Sunday, October 24, 2010
Like the time when a postpartum nurse called me to let me know that a patient's H&H was 6.something. So I ask for vital signs, previous CBC results, and symptoms the patient was experiencing if any. The nurse had none of these things readily available. Hello! You are my eyes and ears Nurse. You gotta give me some info.
So what's been going on? I'm burned out. That's what is going on. I'm so done. I'm tired of my employer and his idiotic and disrespectful management. I left the office an hour early one day (after insuring that someone else would see my last patient if she showed up). Now mind you, leaving early is a once in a blue moon kinda thing. I was informed a couple days later that if I did that again, I would be charged an hour of PTO. This tempts me to keep a running tally of all the times I stay late, work through lunch, come in to help out, etc. What an ass.
I am so burned out that I am thinking about leaving midwifery, or at least trying to find aother job. I would rather be a 'medwife' than deal with the struggle I am dealing with now. We are expected to provide the midwifery model of care in a medical environment. I'm so tired of all the fighting the fight and not really getting anywhere.
I am going back to school to learn another specaialty cause I am so done. I have worked as a CNM for three years now. I would have never thought I would burn out this fast.
Sunday, August 1, 2010
The first lady came in complaining of bleeding. She was contracting with a good bit of uterine irritability. Was only mildly uncomfortable with her contractions. However, there was enough bleeding that it had ran down her leg prior to her arrival. She has a history of substance abuse and has been in treatment for three months. She had only a few visits in the office, poor historian, being confusing when giving her history. She did not have any of her previous babies, but was hoping to 'keep' this one. She didn't have any idea when her last period was so I only had a third trimester ultrasound for dates (which can be off by 3 weeks either way). She had been measuring appropriately for that EDD. Her exam on arrival was 2-3/60/-1. The baby was very active. By her EDD, she was 38 weeks (which means she could be anywhere from 35 to 41 weeks). After watching her for a bit (she was also having the occasional small variable but otherwise had a very reactive strip) then re-checked. She was 3-4/80/-1 with just a small amount of blood on the glove. She continued to be quite comfortable. I decided to just sit on her for the night and admitted for expectant management. I just felt very uncomfortable with sending her home. Her UDS was negative btw.
Eventually, she got uncomfortable and asked for an epidural at 4/90/-1. She putzed along. Hours later she was 6/90/-1 so I broke her water figuring we were pretty committed at this point. She continued to have periodic bleeding that was always just a little runnier and heavier than normal show. She progressed to 8cms fairly quickly but then kinda stalled out. We flipped her from side to side and she eventually arrived at 10cms with no further intervention. She began to push once she was feeling the urge to do so. She took a good half hour to push the baby out and baby came out screaming covered with a small amount of bright red blood. I expected to see evidence of abruption on the placenta but none was apparent except for a sort of thrombosed vessel at the placental border. Not sure if that was the source of bleeding or what. No lacerations were evident. She was absolutely fine afterwards.
The second lady was being watched very closely due to suspected chronic hypertension. She'd had this issue with each pregnancy and a possible abruption with one previous pregnancy. She would have elevated BPs prior to 20 weeks (which means increased likelihood of chronic hypertension as pre-eclampsia doesn't present prior to 20 weeks). We were treating her with medication for her blood pressure. She came in complaining of contractions, just barely shy of full-term (37-42 weeks). She came in requesting an epidural with an exam of 4/50/-3. She got her epidural and then after a few hours went by, no progress had occurred.
The head was too high for rupturing her membranes so started pitocin instead. I broke her water a couple hours after that, her being 4/80/-2. She took off after that. By 2 hours later she was 9cms. We had just enough time to finish a delivery in another room :p
When I checked her she was 10cms but still very high so even though she was feeling some pressure, I suggested lying on her side (Nurse Crappy was the nurse assigned so you know how that goes!) to let the baby come down on its own. 5 minutes later, it was time. The delivery was great the baby just oozed out on its own. I had dad literally catch. It was awesome to watch!
So you would think that women who have had several babies would just spit those kids out. but not always! In fact, once you get up into 5,6, or more kids, the possibility of complications and labor dystocia increases :p
Thursday, July 29, 2010
Tuesday, July 27, 2010
I've known this patient for a couple years, as in providing her care during that time. She's a very large lady, close to not being able to get a weight on our office scale (tops out at 350). She's shy about her body and experiences exhaustion towards the end of pregnancy due to the extra load. I don't blame her a bit, or anyone else for that matter, for being miserable in the summer heat at the end of a pregnancy.
So here she is, term, and begging for induction. Her cervix is very favorable - 4/80/-2. It's her 4th baby. I agreed to an AROM induction.
She had a rough time with the last baby - blaming it on the pain meds she opted for with the last baby. She decided she might get an epidural this time if she needed something. Hopefully, things would go smoothly and she would just take off and birth without needing anything.
