Sunday, March 23, 2008
Beautiful Birth
I was technically off last night and today but I got a call about 6:30pm (I was on call until 7pm) from a patient who I had agreed to be second back-up for her delivery. The other midwife who had seen this patient most of the pregnancy had asked me a couple weeks ago because she knew she would have a lot going on around Easter. The patient, her husband, and her doula are all sweet as can be. Anway, she started laboring yesterday eevening but wasn't ready to go to the hospital, just wanted me to have a heads up. Which was good because we were having a Wii party with the kids and I was planning to have a glass of wine (or 2 or 3 or the whole bottle), which I skipped knowing she was getting ready.
I talked to her once more a couple hours later, she was feeling stronger cxns but not ready for the hospital yet. About 2:45am, I get a call that they are there but will not let the nurse check her. She didn't want to know what she was dilated in case it would discourage her. I talked to the doula and explained that #1 I needed enough time to get there so really wanted to know what she was dilated and #2 couldn't admit her without knowing what she was dilated (I didn't really think she would be only 2cm but still...). So the plan was to check her and not tell her! And naturally, she was 8cm (how much cervix is dilated - 10 being the goal), 100% effaced (cervix completely thinned out, and -1 station (where presenting part is in the pelvis). Perfect! I tell the nurse I am on my way.
When I get there, she's in the tub and doing wonderfully. Her water breaks (actually I think she had a high leak because she had a bulging bag when she was pushing that I popped) while she's in there. She starts to feel a little pushy. I tell her I can check her whenever she wants me to. She gets into the bed and is now 9.5cm. I tell her she can do some little grunty pushes and that cervix will go away soon. I actually ended up reducing itand she pushed for about 38 minutes. Completely non-directed pushing, starting on hands and knees. I was really hoping she would deliver in that position but she flipped around to a sitting position. She crowned beautifully...so focused and well controlled. I believe it was one of the best I have seen. Baby boy was crying before he finished birthing! Straight to momma's chest for skin-to-skin contact and after a while breastfeeding. Delivered the placenta a few minutes later on her own. No pitocin ever needed! Babies really are born without pitocin!!!!
Amazing stuff! I wish everyone could understand what it is to have gone through this experience and how it makes a woman feel.
I talked to her once more a couple hours later, she was feeling stronger cxns but not ready for the hospital yet. About 2:45am, I get a call that they are there but will not let the nurse check her. She didn't want to know what she was dilated in case it would discourage her. I talked to the doula and explained that #1 I needed enough time to get there so really wanted to know what she was dilated and #2 couldn't admit her without knowing what she was dilated (I didn't really think she would be only 2cm but still...). So the plan was to check her and not tell her! And naturally, she was 8cm (how much cervix is dilated - 10 being the goal), 100% effaced (cervix completely thinned out, and -1 station (where presenting part is in the pelvis). Perfect! I tell the nurse I am on my way.
When I get there, she's in the tub and doing wonderfully. Her water breaks (actually I think she had a high leak because she had a bulging bag when she was pushing that I popped) while she's in there. She starts to feel a little pushy. I tell her I can check her whenever she wants me to. She gets into the bed and is now 9.5cm. I tell her she can do some little grunty pushes and that cervix will go away soon. I actually ended up reducing itand she pushed for about 38 minutes. Completely non-directed pushing, starting on hands and knees. I was really hoping she would deliver in that position but she flipped around to a sitting position. She crowned beautifully...so focused and well controlled. I believe it was one of the best I have seen. Baby boy was crying before he finished birthing! Straight to momma's chest for skin-to-skin contact and after a while breastfeeding. Delivered the placenta a few minutes later on her own. No pitocin ever needed! Babies really are born without pitocin!!!!
Amazing stuff! I wish everyone could understand what it is to have gone through this experience and how it makes a woman feel.
