Monday, September 28, 2009

Weekend in revue

I come on call Friday night to inherit an induction left over from Thursday. Great.

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'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

Thursday, September 24, 2009

One very uneventful call

Wow, I had call with not a single delivery. That's unusual. Hardly any pages either....even more unusual. Maybe no one knew the baby magnet was on call!

One triage call...

"Hi I have the patient who was sent over from the office for a pre-eclampsia work-up and serial blood pressures. I sent her out to walk and when she came back her blood pressure was 175/85."

Me: Wait...what??? You sent her to walk?

Anyone see a problem here? Scary. And this nurse is also a CNM. Go figure.

Tuesday, September 22, 2009

Being a nurse

After doing the registry shift the other day I have been thinking about what it is to be a nurse versus a midwife. I know and have known for a long time that I would never be satisfied as 'just a nurse'. It wasn't enough for me. I have been pondering why that is.

I think that working as a nurse turned out to be not at all what I thought it would be. It isn't what I tried to teach nursing students when I was still doing that. Well wait, it can be sometimes. But more often than not, nursing is about completing tasks.

There. I said it. Yes, being a nurse is about getting tasks done. With a little patient education thrown in. It seems that most nurses I work with are about getting their jobs done so they can sit at the nurse's station. I look at their interactions with doctors and midwives (myself included). Rarely is it a team approach to patient care/diagnosis/treatment. It's a doctor (or midwife) giving orders, the nurse running off to complete the orders. Rarely does a nurse make a suggestion to me. I have even asked at times, 'what do you think?'. And the response is usually "I don't know" (not always). I want to include the nurses in the POC...I try to tell them what my thoughts are and why we might be approaching a situation a certain way. Some of interested in learning but most are just like 'whatever, let me do my job so I can go home'. And god forbid I want to do something that means more work (??) for the nurse, such as intermittent auscultation, etc.

When I was in nursing school, I thought nursing would be about that team approach to healthcare. Multiple disciplines working together to achieve the best outcome for a patient. I thought everyone would be equally respected. Yes, I was d*mn naive. After all, I had no healthcare exposure prior to nursing ( Iwas a bartender!). But lets face it, nurses don't get any respect, especially not from doctors.

When I began to teach I tried to instill in nursing students this picture of what I thought nursing was supposed to be like. But really, once you get out in the 'real world', you quickly get beaten down into your place.

I always though that certain specialty areas offered more autonomy, such as L & D or the ER. And they do, but still I see the same behaviors. I don't see nurses that are willing to fight and advocate for their patients. And that's what nurses are supposed to be - patient advocates. But instead many become steamrolled by the juggernaut called healthcare. It's hard to always 'fight the power'. It wears you down quickly. Maybe that's what I am seeing where I work.

As a midwife, I have a great deal of autonomy. I can spend a lot of time with patients. I get to give the orders instead of being told what assinine things I need to go do to a patient. Maybe that's an issue for me - I am a type A personality and I like control. I am learning to give more and more of that control to patients though :)

I would love to hear thoughts from nurses and from lay people who have had nursing care that made a difference (negatively or positively) in their lives.

*Sorry about the rambling!*

Sunday, September 20, 2009


So due to some financial 'tightness' I decided to pick up a couple registry shifts each month. No one wants me to do this - my BFF, my husband, and my mother are all concerned that it will be too much. Well, yes, probably. But it would decrease my stress level about money and we are only talking about 24 hours a month in addition to my regular work.

I did the first shift recently and it went quite well. I was really nervous because I had not been to this particular place. You never know what your reception will be like. Some staff nurses get p*ssed because registry and travelers make big bucks. But I have had pretty good experiences in the past. The staff was very helpful and friendly. I did postpartum though, which was booorrring. It made for a very long draggy day.

I got to meet the doc that a midwife friend of mine has to work with. She's told me all kinds of horror stories about him. I've also heard stuff about him from someone else. I don't know how she stands working with him, although it may be because she is much more laid back than I am. I didn't actually meet him, just was sitting there when he came by. The words coming out of his mouth were stunning. It was all I could do to not tell him off. He obviously does not like women (and I don't mean sexually!). Apparently his wife is divorcing him and I am just not at all surprised! Agh!

