Sunday, September 16, 2007

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.

5 comments:

Anonymous said...

Dear Ciarin

I love your blog, I am looking to study midwifery and your blog realyl helped to reaffirm how much I really want to do it! Your great perahps you could email me if you get a chance saucier@hotmail.co.uk, and I would love to lap up some of your knowledge because you are a genuinly caring midwife with the right attitude which is great!

Thanks Heather :o)

Anonymous said...

Hi there, just found your blog and completely love it! It's so good to get a detailed, realistic description of what a midwife does, and now i'm really looking forward to starting my training!

Thank you!

Ciarin said...

Thank you! Good luck with your training...where are you going?

Louise said...

Hi Ciarin,

This blog was great! My dream is to become a midwife and your detailed blog got me more excited about my future. I have a few questions for you if you don't mind. I know this blog is from about 2 1/2 yrs ago but if you can please email me at louise.k.adams@gmail.com.

Thanks - Hope to hear from you.

Louise

Anonymous said...

Your story is amazing. I have always been interested in labor and birth. After having two of my own, it is amazing to get to see the other side of it.