Chronic Pain letter

Go check out this posted anonymous letter about chronic pain...It really explains a lot about what it's like to live with chronic pain.

Another day on call

I had a fairly quiet call recently. I did a scheduled section with one of the docs...it was delayed a bit as a crash section had to be done first. I felt bad for the lady getting crashed. Her baby's heart rate did a couple big dips but stabilized with moderate variability. I wouldn't have sectioned her at that point. But I guess because the nurse called the doc and acted all panicky, he called it. The patient was 3-4cms and first baby so maybe he didn't want to bother with trying to let her labor. It irks me that the nurse was the one who essentially made the decision to section. The doc didn't even come to evaluate, the patient was already in the OR!

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!

Fibro Fog

I have what I now know are fibro fogs - difficulty concentrating and focusing. Here's a conversation with my husband recently...

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.

Me: Huh?

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?

Busy at day but not at night :)

Favorite office encounter - I met a very sweet lady who came in for a breast complaint initially. So I ask lots of questions and when I get to the 'are you on birth control' question she says yes. She had gotten these triphasic (they have three different levels of hormones in the pill pack instead of just a steady level throughout the month) pills from planned parenthood. She couldn't remember the name but had them with her, also mentioning that she had missed 3-4 so far this pack. Nice. So I look at the pack...there's a lot of pills missing randomly. I get confused. I ask her how she's been taking these. She says she just pops one out randomly each day to take...

Umm, ok.

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.

Does this make sense?

So I made myself available to work regsitry today if they had a shift - although I kept my fingers crossed they wouldn't need me :p So they called me at 5 am to let me know that I was cancelled. Uh, ok. Thanks for waking me to let me know.

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 :)

Epidurals and trampstamps: Safety or bias?

I saw this post with excerpts from an article on the Unnecesarean blog on Epidurals and Lower Back Tattoos.

Are you serious?

This has very little to do with safety and much to do with preconceived notions of women with tattoos.

Whatever.

*my statments refer to the idiots in the excerpts, NOT Jill!*

Fibromyalgia

*Courtesy of WebMD* (My symptoms in red)

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.

LMAO!

I was checking out a new blog, called Uncompromised Airways (because I have so much time for this - seriously, this blogging takes away from time spent on facebook playing Mafia Wars - this is a problem) and came across this picture in a post...hilarious!

Prenatal SSRI usage

I was over at Mitchsmom's blog checking out her latest posts. She had posted a link to a Medscape article entitled Prenatal SSRIs Linked to Problems in Newborns. I find mental health interesting and as a midwife I am in the position of dealing with these issues at times. We have patients suffering from depression, PTSD, bipolar, etc. I feel comfortable enough prescribing antidepressants/antianxiety meds, although not all of the midwives I work with do. But I feel even more comfortable if I have somewhere to refer these patients, and therein lies a huge issue.

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.

Rough Night

I had a rough night recently. I had a patient who was having her second baby and we had a less than optimal outcome. I think it sounds like the baby will be fine in the long run. Even intially the baby was doing better. But you know how these things can weigh heavily on one's mind. These outcomes are so far and few between so makes it even more uncomfortable when they occur. Even though you know you managed appropriately, you still feel a sense of responsibility. You also get a case of the what-ifs....what if I had done this at this point...or done that....or whatever. I even called the physician at one point to come in. He reviewed the strip from home and said I didn't need him. I was very p*ssed off. Some of our docs are very difficult to get out of bed, whereas others will come, no questions asked. I also called the doc back afterwards to review the strip with me from start to finish, which he did from home. I felt better after having done that. Anyway, I got the baby out and am praying this kid is ok.

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.

Ugh.

Sex and lots of it!

I saw an adorable couple in the office and have seen them several times actually. She's a couple days past her due date and we were dicussing various options and plans for the next week or so if she didn't go into labor. She said both her husband and herself were 42 weekers. I told her that it was likely she would carry that long then. But her cervix is changing - 1-2/80/-1 - so I told her for now to just focus on lots of sex and lovin' :) I kinda hope she goes into labor when I am on call...they are lots of fun!

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.

Anywhoo.

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.

Quickie

Ok pervs, it's not what you think! Just a short post before I head off to bed.

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.

More call recently

I took over on a patient who was only 34 weeks by a third trimester ultrasound but 38 weeks by a shaky LMP. We were using the US EDC because the baby did not have the appearance of an IUGR baby, which is what it would have been had we used her shaky LMP. The patient was not exactly reliable. Her prenatal care was very hit-or-miss. She had been in the previous night for contractions, was supposed to be on pelvic and modified bedrest, but the boyfriend apparently threw her under the bus while she was in the restroom and told the triage nurse that she wasn't listening. So the triage nurse ends up sending her home after scaring the crap out of her by telling her that her baby would "live with her the rest of her life if born now". The triage nurse was none other than my BFF! Her goal was to scare the patient into being compliant. I know where she was coming from but told her that was mean!

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!

Random stuff

Call hasn't been too crazy for a change and life has been nice. Good for me but not conducive to blogging!

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?