Saturday, September 19, 2009

Birth with Nurse Crappy

I came in for a labor patient. She was 4cms and planning natural childbirth. This would be her first baby and we had met in the office a couple times.

The nurse assigned? Nurse Crappy. F*ck. I now can anticipate a long day of substandard nursing care. We start the day off with Nurse Crappy asking if she can give stadol to the patient. IV is already started with fluids going. Granted the patient came in just before I came on and the offgoing CNM gave pain med orders. I ask if the patient has tried the tub yet? Of course not. She was ready to jump start to meds. She had probably been in the room pushing an epidural already!

I got the patient in the tub, which she really liked. All is well for awhile. Then she gets out and wants to be checked. Now she's 5-6 cms with a bulgy bag. She wants to try pain problem. Gets her stadol and sleeps.

Time goes by and she wants more stadol...I suggest getting back in the tub, which she does. Then out again for a vag exam and stadol. She's 7cms with bag still intact.

Throughout this time, I only saw Nurse Crappy go in the room to immediately strap her on the monitor when the patient was back in bed. Otherwise, she sat at the desk. She gave up her other patient to another nurse. She starts asking me if I'm gonna break the patients' water. Umm, not at this point.

The patient would periodically vomit. Guess who's holding the bucket and doing clean-up? Me and the boyfriend. Now, I don't mind helping with these things but I kinda expect that the nurse will not assume that I will provide all nursing care! That's not my ultimate job. I also helped with intermittent auscultation. Also the nurses' responsibility.

Guess what else got done by me? Freshening up the linen and chux.
So anyway the patient ends up stalling at 7cms. I discuss various options with her (do nothing but positioning, ambulation,etc, add arom to the first option, or epidural then arom) and she opts for epidural and arom. I tell Nurse Crappy the plan and she says "oh ok, and then start pit?" We all start laughing and I tell her how about we see if the arom and epidural intervention at a time! Geez.

So she gets her epidural and is comfy. I break her water and she's 8cms now. She throws up some more while Nurse Crappy convieniently disappears.

She progresses to complete after me reminding Nurse Crappy to flip her from side to side periodically. The end of the shift arrives but the patient isn't feeling pressure to push so the plan is to have her labor down and a new nurse (my BFF) will take over as well as the oncoming midwife.

Then the patient throws up some more and feels pressure. So I recheck her with the oncoming midwife to find the baby at +2 station. So I decide to stay and catch. We have a beautiful delivery after only pushing for half an hour, over an intact perineum (she had a nice healthy stretchy perineum).

I'm on my way home when I get a text from my BFF. She tells me that Nurse Crappy never checked a temp in the entire twelve hours!

Friday, September 18, 2009

Highlights from hell (aka office)

Ok, the office isn't that bad but it sucks when you are really tired.

- I can't snap my fingers and take away your sciatica, achy back, or carpal tunnel. Don't get frustrated at me. I didn't get you pregnant.

- refrain from telling me how you wish you could just have the baby now or that the baby is ready...and you are 32 weeks along. I didn't get you pregnant.

- You need to drink more water. No, soda and juice don't count. When you offer me more reasons why you can't drink more water, I'm still going to tell you to drink more water. I didn't get you pregnant.

- saw a 16-year-old who is term and really want me to be there for the birth. I wouldn't commit though. I told her she would be fine regardless of who was there. I am entitled to a life outside of work and am decreasing offers to come in on my day off to catch a baby.

I have to admit, while I was safely ensconced in the office bad sh*t was going down at the hospital. A maternal death occured - very sad situation. That hasn't happened in a couple of years. What amde it even sadder is that it was preventable. My heart goes out to the children. Good reminder not to ignore warning signs. Good reminder to also appreciate life and your loved ones!

