Saturday, January 31, 2009

Attn: N is for Nurse

Can I get an invite?

New job?

I think I want a new job. I get this feeling everytime things get particularly sh*tty at work. Lately we (read: the midwives) have been getting a lot of sh*t at work. Dr Boss is doling out the disrespect in more portions than usual. We are all frustrated. But can't talk to him yet because he's on vacation...again. Just not feeling the love...

Example - I got a pretty nice raise about 3 months ago...followed promptly by a cut in bonus per delivery. The reasoning was that all the midwives needed to make the same bonus amount since we would be pooling bonus money. So two of us were making the higher amount, and got dropped down to the lower amount. Essentially this offset the raise and I am no better off than before.

Example - I get a nasty note on a chart. The note was apparently written without reading my notes.

Example - he dictates that every woman should be getting pelvic exams after 36 weeks. There was a big brouhaha over this one - we argued this one.

There are other numerous gripes but my fingers will fall off trying to type them here! We will need to have a very serious sit-down when he returns. Morale is in the tank.

We are expected to be little mini-residents but practice like midwives. Make up your mind Dr Boss!!!!!! We aren't practicing obstetrics! It's midwifery. And there are some differences.


It's Superbowl Sunday tomorrow - woohoo! Go ARIZONA CARDINALS!!!

I'm actually a Redskins fan but seeing how they haven't been to the Bowl since 1992 (they won) I'll remain loyal but put them on the backburner for tomorrow.

Monday, January 26, 2009

How stupid

So I have a lady who is pregnant (go figure :) She just got new insurance at the start of the new year. She had her first two babies with us. Now she is being told that while the prenatal care is covered, the hospital we deliver at is out-of-network. She's very upset about this. The hospitals she can deliver at that are covered are high-tech, low-touch and very 'the doctor is the boss' oriented.

This sucks.

Saturday, January 24, 2009

Unity...or lack of...

I read a post from a CNM-to-be recently on the reasons she wants to be a CNM. They were lovely reasons! Anyway, I made a comment about the division in midwifery. Basically, how sad and unfortunate it is that we 'midwives' can't get it together to bring unity to the betterment (is this a word?) of women. I've seen a lot of discussion on the ACNM listserv about this division. It seems to have become a CNM versus any other type of midwife battle. CNMs seem to be portrayed as part of the establishment....the'enemy' so-to-speak. Unless they are doing birth center or homebirths...then it's ok to be a CNM. Anyone doing hospital births is a sell-out or a medwife.

Kathy, blogger from Woman to Woman Childbirth Education, commented in response to my comments. The following, with her permission, is a copy of her response with my thoughts interspersed...

I just had to comment on the "increasing division in midwifery" and CNMs being part of "the enemy" and "medwives."

I'd be curious to read more of your thoughts on this. Just from your short paragraph, it seems like you're talking about home-birthers viewing CNMs as the enemy. It probably goes both ways -- many in the home-birth community would probably call just about any CNM a "medwife"; while many in the hospital-birth mindset would be upset by many CNMs. They seem to be in the middle, pulled or squished on both sides. (However, many times, CNM groups will join with OBs to oppose legislation that would legalize non-nurse midwives, so there may be some veracity to the "sold out" epithet. Then, since non-nurse midwives are not legal, and no legal birth attendant can/will attend out-of-hospital births, women are forced into having an illegal attendant, an unassisted birth, or an unwanted institutional birth. And they might expect OBs to oppose home-birth, but when midwives also oppose it, it rankles them worse.)

As I mentioned, I believe the deeper issue IS homebirth versus hospital birth. Hospital birth is always made out to be this evil machine that grinds women up and spits them out. I have no doubt that this does happen. After all, I have worked as a labor nurse in less than supportive hospitals when it comes to low-intervention, natural childbirth, etc. But the bad things tend to get all the publicity - there's no interest or drama in the normal, wonderful experiences that women may be having in the hospital. Just as when bad things happen in homebirth - that's what will get televised, talked about.

