Sunday, December 27, 2009
My knee still has puffy spots...but they are mild. I seem to have plateau'd (sp). The first week I was improving daily after the initial 2-3 days. This past week's progress has included more mobility and the ability to walk without a crutch. However, it's really been very slow progression. I have my f/u appointment on Tuesday to go over the results of the MRI and determine the POC. I suspect surgery is in my near future. I was supposed to have had the f/u last week but they rescheduled it to this week so the doctor could be present. That seems to be a huge hint that I will need surgery.
Here's hoping that all goes well tomorrow. I'm looking forward to getting back to work and to seeing my patients. I miss it all :)
Friday, December 25, 2009
It's been quite busy these past few days, with preparation for Christmas, Nutcracker with my mother and the girls, making poor attempts at resting my knee. I've enjoyed the time for the most part...
Highlights (aside from the obvious of spending lots of time with my close family and friends)
-homemade fudge from my BFF
- seeing the Nutcracker
- italian christmas cookies made and decorated bymy mom, me, the kids, and my BFF
Friday, December 18, 2009
Oh dear...am I rambling?
So, I got my christmas cards done. I'm off to do some christmas shopping and dinner with my BFF. I get to ride in a wheelchair - what fun!
Thursday, December 17, 2009
I am struggling with my insurance company - I am surrounded by incompetence as well so that doesn't help. My rheum wanted to increase the dose interval on my meds which would likely require preauth as they are a bit expensive. I get a notice from my insurance that I am now required to use a specialty pharmacy instead of the ease of my local pharmacy. Ok. So I mail the Rx off to the pharmacy, like , 6-8 weeks ago. In the meantime I have some samples from my rheum to keep me going. I haven't filled any prescriptions at my local pharmacy since prior to the new RX. I get told that they can't fill it until the middle of this month....but it will be for the four syringes. Ok, I have enough samples to get by. I call back when I am supposed to and say ship my sh*t (well, maybe not in those words). They inform me that it has to be preauth'd. Uh wait...what have we been doing for past 6 weeks that you guys have had this Rx????
Ok, so I put on my patience mask and they get the ball rolling. Three days later my rheum's office calls me to let me know it's been approved. Woohoo! I go off to have my MRI done and come home to get a message from my insurance saying that my request for additional doses has been approved. Woohoo! I call the pharm to get it shipped. They promptly inform me that it can't be shipped until a week into january. Are you punking me???? Oh and it hasn't been authorized for the additional doses. But wait....did I dream the two calls saying it had? Maybe it was drug-induced wishful thinking. So the pharm chick calls my insurance to be told that the case is still pending. WTF? So I am waiting patiently...*snicker*....a couple days then will try again. It aggravates me because the increased dosing is working. Hardly any temps recently and very quick and low at that (like 99 as a high), they go away within a few minutes. My joints aren't giving me a lot of grief anymore. So aside from some fibro issues and the knee thing, I had been feeling better. Then this happens.
Guess what my temp is right now? 99.8 F*ck.
On the lighter side of things....my husband has been a doll. The girls too. They have been very helpful, waiting on me like the Queen that I am. My bestie and my mother have also been attentive to my needs, as it should be - LOL! I have a plan in place for grocery shopping and finishing my Christmas shopping, all with injured knee.
The knee, btw, is getting better....swelling is down considerably, less painful, and I can bear some weight now. My worst fear is falling. I'm scared it will go out again. I won't know MRI results and plan of care (POC) until Christmas Eve. That sucks. My husband says it ain't right that a football player can get injured and have the MRI and follow-up immediately. I mentioned a slight difference...I'm not an athlete making millions.
Sunday, December 13, 2009
So off we go....me still very drunk and embarrassed. We get there and fortunately it isn't busy. The staff are very kind and pleasant. What can I say? I'm a funny drunk. In fact, my cell phone got into the hands of my bestieso there's some very funny video footage. So, x-rays get done, the PA sees me and says likely menisucs tear which means go home and rest it, ice, pain meds, blah blah. Gee, big surprise. So home I go....they get me all comfy as possible with ice etc. I manage to sleep for a bit then wake frequently due to pain. My alcoholic anesthestic was wearing off. So while finally deciding to take a pain pill (kinda wanted to wait until I was a bit more sober...cuz that whole stop breathing thing doesn't work for me) and researching from my cell phone on meniscus tears, I learn that this was probably already present and I just didn't recognize it for what it was. I had been having these episodes of popping in the same knee for 3-4 months now. Not painful, just weird feeling with occasional twinges of pain. I thought it was just an arthritis thing but now I know that I likely had a tear and just totally blew it out finally.
So where does the poledancing come in? I was NOT poledancing. However my BFF thinks it will be fun to see who can generate the best rumor on Facebook on how I blew out my knee. That's her first crack at it!
Thursday, December 10, 2009
I have another personal patient (multip) who is now past her due date. Don't really want to induce her. We are still waiting for spontaneous labor. We have a week to go until we have to talk induction (42 weeks). At least that will be right before I go on vacation. I promised my husband and children I wouldn't work on vacation. But truth be told...I probably would if any of these personal patients come in. I just don't want to miss their births.
I have another one, a primip who is also term...about 40weeks. I've been stripping her membranes the past two weeks in the hopes that she'll have her baby before I go on vacation. How did I end up with so many personal patients all due around the same time?????
I am inducing another personal patient due to blood pressure issues. She's a multip with a favorable cervix so I am hoping all goes smoothly and quickly with her. I have such a blast with her and her husband. And her daughter is such a charmer...love seeing her!
Favorite complaint - I feel like I have a bladder infection and I drink plenty of water. Comes along with a urine sample that has small ketones and nothing else. "You feel this way because you don't drink enough water." She says "But I do". I look pointedly at her McDonalds cup and ask what's in that cup? It's obviously orange whatever it is. Busted.
I did a new OB appointment with a couple from the Middle East. They have been here for 3 months. They were adorable! She was so worried because she had a miscarriage at 4 weeks the first time and is Rh negative. She didn't get Rhogam afterwards. So now she's scared for this pregnancy. Someone (family doctor I guess) has scared the crap out of her. I explain, via the translator, that she was too early for there to be any concern. I reassure her and have them both smiling and happy by the end of the visit.
Meanwhile, the other primip was 8cms and feeling some pain. We got her epidural dosed and I broker her water. We got her settled again so I went back to dealing with the whiny primip.
The whiny primip had been pushing for awhile - some of her pushes were great and others not so much. The baby had a good bit of caput and momma had protruding ischial spines which were holding baby up a bit. I was a little concerned that she might not be able to get the baby out, especially if she continued to fight the process. After an hour and a half of pushing and slow but steady progress, we got her epidural dosed up again. I also kicked out the family except for the FOB. They were very understanding, and I kept them updated. I talked to the doc on call with me...he basically said to tell her she had 30 minutes to do something or he would come in and section her. Not the response I was wanting. She was potentially vacuumable at this point but he really needed to be the one to make that decision. I was so ticked off that he wouldn't come and evaluate. I went back to the room, where the patient was a little more settled after getting her epidural redosed, and told the patient what he had said. I could see that the caput was starting to crown. I then proceeded to talk to her as if she was my child. I told her she didn't need a section and if she would just suck it up and do the work, she could do this. I told her I wasn't letting her have a section....she was only gonna do this one way. And we got to work.
Forty minutes later, she delivered an adorable baby with a huge conehead after a 90second shoulder dystocia. Apgars were 1 min - 2, 5 min - 6, 10 min - 8, 15 min - 10. I thought I would have to change my underwear after the whole thing was said and done. It was nervewracking! The next day, I went to see her and the baby and both were doing great! Oh, and this was over an intact perieum - and the baby was close to 8 pounds!
The second primip by this time was complete and ready to push. She did a great job. We had a baby crowning fairly quickly. She also had an adorable baby after a 2 minute shoulder/body dystocia. The baby had apgars of 5-6-8. The baby weighed in at almost 9 pounds and momma just had a single periurthral tear that I threw a few stitches in. Change my pants again. Both doing very well the next day.
So two beautiful natural birthes. Then karma had to strike....and I get two shoulder dystocias.....geez.
I went home and got some rest. It's a good thing cause I was destined to be up all night on the Sunday night.
A woman came in who I had seen a few times in the office. She was 4cms in the office and was planning a trial of labor after having a c/s with her first baby. Her first baby was 9+ pounds and OP (posterior position) along with some chorio (infection in the uterus) - unfortunately a failed homebirth. She's tiny as well. Maybe 5 foot at best. I knew this baby was smaller - I estimated between 8 and 8 and a half. She was coming up on 41 weeks so was really hoping she would go into labor over the weekend. Otherwise we would be breaking her water on the following Monday.