And of course, that's not how things went. She piddled around for several hours after I broke her water. She finally asked for pitocin to get things going and wanted an epidural. She was 5cms at this point, contracting sporadically. I advised her that if she was sure she wanted the epidural, to do it now so she could maintain the optimal position for it due to her size. Then we used just a 'whiff' of pitocin and she took off.
When I decided to use the pitocin, I figured I had better touch base with the doc on call with me. Which is when it hit me that the wisdom of the induction in a woman this size was not the brightestmove on my part. I felt so stupid for not having given this any thought prior to doing it, or consulting with the doc prior to now. Ugh.
But anyway, he was fine with starting pitocin....although I didn't come out and say I scheduled this. :p I was a chicken. Everything went very quickly with the labor....5 to delivered in about 3 hours (I even shut the pit off when she was freaking out, we were up to only 4mus). She didn't like the epidural either. I think she just doesn't like the transition stuff - gets very panicked and borderline hysterical.
So when I reflect on this experience, it wasn't one of my better labor managements :p
Monday, July 26, 2010
I had a beautiful birth recently. This little momma was having her first baby. I had met her only at a birth class recently. She came in in labor, was about 4cms, changing to 5cms after walking for an hour. She was contracting very regularly and mildly uncomfortable. She was kinda chilling in the tub, walking around, not doing a whole lot. After a few hours had gone by, I suggested checking her cervix with the possibility of breaking her water or sending her home if she wasn't changing. Unfortunately, she had not changed and did not want to go home. She agreed to getting her water broke, which we did.
Since she was fairly comfy I decided to head over to the office to see a few patients. I knew the patient would have the nurse call me when she needed me to be with her. About two hours later she was ready for me. The nurse had said that she didn't want to do anything like the tub or the birth ball. She was very opposed to moving, which was fine! I just sat with her. Finally, she seemed to be losing focus, crying instead. She asked me for something for the pain. I told her, let's check your cervix, if you are close then you just keep doing what you are doing. If not, then we'll discuss the options.
Woohoo - she was 8-9cms! So I encouraged her to get in the tub which she agreed to. However, she was unable to sit and felt better standing. She began to get more vocal after a few minutes of standing in the bathroom. Then I saw the first little pushes as she involuntarily beared (or bore down? That sounds weird too) down. Then she says "I feel something!"
She climbs into the bed and pushes, totally spontaneous, and I see a little bit of the head. Now, she was -1 station before she stood up! Woohoo - gravity rocks. She pushed her baby out in ten minutes flat :)
Sunday, July 25, 2010
So what do you think?
Saturday, July 24, 2010
Thursday, July 22, 2010
I tell Nurse Crappy - I'm in surgery as you might be able to see, and can't come either. (Perhaps the other doctor should have thought about the wisdom of breaking a mulitp's water when you won't be readily available) I tell her she better get a resident to come stand by.
They get a midwife who's in the office seeing patients to come over as well, which she misses the delivery (but the resident was there for the delivery at least - I wouldn't trust Nurse Crappy to get a patient a glass of water, let alone catch the baby).
7 hours later...
She calls me at the office and says...
"No one ever came to see this patient and she wants to go home. I called Dr S0-and-So who said that no one ever asked him to see that patient. I then called the doctor she was assigned under who seemed rather perturbed and told me to have you come see her, discharge her, and give her an Rx for vicodin."
Of course, I get ticked off. I'm at the office seeing patients. I have no reason to go back to the hospital. I'm not his b*tch. So I call him and ask what's going on with this patient.
He informs me that he knew she was there because he rounded on her yesterday, but forgot to see her today. Was I still at the hospital? I tell him no, I am in the office seeing patients and have no plans to go back to the hopsital. He says "well ok, just thought if you were there you could see her. I'll call her in a Rx then." Ok then!
I had already broken the water of his patient earlier in the day at his request. Gotta draw the line somewhere :p
Saturday, July 17, 2010
So here's the scoop, I had a patient who was being induced due to gestational diabetes controlled by meds. Oh but wait, I forgot, gestational diabetes doesn't exist. How could I forget such an important point. You might be asking "what the heck are you talking about?" right about now. I guess there are some people out there in the blogosphere talking about how gestational diabetes and preeclampsia do not exist. Or if a mother can't cure herself, then it's her own fault. The sheer idiocy that exists in the world scares me sometimes. I'm not really sure how these people function in the real world....or perhaps thy live in Idiot Land only. I dunno...but I digress...
So the patient is getting some cytotec (geez, please don't start - I like cytotec and Henci "Nutcake" Goer be damned). That happens through the night. Then first thing in the morning I get a call from Nurse Crappy. She informs me that the patient has had her 3 doses of cytotec, is feeling a little crampy, and what would I like to do now? Uh. The order I wrote says give one dose of cytotec and can repeat up to 3 more doses. Nurse Crappy says "Oh, well night shift RN (who's kinda a nervous bunny) said it was just three doses." I'm thinking (but I don't say it, Bestie will be proud of me) Oh well, good thing you did a chart review hunh? What I actually say is allow the patient to go for a walk, shower, etc then put the final dose in.