I can't speak to other states, or areas about the CNMs siding with OBs. I don't see that here in my area. As a whole, our region is supportive of birth choices and providers. Personally, I am as well. Working in a practice that focuses on low-intervention philosophy of care, we have women that come to us and say they may switch to a lay midwife for a homebirth. I never try to convince them they shouldn''s their choice and I will support that.

When people say the words 'many times' a group does this or that, I take that with a grain of salt because I would imagine what we hear about are few, sensational cases of this. The efforts of midwives to band to together, regardless of their differences in education and practice location, seem more likely to go un-noticed.

The CNM who attended my first homebirth was subsequently forced to go back to only hospital births because she had to have malpractice insurance which she couldn't afford. She contacted nurse-midwifery organizations, and there was no help available because she attended home births. Whatever group(s) she got in touch with had no interest in helping a fellow CNM attend home-births.That was 4 years ago. And, from what I can tell, she wasn't "the enemy" because she was a "medwife" but that she attended women who wanted to give birth at home. She didn't want to be in "the establishment" of a hospital, but had no other course to take if she wanted to continue to eat.If you blog about it, feel free to use my story and/or reference back to this comment.Yeah, it's sad that there isn't more unity in the birth field, because we all want the same thing -- happy and healthy mamas and babies; we just differ in how best to accomplish that, and focus more on our differences than on our similarities. I agree with you -- very sad stuff.


There IS help through the ACNM for CNMs wanting to do homebirths. However, this is not a guarantee that malpractice insurance will be affordable. Unfortunately, ACNM has no control over this issue. This is a whole other topic getting into malpractice insurance so I won't go there. That one makes me want to bang my head against the wall!

I absolutely agree that we all want the same thing - sad that we can't generate more unity to achieve this goal.

Just FYI for my readers....

My ladies who want natural childbirth...

Do not have to have an IV
May have intermittent auscultation
Can labor in the tub
Can walk
Can be in whatever position they choose
Can birth in whatever position they want
Dad can catch if that's what the parents want

The list goes on....

In fact, the director of maternity services has been asked to submit plans by the CEO for a separate birth unit to be used only by the midwives. This is exciting as I would love to be offering waterbirth, which would be an option in the plan. The center would be staffed only by nurses who are trained specifically for this. Essentially, it would operate pretty close to a freestanding birth center.

One other comment about CNMs that are forced to choose between being medwives or mini-residents and eating...they can make a difference too. They shouldn't be chastised for society's inability to see the value of true midwifery care.

Thursday, January 22, 2009

New style of birth plan

Just saw this birth plan on N is for Nurse's blog so check it out. Totally hilarious!

Natural births

Had a couple of natural childbirthers today. I spent my day running back and forth between them doing labor support. Very hard work for them, and hard work for me too - I'm exhausted and am still on call until morning. *groan*

With one lady I had to give the pitocin speech/recommendation after 16 and a half hours of ROM, and no cervical change for 4 hours (in active labor). Just a little boost....had a baby which daddy did a great job of catching, an hour later :) She was awesome.

The other lady was going for a VBAC - success!!!! Not a big surprise as she had had vaginal deliveries before. She did fabulous as well.

I seem to be having a run on ladies with stalled out labors at advanced dilatations...:PPPP

Evil P

The evil drug pitocin - the bane of any woman's existence who desires natural childbirth.

Not so.

Pitocin gets a bad rap. This has happened due to misuse, overuse, whatever. But pitocin can be our friend at times. It can be the difference between a vaginal delivery and a c-section. When used judiciously, pitocin is good.

Now, I know what many will say...pitocin creates such unnatural contractions and makes it harder for woman to have natural childbirth. Granted yes, it is not possible to mimic the brain's pulsatile release of oxytocin. However, if those natural contractions were strong enough (read painful enough) then we wouldn't even be having this conversation.

Others might say what about more natural ways of encouraging stronger contractions...

My thoughts....

1. If you are walking through the woods and see a mushroom, would you pick it and eat it? Probably not, because it could be poisonous. Not everything 'natural' or herbal is safe. I do think herbs have a place in healthcare (after all I want to get a PhD in Naturopathy) but as withany other type of medicine, careful and considerate use. I'm not opposed to the use of blue and black cohosh - but not necessarily comfortable either. Pitocin has a very well researched history. If I have to choose, at this time I'm likely to choose pitocin. Once cohosh goes in there's nothing I can do to control it if it works too well.