She called me and let me know she was contracting and getting more uncomfortable. I suggested coming in. Two hours later, she finally showed up - just I am really starting to worry! Her water was broke as well, which she failed to mention to me. She was 4-5cms. So I had her walk for awhile alternating with rest. The plan was to wait until she was a little more uncomfortable then have her get in the tub. But then the baby was acting up a little - nothing major but enough that I wanted to keep an eye on the baby. Once I was happy with the baby again, we just never made it to the tub....the waterproof doppler couldn't be found so she would have to get out every 15-20 minutes for a quick listen. We decided not to bother with it. She did many position changes, with her husband on one side and me on the other. I did some massage of her back and later had her husband do some effluerage, whcih she liked. Like the other two women who birthed naturally, she was gorgeous to watch. So calm and relaxed. She was about 5-6cms, when I checked her 4 hours after the first exam. I was a little concerned about the slow progress but just tried to remind myself that labor doesn't always follow Friedman's curve.
In the meantime I caught a baby for the doc on call. This patient had a history of a precipitous labor with her first baby. She went from 5cms to 8 after walking. I broke her water, then got her in the tub. She was the type of person who never seems to be happy with anything but who knows...she was in labor after all. I found it difficult to establish a rapport with her (which is something that doesn't happen often for me) but the nurse was actually doing labor support! What a pleasant change. So I left them to it. She ended up delivering about an hour and a half after I broke her water. I was surprised as I didn't think it would take that long. So that was baby #5.
In the meantime, my other lady is continuing to do very well....seems to be getting more transitiony so I start getting a little more excited. Soon, she wants to push. I check her and she just has a small anterior lip which easily reduces with the next contraction. I tell her she can push when she feels ready. When I look at her pushing and her big belly I start worrying. I so want her to be successful. But her belly looks huge in comparison to her. But she very quickly crowns up and we have a baby! She pushed for 23 minutes. She had small periurethral tears. WOOHOO! She was so happy afterwards. I was so happy for her! Her labor from admission to delivery was about 8 hours....but anytime one has to stay awake all night labor seems long.
I left at 7am, when I went off call.
Friday night was quiet. I had one page from triage around midnight. It was a patient having her first baby. She was initially 2-3cms then 3cms after walking for an hour. She was contracting regularly and uncomfortable with them. I ordered therapuetic rest fro her and sent her home (morphine shot - works by giving momma some rest - when she wakes the prodromal labor will either be gone or will have turned into active labor.) In hindsight, I don't really think it was prodromal labor. I think she was just in very early labor. Why do I think this you ask??? She came back around 6am Saturday morning and was 8cms!
I rush on in. The patient is doing incredibly well.....by the time I get there she's completely dilated and the baby is at a +2 station. I send the resident scurrying off (she was standing by for me) and we get done to business. The patient is doing a beautiful job of pushing her baby out. She is so calm and chats in between the contractions!?! Her boyfriend and family are all present and doing a very nice job of being supportive. I guide her through the delivery of baby #1. She does an amazing job. I repair her tear and off to go check on another patient who I admitted while on my way in.
This new patient was also a primip (first baby) and had come in since her water had broken earlier during the night. This patient was planning an epidural and I had the nurse start pitocin as she wasn't in labor. Her cervix was a fingertip/75% effaced and soft when she arrived. She was also ready to get things going. She was comfortably ensconced in her room with lots of family present. At first I thought the family would be obnoxious but as the day went by, it was the patient who was obnoxious and the family was great! :p I told her I would check on her later.
I then attempted to leave to meet my mother for some Christmas shopping. I was halfway to the mall when I got a page from a personal patient of mine. I had caught her first baby with a student midwife and had spent this pregnancy with her as well. My plan had been to catch this baby even if I wasn't on call. How nice of her to go into labor while I was on call! She's been contracting all night and her water broke a couple hours ago. I suggest she come on in as she says the contractions are now 6 minutes apart and getting stronger. I turn around and head back to the hospital. She arrives a little later and is actively laboring....although you can't tell it by looking at her! She's 5cms and doing beautifully. We get her in the tub where she labors until she's ready to deliver. She moves to the bed and pushes out a gorgeous baby #2 over an intact perineum in six minutes flat. The enitre time, she remained so calm and focused. What a beautiful birth goddess! I aways wish I could take pictures of women when they look like this...But it's so private and intimate. I just want women to see how beautiful they look when they are in the throes of labor. Anyway, she delivered only a couple hours after arriving. Nice.
I check back on my primip who is slowly but surely getting into labor. She's had a couple doses of stadol but isn't quite to the point of being ready for an epidural. She's 3cms now. I tell the nurse if she asks for more stadol again, to go ahead and let her have the epidural. No exam. After all she's been ruptured and if I don't put some specific guidelines down, some of the nurses will check patients frequently even with the water being broke. I decide to head out and try to meet my mom again.
I manage to get lunch and some shopping done with my mother. While at lunch I get a call about a new patient. This patient is also a primip who came in for a labor check. She's 4cms and crying I guess...wants an epidural. Ok, go for it.
I head back to the hospital to check on everyone. The primip on pit has an epidural and is very comfy. I check her and she's 8cms now - woohoo! The family has multiplied...there are about 12 people in the room - no exaggeration! The nurse has told them no more than four people. However, there's not a policy. It's really up to the provider. They want the soon-to-be grandparents to be there along with the FOB, which makes 5 people. I tell them that's no problem. I normally don't put any limitation unless they are interfering with the woman and her labor or if there are complications. She had meconium and so we would also have the neo and nursery nurse there as well, so it was gonna be pretty crowded.
I check on the other primip and she's also comfy with her epidural. She's 6cms and intact bag of water. I leave her be as I am afraid that her fast progress will put me into a situation of trying to be in two places at the same time. I didn't need to worry. The first primip sitch turned into a nightmare and she wasn't gonna deliver anytime soon.
To Be Continued...
Tuesday, December 1, 2009
I was on my way to see New Moon with my mother and daughter when we came across this situation. We kinda looked at each other and looked around the parking lot. No momma in sight. We decided we had to do something, but not really sure what. Then we saw a woman come out of Starbucks and thought maybe she was the owner...nope, different vehicle. I finally told my mother to go buy the tckets and I would trek across the parking lot to the policeman parked at the empty end of this lot - it was quite a distance and likely would make me miss the beginning of the movie getting involved. But we felt like if something happened to that kid, we could have prevented it buy intervening. Then we saw momma come out and unlock the car with her keyless entry.
Hey, at least she didn't leave the keys in the car with the kid!
Tuesday, November 24, 2009
I got called in for a delivery in the wee hours of the morning. She delivered before I could get there....fast! She was 6-7cms, second baby, when she arrived. 20 minutes later...done. I got to do the placenta...what fun.
I was ticked because one of the MAs screwed up a patient's 24 hour urine. Only creatinine was ordered on it. Are you serious? Now why do you think that we might dip a hypertensive patients' urine for protein but only check her 24 hour urine for creatinine?
I got a call from my favorite nut....she's had a lot of GI issues but the GI doc won't see her because she's pregnant. What a big f*ckin' help. Anyway, she calls to let me know she's been vomiting all day. She wanted advice. Uh, go to triage for IV fluids and zofran. It's not like the first time this has happened. You know what you need to do. Why are you calling me first?
I'm looking forward to Thanksgiving and Christmas. Especially Christmas as it involves a vacation of 9 days! Woohoo. I need it. Its been since June since my last vaca...I'm burning out!
Thursday, November 19, 2009
Me: How was class?
Husband: We talked about _____ and it was really interesting. The teacher said that....wah wah wah, wah wah wah. Wah, wah, wah.....
Me: Wait, what?
Here's a conversation I had with my mother...
Me: What's been going on at work?
Mom: It's been crazy. The VP is back from Japan and on a warpath. She wah wah wah, wah wah wah. Then wah wah wah.
And here's one with a patient recently....
Me: So what seems to be the problem today?
Patient: Well, I have all this bleeding. And then I have this pain. And I want to change birth control. And....so on and so forth
Me: Wait, one thing at a time....and let me get this stuff written done.
See a trend?
So, I manage to restrain myself from laughing. I explain to this less than bright star that she has to take the pills in order and no wonder she's having the issues she's having. We have a very careful lesson on how to use birth control pills and I get her all set up and send on her way.