About 45 minutes later...
Nurse Crappy calls to inform me that the patient is crying and contracting every two minutes so she held the cytotec dose (thank god for small miracles - she can do the right thing occasionally). She requests orders for pain meds, and wants to know what I want done with her. Well, did you check her? Of course not. Nurse Crappy is a firm believer of always doing the opposite of what I want when it comes to cervical exams. If a patient's water has been broke for 24 hours and wants no intervention then she'll check her to satisfy everyone's curiousity. But if the patient is intact and you're calling me to make some decisions regarding the plan of care, well hell, who needs that exam as part of the database for making decisions). Oh, and the baby looks good when she's able to trace it....that would hold up in court really well Nurse Crappy.
So the exam has changed, I'm hoping the patient is kicking into labor with no further intervention required (pitocin) so suggest she try putting her in the jacuzzi tub before giving any pain meds. She's not really active yet so not time for me to be there quite yet. Nurse Crappy acts like that's an amazingly novel idea. 30 minutes goes by and Nurse Crappy calls me again. The patient enjoyed the tub and is much calmer now. But she also feels like the contractions of gotten milder. And the contractions have spaced out so I tell Nurse Crappy to give her the final dose.
More on this later...
Monday, May 17, 2010
She's living in the past as far as labor and birth is concerned. No matter what I say to her, she can't seem to move out of the past. I would love and appreciate some words of wisdom on how to handle this!
Her second baby came rather precipitously after laboring all day and only being slightly dilated when the midwife checked her. So the midwife goes home. The patient delivers 90 minutes later unattended. Was the midwife correct in her assessment of cervical dilation or did the patient really gor from almost nothing to delivered in 90 minutes? I don't know.
Her third baby was a long torturtous back labor and pushing out of an OP (posterior) baby. She very much hopes to avoid that again (I don't blame her!). So, every week at the office I feel for the baby's position via Leopolds.....and the remains OA. I tell her this, showing her exactly where the baby's parts are, etc. Still she is fixated on the fear of an OP labor and birth.
She came in recently for a cervical check due to contracting all day. She does not love close to the hospital at all. She's worried that if she cmes in she will just get sent home and the same thing will happen as baby #2 because these contractions feel the same way. I reassure her that the nurses don't decide when she gets to go home, and that I won't send her home without waiting for a bit. Turns out false alarm....
What do I say to her?
- water breaks prior to the onset of labor
- onset of labor doesn't occur by 24 hours out from rupture of membranes
- it's momma's first baby and her cervix is unfavorable
It frustrates me when...
- I call to give the oncoming midwife report and she appears to have an attitude of 'I can't believe you are leaving anything for me other than a perfectly normal spontaneous labor'
- I don't ever moan and groan to the preceding midwife about what I get 'left' but it happens to me
- patients call on weekends about minor gyn problems - really, it can wait a few more hours until the office opens!
I love it when...
- things go smoothly and no intervention is necessary
- a baby is born vaginally
- I can leave the board clear for the oncoming midwife
Saturday, May 15, 2010
We are waiting on word from the transplant coordinator regarding dates for the 4-5 day intensive evaluation. I suspect this is something we will do a lot of....waiting.
Otherwise, not much else going on. We've been debating about cancelling our family vaca this summer. We finally decided to see if we could get a refund on airfare - keep your fingers crossed. It was decided that if we could get that money back then we would do a local vaca instead. But now with the week off I will need for the eval, may just cancel the vaca altogether and instead make the eval week a vaca. I would not need to be there every day and so could take the kids to do things. Then spend the evenings and weekend doing some fun stuff as a family - of course allowing for some naps for him! I just want to conserve my PTO.
We're trying to figure out what he should do this fall for school. It's no longer feasible for him to continue the program he was in due to the physical aspects. I suggested another course of action - do another program, just take one class a semester in somthing fun...ya know, for sh*ts and giggles to keep his mind occupied but not run up a lot of student loan debt.
As the medical bills are starting to roll in, I am anxiously awaiting the decision on his disability paperwork. The website says a decision has been made but we have to wait for snailmail to find out what the decision was :( I'm hoping the eval will be scheduled by the end of the month as the insurance deductible is almost completed for him - would then only add about $300 in medical bills to what I am currently dealing with. If it happens after June 1st then the deductible starts over again....$3000. Keep your fingers crossed.
I like this website as it gives women another chance to share their stories about birth and cesareans. It brings a human face to the numbers and statistics.