2. Nipple stim - yes, go for it...but unless you wanna be brushing the crumbs off for hours, it doesn't seem to be terribly helpful.

3. Walking/positioning, etc - we do all these things to encourage things. This is typically the first line of defense so to speak.

My point is, that I am willing to try different things prior to resorting to pitocin. Pitocin is last resort for many of my ladies.

Tuesday, January 20, 2009


I get a call from a patient in the middle of the night because she thinks she might be in labor. I ask her some questions and it certainly sounds like she is in labor. It's her first baby. I tell her to go to the hospital when she is ready, to get checked out. I'm thinking she will be something like 4 or 5 cms and I'll get to not go in since she was planning an epidural. Then she starts mentioning that she and her husband's truck is not running.


Shall I come pick you up?

C'mon, what do you want me to do about it? Call EMS if you have to I guess :( I figure you knew you were pregnant for nine knew labor would happen at some point, right? So, plan a little bit.

Two and a half hours later, she arrives at triage (she found a ride, no EMS). She has advanced dilatation and the baby is breech. Lovely. Guess who got to get up and go first assist?

On the lighter and less crabby side...I had two very nice natural births. One never seemed that uncomfy until right at the very end - wow! The other had a rude awakening. Her first baby came very quickly - because she arrived at the hospital 8cms! They broke her water and she delivered 30 minutes later. This time she was 5cms and with a thick cervix. I warned her that it might not go very quick as she wasn't that active. She wanted me to break her water which I did. After several hours of minimal progress, we started pitocin. It didn't take much - we never got past 5mu/min and I actually had the nurse turning it down once she was active. My plan had been to turn it off so we could hopefully let her finish on her own. But she delivered before that - the pit was on 2mu.

1st baby - 4 hour labor
2nd baby - 10-12 hour labor

Go figure. Mother Nature is a tricky lady!

Thursday, January 15, 2009

Call so far today

Another busy day in the life of a CNM.

I am friggin' exhausted.

Yesterday I spent the better part of 16 hours working with a personal patient. Her birth plan could have been a checklist of what was not gonna happen. I finally had to go home in the evening as I was so exhausted with no baby in sight. The other midwife caught the cute kid five hours after I left. Delivery was followed by a retained placenta. I went and saw her today and she and hubby were quite happy. I think she felt that even though things didn't go as she had hoped, she was satisfied that we had tried very hard to make things happen they way she wanted.

Flexibility - key.

So I didn't sleep well last night worrying about her so much. This set me behind in rest for today :p

I had a scheduled c/s to first assist on bright and early. Then a I caught a baby of a young lady who showed up completely dilated - she did great but had a couple smallish tears that wouldn't quite bleeding so had to sew 'em up. I noticed that she had a bit of a rectal prolapse while I was down there, which surprised me in someone so young (19) and hvaing a second baby. Come to find out - her first baby, which was 'delivered' by residents in a teaching hospital, she had a fourth degree laceration. For a 5 and a 1/2 pound baby. WTF?

Then a crash c/s, which I first assisted on as it was my patient :( I hate hate hate to see multips get sectioned with a previous history of vaginal deliveries. But it was a fetal distress kinda thing that had been a problem since she arrived. We tried.

But on the other hand, I have now first assisted 6 times and am feeling much more confident.

Then I sat around waiting on a grand multip to have her baby.

I'm hoping for a very quiet night....please please please!

Duh Moments of the day

1. Said to another midwife by a patient when asked who she was planning to have at her birth for an attendant (midwife or doctor)? "I think I will have a doctor because I'm afraid the midwife will get in the way of my husband supporting me during labor.

- Ok, sunshine - let us know how that one works out!

2. Said to me (numerous times this one occurs) after counseling on 5, 10, 12 pound, etc weight gains in far too short a time..."I don't eat that much".

- Well sweetie, got bad news for aren't having a baby, you're having an elephant!

3. Said to me after counseling a pregnant patient on smoking cessation - "My last doctor said that smoking was good for keeping the baby from getting too big".