I had lots of babies show up during the day but nothing during the night, which was nice. I had one little hispanic lady come in. Her last baby was thirteen years ago and was supposedly 4500 grams...which is around 9-14 I believe. He baby before that was 4000 grams, or about 8-13 I think. Nothing in the chart about shoulder dystocia or any problems with those deliveries. She comes in at 6-7cms and doesn't want to move from the bed or want anything for pain. I want to offer her labor support but it just feels weird sitting there so I kinda go make rounds and pop in on her. She has her daughter and her husband with her. She progresses to complete and begins to push spontaneously. And she pushes. It takes her awhile to push well, there's a lot of holding back, but then she throws herself into it. She makes good progress until the head comes out. Then we get a shoulder, which I am able to rotate out from the pubic bone. It turns into a body dystocia, meaning the body is now just stuck in her vaginal canal. We finally get the baby out, who ends up weighing in at 9-1, and doing well after initially being a little stunned. We have a borderline postpartum hemorrhage then everything stabilizes. She's intact aside from a perineal skidmark. Then the daughter says to me "oh yeah that happened with my brother and me when we were born." Hmmm, thanks for the heads up. I almost had a code yellow on this one.
Another patient was a young girl having her first baby at 42 weeks gestation. Things went smoothly, she got an epidural around 4-5cms. She continued to progress well, reaching 10cms shortly before 2pm. She labors down a bit until she feels pressure. We start her pushing at 3pm. At 4pm, she's made a little progress - the caput is descending :p I start thinking of the words of the physician from the day before (he was joking but still) "a 42-week primip? when do you wanna do the section?" I told him, to knock it off, that she would be fine :p So anywhoo, I decide to stop pushing for a bit and let her rest as well as maybe some more laboring down. The baby looks fine and she's comfortable with her epidural. We put her on her side with the peanut for half an hour, then we flip her to the other side. At 5pm, we start pushing again....the head has come down maybe a little during that time but now her pushing efforts are becoming much more effective. After she pushes for 24 minutes, we have beautiful baby weighing in at 8-14 over a second degree perineal lac. Both momma and baby were doing well! I felt tempted to call the doc and let him know we wouldn't be needing his c/s!
Another primip was sent over from the hospital for labor. She progressed well also reaching 10cms shortly after the previous patient, but felt no urge to push so laboring down was the phrase of the day. Once she began to feel pressure, the nurse checked her and says the baby is +2 (station in the pelvis with +3 being crowning). The heart rate is starting to drop with contractions, so I'm all like let's have a baby! The nurse does a few trial pushes and comes out and says she isn't pushing well. So I go in and evaluate....the patient pushes beautifully so tease the nurse for a moment and then we get down to business. Unfortunately, baby doesn't like this part of the process and we start getting some ugly strip. I ask the patient if I can cut an epis (something I have done maybe 6-7 times before - I only reserve it for this kind of scenario!) after explaining why - she says yes. So I cut a very small epis (the equivalent of a first degree lac) with very dull scissors....wow, I was ready to start gnawing on her perineum cuz the scissors were so dull...geez...oh....that sounds gross doesn't it. Anyway, she delivers with the next contraction and no extension of the epis. She has a beautiful baby weighing in at just under 7 pounds, does quite well. I repair what I broke and everyone's happy.
I am frustrated with one of the midwives...I think she's clinically depressed. I think she has a lot of personal issues. Professionally, she's had some tough call to just be starting out with. Not really sure if it's her labor management or just a black cloud following her. I remember when I was new I had a placenta cloud following me. I've tried to extend a hand but she doesn't seem interested in help. I asked her to give me a call when she was done seeing patients because I wanted to let her know what was going on with an antepartum patient so I wouldn't have to call her and wake her in the morning if there was nothing else going on. I also wanted to invite her and her kids over this weekend to hang out. She never called. So I called her and left a message...she never called me back. I'm worried about her well-being. I really hope she will be ok.
Sunday, November 15, 2009
So that call is about par with the one from a nurse at 3 am to let me know that the antibiotics are working and the patient is afebrile (without a temp). Gee, thanks.
The kicker....I was sleeping really well...I mean really well. Like I was achieving restful sleep! Which I haven't see much of these days. Oh well, I did get lots of blogging done :)
Are you serious?
This has very little to do with safety and much to do with preconceived notions of women with tattoos.
*my statments refer to the idiots in the excerpts, NOT Jill!*
What is fibromyalgia?
Fibromyalgia is widespread pain in the muscles and soft tissues above and below the waist and on both sides of the body. Fibromyalgia is a syndrome-a set of symptoms that happen together but do not have a known cause. In this syndrome, the nervous system (nerves, spinal cord, and brain) is not able to control what it feels, so ordinary feelings from your muscles, joints, and soft tissues are experienced as pain. People with fibromyalgia feel pain and/or tenderness even when there is no injury or inflammation.
Fibromyalgia does not harm your muscles, joints, or organs, and there are many things you can do to control it. When it is not controlled, you may not have any energy, or you may feel depressed or have trouble sleeping. These and other symptoms can be bad enough to cause problems with your work and home life. With treatment, most people with fibromyalgia are able to continue working and participating in daily activities. Some people adjust their work duties and lifestyle if their symptoms are severe.
What causes fibromyalgia?
Experts have theories about what may cause fibromyalgia, but there is not enough evidence to support any single cause. Some think that people with fibromyalgia may have nerve cells that are too sensitive. Others think that chemicals in the brain (neurotransmitters) may be out of balance. Or it may be related to problems with the deep phase of sleep.
What are the symptoms?
The main symptom of fibromyalgia is pain in the muscles, soft tissues, back, or neck. Also certain spots on the body hurt when you press directly on them (I have 14 out of 18 - that sucks!). Experts call these tender points, but you may also hear them called trigger points.
Fibromyalgia also causes sleep problems (the past 4 months or so have been rough!) and tiredness.
Less common symptoms include headaches, morning stiffness, trouble concentrating, and irritable bowel syndrome. As with many conditions that cause chronic pain, it is common for people with fibromyalgia to have anxiety and depression. These can make you feel worse. (Also read in a pamphlet from the rheum office that one can experience bladder irritation - check, PMS, PMDD, painful perios - check, acid reflux - check, numbness and tingling sensations - check, dry eyes and/or mouth - check, 'allergies' - check)
Fibromyalgia is a long-lasting (chronic) condition with no cure. Symptoms tend to come and go. You may have times when you hurt more, followed by times when symptoms happen less often, hurt less, or are absent (remissions).
Some people find that their symptoms are worse in cold and damp weather, during times of stress, or when they try to do too much.
How is fibromyalgia diagnosed?
Doctors can find out if you have fibromyalgia based on two things. One is widespread pain, which means the pain is on both sides of your body above and below the waist. The other is tenderness in at least 11 of 18 points when they are pressed. Your doctor will also take steps to be sure you don't have other conditions that cause pain, such as rheumatoid arthritis, polymyalgia rheumatica, systemic lupus erythematosus, or other autoimmune diseases.
How is Fibromyalgia treated?
You may be able to control your symptoms with regular exercise and by finding better ways to handle stress. Good sleep habits are very important, too. If you have trouble sleeping, changes to your routine, schedule, and sleep surroundings can help. Counseling can help you cope with long-term (chronic) pain.
If your symptoms are troublesome, your doctor can prescribe medicines that help you feel better.
Symptoms of depression, such as a loss of interest in things you usually enjoy or changes in eating and sleeping habits, can often be successfully treated if you tell your doctor about them.
Some people with fibromyalgia also find complementary therapies helpful. These include acupuncture, massage, behavioral therapy, and relaxation techniques.
My counseling of women with depression typically involves a discussion of SSRIs and third trimester use. Prior to reading this article, my discussion focused on neonatal risks. I was not aware of the possibility of preterm birth, lower 5 minute apgars, or increased risk for NICU admission.
The problem of access to mental health services is a huge one in this country and where I live. Patients without private insurance must call Magellan themselves (which is an issue sometimes - when your depressed, who wants to pick up the phone when all seems hopeless?), then they often get to wait up to 2 months for services! Once they have their initial appointment, they often are put into group therapy while being on a waitlist for one-on-one therapy. But they also get their meds managed. My personal preference is to start someone ona SSRI and then have mental health take over management of that.
We do need to carefully weigh the benefit to the mother against the risk to the fetus/neonate. This article seems to imply that as well as being in favor of the well-being of the baby as a priority. This is a slippery slope - and a source of much controversy in general - to consider that the well-being of the baby may be more important than the well-being of the mother. In a perfect world, where patients could easily get access to counseling and other forms of therapy, it would be easier to say "ok, let's not use SSRIs until baby comes". Research shows that patients will benefit from both counseling and med therapy. But the reality is that with resources severely limited, sometimes SSRIs are the only tool we have.