Nurse - I have a patient who came in for r/o labor. She was 2cms when she got here (ok, it's her first baby - just send her home at this point!) so I had her walk. I recehcked her and she was 3cms. So I sent her back out to walk and will re-check her in 30 minutes. What do you want me to do with her?
Me - I suppose recheck her in 30 minutes and send her home if she hasn't changed, otherwise page me back (thinking, 'wow, you could have made this a one wake-up episode if you ahd just waited the thirty damn minutes then woke me up!).
1 hour later....the pager goes off.
Nurse - She's 3-4cms now.
Me - jeezus, send her home already - tell her to come back when they are closer together and stronger (which should have been the plan when she came in at 2cms).
Nurse - Can I offer her something to help her sleep?
Me - Sure....we could have done that 2 hours ago.
Diaper Free on Peaceful Parenting shows us a new eco-friendly and green way to live.
I don't know if I believe this or not but wow - just think of the trees we could be saving...not to mention money!
h/t to Kathy at Woman to Woman CBE
Wednesday, April 28, 2010
Even one of the docs I was doing a section with (their patient, not mine) was ready to bang her head against the wall. This doc is one of the nicest most patient docs ever. But Nurse Crappy can do that to you.
My BFF joked that she ran into Nurse Crappy in the cafeteria and asked her to not kill my patient today. That had me laughing at least.
But I have to be nice. There's been a b*tchfest recently about us midwives on the part of some of the nursing staff. I can't bark orders at intellectually challenged nurses anymore. I have to mentor them instead. F*cking p*sses me off. I don't see my job as being about educating and mentoring the nursing staff - don't get me wrong, will do this with those I like and those that are interested in that from us - but it's not my job to focus on nursing staff development. Seriously - that's what the nursing educator is for. Not really sure what she does. But theoretically that's her job. I see my job as protecting my patients from those who are lazy or incompetent. It gets old....hence the 'barking' of orders.
This particular patient was a really nice lady that showed up wanting to VBAC. Unfortunately she was barely dilated and her water had broke. I always hate it when that happens because even though we can be pretty liberal with time constraints, it still creates a sensation of pressure for everyone involved - the midwife, the patient and her family, the nursing staff, etc. This lady was very much wanting not only a successful VBAC but a very natural experience as well. I was able to accomodate this up to a certain point. The plan was to leave her be to ambulate, do nipple stim, etc in the hopes of increasing the little bit of labor she was having. Her labor appeared very prodromalish (is this a word?) to me. I was a little concerned but kept that to myself. I gave her a peptalk (inlcuding a discussion about previous c/s baggage and letting it go) and everyone was on board with the POC (plan of care). Under no circumstances did she want an epidural. I've heard that before and usually dread hearing it. It inevitably sets a woman up for guilt IMO, if she decides, once she's in the heat of the moment, to get an epidural.
Fastforward several hours later.
The patient and myself are both ready to move to the next step as labor hasn't seemed to progress. The POC is a nap with a narcotic to help her sleep for a bit then on to pitocin. I head off to get some dinner and chill for a bit. I get a call from the nurse who says the patient woke up from the nap feeling like things were different and that she felt herself dilating. She doesn't want pitocin and thinks that the birth will be sooner rather than later. Ok. Stranger things have happened so I head back to the hospital.
She feels like she needs to push. I check her - *sigh* disappointment for all, she's progressed a little but still in the latent phase of labor in terms of dilation. She falls back to sleep. I head out to try and get some sleep myself - feeling really tired as all the husband health stuff is taking its toll on my autoimmune issues.
Once we hit the 18 hour mark, the patient and everyone are in agreement with re-evaluating her cervix. Nothing has changed, so now we start pitocin. I tell the nurse to call me when she gets active and I will come back.
2 hours later...
The nurse calls to let me know the patient is demanding my presence at her bedside...WTF? She also wants more narcotics. I, being a little irritated with this demand for me to be at her bedside, fall back asleep. I know, not very nice or mature of me....was also really feeling tired. A little more time goes by and the nurse calls again to let me know the patient wants to know where I am at. Has she called her doula to come? Nope. But I better get my a$$ up there ASAP. Apparently she called out on the call light screaming. Now she wants an epidural. She's now 4cms. And the pit was shut off at the patient's demand. I head in and arrive as she is signing the consent for the epidural. She looks so exhausted but not really seeing the behavior from her that the nurse was describing to me. Of course, the relationship between the provider and patient is different from the patient and nurse relationship frequently. She absolutely wants the epidural so we go with it.