Monday, September 14, 2009

Wednesday, September 9, 2009

Let me call my childbirth educator

I had a laboring woman recently, wanting natural childbirth. Things weren't going smoothly (the baby was OP) and we had been trying multiple positions, etc in an effort to get the baby to turn. At one point, the woman is crying and begging me for something for pain. The father is arguing with her about it. He doesn't want her to have anything. We manage to keep her going and don't give her anything (although I was ready to). Time passes. No progress. Baby is still OP. Mom is getting out of control. I talk to dad about the various options including continue with position changes in the hopes that baby will turn, try the peanut, Get IV pain medication, get an epidural and put her sidelying with the peanut. Possibly pitocin if necessary. He gets upset and tells me that epidurals and pitcoin are a joke...blah blah blah. I felt like I was being very reasonable but also honest about the options. He told me he had to make a phone call...he was gonna call his childbirth educator who they had spent 10 weeks with so "I think she knows about this stuff". The 'better than you' was left off the sentence but was definitely implied. I told him to that was fine and to let me know what they needed from me. I went out to the nurses station and declared that I was done. I told the nurse to let me know what they need and I will order it but that I wasn't going back in there otherwise.

It's one thing to decline an option I offer - no problem. But no need to be an a$$ about it. And I promise that I know just as much as your childbirth educator/massage therapist/mechanic whatever.

Well anyway, I went to the patient because she was wanting to her what her options were. I asked her to give me a little more time in the tub on her hands and knees in the hopes the baby would turn. She did that very reluctantly. Then we re-checked and she was an anterior lip and the baby was changing his position. I had her wait fifteen minutes on her hands and knees then was able to reduce the anterior lip and push. She pushed for about an hour to deliver her baby into our waiting hands (dad was helping catch) over an intact perineum.

So I have mixed emotions over this experience. It's a very fine line to walk between encouraging and supporting a women's desire to go natural and her requests for pain relief. Especially when things are not going 'normally'. I think we pushed her harder than we should have. But yet I am happy (and hope she was too) that she did it naturally. But I feel like I forced it on her but not allowing pain meds/epidural. I would have had she not made any change but by that time she was so close to being ready to push I couldn't see drugging her at that point or making her numb. I'm uncomfortable also because I did what I did out of some desire to keep the peace between her and her significant other. And that's maybe not the right motivation. I don't know....gotta ponder this one a bit more.

Oh, and I got an email from the nurse that was working with us last night. She's sweet as can be, a future midwife, and a doll to work with. Apparently she was planning to give a bath to the baby (which she would have not done had the parents told her they didn't want that done) and the father got upset and threw water all over her papers. Then when another nurse later came in to check on momma, he told her she was stupid three times to her face (not sure what the context was).

Vit D and Christine Northrup

Here's an interesting article about Vitamin D levels and possible relation to breast cancer among other cancers.

Prevent Breast Cancer with Vitamin D

Monday, September 7, 2009

Happy Labor Day - shout-out to nurses!

Hope everyone is having a wonderful Labor day weekend. I am aside from the fever of undetermined origin that continues to nag me.

Go check out this nice shoutout to nurses on Reality Rounds' blog.

Vitamin D levels

I did get my vitamin D level checked on the advice of my best friend and an anonymous poster here on my blog. Turns out it is low - 24.5. The normal range is 32-100 but it says 32 is a threshold for optimal health.

So low levels of vitamin D can be associated with increased inflammation in heart disease, arthritis, and MS. And of course, it can f*ck up your bones too. Nice.

Who would have thought that living in Arizona, you could possibly have low vit D levels????

Divorce cakes - these are fabulous!

The labor from hell

So the labor from hell was miserable, especially for the patient of course!

I had come in at 7am because I was scheduled to first assist for a section. I had told the off-going midwife the night before not to worry about calling me early as I would need to be there anyway. Well, she never called me at all so I assumed there were no labor patients there. Wrong! This patient, someone I had spent a lot of time in the office with and a young girl at that, had come in around 2 or 3 am. She had done the walking thing and had changed her cervix to 4/90/-2. She was planning natural childbirth. So she was admitted for expectant management.