Thursday, March 20, 2008
On call
I'm on call today (7am-7pm). At 7am I get a call from the off-going medwife to tell me about the two patients at the hospital. One is a women at 40.1 weeks VBAC, and previous successful VBAC, who came in contracting about every 5 minutes but mild. The medwife kept her because even though her cervix wasn't changing, she didn't think a VBAC should be walking around unmonitored when contracting that much. Um...ok. I told the nurse to send her home (she was requesting to go home anyway as her cxns had spaced out to 8-10 minutes anyway).
The other patient on L&D, a 36 weeker who was contracting and having pain. she ran a UA and CBC...the patient had a UTI, slightly dehydrated, and no cervical change. She got ampicillin IV during the night as well as stadol. Um...ok. I asked the nurse to give the patient the option of going home (with some oral antibiotics) or staying in the hospital and just watching her. Guess what she chose? She wanted to go home. How's that for clearing L&D out?
Actually, I wish they were in labor so I could catch babies but not at the expense of subjecting patients to unneeded intervention.
The other patient on L&D, a 36 weeker who was contracting and having pain. she ran a UA and CBC...the patient had a UTI, slightly dehydrated, and no cervical change. She got ampicillin IV during the night as well as stadol. Um...ok. I asked the nurse to give the patient the option of going home (with some oral antibiotics) or staying in the hospital and just watching her. Guess what she chose? She wanted to go home. How's that for clearing L&D out?
Actually, I wish they were in labor so I could catch babies but not at the expense of subjecting patients to unneeded intervention.
Dreams
My youngest child will be adventuring off to K5 this fall and this makes me very sad. My baby will be in elementary school!
I occasionally dream about having another baby. Typically in the dream, I am full-term and in labor. Last time I dreamed that I checked myself and was 7cm so told my husband and mother that we needed to go to the hospital. The hospital we were going to was the one I catch babies at in real life so this means it was 45 minutes away. But then my water broke and I flt like I needed to push. I re-checked myself and was complete (10cm) with the baby on its way. I told my husband and mother they would just have to help me have the baby as I was not having it in the car on the way to the hospital! Then I woke up.
Does it sound like I have some regrets and also some angst about my youngest daughter? You're damn right then! I do have some regrets about my birth experiences. I have regrets that I didn't have the birth experience I dream about. I have regrets that I didn't breastfeed longer.
If I could go back and have another child (I can't - my tubes are tied) would I? No. I would be doing it for the wrong reasons.
I simply think of the whole getting up through the night, diapers, etc. That typically gets the thought out of my head. My husband would not want a fourth child. So whatever it takes to convince myself I wouldn't want another baby :p
And let's be real. I'm not the most patient mommy in the world. My kids drive me nuts. There are days I could lock them in a closet with some bread and water (Disclaimer: this is a joke, I would never do this, this is child abuse, do not try at home).
I occasionally dream about having another baby. Typically in the dream, I am full-term and in labor. Last time I dreamed that I checked myself and was 7cm so told my husband and mother that we needed to go to the hospital. The hospital we were going to was the one I catch babies at in real life so this means it was 45 minutes away. But then my water broke and I flt like I needed to push. I re-checked myself and was complete (10cm) with the baby on its way. I told my husband and mother they would just have to help me have the baby as I was not having it in the car on the way to the hospital! Then I woke up.
Does it sound like I have some regrets and also some angst about my youngest daughter? You're damn right then! I do have some regrets about my birth experiences. I have regrets that I didn't have the birth experience I dream about. I have regrets that I didn't breastfeed longer.
If I could go back and have another child (I can't - my tubes are tied) would I? No. I would be doing it for the wrong reasons.
I simply think of the whole getting up through the night, diapers, etc. That typically gets the thought out of my head. My husband would not want a fourth child. So whatever it takes to convince myself I wouldn't want another baby :p
And let's be real. I'm not the most patient mommy in the world. My kids drive me nuts. There are days I could lock them in a closet with some bread and water (Disclaimer: this is a joke, I would never do this, this is child abuse, do not try at home).