Saturday, November 14, 2009
Lately I feel like a failure as a midwife. It seems like I have these occasional spells where things seem to go wrong a lot. I begin to wonder if it's me, maybe I suck. That's a really uncomfortable feeling. I also start to worry that maybe my mental clarity is not so hot. Guess that can be due to fibro. But really, when I look at whatever has happened, it seems like I made the appropriate actions but yet, just feel like I still screwed up anyway.
For example...I saw a patient quite some time ago. The patient had a reactive RPR but a negative TPPA. So that means she doesn't have syphilis. I let the patient go but chased down a doc when I had a chance later that day. I asked him if I needed to be concerned and do anything further regarding the labs. He said no, just find out if she has previously had syphilis and been treated. I figured this patient, who was a doc patient, would be ok til her next visit. We could check on it then. Maybe this is the part where I was stupid? I should have called her at her home. And I didn't document that conversation. That was definitely stupid. Anyway, so another doc sees the patient and is concerned as to why we haven't 'done anything' prior to now. She wants to send the patient to the perinatologist. I related my conversation with the previous doc and apologize for not having called the patient back at that time to further ascertain what may have caused her RPR to be reactive. But she seemed perturbed.
Causes of RPR being reactive (other than syphilis) - pregnancy, connective tissue disease, bacterial or viral infections, advanced cancer, myeloma. There may have been a couple other things but can't remember now.
Thursday, November 12, 2009
I only caught one baby on my last call. And it was in the evening so I ain't complaining considering how crappy I have gone back to feeling since Tuesday afternoon. This particular patient, I had seen a couple times with this pregnancy and also with her pregnancy last year. She came in to L&D and was 4cms and requesting an epidural. I was at the office seeing patients so gave orders for that and said I was almost done and would be over shortly. I expected that she would have an epidural by the time I got there. Uh, no. Apparently there was a section going on and they were just finishing up. I checked her and found her to be 7/90/-1 with a BBOW. I asked her if she was sure she wanted an epidural and she was very sure! She finally got her epidural, we put her on her side to rest, and anticipated a baby soon. I was kinda hoping to make it to her second dose of antibiotics but didn't really think we would. But alas, we got close to the time so decided to break her water as her contractions were spacing out . Although, sometimes when putting a women on her side, the contractions may space out but they become stronger. However, she also wanted to get the labor over with.
I checked and she was 9/100/-1 with a very BBOW. I broke her water and figured we would have a baby very soon....and we did. She felt pushy about 20 minutes later and was complete. So she started pushing. It took her about ten minutes to get the hang of pushing again, then she moved that baby right on out. She was kinda in a squatting position....she was holding the nurse and her husband's hand to pull herself almost upright. This was very effective for her. I kinda wish we had had time to get the birth bar out for her but she was gonna deliver without it anyway. She delivered over just a small perineal ding and it was her smallest baby yet! I had told her that the baby looked small earlier in the night, maybe 7 pounds. She said "that's what you said last time and he was 7-11!" This baby was 7-2. I rock.
I admitted someone about 2:30am but no need to go in as she was a primip and wanting an epidural at 3cms (SROM). That's unusal that that happens to me! Typically if patients come in around that time, they are going natural or are a primip and 6cms who might deliver prior to 7am or etc. All of these scenarios would require me to go in. When I checked back this morning she was 4cms with spacey contractions (probably because of the epidural) so I started a little pit, then handed off to the next midwife.
Speaking of the next midwife...While I was hanging out waiting on my lady to deliver, this midwife had a personal patient of hers come in. So you would think "cool, I don't have to manage this patient and potentially be here all night - yah!" But this midwife has health issues so if she doesn't get enough rest, she ends up needing to go home to bed. Twice before she has asked me to take over in the middle of labor. Both times, they were personal patients of hers, and both were having natural childbirth so needed labor support. This left me in the awkward position of having to step in during very active, almost transitional, labor for both. Not cool. It's not fair to the patient or to me. I had never met thses women before even. Fortunately her patient this time was 9cms when she arrived and it was her 5th baby I think. So it didn't take long. But imo, either commit or don't....just plan to follow through. What I mean is...if you know you are tired or that the patient is earlier in labor and it's night time then maybe don't come at all. If you agree to come, then stay. And if you can't do that, then maybe you shouldn't be committing to patients like that. If someone comes in that is a personal patient of mine....if I agree to come in for her at that time then I consider that a committment that I will foloow her until she delivers, no matter how long that might take.
There's a doc who drives a mercedes...red....license tag says 'empuje'. He's a funny guy. Until he parked in the CNM parking spot instead of one of the many open OB spots. There are only two CNM spots....and they are compact spots. My car is not huge but nor is it a compact car. But because he didn't want to park ten feet further away, he parked in the CNM spot. Seriously. The neos have done this as well, on occasion. But it's worse because one of them drives a SUV. Geez. I have parked in the OB spot before because of either someone's big a$$ SUV or crappy parking job in the CNM spots. I ain't shy.
Tuesday, November 10, 2009
I was in the office and encountered some interesting and fun patients.
I have a lady who's first baby I caught last year and I am now seeing with her second child. I am eagerly looking forward to catching this baby! She brought her daughter with her, who I have not seen since her birth. She's adorable and so big! We always have a good time cutting up.
I have another lady who is pregnant with her third. She's a doll...she has RA so she and I have bonded over rheum issues :p I am hoping to catch her baby as well.
I saw a teen who has bipolar, history of substance abuse (currently smokes pot to avoid doing meth I guess), and smokes. This was my first time meeting her. She had her mother and boyfriend with her. I asked if this was his baby...was actually joking with him...he answered no then she did also. I hesitated because I thought they were joking back. Uh no. It's not his. Ooookay. Anyway, she has this fabulous bubbly personality :) I had to give her an Rx for her BV that showed up on a pap and culture done by the NP. But frankly, I didn't need the labs to make a diagnosis. I could have done it when I walked in the room. I had a flashback and thought I was at the beach. Seriously. You didn't notice that anyone????
I had another teen who I wanted to smack. I normally do quite well with teens but this one wouldn't look me in the eye, kept looking at her teen sister and giggling. Her mother would answer questions for her, even when I had my back to her and was facing the patient when I asked. The mother answered when I asked if the baby was moving lots... Uh, last time I checked mom, you weren't the pregnant 16-year-old. The patient got smartass with me when I tried to counsel her on her diet and weight gain. She flat out told me that she eats nothing but junk. I suggested some reasonable substitutes and just cutting back on the junk. She just kept giving me lip, so I just gave it right back to her. Betcha I won't see her again....until she shows up in labor as my luck would likely have it.
Saw a couple of new OBs, one of which is the sister of another patient of mine :)
Sadder news...The rheum said I have fibromyalgia along with whatever arthritic disorder I have. I wasn't hugely surprised as i suspected this was coming. But it's still a bit of an adjustment. Then, after feeling pretty decent all weekend (aside from the usual lack of sleep), I started feeling pretty crappy this afternoon to be topped off by falling about a half an hour ago. I am feeling supercrappy now. The arm of the chair practically went up my butt when it flipped out from under me.
Monday, November 9, 2009
Anyway, the patient returned with her water broke this time. She was 3cms on arrival. So we got ready to have a baby. She wanted an epidural which she got. A touch of pitocin and she delivered a short time later. Fortunately the baby came out looking more like a 36 weeker and was breastfeeding very well. She'll go home with her momma after all. And hoepfully not live with her for the rest of her momma's life. LOL!
I had another patient who I took over on and was not real happy with the management. The midwife on call never came in during the night to do labor support. The pateint had been there since late evening and had 4 doses of stadol at that time. Her labor was essentially stalled by the time I arrive that morning. She was 7-8cms. After trying everything possible and suspecting that the baby was too big and OP to boot, we sectioned her. It was totally the right call....the baby was straight OP and 8-3. Her pelvis was so little there was no way that kid was coming out of there. The doc on call (from another practice) was a little crabby when I updated him on the phone - he couldn't understand why I had waited so long to call for a section. Uh, well cause the baby looks fine and I wanted to give her every opportunity to deliver vaginally. There have been many times where other providers would have cut a patient but because we midwives understand that not every labor goes by Friedman's curve, we have gotten a vag delivery.
