's heart rate that indicates distress). They don't always have the knowledge they should. It's kinda scary. It's the warm body syndrome - as in any warm body will do.

The day started off with me having a cervidil induction - this young lady was on her second cervidil and contracting quite a bit. She had a lower pain threshold (everybody is different and that's ok) and wanted pain meds. The midwife on asked me to check her (which is kinda flattering because the midwives normally like to check their own patients so the most of the nurses don't). The patient was 2cm dilated. We medicated the patient and let her rest. Once she woke up and started hurting again, the midwife wanted to go ahead and get the pitocin (synthetic hormone that triggers contractions) going. The patient was allowed to take a shower and then I got her on the monitor. She was having some very mild early decels (a deceleration in the heartbeat that mirrors the contractions - usually indicates head compression and is a normal finding - when they are more dilated). I started the pitocin at a very low dose and watched. The midwife came in and placed a IUPC (intrauterine pressure catheter - this midwife who was on MLOA most of my student time there is apparently a big fan of internal monitors). She was now 3cm dilated. While the midwife was inserting the IUPC, we noticed a little more blood than normal show. Hmmm...less than ten minutes after the midwife walked out of the room the baby's heart rate dropped down into the 80-90's (normal is between 110-160). So I start doing all the 'stuff' you do in the situation - flipping her position, cutting of the pit, oxygen, etc. The heart rate stays down. Three minutes into the decel I have help in the room, including the midwife. The doctor follows a couple minutes later and we going rushing off for a c/s. I took over the other laboring patient and that nurse went to do the c/s (I hadn't been oriented to their OR so opted not to go). So what was the cause of that prolonged decel in a baby that had otherwise looked absolutely fine prior to then?

Velamentous insertion, which is where the cord, instead of originating somewhere on the body of the placenta, instead originates from the edge of it.

This is an example of what a normal placenta looks like (below).

The three vessels that run between the baby and the placenta are very important to the baby's well-being. One of those vessels had likely torn thus causing the decel in the heart rate. The baby was fine fortunately - big boy weighing 8-13 and mom recovered well from the anesthesia.

So while they are off during this emergency c/s I care for a young woman who is stalled out at an anterior lip (which is like 9 and a half cm dilated). She has an eipdural. In this part of the country it seems that when women have epidurals, they get Foley catheters (a catheter left in place to continuously drain the bladder - when you have an epidural, you lose the sensation associated with a full bladder). I'm in the room introducing myself, talking to everyone, and checking all the lines she has. I notice there's no catheter so I ask the patient if the nurse had emptied her bladder since having the epidural. She says no. She had her epidural at 0700. It's now 1130 and she has had at least 2 liters of fluid since then (momma was running a temp probably related to prolonged ruptured membranes and all the fingers and IUPC that was hanging out of her vagina - well the fingers were hanging out but the vaginal exams is what I mean!). When momma runs a temp, the baby's heartrate will start go up. So bolusing her can sometimes alleviate this stress on the baby. Oxygen can help too but the nurse had not done that either. So I put in a catheter and get a whole lotta urine back, slap some oxygen on her and before you know it she's complete and numb! Her epidural was working all too well - apparently the CRNA likes to really make them numb - grrr.

The charge nurse comes up to me and says, I want you to take the new labor admission and give this patient back to the original nurse (who has the personality of a fish). I explain that I have already bonded with this patient and would like to keep her. She is concerned she will need a c/s because of the lack of progress. I gumble and think to myself "well if someone had bothered to assess her bladder and and cut the damn epidural down we might have already had a baby by now" but I am contract here so I just say "ok".

So my new patient is another primigravida (first pregnancy) who came in to triage at 5 cm - asking for an epidural. Just my luck - most of the patients I worked with as a student midwife did not want epidurals so I guess I got a little spoiled by that. So another nurse (who I do like) comes and helps me get her admitted and the epidural. She continued to labor and make good progress. She probably had her baby about an hour after I left because she was complete (10cm) at shift change. I thought for sure I was going to have a shift change baby - which kinda sucks for the nurse because then you have to stay and do paperwork. At least I do because I don't want to desert the oncoming nurse.

Teamwork is not something I see much of with these nurses. When I worked L&D in South Carolina, you always had back-up for delivery. Out here, it doesn't seem to work that way. At the big factory L&D I worked at when I first moved here and couldn't stand, you were always on your own. Same at these other places. It's weird how geographic location really does make a difference in some things.

Thursday, September 13, 2007

How exciting

Went to my new jobplace today to fill out paperwork.

Credentialing paperwork = life history

My god, the amount of paperwork to fill out between regular stuff (I-9 etc) and the credentialing stuff was enough to kill a whole forest!

But it was exciting - one step closer to working as a midwife again. I so very much miss it. I start with nursing clinicals tomorrow on OB but it's just not anywhere near the same. I guess it's better than nothing. At least I can work on teaching nursing students that pregnancy and birth are not pathophysiological processes...hopefully the nurses won't come behind me and screw up their heads with junk! I'll post this weekend to let you know how it went.