Once the epidural is in, mom is sound asleep, pit re-started, and baby looks good, I go home to bed with 4 hours of call left. The oncoming midwife caught her baby just over 4 hours later. I'm very happy that she was successful in VBACing....but I feel worried that she may not be happy with her birth experience. *sigh*
Monday, April 26, 2010
I brought him home (yep, he's still surviving on that 5%!) after 8 days in the hospital. He and I were both getting a little stir crazy. It was finally decided that he didn't meet the requirements for the three lead pacemaker. Both the nephrologist and the internal med doc said "He needs a heart". Well, thanks for that newsflash :P The cardiologist who really wanted the pacemaker pretty much bowed out once it was decided that the pacemaker wasn't gonna help. The 'winning' cardiologist ended up discharging him home after putting him on a new beta-blocker (sotolol - go ahead look it up.....it'll scare the crap out of ya). He had been having lots of PVCs and had 2-3 runs of V-tach (non-sustained). He didn't have any awareness of the V-tach episodes as they weren't fast enought to trigger his AICD nor did they last more than 24 seconds. Nice. As if anxiety levels weren't slightly elevated already. He was to follow up the following week and the transplant route is now under way. We got an information packet from the transplant program and the newest leg of the adventure begins. Currently waiting on insurance authorization to proceed with scheduling the appointment for the consult. He's been in much better spirits since coming home. No coughing and down about 34 pounds total. I'm still not used to his new look - skinny :p
I have been on call a lot due to another midwife being out of town. I have caught so many babies in such a short time that some of the labors and births have blended together a little :( I was on call for my weekend and broke my previous record of 7 babies in a weekend! I got about 3 hours of sleep in a 41 hour period of time...and not all in a row! Everyone that came in wanted to have natural childbirth. I was so exhausted that I started hoping women would get epidurals so I could sleep. But then of course, I felt guilty for thinking that. But it was really the sleep-deprivation speaking. If I recall correctly, I had something like 4 epidurals, 1 IV pain med labor, and 4 natural childbirths.
Two of the women were ladies I had seen a lot of in the office so it was extra special to get to catch their babies. One lady had a history of vacuum assisted birth with her first child and very much wanted to avoid it this time. She did! But it was getting to be a close call. In fact I had called the doc on call to come in to stand by vacuum. In the meantime, she got riled up and pushed her baby out about the time he arrived. I was very happy for her...and the baby was almost half a pound bigger than her first! I don't know if she just reached a point where she had a psychological block and couldn't get past it initially or what.
The other lady was having her first baby and had a beautiful natural childbirth - one of those ones where everything goes smoothly and damn near perfectly. Love it!
I've had some more births since that weekend...lots of fun and interesting births but can't remember much right now :p I think I have a touch of stress, busyness, and maybe some fibro fog going on :p I need to try and blog more often before i forget details I guess. We'll see what I can do.
Sunday, April 11, 2010
Events preceding admission - he was feeling worse and insurance was dragging feet about pre-authorizing a heart cath. Cardio people were very uncomfy about the delay so advised us to go to the ER. He could get the cath done as an emergency procedure. Direct admit wasn't an option due to the insurance not being contracted with the hospital. But emergency admission would be covered.
Day 1 - arrive at the ER, things move promptly. Three hours after arrival he's off for the heart cath. Then admission afterwards. He vaguely remembers the doctor exclaiming "How old is this guy? His heart is very bad!" and that the ejection fraction was 5%. No one comes to see us afterwards. My husband is stable at this point but has pulmonary edema still.
Day 2 - labs are mostly ok except creatinine is a little elevated, BNP is horribly high (13,000). More waiting. The doc finally comes by and discusses the cath and results. Yes indeed, the ejection fraction is now 5%. He's amazed that someone my husband's size is still alive. Well, I guess that's reassuring....or not. He wants to put in a BiV pacemaker but after further reviewing the chart determines he is not a candidate. Insurance will not pay for the pacemaker so he has to meet the criteria for a research program to get it. So next plan is to recheck labs and chest x-ray in the morning and send him home if all is well. The following week, the doc will get him set up for a transplant consult. Traumatic afternoon involving som crying and statements such as "I don't want to die!"
Later that night - another cardiac doc comes strolling in. He wants him to have the pacemaker. This particular doc is actually my husband's doc (even though we have never met him - we had been seeing the PA the past couple months) while the first doc is on call for the weekend and did the heart cath. He says he's gonna get my husband fixed up and it's too soon for a transplant.
30 minutes later - my husband has a very scary bout of chest pain treated with MONA (morphine, oxygen, nitro x 2, aspirin). I was ready for him to code. No ecg changes though. Uneventful remainder of the night.
It's gotten around the staff by this time that I am a nurse . Most are receptive to that. Which is good cuz I sure would hate to have to be a b*tch. But as anyone knows that's been ill in the hospital - he's not just another patient....he's my husband and father of my children - I'll guard dog him more than I have ever guarded a laboring women. And that's saying a lot!
Day 3 - first doctor comes in and says we can go home and to call his office in a couple days and he will get a transplant consult. Other doc comes in and says he has a research person coming to take a look at my husband.