I had another patient who precipted (sp) - she rolled in the door and was 6-7 cms, delivered less than an hour later. She was so mad at me and th enurse because we wouldn't give any Stadol (I was willing to give her some but she delivered by the time the pharmacy had it in the system so just as well). I felt so bad because she was looking at us with these pleading eyes. Afterwards, it took her a while to smile at us (she was spanish-speaking). She did a beautiful job though pushing a big baby out!
I had a woman come in sorta in labor recently. She was having her second baby, but it had been quite some time since the first. I had seen her in the office a couple times and we had hit it off. She's absolutely gorgeous, very intelligent, but has a husband who sounds like a bit of an a$$. From what she was telling me, he has a bit of Peter Pan syndrome going on!
Anywhoo, she came in and was initially 3/60/-2, contracting regularly. Her plans were for natural childbirth. Her first labor had only been four hours, but again, was quite some time ago. I think she had some expectations that this labor would be just as quick if not faster. I had warned her that while that might happen, not to pin her hopes on it.
The nurse sent her out walking for an hour or so, and when she returned she was 4/70/-2. So I kept her. And it was downhill from there! Well, ok, maybe not quite that bad. But it sure wasn't a smooth labor. I had the nurse send her out walking again until I could get over there from the office. Once I arrived she was alternating some walking with resting on the birth ball. She had a goofy friend with her who was very ....manic almost. She was sweet but driving me nuts and I felt like she was throwing off the vibe in the room. I really love a quiet, calm atmosphere. I realize that not every patient wants or needs that but most do. This chick was almost bouncing off the walls with excitement. And the patient was starting to feel irritated as well (shge mentioned to the nurse that she hoped her friend would go soon). The husband wasn't there, and my patient wasn't sure that she was gonna tell him yet that she was at the hospital. I was a little concerned by that as well, as I feel like the patient was anxious about how things were going to go.
I was thinking to myself 'great, what other issues can we drag into this room?' OH, and she has a history of sexual trauma. *sigh* I'm feeling those instincts kick in. Oh, and the baby was doing some strange things on the monitor. The strip would look fabulous then would do funky things. Not bad, just odd. Some of it was dehydration - she admitted to having drank very little that day and reported feeling much better with IV and oral hydration. The baby straightened out a little better as well. But there were still some oddities about the strip. I was still comfortable enough to get her off the monitor though.
After a couple hours went by, we re-checked her and she had not changed. I offered her three options...1. Go home (although due to the oddities in the heartrate I was a little uncomfy with this one), 2. Break water in the hopes of getting things going, 3. Do nothing and just wait. She opted for #2 so I broke her water and sent her out walking again. We both thought she would take off at this point.
She walked for a bit, then used the ball while I rubbed her back, then rested for a bit. Time went by. By this time, her husband was there and was being a great support person. I was very pleased - he wanted to be very hands-on so I had him rubbing her back, etc. My arthritic hands can't take massage too long! Around midnight I decide to check her as she doesn't look like she is doing much. She's 5/80/-2. Great. 1cm in three hours. Not promising. I decide to go lay down for a bit.
Two hours later, feeling a little refreshed, I recheck her. She really seems to be in the same place when I watch her. That makes me nervous. And I am correct...she hasn't changed. Crap. I discuss options with her...#1 augment with pitocin or #2 continue with position changes, walking, etc. I know this isn't a big baby. Her last was 6 pounds and I really don't think this one is much bigger than that. Can't really tell what position the baby is in but believe it's not OP. Her contraction pattern and where she's feeling the most discomfort support that as well. Byt his time, I am starting to think I screwed up and should have just sent her home when she didn't change at 4cms. But oh well, now we are committed. She wants to wait a little longer before starting pit so I encourage her to try some different things. She's getting tired, which always concerns me. Her contractions are spacing out a bit.
A couple more hours goes by...minimal change in the cervical exam, maybe 5-6cms now. She and her husband are now agreeable to pit so we get it started. It starts to work very quickly and I can see the change in her behavior. The husband, nurse, and I continue to do labor support. She decides she wants some IV pain meds, of which she gets two doses before she delivers. She starts to move along nicely. Time goes by and she wants to be checked...she's 8/90/-1 - woohoo! She really starts to zip. Soon she is spontaneous bearing down so I re-check to find her 9.5cms but the last little bit of cervix is very soft and will retract easily if she just pushes with a few grunty pushes, which she does. Then it's gone and I tell her to push however she wants. She goes full force and births a beautiful little baby (and I do mean little - 5-12) in five minutes over an intact bottom. The baby has asynclitic molding...meaning the head was in her pelvis cock-eyed which was the cause of the long, drawn out labor!
Afterwards we chatted for a few minutes before I went home exhausted to my bed. She said she was thinking of asking for an epidural but thought it would be too late. I told her that it wouldn't have been, and I wouldn't have offered it to her though. My general philosophy is that if you want it, you have to ask for it. It's rare for me to offer it because I know how I was when I was having babies. I would never ask for one but when it was offered to me I took it (when I was asked in the midst of a contraction no less!). I'm very glad she delivered half an hour prior to the end of call because I had promised her I would stay until she delivered and I was f*ckin' tired!
Other random stuff...
My husband has been getting on my nerves a little lately - he hasn't been doing much at all around the house and it's p*ssing me off. I feel like I shouldn't have to do a lot of cleaning when I work all these hours. I think he should be responsible for making sure the kids don't tear up the house. We just might have to have a little talk...
I have the rheumatology appointment today. Finally. It's only been two months....geez. I hope that the fact she is so busy is a good sign. It's been a rough couple months for me with these pains, fatigue, and low-grade fevers. I hope to find out what the heck is going on and how we can go about fixing it. I would like to get to feeling better so I can start exercising and making some other changes for my health. My BFF has been very inspirational! Smoking has been gone now for 2 and a half months.
I recently had a killer hormonal migraine alomng with a sinus infection. I'm not a wuss when it comes to pain. I live with it daily and have a fairly high tolerance. But this was the worst headache I have ever had. I was in a tears a couple times because it just wouldn't stop. I was taking vicodin and tylenol with no relief. Finally, after a day and a half, I had my hsuband take me to the urgent care center where I was given toradol IM and some zofran (I was nauseated), which worked beautifully. Time to change my birth control pills! I've only had these headaches since being on YAZ. I hate to give it up because it works so well for my other issues but the headaches and the fact that my sex drive is in the toilet are just not worth it anymore. I'm gonna give Loestrin a try.
Now that you know so way intimate stuff about me, what else can I tell you?
Friday, October 30, 2009
Check out Labor Nurse, CNM's post on her blog ReBirth....
I've had these issues as you all know....you can review my trials and tribulations of poor nursing care in this post about Nurse Sucky, and this post about Nurse Crappy.
I'm not alone!
Saturday, October 24, 2009
18-year-old multip who has class B diabetes and hypertension - she was being induced for these reasons at 38 weeks. Trust me, that baby needed to come out...much safer out than in as momma was very non-compliant (I hate that term but appropriate in this case). She had been on insulin prior to getting pregnant. They stopped the insulin when she got pregnant and she was to do diet and exercise. I thought that sounded a little odd but whatever. She came to us late in the pregnancy because she didn't like the care she was getting from her previous doctors. Or perhaps they wanted her to do things like eat right, monitoring, etc. Low and behold, we asked the same thing. She would apparently just not show up for NSTs and things of that nature. She also comes with an overbearing mother. Her mother is very much focused on looking like someone who knows something about everything. When I met her on L&D, she informed me that her daughter has diabetes and htn....uh yeah, I kinda got that from her H&P, from the midwife who scheduled the induction. And that might be why we are checking her blood sugars periodically and told her she could only order certain foods from the menu. How's that for a clue. The mother than proceeds to ask me all kinds of questions such as...
- Shouldn't she have the baby 2 hours after water breaks?
- Won't she have a dry birth?
- I've seen a baby with a rash because the water was broke for 6 hours (huh?)
- They'll start with a low dose for the epidural right?
- It goes in the spine right?
And on and on in that vein. The patron saint of patience must have been by my side as I answered all her questions that had nothing to do with the real concerns (a wbc over 17, baby sky high for even a multip, etc). And it isn't like I broke her water, it was spontaneous.
A patient came in through triage, after being seen in the office by the nurse practitioner. Her first visit with us was at 27 weeks. Then she disappeared. Now she's 36 weeks, contracting, blood pressure is up - lovely. Who needs that silly ole prenatal care - blood pressure issues are no big deal!
Another patient unfortunately had to have a c/s for CPD (this is actually a rare diagnosis - it gets tossed around a lot though). The baby was in the 9-pounder range, momma was a very large lady with a smaller pelvis :( Bad combo and unfortunate for her. We tried everything we could think of to get her dilating better and get some descent of that head, but nothing was working.