Monday, September 10, 2007

How to choose a provider

Ok, you are the woman - you just found out your pregnant. How do you choose a provider?

First the options available (depends on where you live to some extent)...

1. Certified Nurse Midwives (Of course I put this first - I am one :) -
A certified nurse-midwife (CNM) is an individual educated in the two disciplines of nursing and midwifery, who possesses evidence of certification according to the requirements of ACNM. Work in hospitals, birth centers, homebirth.

2. Certified Midwives - A certified midwife (CM) is an individual educated in the discipline of midwifery, who possesses evidence of certification according to the requirements of ACNM. Work in hospitals, birth centers, and homebirth.

3. Direct entry Midwives - generic term that includes a wide range of practitioners who enter the profession of midwifery through routes other than nursing education. While in the past most were apprentice-trained, there has been a recent trend toward credentialing DEMs following more standardized
educational preparation. Work in birth centers or homebirth.

4. OB/GYN - a physician who has received additional training in the specialty of obstetrics and gynecology. Work in hospital and rarely OOH.

5. Family Practice doctor - a physician who provides care to the entire family including birth - some provide this service and others do not. Some have received additional training, such as a fellowship. Work in hospital and rarely OOH.

6. Certified Professional Midwives - has received formal education, with no nursing background, work primarily OOH (out of hospital).

Ok, the options to consider when choosing a provider...(some may add to this list!)

1. The most important thing - whether they have caught (midwives catch, pizza is delivered) 100 or a 1000 babies, they should be as excited about your birth as you are! It is an honor, not a job, to catch someone's baby and be a prt of this special moment in their life. It should not be treated with a cavalier attitude. If they aren't excited - trust your instincts and find someone else. Which brings me to another very important point...

2. Trust your instincts!!!! If they don't feel right for you - find someone else!

3. Think about what kind of birth you wish to have. Remember, hospital does not equal the safest birth. Some may not have all options available to them depending on where you live.
Homebirth - you labor and birth in the setting and comfort of your own home
Birth center - a homelike atmosphere is created and birth is treated as a normal process
Hospital - a homelike atmosphere is faked by having pretty rooms but the general view of birth is often high technology and limited by hospital policies and procedures
Whatever birth experience appeals to you - you will need a provider capable and/or willing to work in which ever setting you choose
4. Trust your instincts ....did I repeat myself? That's because this point is very important. Talk to the provider about what type of experience you desire. If they poo-poo your ideas then perhaps they are not the right provider for you. The provider should be open to your ideas...if they have valid reasons why something might not be right for you that's one thing. But they should NOT poo-poo your ideas out-of-hand.
5. Who and where you choose will depend on your health as well. If you have a lot of health issues, you may be limited to the hospital. This is where it becomes even more important to choose a provider who will be there for you, advocate for you. I am a firm believer that the significant other has a very important role in your birth experience - it's not the role of advocate. They shouldn't have to do this role. They should be busy working with you to labor and birth. The provider should create a cocoon around the family.
Ok, my mind is going blank and my stomach is saying feed me so I will end here. But please, if you have questions - ASK!!!!!

Vaginal birth vs c/s birth

Vaginal delivery - some facts

1. Recovery - almost immediate
2. Breastfeeding - immediate
3. Food - almost immediate
4. Respiratory distress in the baby - much less likely as the baby gets a good squeeze coming out of the vagina, which helps to push out secretions
5. Vaginal birth - safer, mom and baby less likely to die or have complications (such as wound infection, acute renal failure, etc)
6. Bonding - immediate
7. Depression - less likely

Cesarean section - some facts
1. Recovery - 6 weeks
2. Breastfeeding - sometime after you go to the recovery room - 1-2 hours after birth
3. Food - Nothing but ice chips while in recovery then clear liquids the first day
4. Respiratory distress in the baby - much more likely - no squeeze so mucous and fluid tend to stay put longer as baby (and someone with a bulb syringe and suction) work on getting it all out.
5. Cesarean birth - safe...but not as safe as vaginal birth! Risks involved - death, infection, more likely to have a placental abruption (placenta prematurely separates - life threatening) or placenta previa (where the placenta grows over the cervical os) in the next pregnancy, etc.
6. Bonding - whenever the staff feels it's appropriate - 1-2 hours later maybe
7. Depression - more likely
An interesting possibility that's being researched is the impact of babes born by c/s not being exposed to maternal flora (mom's vaginal bacteria that is normally there). The newborn's gut is sterile until they begin to be exposed to bacteria, which then grow and live in the intestines. This is good - it's called a symbiotic relationship. The bacteria need us to live, we need them to help us digest our food! Imagine what the possible long term impact of this could be! The babies are exposed to bacteria but there may be a delay after c/s.