The doctors argue. The second doctor wins. They will go for the pacmaker. No one consults us as to what we would like to do. The second doc never comes to see us after winning my husband.
Day 4 - we spend a lot of time waiting. First doc stops by and says my husband's care was taken over by the second doc. The plan is to have an electrophysiology eval for the pacemaker. But it's the weekend so probably not until Monday. Still haven't seen second doc although he is apparently a bit of an nightowl.
And before you ask....the docs are from the same practice (but different offices) and have worked together for 20+ years. I plan to push for both plans - the pacemaker and the transplant consult.
I'll keep you posted.
Saturday, April 3, 2010
I'm breathless at times from anxiety. I feel this intense fear because I know 'it' could happen any moment now. What's 'it'?
'It' is death, heart attack, chest pain, etc. All the bad things that might happen due to his condition.
I try not to focus on 'it' too much but it's damn hard to avoid. I don't know if I should be talking to the children now about what's happening with him. That would be a painful conversation. And what exactly do you say? Without scaring the crap out of them? My daughters understand that daddy has a bad heart but I think only my older daughter has a realistic idea of what that means. To some extent anyway. My son is mentally disabled and has no clue. So I rely a lot on my older daughter to help keep an eye on him. She knows to call 911 if something happens to daddy while mom is away at work or out of the house. She knows what to tell them. I worry that I am burdening her too much though so I try to really watch what I say.
I hate when people ask me "How's your husband?". I know they are just being courteous or well-meaning. But what do you say to answer that? He's great? He's fine? He's dying?
Friday, April 2, 2010
While he has since recovered from the pneumonia, he continues to be tired and run-down. He had the CT angiogram of his chest, however the tech didn't put down any pulmonary pressures - which was the point of doing this test! I was aggravated to say the least. He's now having ECG changes which indicate that his non-ischemic dilated cardiomyopathy is becoming ischemic dilated cadriomyopathy. What does that mean you ask? It means that his heart muscle may now be deprived of enough oxygenation whereas it wasn't before. Not good. We have decided to proceed with left and right-sided heart cath to get more exact numbers and hopefully clear him to have a third lead put in his heart (currently has two - one to shock and the other to pace). We were told that the third lead might increase his function and might help him to feel better. Ok, sign him up! The cath will probably be sometime in the upcoming week.
The next day, he has an hour of chest/arm pain in the wee hours of the morning. He's up out of bed, can't get comfortable. I find out about this 6 hours later when i call from work to check on him. Naturally we had a little discussion about signs of bad shit happening! If it happens again, we were instructed to bring him to the ER and they will do the cath as an emergency. Fortunately it hasn't happened again.
So I watch, and we both wait. It's stressful. I think he's getting depressed. He spends all his time sleeping or watching TV. I told him today - you can't just give up and grow roots into the sofa. You should do what you can do. Stay active to whatever extent possible. Spend time with the kids, with me.
My best friend and I have had a fight. It's pretty bad. I said some things that weren't very tactful or came out quite like I meant them to. She said some things that I don't know if I can get over. Not sure what will happen with this situation.
Saturday, March 6, 2010
Second, why oh why, must a nurse check the patient here for induction prior to starting pitocin when I am here and I opted not to check her???? This was Nurse Passive-Aggressive.
Third, got a call from a patient who complained of getting a racing heart rate after eating something sweet. Sooooooo......don't eat anything sweet. Problem solved.
I'm being tortured....all three of my f*cking favorite nurses are here - Nurse Sucky, Nurse Crappy, and Nurse Passive-Aggressive (PA for short). At least I only have to deal with Nurse PA.
Wednesday, March 3, 2010
My husband went to the cardiologist on the 19th. I had started him on a z-pack that day for this persistent phlegmy cough (yum!) and congestion. The PA agreed that was appropriate but wanted to check an x-ray as a precaution. He weighed 240 that day. He was 239 on our home scale.
He takes his antibiotics...on the following Tuesday we get a call that they want a CT of his chest. There was a possible lesion on his lung. WTF? So that was scheduled with his yearly echo on Wednesday.
By Thursday, he's feeling a little better and getting some sleep. Friday about the same. Saturday we go to the heart walk and have to stop after a mile as he is SOB. He goes home and sleeps for 4 hours straight. He feels a little better that evening.
Sunday - back downhill. Th cough is worsening and he feels very tired. He sleeps poorly Sunday night, keeping us both awake a majority of the night. I call the cardiologist Monday morning. They get him in to see the PA again that afternoon.
The results are not good. He weighs 246 now. He's gained 6 pounds in 10 days and has barely been eating due to the nausea. The CT shows no lesion but he has pneumonia. He also has pulmonary edema. I point out the right-sided jugular vein distention I have noticed. The echo shows significant worsening of his heart, A-Fib, pulmonary hypertension. His ejection fraction remains in the 10-20% range.