I have a momma in the office who stinks of cigarette smoke and has some very strange dreams about chihuahuas.
I have to start taking notes on things I want to blog about. I'll be thinking 'oh, I need to share this, this is good!' But now I can't remember a d*mn thing!
Friday, October 23, 2009
We have some paranormal activity in our house. Sometimes I see figures of little children at my bedside. They usually are whining and wanting to get in the bed. Nothing seems to make them go away...even closing my eyes and trying to go back to sleep. I sometimes am bitten while lying in my bed...even in the daylight! After the cat bites me, she seems to magically fly across the room. I hear voices late at night - in the form of sportscasters. My husband apparently can't hear the voices.
After watching the movie, I told my friend that the first time I found out that my husband was standing over me for two hours watching me sleep...his a$$ would have been gone! Anyone who knows their scary movies, knows that's a set-up for disaster! Course one might deserve what they got for pulling the stupid sh*t that the boyfriend was pulling!
Anyway, go see it!
Monday, October 19, 2009
I found it really interesting to hear from a SAH mom who was very outspoken about her belief that women who have children and work are selfish. She stated that "if you don't have time for children, then maybe you shouldn't be having them". I would actually agree with that statement but not in the context in which she made it. She's implying that any woman who works, couldn't possibly have time to spend with her children. That a woman who works could not contribute to the health and well-being of a child. That a woman who works couldn't possibly raise a wonderful human being.
Yes, this lady was really opinionated. In fact another SAH mom stood up and said that "she does not speak for all of us!".
In general, it seemed that the SAH moms were more likely to be judgemental about working moms. I did not hear any judgements made towards women who choose to stay home. I understand that SAH moms are often undervalued. Working in the home is a career like any other. But I wonder where that defensiveness comes from. Perhaps SAH moms have had to spend so much time justifying their choice, they opt to criticize those who made a different choice.
Dr Phil mentioned some interesting statistics that over a lifetime working moms will spend 80% of the time that SAH moms do with their children. He also mentioned that children who had working moms and were in quality daycare (quality being a key word) were more likely to score higher on school readiness tests, have higher vocab, social skills, etc.
Women raising children are very likely to raise children in their values and traditions. Some women value their children above all else, including themselves. The SAH moms seem to feel that raising their children is the most important thing in their life. I can respect that.
But it's not the most important thing in my life. It's one of the most important things in my life. But my life as a woman and a human being does not begin and end with my children. I had a life before they arrived and I will continue to have a life after they grow up and move on to their own lives. I am not the type of woman who can give up myself for my children. Maybe that does make me selfish in some eyes. I like to think it makes me a better person for my children, my husband, and those around me. Because I could not be a happy person as a SAH mom. I would go insane and might take that out on my family! I love my job and am very passionate about it. Do I feel guilty at times? Sure I do. Being a midwife isn't always an easy career when you have children. But I contribute to society in a very valuable way. I also think that I contribute to my children's health and well-being. I am raising my daughters especially to be strong, beautiful women who can do whatever they want in life.
I also like to think of the women who were working moms who made huge changes throughout our history. What would one say to some of these women? You should have stayed home with your kids instead of fighting for civil rights, for freedom, for healthcare, etc. The world would be a better place had you done that. Yeah, not so much!
I really do have respect for women who choose to stay at home and make child-rearing their top priority. Not all of us can afford or choose that though. We women need to stick together and hold motherhood up, in all its forms, as a tough job and one to be greatly valued.
Saturday, October 17, 2009
- I had to give bad news to an adorable couple, who I was very excited to see pregnant as she is the sister of another of my patients. She was in the process of miscarrying :(
- I saw a patient postpartum, who's baby I caught. She's doing very well with breastfeeding and looks great. The baby is beautiful of course. Her and her husbadn had given me a wonderful thank you card, an announcement, and a gift card - suuuweet! I love cards and gifts - they certainly aren't necessary - but are always very appreciated :p
- I spoke with my favorite nut. She's the sister of a friend of mine. This friend (I sometimes have to question how much a friend she is!) sent her sister to me with the warning that she was a nut. She has mental health issues but manages them pretty well, goes to school full-time as does her partner, has a great dry sense of humor. She can drive me crazy but I admire her for being a pretty tough cookie. Anyhoo, she had been in the hospital with pain issues r/t GI issues (intentionally being vague). We were medicating her, hydrating her, and trying to figure out everything wrong with her....physically anyway. The midwife on call went to see her then came to the office and proceeded to tell me how they did a UDS on her and maybe she's a drug addict and why are we drugging this baby and why aren't the docs managing her blah blah blah. This is Ms. It's-Not-About-Us,-But-About-the-Patients. We could also call her Ms. Holier-Than-Thou. She really was p*ssing me off because of her attitude. This is 'my' patient, quit dogging her out. She may be a nut but she ain't a drug addict just because she has mental health issues. I pointed out that we had been seeing this patient since 5 weeks pregnant and not once had she presented with a complaint or request for pain meds. And she's more than halfway through the pregnancy. Back off B*tch! Anyway, she talked to one of the docs to decide what to do with her as the surgeon said no surgery and apparently the GI doc talked to the surgeon and decided he didn't need to come see her?????!!!!! WTF???? Our doc said send her home for the weekend and then refer her to the perinatologist. WTF??? Why? This is totally non-pregnant related. She needs the GI consult. So guess what I'm gonna do when I see her next week? Off to the GI doc.
- I think I only said drink more water twice on one office day.
- I saw a lady for what was supposed to be a new OB but apparently she had miscarried a couple days prior. She came for her appointment anyway. I sussed out the sitch and it sounded like everything was proceeding appropriately. We discussed grief. We talked about trying again and timing for that. I suggested bringing her back for a WWE in a couple weeks. She declined for religious reasons. She told me that she didn't do paps and would return when she was pregnant. Ok. Whatever. I can respect that as long a woman understands the risks and benefits of testing. I am no longer 'shocked' by out of the ordinary preferences. I'm growing so much :) Not just my a$$ either.
- I saw a doctor patient (because I apparently had a slot open) who was around 29weeks complaining of low pressure, white discharge, peeing frequently, and not feeling the baby move as much for several days. It's her third baby. Um. ok. So I evaluate - lots of fluid in the vaginal vault. Did you have intercourse recently? Yep, the night before. Well, there ya go! No ROM. I explain about common discomforts of pregnancy...i.e. does it feel like the baby is going to fall out when you walk. She looks at me with shock and says yes. As if she is amazed that I know what she is talking about. I explain about pelvic floor muscles and multiple pregnancies. I put her on the monitor. Looks gorgeous. Lots of "contractions" - you know...every 30 seconds, very jagged looking. You labor nurses and midwives know what I'm getting at. Fake contractions! I palpated...not a dayum thing! Go home hun...chill. Come see your doctor next week and drive him crazy..I have enough pain-in-the-a$$es of my own.
- I saw a young patient who had HELLP syndrome with her last pregnancy. She complained about having to stay in the hospital for a week after the birth, being induced, etc. She's really looking forward to doing things her way this time. I said, "If all is well, we do it your way. If all is not well, we do it our way". I hope we get to do it her way!
- I saw a new OB, who is late in the pregnancy and a nut. She has schizo among other issues. I use the term 'nut' affectionately (so don't flame me, I have mentally ill people in my family and I just might be one of em!). This one was hospitalized at the beginning of the pregnancy for trying to kill herself. Her other baby died a couple months out from accidental ayphixia. And she laughed when talking about it. She said she worried that it was her fault for having the blanket in the crib. And laughed. I understand that it was likely r/t her mental status and meds but it was still creepy. It happened last year. Can anyone say social services?
Wednesday, October 14, 2009
I caught a baby for the doc - it was a woman having her third baby. She did an amazing job at pushing out her baby and I got to use my fav spanish saying - "Si, se puerdo (sp)".
Another baby came very fast in a multip who's water I broke at 4-5cms. She delivered just over an hour later and it was so cool. She squatted and pushed the baby out with her arms wrapped around my shoulders, which meant I couldn't see as my face was in her chest....glad she was wearing a bra or I would have been breastfeeding! LOL! I had one hand underneath the baby's head and just felt the baby being born into my hand. I wish more women would birth out of the darn bed! I was so high after that birth...and it was her first natural birth as she had gotten epidurals with her two previous pregnancies then delivered half an hour later.
