Tuesday, July 28, 2009

A Reminder

Someone anonymous posted a comment that had me really thinking how many women don't get the basic premise that their body is theirs!

"As someone who is about to have her first child in a geographic location where I am utterly guaranteed to have never seen the person delivering my baby until they glove up, I appreciate the familiar. I feel empowered when I know there are things I can rely on. Touring the hospital enivornment and getting to know the policies that will ultimately dictate my options has helped me to feel confident about things I can and cannot change and that has helped me build confidence in myself. "

To Anonymous and any other woman:

Your body belongs to you. Even in labor and birth, your body belongs to you. No one can force you to anything you don't want to do. That is assault. You can say NO. You cannot be spanked, punished, or disciplined because you chose to say NO. Your doctor, or whoever, is not your daddy or your mommy. You can say NO. It's not always easy but you can do it. And if you at all have a choice, find a provider who will have a partnership with you...not a dictatorship. You are in control.

I'm amazed at how often I have to remind women that they are in control. I tell her, you don't have to ask if the baby can stay on your chest after the birth. This really sparks some interesting thoughts on gender differences. But I am really tired right now and am not sure I can wrap my brain around that now...so more later maybe.

Random office visit

A patient at 39.1 weeks wants to be induced. Her reasoning? With her last baby she only dilated to 3cms and had to be given pitocin to continue laboring (at 39 weeks no less). Her exam today? 2/60/-2. My explanation? You weren't in labor last time, someone took pity on you and agreed to induce you. Had you waited another week or two, you would have spontaneously labored. Guess what you are gonna do this time? >:)p

Birth junkie?

Oh dear, I think I might be a birth junkie...

You might be a birth junkie if...

I need your opinion!

One of the midwives I work with says that we should be careful about agreeing to be at a woman's birth even if we aren't on call. She wonders if we are disempowering women by doing that. She feels that we should be instilling the confidence in women that they can birth no matter who is there.

I agree with that. But I think it's also important that women feel comfortable with whomever shows up for birth. We are fortunate in that all the midwives in the practice are on the same page in terms of philosophy of birth. But we all have different personalities and attract different types of people. Is it so wrong to want to be there with a woman you have bonded with throughout her pregnancy...and that she wants you there? Would I really be disempowering her by making that committment? I just don't think so.

I'd really like to hear from others on this subject!

Wednesday, July 22, 2009


I may be posting less frequently than I used to. I'm running a blog for the practice I work in and will be focusing a lot on that blog...so leaves less to post here. Just wanted you to know :( But still plan to be around :p

Tuesday, July 14, 2009


I went out of town recently to a place with no electricity or indoor toilet. I was not a happy camper...in every sense of the word! There was an outhouse...it was reasonably clean but the flies during the day were out of control! I was in this environment for a retreat, which otherwise was great. Oh wait, the sleeping sucked too. But other than those things, we ate well, drank well, and got a lot done!

I'm not really an outdoorsy kinda girl. I prefer my outdoors in small doses. Like a couple hours. I don't mind light hiking, etc but just not into roughing it for more than a day or so. I much prefer cities...like Las Vegas, San Diego, etc.


I had another wonderful birth recently with a woman who I had been seeing regularly in the office. She very much wanted to have her baby and not go past her due date due to some extenuating circumstances. I had told her that if her cervix was 'ripe' (ready for labor and not thick, closed and high) I would accomadte her. Turns out her cervix was definitely ready at 3-4/80/-1. I scheduled her for a few days later but just before her due date for an AROM induction (breaking the bag of water in the hopes of labor starting). Of course I had discussed the risks of doing this with her and possible pitfalls. She was also thinking about trying to have natural childbirth with this baby as she had epidurals with her two previous babies.

Shortly after she arrived, I checked her...she was now a solid 4/90/-1 with just occasional painless contractions. I ruptured the bag to find clear fluid and sent her off to start walking. She gradually started to contract more, reporting that they were initially about every 15 minutes, then ten, then five. It was a nice, steady buildup for her. She was starting to get a little uncomfortable with them but breathing well through them. She was alternating between walking and resting in the bed. I had advised holding off on the tub until she was a little more active.