Tuesday, March 18, 2008
Office
I have been in the office too much lately. I need a break....meaning more call so I can catch babies! And frankly, I just like the unstructured environment of being on call. I do enjoy my time in the office normally - I really like meeting women and families so I can establish a relationship prior to meeting them on L&D. But with one of the NPs still out of the office sick...grrrr....too much!
We have a new doc starting this week. I haven't met him yet but I hear he is very nice. I saw him from a distance. He's handsome, mid-40's, and single. I need to introduce him to my mom! She's gradually starting to date again - my stepfather was a MD so why shouldn't the next one be one as well!
We have a new doc starting this week. I haven't met him yet but I hear he is very nice. I saw him from a distance. He's handsome, mid-40's, and single. I need to introduce him to my mom! She's gradually starting to date again - my stepfather was a MD so why shouldn't the next one be one as well!
Sunday, March 9, 2008
IUFD
Mommy was 20 weeks, I took her to the US (ultrasound) room because I couldn't find FHTs (fetal heart tones). I'm no pro with US but could not find cardiac movement. I told her that I was concerned and sent her for a 'professional' ultrasound. Definitely a IUFD (intrauterine fetal demise) :( I caught the baby a couple days later...was my first time catching an IUFD. I had watched these before as an RN but to be the one catching this tiny baby...this is a time when I would gladly trade back to being a nurse and letting someone else do the deed. Will these people forever associate me with the birth of their dead baby?
Another woman spontaneously ruptured at 17 weeks. She made it a week before delivering her tiny baby into my hands.
They say bad things come in threes...
Another woman spontaneously ruptured at 17 weeks. She made it a week before delivering her tiny baby into my hands.
They say bad things come in threes...
Trust
Let's talk abut trust. Is it possible to be well informed but still have trust in your provider? Every now and then I get a patient who is so adamant on doing things their way to the point of unsafety. I certainly believe that women should be well-informed and an active participant in their healthcare. I love it when women come in and ask good questions and express their thoughts and concerns openly. It warms my heart and I try to foster this relationship with every woman I see in the office or on L&D.
However, occasionally, I get a woman who is so deadset on a vision in her head of what her childbirth experience will be that I wonder just what they have been looking at on the internet. For example, I remember a couple I worked with who would not let the nurses on L&D even auscultate the baby. I went in to talk to them and explained that even if they were having a home birth or at a birth center, that the fetal heart tones would be auscultated periodically. They finally consented to this. I've had other patients come in either prenatally or to L&D with very set ideas on how things will go.
Now, I am certainly not unreasonable. If a couple has planned natural childbirth then they don't need an IV, they can be up and about, in the tub, eating, etc. These things are not a problem. But for example, a woman showed up for IOL at 41.5 weeks. Now, we typically offer induction of labor at 41 weeks. If a patient wants to go longer, we inform them of the risks and let it be their decision. This woman was already dilated 5cm (was told this in the office) but the baby was ballotable (head still floating). She wanted an AROM (artificial rupture of membranes) induction (break the water in order to create stronger and more frequent contractions). This was her second baby. She was insistent with the nurse that she call me and would not allow the nurse to check her prior. I was not in the hospital, and I live 45-60 minutes away. I was off call in one hour when she called me. She tells me what the patient wants...AROM, no pit (synthetic hormone used to induce labor), no IV. She didn't want anything from us other than for her water to be broke. Ok, that's fine. I grumble about having to head to the hospital and being off call by the time I got there but told the nurse to check her and I would head in that direction (we have a WHNP who doesn't always do the most accurate vag exams and I wanted to know the station). She calls me back 15 minutes later (what the hell took so long???) and the patient was indeed 5-6cm...but baby's head was far to high to break water. If the head is still floating, then you worry about a prolapsed cord which is a ticket, non-stop, to cesarean section. So I tell the nurse that there is no way I will break her water. The patient ended up going back home and was supposed to come back the next day (I agreed to this).