The third birth was in a patient who had some BP concerns so we were inducing her - second attempt. This would be her second baby, the first weighing at 9-6! I had sent her home a few days previously as cytotec had not worked to ripen her cervix, her labs, were normal, and her BPs weren't too bad. But then she started getting yucky with the BPs again so another midwife put in a foley bulb and had her come in in the morning for pitocin. Her bulb had fallen out during the night so she was 3-4/60/-2. I waited until she had been on the pit for awhile and was starting to feel crampy, then broke her water. She was 4/70/-2 at that point. She got an epidural shortly thereafter (which was her plan from the gitgo). The nurse checked her while I was finishing the previous delivery and she was 10/100/0! She moved along quickly once she got going. What ended up being so surprising about how fast she moved and only fifteen minutes of pushing was that her first baby was 10 years ago, this baby was good-sized at 8-9, and was OP! I was totally caught off guard when I saw this baby's face looking up at me, batting his eyes :)
I went home to sleep but then had to go back as two grand multips came in...neither of which delivered by morning :p
I had a stalker as well....the dayshift postpartum nurse called and paged me a minimum of 12 times in a 12 hour shift. Mostly for stupid sh*t. It was so aggravating as she seems dumber than a box of rocks. I tried to be past but frankly, it was all I could do to not be mean. Example of one conversation...
Me : Stop calling me on my cell phone and at the office, I'm trying to see patients. I don't have my cell phone on me anyway. Page me first.
RN: I did and waited an hour, you didn't call me back.
Me: You didn't page me correctly, my pager never went off. I know it's working because I just got a page from L&D - they seem to manage to get ahold of me the appropriate way.
RN: Oh, sorry.
What was she calling for this particular time? To let me know that the surgical consult wasn't going to happen until tomorrow and the patient needed to be admitted instead of 23 hour obs. That's reasonable right? Well, I had spoke to her an hour and a half previously about the patient's admission - I told her I would come by after office hours to write orders. Seriously, why are you calling me again.....arrrggghh!
Monday, October 12, 2009
I get a call from a patient (#6) who has been harassing us to induce her since 37 weeks. Because she has big babies. That's her reasoning. Oh, and she's dilated 4-5cms and keeps getting sent home from the hospital. She knows she's 4-5cms because she checks herself. And the baby's head is low and the membranes are bulging. I'm amazed and impressed as it takes most labor nurses a minimum of 6 months of practice to get this skill down. wow. In reality, she's 3-4 and the head is -2 per one of the midwives in the office last week. Her biggest babe was 10 lbs. This one isn't that big. But she's now almost 39 weeks and calling me to let me know how uncomfortable she is. I've spent more time on the phone with this patient then I do with my mother! I tell her to come in and I will see what I can do for her. When she arrives, she's actually really 4-5cms so I send her out walking while we wait for a bed to become available for her.
Patient #5 arrives...she's truly a pre-eclamptic. While BPs aren't too bad 140's over 80-90's, her labs have changed significantly in two days' time. Her cervix has also changed a little since the day before to 3-4/60/-3. So I chat with the doc and she agrees that now is the time to have a baby. It's her fourth so ought to go fairly smoothly. I decide to do some cytotec first to get her cervix really really ready....I also wasn't planning on starting an induction this late in the afternoon if it wasn't truly critical.
So I now have one delivered patient and 5 in the works. Oh, I'm lovin' life at this point!
Patient #6 progresses rapidly (it's her 5th kid) after I break her water. She gets one dose of Stadol and pushes out an adorable baby weighing in at 7-10. Not bad, she was very well controlled and did a great job. Had some placenta issues requiring the doc to come in (who was laready in the building at least) - that was the only down side.
It's time to focus on #1. She had gotten an epidural so I broke her water earlier in the afternoon. She was 4/100/-2 at that point, with some caput bulging through the cervix! Naturally, her contractions start to space out. That's about typical for how my weekend is going. So eventually I had started pitocin. When I finally went to see her again almost four hours later, I asked her if her nurse had been changing her position, because she was in the same position I had left her in. This particular nurse, we'll call her Nurse Sucky, spends lots of time charting...at the nurse's station or if she is absolutely required to be in a patient's room...ya know, like, for delivery....she starts through the whole darn delivery. Drives me insane because she pays no attention to what's going on...ya know....like fetal heart tones....shoulder dystocia in progress, etc. Nurse Sucky had not moved the patient a single time! I promptly change the patient's position and mention turning the pit up as if we might want to have a baby *dripping sarcasm here*. It's just about shift change and I have requested one of my fav night shift RNs, Beetus, to take over. I ask Nurse Sucky what the patient's most recent temp was as the baby was a little tachy and the patient had felt a little warm, not to mention her heart rate was a little tachy as well. Nurse Sucky says "I haven't checked recently, let me go do that now". Yes, go do that. I know good and well, that she probably hadn't checked one at all this shift! I look it up and low and behold she had....at 8am, almost 12 hours previously. WTF???
Nurse Sucky comes out and tells me it's 98.5...really? I'm surprised. I decide to go check her (vag exam #3 since breaking water - including the exam when I broke her water) and she's now 8/100/-1 but the caput and molding are lower. This kid is trying to come before she's completely dilated...strange. Plus she's feeling some pressure soon thereafter and is 9cms. Then we get stuck. We have adequate labor (I put in an IUPC at one point) but I know we are running out of time. Baby is looking ok but less and less happy with the process. We spend about 3 hours at 9 then 9 and a half, then a very persistent anterior lip. We change positions frequently, use the peanut, etc. The patient is pushing involuntarily the last hour and a half of that. The lip just would not go away...but the baby wanted to come...the head kept moving down. Finally I call it...call for a section but I put her into one last position - all the way on her right side with the HOB flat. I tell her I will check her one more time before we move to the OR. She's still pushing involunatrily with each contraction, despite repeated boluses on the epidural.
I check her before we get ready to move....the lip is still there but much smaller and a little further back on the head (the caput is just about crowning at this point!) so I have her push while I successfully reduce the lip. I'm so excited - she's gonna do it! I tell everyone to hold on the section and instead she delivers her baby after pushing for fifteen minutes. I did cut a small epis (the equivalent of a first degree perineal lac) due to the heart rate issues and long crowning. Baby came out kicking and screaming with a helluva lopsided molded head! Asyncliticism was the culprit for the cervix not going away. It was all very unusual because if the head is asynclitic then you usually don't get much descent of the head. It also goes to show how inaccurate non-reassuring fetal heart tones are on EFM - as the evidence tells us. But it's still very difficult to wait out a bad strip. This is another prime example of why it's bad to be induced and get epidurals sometimes. Because then you are obligated to use EFM.
Anyway, Beetus and I were very happy that she had a vag delivery. I don't think the patient truly appreciates how close she was to a section. Most OBs would have cut her long before I made the decision to do so.
Patients #2,3, and 5 are all quiet. Patient #2 was on cytotec at this point. I had stopped her pit that morning when I cam in and discovered she was NOT 4cms truly. The foley bulb must not have been all the way through her cervix. Her external os was 4 but the internal os was 1cm! So, I go home to get four hours of sleep...
...when the nurse of patient #2 calls to say she's 9cms and I need you to come. WTF??? Naturally I missed the delivery (it was her third baby). Instead the doc happened to be in house for another delivery so she caught. I was p*ssed. Turns out the nurse had checked her earlier in the night to discover she was 4, then 5 cms. She should have called me at that point. I was so mad. But I know she was just trying to let me sleep. But I told her, it's my job to be there...especially when they are planning natural childbirth!
Patient #3 and 5 are quiet so I round on postpartum and go home to take a nap. Once the pager quieted down anyway! I slept for about 2 and a half hours. I called up to L&D to see what's going on...patient #5 is 5cms but not really feeling them, says Nurse Newbie. Ok, I decide to run to the grocery store then will head to the hospital. Naturally, I get a call from Nurse Newbie an hour later....#5 is 8cms with a bulgy bag and pushy. Greeeaaatttt. I go like a bat out of hell and miss it by 2 minutes. F*ck. Apparently she did a fab job though :)
Patient #3 is all that's left and she continues to do nothing after 4 does of oral cytotec, 2 cervidils. So, cervidil #3 goes in and I leave her for the midwife who left all this for me Friday :p But I'm back on call tomorrow....I bet she's still pregnant.
Friday night I got to stay home even though I had 4 patients admitted at the hospital. I went to the WNBA championship game with Beetus and my older daughter, who really likes basketball. It rocked - we had such a great time, even though the hospital kept calling and paging me. I had told them that I would be unavailable except for emergencies and deliveries until halftime and the end of the game. But naturally, that message didn't make it around to everyone. The game rocked, with our team winning :) I was so exhausted though. I am in the midst of a rough week of call. I had just finished call at 7am Friday morning, only to be back on at 5pm for the weekend. By the end of the game I had such a bad headache, and my neck and shoulders were killing me.