- Please stop procreating

Tuesday, January 13, 2009

An update

So I recently posted on An Unpleasant Experience and wanted to give you the update. One of the other midwives rounded on her the next day and she was absolutely thrilled with her birth experience and me. She told the midwife that I was great!

It's interesting how differently the perspectives can be.


I forgot to tell you about one of those births from this weekend...

This woman was a term patient who came in with contractions and appeared to be quite uncomfortable with them. This would be her 6th baby and another VBAC for her. :)

Her vag exam was closed/80/-2. Hmm, ok....but she has a history of fast labors and is contracting regularly. So she walks for a couple hours. Now she's 1-2/80/-2. Ok....well, let's let her walk another hour and just keep an eye on her.

Now normally, I would have sent the woman home when we discovered she was closed....but it is her 6th baby, and she looks sooooo uncomfy.

Afetr another hour she's 2-3/80/-2. Hmmm.....ok, go home. Come back when you are complete (which is what she would inevitably do - with me being at home when it happens). I go talk to her, planning to send her home, but am really just bothered by how much pain she seems to be in. It doesn't match where she is in labor. So I check her just to be sure...

She's now 3-4/100/-2, 15 minutes after the nurse had checked her. Ok, maybe we'll just keep her then.

An hour later, she's 8/100/-2 with a BBOW.

Less than an hour after that we had a baby. Wow.

L&D Rules

I found this and thought I would share....labor and delivery nurses will get it...everyone else, maybe not. This is a joke!

Rules of the Labor and Delivery area

1. Don't ask me if my wheel can tell you if you got knocked up on the 15thor 16th. That's too damn close to have 2 different partners anyway.Just suffer for 8 more months, assuming the father is not the one it should be. For real. I get asked when a patient may have conceived from time to time. Usually it's related to being sure who the FOB is

2. Bed rest does not include walking around Walmart or running by the mall topick up something. I'm gonna start handing out this instruction when I have to put someone on bedrest!

3. Don't come in the middle of the night because you've been throwing up for a week and then ask me to get you something to eat.

4. Breathing hard and faking to your family like you're having contractions WON'T open up your cervix.

5. Tears and rolling around in the bed also will NOT open your cervix.

6. Doing sit ups while in the bed to make the monitor "go up"also... WILL NOT open your cervix.

7. Until your cervix is opening, don't plan on staying.

8. If you fight with your boyfriend and need a little TLC... go to his mother's house, not the labor room.

9. If you are there with someone in labor, don't try to read the strip and tell me what's going on. You don't know the difference between a fart and a contraction and you'll likely just piss me off and delay your loved one getting pain medication or her epidural.

10. When I ask the patient a question, that's who I want the answer from... OK? I don't need her mother to tell me when she had sex last....

11. This day and time, if a patient is between the ages of 37 and 42... she has had approximatley 2-5 partners. If she is between the ages of 28-36, the average is 7. If she is in her early to mid twenties, then her age is how many partners she's had... If she is a teenager, then "too numerous to count" applies. (and she has had, or currently has chlamydia or trich)

12. Open your damn legs. If you were a virgin, you wouldn't be here.

13. Shave that sh*t. If we wanted a trip to the jungle... we'd go there.

14. Clean your ass before you come in. Unless you have the umbilical cordhanging out, are in a serious accident, or are bleeding profusely, take time towash it up a bit... it's going to be on display. (Why do you think I like to get women in the tub? JK)

15. You'd better be nice to your nurse. She, not the physician, decides when you get pain medication... There is such a thing as placebo. We can also make you wait the entire 2 hours... adding 45 minutes for our convenience... or we can give it to you 15 minutes early.... it's all in your attitude.

16. The fewer visitors you have in with you... the better mood your nurse will be in.

17. Get rid of that one "know it all" visitor before it's toolate. She can ruin the entire experience for you by pissing me off.

18. If this is your 6th baby, either get the epidural before you come in, or don't plan on one.

19. Don't blame us when you're baby can't say it's own name when it's 5. Chances are, it was the cocaine you snorted in the parking lot,just before you were rushed in abrupting.