So what's my point? It comes down to a trusting relationship between the provider and the woman. It's teamwork. It's not a dictatorship, where one party calls the shots and the other should just meekly follow along. The worst is when a woman comes in and says "my massage therapist/bradley instructor/bank teller says I should...". This has happened. I know this will sound uppity and all, but I am pretty damn sure I went to school longer than a massage therapist and likely have caught more babies than her. A woman should have a provider that she trusts to answer her questions honestly and accurately. In return, a provider should be able to trust the woman to be forthcoming and honest about her plans and intentions. I had a woman come in around 20 weeks, we hadn't seen her since her initial visit at 8 weeks. I asked where she had been, she informed me that she was planning a homebirth but did want an ultrasound. Ok, fine, not a problem. I ordered her ultrasound, wished her well, and told her to let us know if she needed anything. This I can deal with.
Anyway enough! Words of wisdom for anyone seeking care during pregnancy. Trust. If you can't trust the midwife/doctor/massage therapist that is providing care...find someone else!!!!
However, occasionally, I get a woman who is so deadset on a vision in her head of what her childbirth experience will be that I wonder just what they have been looking at on the internet. For example, I remember a couple I worked with who would not let the nurses on L&D even auscultate the baby. I went in to talk to them and explained that even if they were having a home birth or at a birth center, that the fetal heart tones would be auscultated periodically. They finally consented to this. I've had other patients come in either prenatally or to L&D with very set ideas on how things will go.
Now, I am certainly not unreasonable. If a couple has planned natural childbirth then they don't need an IV, they can be up and about, in the tub, eating, etc. These things are not a problem. But for example, a woman showed up for IOL at 41.5 weeks. Now, we typically offer induction of labor at 41 weeks. If a patient wants to go longer, we inform them of the risks and let it be their decision. This woman was already dilated 5cm (was told this in the office) but the baby was ballotable (head still floating). She wanted an AROM (artificial rupture of membranes) induction (break the water in order to create stronger and more frequent contractions). This was her second baby. She was insistent with the nurse that she call me and would not allow the nurse to check her prior. I was not in the hospital, and I live 45-60 minutes away. I was off call in one hour when she called me. She tells me what the patient wants...AROM, no pit (synthetic hormone used to induce labor), no IV. She didn't want anything from us other than for her water to be broke. Ok, that's fine. I grumble about having to head to the hospital and being off call by the time I got there but told the nurse to check her and I would head in that direction (we have a WHNP who doesn't always do the most accurate vag exams and I wanted to know the station). She calls me back 15 minutes later (what the hell took so long???) and the patient was indeed 5-6cm...but baby's head was far to high to break water. If the head is still floating, then you worry about a prolapsed cord which is a ticket, non-stop, to cesarean section. So I tell the nurse that there is no way I will break her water. The patient ended up going back home and was supposed to come back the next day (I agreed to this).
So what's my point? It comes down to a trusting relationship between the provider and the woman. It's teamwork. It's not a dictatorship, where one party calls the shots and the other should just meekly follow along. The worst is when a woman comes in and says "my massage therapist/bradley instructor/bank teller says I should...". This has happened. I know this will sound uppity and all, but I am pretty damn sure I went to school longer than a massage therapist and likely have caught more babies than her. A woman should have a provider that she trusts to answer her questions honestly and accurately. In return, a provider should be able to trust the woman to be forthcoming and honest about her plans and intentions. I had a woman come in around 20 weeks, we hadn't seen her since her initial visit at 8 weeks. I asked where she had been, she informed me that she was planning a homebirth but did want an ultrasound. Ok, fine, not a problem. I ordered her ultrasound, wished her well, and told her to let us know if she needed anything. This I can deal with.
Anyway enough! Words of wisdom for anyone seeking care during pregnancy. Trust. If you can't trust the midwife/doctor/massage therapist that is providing care...find someone else!!!!
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