I had to go into the OR to do a scheduled primary C/S on a patient of mine who had an IUGR and breech baby. I told my lady that I would be done in about 45 minutes. She told me that she thought she would be ok for 30 minutes. :) I told her to walk for half an hour, then get in the tub. She agreed to that plan.

While we were almost done in the OR, the nurse comes in and says she's 6-7/100/-1 and asking for an epidural. She wanted to know if she could go ahead and start the IV. I was a little frustrated because I wasn't a point yet where I could leave the OR, but was close. I told her to just put her in the tub and start the IV there. The CRNA couldn't come anyway until the c/s was over. I was able to leave once the skin incision was the only thing left to do.

She was just getting in the tub as I arrived and no IV had been started yet. She was really starting to go into a 'zone'. I gave her a choice...I told her she could either commit now to doing this natural or we could start the IV and try to get her an epidural but that I didn't think she would make it long enough for that. She never answered me so I told the nurse to not worry about the IV. I sat with her while she labored in the tub. She really was coping well - humming loudly, rocking a bit. The dad (this was his first), who had earlier informed me that he spoke three languages - spanish, english, and stupid, kept asking her if she needed to push, did she want an epidural, etc. I told him to quit speaking stupid at her, that she was in a 'zone', and it was better to not distract her from her work. I had that kind of relationship with them :) He finally quit pestering her.
He was supposed to catch but decided that his mother would catch instead. I was a little disappointed as it's an opportunity that only comes around rarely but whatever.

My patient started to get up on her knees and push so we moved back to the bed (we are not supposed to do waterbirth at this hospital). She made herself comfy and pushed her baby out with fabulous control over an intact perineum, into the hands of the grandmother. It was amazing to watch her and I had goosebumps! She felt tired but proud afterwards. I was very proud of her as well :)

Wednesday, July 8, 2009

Reducing infant mortality rates

Check out this video - it speaks to infant mortality, mdiwifery care, etc. It's a trailer, about 2 minutes long.



I thought this was an interesting post about a woman's experience of miscarriage. She found it to be an enlightening experience. I am very happy that good came out of bad for her!!!!

My experience was not enlightening in the least bit. When I was 17, I got pregnant with my then (abusive) boyfriend. I bled for a month and finally miscarried at 12 weeks. My boyfriend took me to the ER where I sat in the waiting room with a washcloth between my legs. When the nurse took me back (this is the only kind act I remember), she took me to the restroom to help me get changed. When she saw how much I was bleeding and how upset I was, she said 'oh honey, I'm so sorry. Let me help you.' Makes me cry a little to think about that one small act of...kindness and consideration. Because it was the only one that occurred that night.

I laid on a gurney for three hours, in terrible pain, passing clot after clot of blood. I remember telling my boyfriend that if this was what labor would be like that I wasn't getting pregnant ever again (hunh, three kids later). I wasn't offered any pain meds as I was only 17 and didn't have a parent with me. Turns out I had a partial molar pregnancy ( this is where the placenta basically overgrows, filling the uterus with grape-like clusters, the baby usually either doesn't grow or does but dies early on). I had to have a D&C at a later date and follow-up bloodwork.

The ER experience is unpleasant....ER personnel, in general, don't like pregnancy or pregnant women. They would rather try to get a laboring woman up to L&D and risk her delivering in the elevator than just keep her in the ER, catch, then send her up! Silly! Anyway, I advise women who are potentially going to miscarry, that unless their bleeding is too heavy, to stay home. Have someone with them who will help look after them and provide lots of TLC. Because whether you lose a baby at 8 weeks or full-term, it's a tough experience emotionally. It's still the loss of a child, your child. It took me four months to move on after what had happened.

The long and short of it!

I had a momma whose birth experience was tough, veered off the track of what she wanted, but then kinda returned back to it :) This was her first baby and she was planning natural childbirth. She a doula and a doula-in-training along with a terrific husband for support. As a side note, I remember talking to this couple as a consult only when they were thinking of transfering care to us. The husband was really leaning towards having a doctor provide care whereas the momma wanted a midwife.