20. If your pulse is 50 when you come in... from all the downers you'vebeen downing... chances are your baby will be several bricks shy of a full load. It's your fault, not ours.

21. When I ask you if you smoke... you should include marijuana in that answer.Other things that should be included are, hashish, crack, meth, and any otherillegal drug that you may have smoked. Nicotine is the least harmful of all thecrap you could smoke...dummy.

22. Don't bitch at us because your baby has to stay in the hospital until it's 2 months old, weaning off of Methadone or Morphine. Regardless of what the bullshit clinic says to you.... Methadone is NOT healthy for babies.

23. If you call us and say you're bleeding profusely, then I'd bettersee some blood when you come in. Do you know how many people we notify for shit like that!

24. Hard labor doesn't just stop with 1 bag of IV fluids. We know a fakerwhen we hydrate one.

25. If you're an addict, we already have a preconceived notion about you,and we probably don't like you. Nothing personal... it's just the way itis. You chose that life... now live it.

26. Regardless of the fact that your neighbor's sister's aunt had ababy at 30 weeks and it is perfect... that does NOT mean we're going to letyou have yours at 30 weeks.

27. Your neighbor's sister's aunts baby likely had to stay in thehospital for 6 weeks, and could possibly have problems that you're not awareof... dumb dumb.

28. You'd better tell us if you're on narcotics... trust me......We'll know soon enough, because our drug of choice is Stadol.... HA HA.

29. If you have track marks on your arm, "NO YOU CAN NOT GO OUT AND SMOKE" with your IV. What do you think we are, Stupid?

30. Don't scream. We hate screamers. It get's on our nerves and we just sit at the desk looking at each other and grinning and making faces. It'snot to your advantage.

31. If you don't have custody of your 3 other kids, chances are youwon't go home with this one either. We ARE calling Social Services.That's our job.

32. If the baby's dad is in jail, and he's still your boyfriend, we automatically assume "birds of a feather flock together".

Monday, January 12, 2009

The weekend

The weekend consisted of four straightforward births, tons of pages (I was tempted to take a sledgehammer to my pager), one pretermer on mag, and an admit for hydration related to a stomach virus.

I received two calls early this morning regarding postpartum (2 weeks) back and abdominal pain and the other early pregnancy with diarrhea, having traveled out of the country recently. Both calls came back to back three hours before the office opened. After determining that neither seemed life threatening, I instructed them to call the office for an appointment. Grrr.

Friday, January 9, 2009

An unpleasant experience

I was on call a couple nights ago for 12 hours during the night. What I thought was going to be a beautiful birth, turned into a very unpleasant and teeth-grinding experience.

It starts out with finding out I get an awesome nurse whom I really enjoy working with but rarely get to as she is usually charge nurse. So we're thinking that we are gonna have this really nice birth in the evening, then I'll go home and be in my own bed :)

Not so at all!

The patient was a very young primip who I had seen a few times in the office. I felt like we had bonded but then I hadn't seen her in a couple weeks. She has some extenuating circumstances which I really didn't know any details about, in terms of her social system. Anyway, she's in active labor when I get there (the previous midwife had admitted her around 3 or 4 pm, when she was 5cms). She's planning natural childbirth and has a pretty straightforward birth plan. She has two doulas (one of which is one birth away from being a homebirth midwife - which is what she told the nurse). My first moment of unease occurs when I walk in the room to say hello and the doula is right in the patients' face. I can't really establish a connection as the doula doesn't move away at all. Ok. Well, she has a crowd of people around her aside from the doula so I decide to just say hi and head out of there.

I realize it's not about me but about the patient but it still felt weird to not be able to really establish, or re-establish the connection. I'm not used to that. So I just let it go and kinda chill at the nurse's station.

Later, she requests a vag exam - about two hours since the last (the previous midwife had called her 6-7cms). I check and am disappointed to discover that I can't call her any more than 7cms. I offer to break water....she consents to that. I now figure she will zoom along and we'll have a baby soon.


Next exam - 8 (and this is being generous)cms, no descent. Cxns every 5-7 minutes???? WTF??? Now, I am kinda wondering what is going on. Does the patient have a psychological block? She's also starting to fight the labor - won't relax at all...even in the absence of contractions. The family doesn't seem to be on the same page as the patient and doulas. Whatever, I'm totally staying out of it.