As we leave the game, I get a call that one of the four patients, who is there for an elective induction (grumble - the patient was insistent that she was in labor and apparently refused to leave - her cervix was 1/50/-2??!!), had a foley bulb in but it fell out and she's 4cms now and wanting to get in the tub. I'm thinking "f*ck, there goes any chance of sleep". I lay down and finally drift off to sleep about 45 minutes later when another nurse pages me. Dear God, shoot me now. Another patient who is being induced with PO cytotec for GDM, hypertension, and PUPPS needs some calamine lotion and Benadryl. I'm like "are you serious???? You called me for that????" But just as well, as a hypertensive patient should not get Benadryl as it can raise BPs. I go back to sleep, anticipating that I will get a call soon to go be with the elective chick, who is planning natural childbirth (even though she so badly wanted to be induced - this wasn't her first attempt at being admitted to the hospital, and she's only 40.2). Next thing I know, it's 8am!
This was one of those times when I check my pager to make sure it is working.
I call the hospital to get updates...
-primip (#1) induction due to being 41.3 and wanting to be done - she was getting cytotec through the night...she's now 3/100/-2 and wanting something for pain and asking when she can have an epidural
-elective induction (#2) ended up taking a sleeping pill but is now on pitocin but not feeling them
-Patient #3 with GDM, htn, and PUPPS isn't doing anything yet
-Patient #4 had a foley bulb and was scheduled to come in in the morning for pitocin but actually came in, in labor, around midnight with the foley bulb having fallen out. She was 3/80/-2. She was currently comfortable with an epidural and 6-7cms.
So I get up and head on in. I forgot to mention that I was expecting a fifth patient, someone I had been seeing, to show up for re-evaluation of BP issues.
Enough for now....I want to keep everyone in suspense....will post more later.
Saturday, October 3, 2009
A call at 10pm from a patient who is a G5P3 and 37 weeks. She tells me she's been dilated 5cms for a couple weeks now and they keep sending her home from the hospital. She's tired, not sleeping (3 hours in the past three nights....exaggerate much?), and has big babies and wants to be done. She has an appointment in the morning with another midwife but is tired of being pregnant. The unspoken question? "Can you induce me tonight?". My spoken answer? "No induction until at least 39 weeks (spoken in my head - "especially not at 10pm"). We can do it then as long as your cervix is favorable (who knows if she's really 5cms)". I politely reminded her that I didn't get her pregnant and that her discomfort was not my fault. This was after listening to her complaints for about 15 minutes and trying to be emphathetic. She saw another midwife the next day with the same spiel, who asked me what I thought and I said not until 39 weeks. And she checked her....she was 3-4cms.
4 babies graced me with their prescence (sp) in one 24 hour call shift. All were nice births with no complications.
Had another lady who chatted with her mother the entire time she was pushing and birthing (she had an epidural). I was ready to bang my head against the wall. But she still did good - took 30 minutes to push out her OP baby.
Had a lady who came in because she had been feeling sick for three days. She was something like 30 weeks pregnant. I diagnose her with the flu and she is slightly dehydrated. I give her an Rx for oseltamavir and phenergan since she can't keep anything down. She promptly tells me that she probably won't get those filled because she doesn't have the money for the copays. I ask how much the copays are and she says it varies but the last Rx she filled cost her $4. But you can manage to scrap up money to buy cigs. She tells me that if she gets to feeling worse she'll just call an ambulance. Nice. My tax dollars at work. So why did you bother coming to see me at all and bringing your nice little flu germs with you?????
In other moves....I went and saw the FNP regarding my 'spells'. Because these spells are really getting aggravating...and very persistent. She ran a buttload of tests (some of which I would have declined had I known she was checking them - like syphillis, gonorrhea, chlamydia - really? C'mon I know I don't have STDs). Anyway, here are the significant results....for all you medical people that want to play guess the pathology...Norms are in parentheses.
Med Hx - beta thalassemia, hypothyroidism, spondylarthropathy, IBS, PMDD
Meds - levothyroxine, Yaz, folic acid, rantidine, multivitamin, zyrtec, methotrexate, humira, vicodin prn, skelaxin prn
Symptoms - Low-grade temps (normal is 97.5 area, these run anywhere from 99-100 degrees), fatigue, weakness, muscle and joint pain, shoulders and neck very painful at times especially.
WBC 12.6 (4.0-11.0) This has also been mildly elevated in the last two CBCs I have checked.
RBC 5.58 (3.7-5.4)
Hemoglobin 11.6 (11.5-16)
Hematocrit 37.9 (35-48)
MCV 68 (78-100)
MCH 20.8 (27-34)
MCHC 30.6 (31-37)
Retic count 2.0 (.5-1.5%)
Remainder of CBC WNL.
Serum iron 40 (35-175)
TIBC 412 (250-400)
% Saturation 10 (15-50)
Ferritin 368 (9-120)
CRP 11.7 (<8.0)
Vitamin B12 286 (243-894)
Folate >20 (3.1-17.5)
Rheumatoid Factor <7>
ANA screen positive (negative) This has always been negative in the past
ANA titer 1:160 (<1:40)
HIV, Hep B and C all negative
Transferrin 336 (188-341)
Lyme disease negative
Urine culture negative
Thyroid panel WNL
And there you have it. Feel free to ask any questions and play detective. I have some thoughts in mind but frankly find those ideas a little scary. The FNP wants me to see a hematologist so I have that appointment scheduled for just over a week from now.
Monday, September 28, 2009
The patient is a 300+ pound multip with what feels like a pretty darn big baby to me, although it's hard to tell. The induction was elective and one of the other midwives gave in and scheduled her in for her call day, which was Thursday. The starting exam was 2/50/-2 and the plan was to start pitocin. IMO, this was a poor choice. I have found that multips with this kind of exam take a couple days of pit if you don't do some cervical ripening first. Bring em in the night before for a little cytotec then they are ready for pit the next day...and they will deliver the next day as well. Keep in mind, I didn't agree with doing an elective induction in the first place but casn't really say anything because I have given in to begging, pleading, crying before myself. I try very hard not to but it's difficult sometimes. Anyway, midwife #1 pits the patient all day with nothing happening. Midwife #2 comes on that night and shuts the pit off and rests the patient. Midwife #3 comes on Friday morning and breaks her water because the patient says "if you break my water, I'll take off". Sounds like a great reason to break someone's water at 2 cms. They pit her all day, she gets an epidural at one point and is 3/supposedly80/-2. She stays that exam right up until I take over at 5pm. I stop the pitocin and switch to PO cytotec x 4 doses. The next morning, before the final dose of cytotec, I check her because she is feeling pressure....yahhh!!!! She's now 5/90/-2! Woohoo....snoopy dance. We skip the final dose of cytotec and start pitocin. She delivers, 4 hours later, a chunky (10 pounds 7ounce) baby after pushing only 20 minutes. This baby was about 2 pounds bigger than her last! It was a tight tight fit...I almost had a code brown going on. But anyway, 4 midwives later we had a baby....the only midwife who didn't handle her was the on with no privileges yet!
I was frankly a little crabby that I was left with this induction. I just feel like I often have to 'clean-up' after this particular midwife. She has health issues and only works part-time because of those issues. Many times she has agreed to special a patient for labor. Then if it doesn't go quickly, I have to take over because she doesn't feel well. Then patients sometimes feel abandoned or are unhappy that they have to have me instead of 'their midwife'. It's sucky and unfair.
Other than a precipitous delivery earlier that morning, it was very quiet! I had a little drama with my husband and his heart Saturday night but he's fine. I had a few calls....trivial stuff....
One call was from a patient that just had been recently released from the hospital, where she was an antepartum patient. She had a low AFI and was being monitored. Well, she calls me concerned about the watery discharge she has. I advised her that she should come in to get checked out. She didn't really want to seeing as how she had just left. She wanted to wait until her appointment in the office, three days later. She never showed up. In the future, I think I will start triage phone calls with "What do you want me to tell you?". Because they usually have what they want to hear in mind already :p
Got a call from a patient with pelvic joint pain. No contractions or bleeding....just her pubic pain and hips are very painful. What did you want me to do about that on a Sunday night? Told her to get an appointment in the office and we could get her going on some physical therapy and a belly band.
And I am a Justin Timberlake fan and thought this was hilarious....it's from SNL with Beyonce. Hat tip to my BFF for showing me this....(couldn't embed so here's the link).
Justin and Beyonce Parody