Thursday, November 19, 2009

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, 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.


Beetus said...

Gnawing on the perineum, huh? Very unconventional. :p

Ciarin said...

Well, you know us midwives....evry unconventional and will do anything for our patients!

Joy said...

You should totally call that doctor and tell him you don't need his c/s!