When I arrived, the night shift nurse had just checked her because her water broke - calling her 6/90/-1. So off we go, me thionking she's gonna have her baby by lunchtime. Boy was I wrong. Even after her water breaking, she never really would contract more than every 4-6 minutes. They felt strong but progress came to a standstill. And the patient was doing a wonderful job of staying relaxed and breathing with her contractions. WTF?

I go do my section then come back to do labor support. At 10ish, I recheck her because she's feeling pressure and shaking a bit. She's the same (well, actually I would have called her 5/100/-1). That sucks. But onward and forward. We continue to try different positions, the tub, etc. At lunchtime, I have to go do another section so leave her for a bit.

After the section, come to find out the nurse had checked her and she was...any guesses? 6-7/90/-1 per the nurse. So I am feeling a little aggravated because I don't know if this is change or just the nurse feeling the same exam but calling it a little differently. I would rather have been the one to check her but the nurse said she felt like she needed to push (the patient, not the nurse) and she didn't know how long I would be in the OR. Jeez, you could have come asked me - it's not like you had to go to another part of the hospital to find me and the patient is a primip for gawdsake! My favorit expression - it ain't gonna fall out!

So more labor support, more time goes by. I blow off office hours to stay with her thinking we will have a baby in the afternoon. The patient continues to do very well (now I start questioning how well she's doing - probably because things aren't progressing!) and contractions do palp strong.

Around 5pm, I decide to check her and she's what I would call 6/90/-1 with a bag! So we break her water, again. And we continue on, thinking this will do the trick. Her contractions get a little closer together for awhile (every 3-4min) but then gradually space back out to 4-5 min. They palp strong, patient is coping well. WTF??

I start thinking about pyschological blocks. That's the only thing I can think of. Her pelvis, while a touch on the small side still feels roomy enough to birth a #6.8 baby (which is what I am estimating).

Around 6:30pm, the patient is starting to struggle to work through her contractions. We have continued to try multiple positions and the tub. I can look at her and tell she's losing it. The exam is unchanged.

I pull the patient's momma out to the hallway to chat for a bit. The patient is underage and I need to know her momma's thoughts on where to go from here. I am of the opinion that the patient needs an epidural and pitocin at this point. She hadn't wanted pitocin earlier when I suggested - not because she didn't want the interference but because she just didn't want to hurt more and she knew pit would make her hurt more. Her and her mother didn't want an epidural because they had heard too many bad stories, not because they were worried about the effects of epidural on birth. So, I talk to mom for a bit...she's not happy with the thought of an epidural but willing to consent for it if its what her daughter wants.

We go back in the room where my patient is definitely starting to lose her ability to cope. She wants the epidural. So that gets done. The nurse checks her after putting her catheter in. She's the same. Pitocin gets started and the patient is instructed to go to sleep for a bit.

We fight with the pitocin and her contraction pattern for awhile. Her contractions just didn't want to pick up. Her body was just fighting this process??

Around 11pm, I finally recheck her, thinking I will put in a IUPC because her contractions continue to be dysfunctional looking. And that's kinda my ward or good luck charm. I'll say lets go put in an IUPC and then discover the patient is too close to delivery and doesn't need it. Sure enough, the patient is 9/100/0 with a touch of caput. Woohoo!!!!!

So we wait some this time I am absolutely exhausted but a friend brings me coffee which helps. Finally, around 1am, the patient is feeling a lot of pressure and feels like she needs to push. I check her and she's 10/100/+2 and the caput is crowning :p We start pushing. It only takes about 10 minutes to get the hang of it. She pushes for about an hour, finally delivering an adorable baby over a couple little dings in her bottom.

We had long crowning so the baby came out floppy initially and the labor nurse panicked (well, I think she did but she doesn't think she did) and called for nursery without taking a minute to assess and mess with the baby herself. This kinda irked me and we had some discussion about it later. She's a new nurse (maybe been doing this for about a year now) and she hasn't learned how to truly assess babies yet. I knew the baby was stunned and needed a chance to get going. Our apgars were 2 and 9, with just blow-by and stimulation to get the kid going.

