Sunday, April 27, 2008

Begging for induction

By the way, the lady I spoke about in the Induction Doctor post who was impatient because her induction wasn't going fast enough and ended up going home? I saw her in the office four days later and she begged me for induction...said she would be patient this time. She was 40.5 weeks. I suggested waiting a couple more days but to no avail...I caved in and set her up for that evening. I gave her the spiel about induction not going quickly, etc etc. Naturally her IOL took 20 hours. She was a crabby patty when I showed up the next day and she was still pregnant. I told her not blame me - I didn't get her pregnant and I certainly didn't beg her for an induction. Yeah, ok, I didn't say this. But I thought it. And on top of that she had the worst labor nurse that works there! I got that fixed though at least. But once she finally got to 10cms, she spit that kid out in four minutes - woohoo! She went and had her cigarette, then I was her new best friend after that. Amazing what pushing a baby out and smoking a cigarette can do for one's state of mind.

Las Vegas/ Juvenile deliquent

Just a quick note...we left for Las Vegas today and arrived safe and sound. Oh, 'we' being my mother and I. I got lucky last night - was on call and my pager never went off, never had to go to the hospital!

We had a nice dinner - just did buffet tonight to take advantage of the crab legs and shrimp :) Yummy! Gambled a little on the blackjack tables with minimal losses. We have been practicing a new system, especially for my mom as she is a blackjack 'tard.

On a more sour note, we returned to our room to my husband having just left a urgent message to call him back immediately. Naturally I start thinking the worst...which of my children is maimed???? No one was hurt. Instead I discovered that my older daughter had a juvenile deliquent moment. She was playing basketball where she shouldn't have been and broke a car window. Ok, if that was all, I could be a little less upset. I mean, accidents happen, doesn't mean she's gonna spend her adult years in the state penitentary (sp). But! She decided to autograph her little mishap...yes, you guessed it...she wrote her name on the car door with a rock. Well, she won't be sitting for a week and she is losing her expensive birthday party we were having for her in a couple weeks. And she'll be working off the bill for the next few months. I am still in shock. I don't know what possessed her to do that. I mean, she obviously wasn't thinking...if she had been she would have written someone else's name! Haha - just kidding!

Friday, April 18, 2008

Induction doctor

Had a busy busy morning today. I caught three babies in 3 and a half hours - fun! The first, was a young lady who had ruptured spontaneously two days prior with no labor. After trying to help mother nature along with no luck, she finally went into labor last night. She was pushing when I got there and delivered her baby boy a few minutes later. She did a great job and was very much a trooper. She had been ready to toss in the towel the previous day and have a c/s but she rallied. The next one was a young lady who came up at 8cm...she did a great job as well. The third lady had to deliver her baby in triage - not the ideal situation but we had a blast (well she wasn't enjoying it as much as I was maybe).

My fourth lady was not in labor. In fact she was there for an induction. Wanna know why? Because....*gasp*...she was a day past her due date. OMG! Anyone wanna guess who had set this induction up and failed to explain that induction may have to occur over a couple days even though we discussed this very situation a few days ago during a provider meeting? Yes, Dr Newbie. Granted the woman was very much on board with being induced. When I asked her why she was being induced, she looked at me like I was stupid and said "because I am a day past my due date". Ooookay. So she smokes as well...not a problem initially. She was put on hold due to L&D going crazy so she was able to go and smoke when she wanted to do (not that this was admitted to us - naturally she denied that she was smoking, although that perfume nicotine eau du toilette (sp) was very fresh). C'mon, don't lie to me. It's not like I'm gonna put you over my knee and spank you because you are smoking. At this point, if you haven't quit during the nine months of pregnancy, I certainly wouldn't expect you to quit now.

So anyway, about 1230 they get the pitocin going. I decide to go home and get a nap (having trouble with sleeping the last three nights so am exhausted). I get a page 2 hours later from the nurse. The patient is upset, the pitocin isn't doing anything, she wants us to do something else. Her other pregnancy was induced by "giving her a shot, breaking her water, and putting soemthing in her cervix to open it up". Ooookay. Naturally this was at another hospital by another practice. The nurse explains to her the following...

1. How pitocin works, and that it typically takes more than two hours to work, as well as the need for monitoring

2. I'm not breaking her water when she's 2/50/-2 with no contractions (prior to the pit). No, not going to happen.

3. If she wants to continue on with pitocin great but no more starting and stopping so she can smoke (the patient wanted it off so she could go for a 'walk')

4. Offer to forget the pitocin and try cytotec instead

5. Offer to d/c her home and and wait for labor to start on it's own (hmm, novel concept)

God bless her! She wants to go home...good for her. I had the nurse tell her that labor was liklier (is this a word?) to go quicker and better if she just did it herself.

Thursday, April 10, 2008

A nice birth

This woman came in yesterday evening in labor. I had been seeing her quite a bit in the office and really was thrilled that she came in while I was on call!

She was 7 cm on arrival, nicely thinned out, tolerating her contractions well. She labored beautifully, using the birth ball. Got back into bed about two hours after arrival and asked me to check her. She's now 9cm, head nice and low in the pelvis, bulging bag of water. She asks me to break it, which I do, to find clear fluid. A little less than an hour later she wants to push so I tell her to go for it. she pushes for about 18 minutes, crowns slow and controlled. Delivers a handsome 7 pound 15 ounce little boy named Jalen. Intact perineum. Fantastic fun!