Thursday, September 6, 2007

New desk and a sign of things to come

I got a new desk today at work! I feel so cool :) What happened is our staff has grown quite a bit during the last few months. The clinical director and the program director have offices then there's a third office with two desks in it that we all fight to share. These offices surround a general meeting/lounge area where there are three more computers sitting on counters. These computers run on gerbil power. The computers in the third office run on actual electricity so hence the desire to work in that third office. Otherwise you resort to the library computers, which do run good - but then you have to hunch over your work like the Hunchback of Notre Dame cuz students are in there too. Soooooo....a new office was built in the largest classroom with three desks. And I got to choose one. Granted I have to share with another co-worker but she works part-time and is usually there when I am not. So it works out good!

My older daughter, who is 7, has a best friend who she rides the bus with, has the same classroom with. It's so cute because she was invited to go rollerskating with her friend on Sunday. So I had to call and speak to her mom then she had to of course speak with her friend. I watched her on the phone and saw our future...hell is a teenager. I already understand why some species eat their young - no teenagers that way.

Tuesday, September 4, 2007

Here's an interesting article about women who have their ovaries removed at a younger age, experience an increased risk for dementia among other things. Another reason for women to keep their ovaries and other parts :p Granted, there are valid reasons to remove female body parts but there are probably far more times where are body parts are wacked off. Not cool.

Monday, September 3, 2007

Designer Vajayjays (sp)

Has anyone had this done? The whole though of 'rejuvenating' our vaginas absolutely sickens me. I want to hear the thoughts of someone who has this done though.

Here's the link on this topic... Vaginal Rejuvenation

It sounds like ACOG (American College of OB-GYNs) might be on the right track for once. Why do women need to have their vaginas tucked, and nipped, and rejuvenated, especially after childbirth and aging? Why??? Is it to please a man? Why do women get boob jobs? Many will say "So I feel better about myself". Perhaps we need to spend that money that went to the vagina fixer-upper on some therapy?

I think that there are some vaild reasons for 'fixing' our bodies up - you know, after being scarred and disfigured and that kind of thing. But to say, my pussy is tired and worn out, or not as pretty as it used to be before I had babies...come on, give me a break.

My husband informed me that he likes mine just as much now as he did 15 years ago - nice to hear that but if it wasn't ok? There's the door, don't let it hit you on the ass. :)

Miss me?

Miss me? You know you did!

Well, it has been a busy busy past few days. I have lots to share...where to start???
Ok, let's start with the fact that I got a job!!!!!!! I heard from the practice I interviewed with a couple weeks ago, on Friday. I am very excited but unfortunately I won't be starting until November. So that's another 2 months in which my brains may continue to seep out of my head. It was actually my decision to not start until November out of loyalty to my current employers. They won't have another faculty member to take over my portion of clinicals until then. I will continue to work one day a week for the school teaching in the classroom. I'm excited and think this will work out nicely. The only thing I am a little nervous about is that the docs in the practice apparently expect the midwives to tell them what they want done. For those not familiar with what I am talking about...midwives must have a collaborative physician to refer patients to or to provide additional services such as c/s, vacuum extraction, etc. The docs I have worked with previously have come in and done their own assessment then made a decision. In a way, this was nice because if a woman was going to get a c/s, it ultimately wasn't my decision! Oh well, I will have to adjust to that. I'm so excited to get to work as a midwife...just wish I didn't have to wait so long but I guess I'ved waited this long, two months more won't kill me.

In the meantime, I signed on with a contract agency to work some per diem shifts (per diem is just working whenever I feel like it basically) on labor and delivery units in the area. The credit card bill has gotten out of control between trips to Vegas and tattoos so to pay it down quickly I decided to do this. I have other reasons as well...the money is really good - being a teacher does not pay well, not like working as a nurse in the hospital. These contract nurses tend to be reimbursed pretty well due to the fact that you have no guarantee of work and the ability to walk into a facility you have never been to before and start working without orientation. I also thought it would be beneficial to be back on L&D so even though I don't get to catch the babies, I'm at least able to watch others (good and bad) do it. Plus I get to work with mommas again!! I did a shift Friday evening - got a call that my old midwifery clinical site needed some nurses - how cool! So I got to spend time with the staff and midwives working which was great. I'm supposed to go back again this coming weekend. So maybe I will have some stories to share from there. No babies were born while I was there Friday. I had a patient with cervidil in (a ribbon that is coated with medication and inserted in the vagina - it 'ripens' the cervix - the cervix becomes ready for labor) and another patient with some kidney problems who is just growing her baby for induction.

We went to Vegas again Saturday morning, came back last night. This time we drove, which was awesome. I saw Hoover dam for the first time which was cool. It took about 5 and a half hours to get there and just 5 coming home. It's a gorgeous drive - the desert is so beautiful. On the way home we ran into some storms - rainbows everywhere!!! There were two - one inside the other- that were really beautiful. I've never seen a rainbow with such brilliant colors - and we drove through the end of it! There were colors everywhere but no leprachaun :( I would have loved a pot of gold as I had no luck in Vegas. But we saw Justin Timberlake at Mandalay Bay - he was awesome! I really like his music. And Timbaland was there as well - he was great!
Well, enough for now - must go off and see what others are posting - Have a great labor day!!!!