She had been ruptured for about a day and a half with no labor. So it was decided to start pitocin and she eventually got an epidural also. Her labor progressed slowly throughout the evening and night. By the time I took over she was 10cms but very numb. The epidural had been cut off about an hour already. I had to go into the OR to first assist anyway and my student hung out with the patient and also tended to an induction that was there as well. The epidural finally wears off and the lady starts pushing. She makes slow but steady progress. Not all of her pushes were very effective so we tried multiple positions to encourage her progress. Finally, I suggest the toilet (don't know why I didn't think of it sooner). I had told the student that if that didn't bring on some significant progress then we may need to move to the next step (vacuum). Fortunately the toilet was very helpful and she delivered not too much longer after that. All told, she pushed just shy of three hours to deliver her handsome boy of 9-1! So we kinda got her back on track with her desired plan. Her IV was accidenly pulled out during pushing so we didn't restart it or pit :) She had no epidural in place anymore. She got off the monitor for a short time. And she got to push in multiple positions. Course we had some bleeding afterwards but not too bad and not surprising due to the size of the baby and the slogging of the uterus.

The other lady who was there for an induction was past 41 weeks and just ready to be done. She was having her 5th baby. She started at 1/50/-2 :ppppp. Here's her timeline....

10am - pitocin finally started after torture with multple needle sticks.

3:30pm - having mild cramping but no big deal, the nurse wants to increase the pit beyond 20mu/min. Ok. She's still the same exam.

4:15 - she wants an epidural now, and is 3/100/-2...ok, that was her plan anyway.

5pm - we arrive at the hospital from the office, the nurse had just checked her and she was 4/100/-2.

5:10 - she's not getting any relief from the epidural but doing well, her water breaks.

5:14 - she's 10/100/+2

Unfortunately another nurse had this patient and then turned her over to this nurse for the epidural. The other nurse sucks. She's the type who has a very unpleasant, gruff personality (which is surprising since she used to be a midwife in another country) and spends the entire delivery over on the computer charting and not paying attention to whjat we have going on!). She had nothing set up in the room....no table :P Not a huge deal, I threw some gloves at the student and started setting the table.

5:19 - Birth of a beautiful baby :) What fun that was!!!!!!!!!!!!!!!!!!!!!!!!!!

Interesting births

I have had some interesting births recently. The weekend was not as busy as I thought it might be but some interesting stuff did happen.

I had one baby who delivered OP after twelve minutes of bradycardia - yikes! When I looked back and realized it had only been twelve minutes I was shocked. It seemed like a lot more time had passed!!!! I had to cut an episiotomy unfortunately. There's a skill I utilize very little and only in this particular situation. The patient was totally ok with that, had an epidural, and could hear the slow thunk...thunk...thunk...of the baby's heartbeat. The cord was long and skimpy with a true knot (maybe the second or third I have ever seen) as well as wrapped around the baby's neck. The true knot and nuchal cord may have been responsible for some earlier EFM strip changes but I believe the true culprit for the bradycardia was she was abrupting at the end! She had a low platelet count so not terribly surprising in hindsight. Abruption is when the placenta tears away from the uterine wall prematurely (meaning the baby is still using it!). You can often tell because the baby is followed by a bunch of clots and blood, which was the case here. Baby came out absolutely fine, great blood gases, apgars, etc. I then went and changed my pants. Thank whoever these types of situations are not real common!

I had another lady come in having her 7th baby. With the face presenting first. This was a first for me!!!!!! With a face presentation, the chin must be facing anterior (or up) to be able to manuever the birth canal and deliver successfully. If the chin is posterior (facing momma's back) then it's very unlikely the baby can deliver vaginally. Fortunately this baby was chin up...and momma's pelvis was more than adequate. When she started to push the baby spontaneously (momma was doin' the natural thing), I could feel something nobby and thought the hand was coming down with the head! When she was almost ready to crown, I spread the labia and couls see an eye and the nose (not a hand) peaking out at me! It was a little surreal! The nurse, who had never seen a face presentation either, was looking at me like 'what now?'. I just told her that the baby was coming and we would just wing it! The baby converted to OP as the head was delivering and came out fine...well, the poor kid was molded and swollen in places she shouldn't have been due to the presentation issue, but otherwise fine. She had to go to the nursery for observation as she was having a little trouble with her breathing (also not uncommon in a face presentation due to the swollen nose!). Oh, and the baby was big...8-12! When I rounded on the momma and babe the next day, the baby looked beautiful! All the molding and edema was gone :)

Pit to distress?