They feel comfy with treating him outpatient and give him Rxs for lasix and levaquin. He's to have a CT angiogram to explore any underlying causes of the pulmonary htn (as if the total heart failure wasn't enough reason).
He's feeling a little better now. He's down to 232 as of this evening. That's 13 pounds of fluid loss in the past two days! He's sleeping better and the cough is decreasing. he has a little more energy now.
He's been so stable for so long (8 years now). I think I had convinced myself that he was ok and would live a normal lifespan (he's 41 now). This brought all those fears back. The fear of losing my husband...my children losing their father. I'm depressed and exhausted and in pain (having some issues with insurance about getting my RA meds so was a couple weeks overdue on taking them).
I may not post much for a few days so bear with me. Will see how I feel.
Tuesday, February 23, 2010
On arrival, Nurse Crappy checked her and found her to be 6-7cms. My thinking was 'great, it's gonna be an awesome labor and birth!' Little did I know what was to come.
She was handling the contractions well. The baby didn't look too hot on the monitor but wasn't bad either. I felt the strip was reasonable enough for her to just have intermittent auscultation. I wanted her to be able to get in the tub, walk, etc. Her contractions were kinda irregular. She decided on getting in the tub with lots of bubbles to keep herself covered. She seemed to be very modest. She was very comfy in the tub and was sleeping so i headed over to the office to see a couple patients, do rounds, etc. I told her to have the nurse call me when she got more active again and I would come back.
I returned to the hospital around 3pm which was good timing as the patient was asking for me. She wanted to be checked, which I did. She was 7/80/-2 with a bulging bag of waters (BBOW). She was a little disappointed that she had not changed in that 5 hours. I recommended that she keep doing what she was doing (positions changes, nipple stim, walking, etc) and possibly consider breaking her water. Her husband and mother were present and doing a nice job of labor support.
Around 6pm she wanted to be checked and have her water broken if no change. She was still the same, although her cervix felt slightly swollen to me at this time. I broke her water (light meconium) and figured that would get her progressing again. She did start to contract a bit more but the intensity didn't seem to be changing based on how she was behaving. Then the contractions went back to their previous irregular pattern.
At 9:30pm, I checked her and she had not changed other than the cervix was definitely starting to feel like it was swelling. The baby had lots of molding but was no lower in the pelvis. I'm concerned at this point as she has made almost no progress in almost 12 hours now. She's also exhausted - has been in labor for just about 24 hours now. I start making pitocin noises. She declines. I encourage her to continue with rest breaks alternating with various activities.
Shortly after that, she is lying on a mattress pad on the floor, feeling pressure in her lower back and butt. I have suspected that the baby is OP, but not really sure. She's had a lot of back labor. Her mother tells her to go ahead and push. I say no as I had to just checked her shortly before and she was still 7cms. I suspect that the mother had been encouraging the patient to push when I was not in the room, which was the likely cause of the cervical swelling.
About 11:30pm she's practically a zombie. And she wants to be checked due to the pressure she's feeling. She's still 7cms, head no lower, and cervix swollen. She's starting to get agitated. I again discuss pitocin and pain management with her. She again declines.
Shortly before 1am, she again wants to be checked. We had been using the peanut so I thought we would check her before flipping her to the other side. No change. I recommend an epidural and pitocin. The patients mother wants a second opinion. She tells me "I thought you were supposed to be about natural" or something to that effect. I explain that 15 hours at 7cms with a swollen cervix wasn't normal. The epidural would stop her from pushing against that cervix (which mom was probably coaching her daughter to do). The pt's mother wants to see a doctor. She says "There must be a doctor here in the hospital or the doctor you spoke with should come in". I had consulted with my back-up and shared that info with them. I told her there was no one but a resident around. She wanted me to get this resident and have them check her daughter and offer a second opinion.
I went out to talk to the resident. I'm pretty irritated at this point. Little did I know this resident was a dipsh*t. I was told after my convo with her that she was an idiot. I explain the situation to Dr Dipsht and ask if she could help me out. She looks at me and says "Maybe. I ahve some patients in triage to see after I finish writing this note". Seriously? Maybe? I tell her to forget it. I'm thinking she better not ever ask for advice from me on management of her patients as I will just tell her 'maybe'.
I get my back-up to call and speak with the family. The patient then consents to the epidural and pitocin. The mother sits in the corner and pouts.
The pitocin gets started about 2:30am and I decide to go home. I haven't had dinner and am tired. I eat, start taking my clothes off and the pager goes off. It's 3:30am. I have another patient who's 7-8cms. I turn around and head back in. I'm almost there when I get a call from the nurse who says she got up to four of pit, then the baby had a 15 minute decel. *sigh* She still hasn't changed although the cervix isn't as swollen now. I order terb and they get the baby stabilized by the time I arrive. However, the pt's mother wants to see the doctor. She wants to know why he isn't there if there's fetal distress. She wants a resident to look at the strip. She's ticked cuz we never got her a resident when she asked before. I have the nurse call my back-up and tell him to come in and see these people and evaluate the situation. he calls for a section in 30 minutes and heads on in. I know that there's a very real possibility that these people won't consent to a section. Fortunately the baby looks better when I arrive a few minutes later.