Friday, September 4, 2009


This is just some miscellaneous crap because I'm too tired to do a real blog post right now.

Hmmm, speaking of being too tired from work related things...Check out the blog RN Obesity Blues. This L&D nurse blogs about her life, chronic illness, women's healthcare and more. She's new to the blogosphere but very well spoken. I think she's gonna have lots to say (and hopefully it will make sense! Haha!).

I had the labor from hell recently...well, I didn't but my patient did. Will post over the weekend about that.

Going on two weeks now not feeling terribly hot. Less temps now, more nasal congestion. Husband is sick, older daughter is home sick. I think at least my daughter has the flu due to high temps. I also noticed she was growing a little curly tail, so maybe swine flu?

I'm already to role to do some registry work to pick up a few extra just waiting to hear about a shift.

I'm glad I didn't let this blog go. I still have lots to say that just isn't appropriate for my real 'professional' identity to share.

And....ummm....well I had something else I was gonna say and just forgot it....

Oh wait, I remember...The grand total for last month - 24 babies. Am I a baby magnet or what?????

Wednesday, September 2, 2009

Nursing students with too much time on their hands

The Laryngospasms - funny!

Pushing with an Epidural

"I worked with a woman whose doc said at week 10 of pregnancy that he thought she would need a c-section because of her anatomy. He induced her at week 39 to avoid big baby. Told her the baby felt BIG like 8.5. Labor moved a long. she got epidural at 4 cm, 80% -2. Was complete 7 hours later with lots of pitocin. Pushed for three hours, mostly in lithotomy position (My suggestions of side pushign shot down and laboring down too.) and doc called it. Baby didn't move past 2. Mom had been up all previous night and not eaten in 24 hours. She was toasted. Mom started pushing before she had pressure. Doc wanted coached pushing instead of laboring down. I see it all as an orchestrated c-section set up. But I don't know. So I am wondering if you have some gems up your sleeve for helping a mom with an epidural push through a "tight fitting pelvis."I feel like hands and knees or a supported drape could have been helpful, but those are not going to happen with an epidural. I don't know. Or something with one leg higher. By the way, the baby weighed 6.5. Not so big. This hospital is super management oriented, very high c-section rate. Most moms get induced. No one goes past 40 weeks."

This is a sad sad story. Now, it is possible that her pelvis was too small but in hindsight, knowing the baby was only 6-5...Hmmm, I'm inclined to think that mismanagement of labor was more likely.

Do I think she was set up for a section? Looks that way! First of all, no research supports induction for suspected macrosomia or LGA babes - in fact, these women are more likely to end up with a section!

Suggestions for pushing with an epidural? Here they are.... Everyone feel free to add any other tidbits that I may not have listed.

1. Laboring down is important - specifically with the woman on her side and a peanut wedged between her legs. This opens up the pelvis and allows baby to get in an optimal position for being born.

2. Once actually pushing - I usually have the woman push for a bit in a semi fowlers. We experiment with towel tug-of-war, using the hand grips, pulling legs back. Whatever seems to get the most out of her pushes and feels more productive to the woman.

3. I then like to flip to one side and push for about 15-20 minutes, then to the other side 15-20 minutes. I've not had this fail me once :) We can usually see a fair amount of the head after this. I then put them back into either semi-fowlers or squatting (this can be done with a birth bar - lower the foot of the bed and raise the back of the bed for support - works great for epiduralized women). Important note with squatting - the baby needs to be low in the pelvis for this position to be effective.

4. We have a baby!

There are various positions for OP babies as well. Also, hands and knees c an work for some women with epidurals - just depends on how heavy the epidural is. I had a woman who we ended up cutting the epidural off and was able to walk to the toilet with assistance after awhile, where she pushed for a bit.

I really suspect though, in the previous scenario that pushing was only a small contributing factor. I think the induction was inappropriate, coached pushing instead of waiting until mom had pressure, not allowing laboring down. Lotta things wrong in this scenario.

As an aside, Rixa has a post with references regarding this subject so go check that out on Stand and Deliver.