I was just reading a post on Unnecesarean.com regarding the term "pit to distress". The author seems to find it shocking that this term exists. What the term means is to use such aggressive amounts of pitocin to overstimulate a women's uterus, which in turn causes the baby to crump (become distressed), and a c/s is needed.

As a former L&D nurse and now a midwife, I have heard this term before. The context in which I am familiar with it is a little different than it is described on the above post. The term was used in situations where the baby was looking less than stellar during latent labor and it was already predicted that the a c/s would be likely for this reason. The pit to distress term would simply mean, go ahead and pit hard so we can section the baby.

I was a little shocked to find out that this has actually been written as an order??? I find that difficult to believe as that is a real red flag legally! But also just the nerve of some provider to order a nurse to intentionally cause potential harm to the invisible patient, in the form of oxygen deprivation, and to the visible patient who gets this c/s.

It is also p*sses me off to know that pitocin is used so irresponsibly. This behavior causes a backlash that makes life difficult for those who use the drug in a responsible manner. Women will hear about this practice and then worry that this will be done to them...and refuse pitocin. And there are situations where pitocin can make a difference between a c/s and a vaginal delivery (in a good way). I guess it will come down to trusting your provider and the relationship you have with them...if you don't, you should be running from them!!!!!

Friday, July 3, 2009

My thoughts on nursing shows

Having had a couple weeks now to watch Nurse Jackie and Hawthorne, I can comment now.

I really like Nurse Jackie. Is it realistic? Maybe not so much, although it takes some very real issues and just amps them up for TV (substance abuse, etc). I don't think people will get the wrong ideas about nursing, based on watching this show, any more than they would about doctors, after watching ER, etc. I know a lot of nurses are p*ssed off about this show but at the end of the day - it's just entertainment. I think it shows the compassion that nurses have for their patients. I think it shows the difference between doctors and nurses. I think it shows that we are intelligent team members and not just 'handmaidens'.

Hawthorne - seems a little boring. I am not sure I will even continue to watch this one much longer. This show seems to make an attempt at being more realistic than Nurse Jackie (meaning not so off-the-wall). However, the portrayal of the CNO is a joke - I haven't ever seen a CNO like that. Have you? The CNO's I have known (granted, not that many) are so far removed from the staff that at times one didn't know who the CNO was, nor would one recognize her if they saw her!

I see Nurse Jackie being around for a few seasons...not so much with Hawthorne.


I had a woman who had a waterbirth recently...to bad I missed it! What happened was...

The woman came in having ruptured her membranes. The nurse naturally felt the need to check her (she was not in labor at this point) and she was 1-2/50/-2. This multip was planning natural childbirth and had done it before so the plan was just to have her chill until labor kicked in. In the wee hours of the morning, I get a call from the nurse who says she is looking more active. So I come on in to procide labor support and keep an eye on things. I check her...she's 2/70/-2. *sigh* Not at all what I expected because based on how she looked she was looking like she ought to have been at least 5 or 6 cms. But sometimes this is just a sign that the labor is getting ready to go fast.

So I go back to sleep...I got some great sleep with my pager going off less than hourly :p

About 4 hours after I checked her, I roll my butt out of the recliner and head to her room. She looked pretty uncomfortable, was reporting some back labor. My thinking was that the baby might be OP and that's why the labor seemed to be taking a bit. So I ask her if she wants to get in the tub and of course, she does. Doesn't mention feeling pressure to me at all. I go off the floor for coffee. They call me on my cell phone to let me know she is delivering in the tub as we speak. Crap. I missed it....grrr. But the patient was thrilled and all was well!

I'm on call all this weekend...I have seen a lot of term patients the past couple days, stripped some membranes of those who wanted that, andf am expecting to catch 20 babies or so! Ok, so that might be overstating things a bit. But I heard from women that three husbands are predicting Saturday. Another's co-workers said this weekend sometime. Another one, I checked and think she will go by this weekend. So this ought to be interesting! Will keep you all posted.