An hour later - the patient feels like she needs to push. Exam - no change. Contractions still not very strong and still spaced out. I decide to have the pitocin talk as patient is not tolerating things very well anymore and is getting exhausted. She yells at me. I leave the room without saying a word.

I'm totally pissed. I've never been yelled at by a patient. I have had it with her snottiness (she has been this way with others as well - the nurse, family). I absolutely cannot stand bad behavior in labor - there's no excuse for that.

The patient sends her sister out to let me know I can come talk to her now. Oh really. The sister says she told her that I looked pretty upset when I came out. You don't say. I tell the sister that I will come back a little later when I have chilled out first.

There were no more episodes like that, at least with me.

Eventually the patient agrees to pitocin after trying some other things first. She begins to progress. She gets to complete and pushes for about an hour to deliver her 9 pound baby with a 1st degree tear and some bruising after a mild shoulder dystocia. I then get the third degree about the repair I am doing. Jeez lady, give me a friggin break.

I'm just glad it's over. While we were finishing all this up triage went nuts, with several being my patients. I delivered a baby for another midwife from another practice and one for the doctor she works with. I admitted one very preterm patient for observation and 3 others for labor. People were having to wait in triage to get beds on L&D, with people waiting for eval out in the lobby, including one of my patients who was scheduled for induction but put on hold - however thought she was in labor. She sat out there for an hour screaming. The patient and her husband are pain in the butts and this was pretty typical of her behavior. I knew she was at least 3 cm since she had a foley bulb that came out during the night. She was 5cms when we were finally able to eval her. Then it was time for me to go home ....thank god.

I hugged the oncoming midwife when she got there.

Wednesday, January 7, 2009

Things of interest

After having five straight days off hanging with the kids and my husband I was ready to go back to work! I love them, but jeez they drive me crazy after awhile. You hear the five-year-old constantly hollaring for her brother to come help her with something or another. The 8-year-old just thinks she knows everything! And the 14-year-old grumbles and moans if you ask him to do something like take out the trash, empty the dishwaher etc. It's enough to make you run out of the room screaming....which I did a couple times :)

I have just been in the office since returning to work. I am on call tonight and then all weekend...woo...hoo. I hope it's either feast or famine and not in between :p

I had a young mother in the office the other day who I had to call the crisis intervention line for. She's on her third baby and has a lot of different psychosocial issues. I felt so bad for her, wishing there was a magic wand I could wave and fix it all for her. I don't know what happened after I left as they were there at the office quite late talking with her. I hope they have some good recommendations for her and she will follow through.

I have a patient who looks just like Milla Jovovich! What a trip! I caught her first baby and am now seeing her with this one. Hopefully will catch this one too.

I have another lady who I have been seeing all through her pregnancy. It's her first baby, and she's due today I think...she's planning natural childbirth and does not want induction at 41 weeks (which is fine). She is open to membrane stripping but her cervix is closed still. I tried to reassure her that the baby knows his birthday but she is miserable with contractions and seemed rather surprised when I mentioned that they will get stronger. She was whining a bit and I felt like telling her to just suck it up. But I couldn't do that as she and her husband are absolutely the sweetest people I have ever met. So I told her to suck it up in a really nice way :)

Well, I have only four hours of office today prior to going on call for just 12 hours. It has been decreed that we midwives must be in the office as much as possible to build our practice...*sigh* But we can't convince the powers that be to give us 20 or even 15 minute time slots for return OB visits. Now we all take however much time we need with each patient, which naturally results in us running behind to varying degrees. So instead of giving us extra time for those visits, the powers-that-be agreed to an extra ten minutes out of every hour as a blocked slot in which to play 'catch-up'. In return we had to add 30 minutes of time to all our office hour shifts AND they took away out emergency only blocked slots - which were rarely used. We got screwed in the end because when I calculated the time out...we are actually working an additional 20 minutes on top of what we were before. It doesn't balance out, that's for sure. And now the office staff that schedules appts will manipulate these blocked slots to where you will be booked two hours straight then get 20 minutes of catch-up time.