I love my job!

Against medical advice

I can't really go into much detail but I had an experience last night that I have never had before.

A woman was having a normal labor, progressing nicely. Then she stalled out at 8cm, started having a very non-reassuring heart rate. Despite our efforts to correct the situation, we had no success. The doctor was called to come in. I anticipated a c/s. The family and woman refused. I watched this non-reassuring strip for over four hours. Amazingly, the baby came out finally with 9/9 apgars. So short term, baby seems to be ok. Whew.

By the way, it was the new doctor on call. We actually worked well together.

Wednesday, April 9, 2008

The Shine and a New Doc

We have a new doc, let's call him Dr Newbie, that started taking call not too long ago. He has managed to alienate every single one of us midwives already! He is a couple years out of residency but comes from a much smaller practice than ours (I believe he was doing an average of 5 births a month -we do over a hundred). It's apparent to me that he is very much still 'green'. It makes me uncomfortable to work with someone who isn't that much more sure of themself than I am! For example...

1. He told me I needed to get a patient in Robinson's for pushing...umm...huh? Do you mean McRobert's (a position that involves momma's knees behind her ears, meant to be used for shoulder dystocias but many nurses and OBs use for routine pushing).

2. The head was at a +2 station - when momma pushed effectively, we could see the head easily. He claimed she was at a 0 station.

3. He 'suggested' I put in an IUPC (intrauterine pressure catheter) because 'we' couldn't tell when her contractions were or how effective they were. Hmmm, she cam in at 3:30 8cms...complete and pushing at 4pm. Uh, seems pretty effective to me, not to mention she was going natural and therefor feeling great urge to push with each contraction (which was about every 2-3 minutes). Furthermore, how do you get a IUPC in when the head is at +2? Believe it ir not, I got it in...and am kicking myself now for allowing myself to feel pressured to do this. A few minutes more of hoovering he left the room to go 'deliver' another one of my patients who had progressed much more rapidly than I thought she would. The minute he walkded out, I pulled that stupid thing out - she was pushing it out anyway :p

4. The baby was 10 pounds 6 ounces...he didn't bother to come back and check on me. But fortunately I have had my share of postpartum hemorrhages, and I managed this one just fine.

So, god bless the nurse, she didn't take any orders from him but instead waited for me to give them. Everyone was looking at him like he was nuts, and looking at me to see what I wanted to do. Oh, and he told the nurses in the other delivery, he wants methergine at every delivery he does.

He has also told someone that he does everything by the 'book', every woman gets an IV, pushes in stirrups, continuous EFM, etc. was he every hired with this attitude and philosophy? Well, needless to say, the "physician extenders" (a rather derogatory term used by the owner of the practice that refers to advanced practice nurses) were not given an opportunity to interview. Let's chalk up another one for the good ole boys network!

So the shine is off the new job now. At a provider meeting recently, it was pretty clear to me that we are not respected as professionals. The owner told us we were not 'equals'. I understand they have more education but come on! Talk about rude and disrespectful. I really left the meeting with a bad taste in my mouth. *sigh*

Thursday, April 3, 2008

The third

The third fetal demise happened last week. I had done this couple's new OB visit 13 weeks ago. She had been seen 3 weeks previously, where the medwife showed them the heartbeat on ultrasound, I guess because they couldn't hear it yet with the doppler. This heartbeat with doppler, no cardiac movement with our little office US, official u/s...fetal demise.


This is it since bad things happen in threes, right?

Green Badge

I got a green badge today and am so proud of myself! What does a green badge mean, you ask? A green badge has many benefits. I'll list them and then you can guess who gets green badges.

1. I get to eat free now! I can't wait to see if the free food in the lounge is better than the plebian food in the cafeteria.

2. I will no longer be mistaken as an employee of the hospital.

3. I will no longer have to explain who I am.

4. I can hang out and hobnob with the doctors in the lounge now!

Have you figured out who gets these green badges? Yes - medical staff!

So here' the story...

When I received privileges at the hospital at the beginning of December last year, my co-worker took me over to get my badge and she needed to get her's replaced (she had an old white one that the hospital was no longer using). They refused to issue us green badges and instead gave us purple badges (which are what the nurses and other employees in the OB department get). We attempted to argue with no success. We were told that we were NOT part of medical staff but instead, were allied health professionals. how come all the CRNAs (certified registered nurse anesthetists) and every other midwife has (including the medwife in our own practice!) a green badge? Even the residents get green badges!

So time goes by...3 months later, I bitched and complained and finally said the right things, which were suggested by the medwife! The office manager contacted the chief of medical staff's assistant - a couple days later - walah! A green badge for all midwives!

It's a triumphant day for midwifery at this hospital.

PS I can park in the doctor's parking now - wow. Not that I will, because there are CNM parking spots by the building that houses OB. Although they are compact size spots...apparently midwives are supposed to drive VW bugs or something.

Tuesday, April 1, 2008

L&D nurse wannabes

Conversation between me and a nurse orienting on L&D.

Me: She's 8-9 centimeters now.

Nurse: Oh, she's 8-9?

Me: Uh, yes (said slowly as nurse seems to have trouble understanding).

Nurse: Do you want me to start having her push?

Me: uhhh, noooo, not until she is 10 cms.

Nurse: oh, ok.

Does anyone see anything wrong with this conversation?