At this point, I kinda wish these people would just fire us and I could hand them over to the resident :P
My back-up arrives and has a long convo about section versus expectant management after checking her. She is 8-9cms and cervix is less swollen. The baby has a lot of caput now as well as molding. The caput is at 0 station. He doesn't mention any of this until we are back out of the room. He just wanted to section her and be done with it. Frankly I was feeling the same way. The patient informed us she would only consent to a section if the heart tones were down and don't come back up. She couldn't clarify to us how long she would wait. She very much felt that the pitocin was the cause of the decel, even though the baby continued to have some decels with no pit and no contraction.
So no section. We watched and waited. At 7am, we turned the whole situation over to the next shift. I wished the patient the best of luck, hoped she would birth a healthy baby vaginally.
I touched base with the midwife who followed me - the patient delivered vaginally 5 hours later with 9&9 apgars. Go figure.
Sunday, February 14, 2010
I am having a nice weekend other than the cold my husband has graciously shared with me. And from the sound of it this morning, my younger daughter is getting it as well. Ahhh, the gift that just keeps giving (the cold, not herpes! LOL).
Friday night my BFF and I went out for an adventure. We went to dinner at a japanese fusion and sushi restaurant. We had hot saki, japanese beer, and sushi - yum! We talked and generally chilled there for almost three hours. Then we headed off to a dive gay bar. The men looked like women and the women looked like men. It was interesting to say the least. They had karaoke going on so my BFF sang for the first time. She sang You're So Vain by Carly Simon and SexyBack by Justin Timberlake. Both so appropriate for me :p The only mishap occurred when I couldn't find the toilet in the restroom. I kept trying to figure out why there was a padlock on the stall. I wondered if I was supposed to use the men's room. My BFF went in the restroom and pointed out the toilet in the corner. The padlocked door was a storage closet! Yes, I had had a drink or few.
Last night, I went out to dinner with my husband. Neither of us was feeling really great so decided to keep it to just dinner. The original plan had been to see the movie Legion. We went to dinner at a very nice seafood restaurant. We started off with raw oysters whcih were so delish (except for two that weren't cleaned very well and kinda bland tasting). Then we had salad, lobster tail (with drawn butter - practically orgasmic), crab cake (yummmm), asparagus/green beans/carrot (the asparagus were slightly undercooked), mushroom risotto (bland), and scalloped potatos (to die for). We were sent home with a free dessert due to the long wait times so I chose a tuxedo dessert - will eat that later today. The wait time on dinner was looonggg - at one point, we saw another couple get up to leave and they had leftovers on their table. I told my husband we should go sit at that table - lol! Then the guy beside us finsihed his dinner and had a few green beans left over - I debated about asking if i could have them. In the end I opted not to ask :p
Today - feeling pretty crppy so will chill. Originally my BFF and I were supposed to go to a tea party but we decided we will just have a movie day.
Thursday, February 11, 2010
Here's what I did with my tax money...
I bought tickets for a Cirque de Soleil show in Vegas later this month. I'm treating my mom and my BFF on that.
I bought full access passes for the Dinah Shore Palm Springs thing. For those that don't know - it's a total lesbian fiesta. Since my BFF is totally gay and never been, I agreed to go. I am psyched - should be lots of fun. My BFF is paying for the hotel but I told her she couldn't be hitting on me and better get two beds! LOL!
I caught up my student loan payments.
I bought airfare for myself and my family to Florida this summer for a family reunion/vaca.
I paid some bills.
That's the gist of it. :pppp
At the time that my husband was meeting me at the hospital, the ER called saying they had a screaming patient from our practice. So I decide I better wait and see what's going on. I asked my BFF (and she is such a fab BFF!) to meet my husband and get my younger daughter.
the patient came up and she was a doc patient. But she was 10/100/+2 so there was no way that the doc was gonna get there in time so I stepped in.
No good deed goes unpunished.
I ended up haing the tech get the tickets out of my bag and take them down to my BFF who was waiting in the parking lot for my husband to show. I had her take me phone so she could answer it when my husband called. It was chaotic! In the meantime, the patient delivers her baby but then promptly has a postpartum hemorrhage. So we get that dealt with then she needs a repair. It's not a big tear but is very awkward to repair. It was a first degree perineal but the skin had sheared away partly up the labia. So getting that to all approximate was difficult. That's only the second time I have ever seen a tear like that. I get her all situated.....do pictures, etc.
My other patient is now active and needs labor support. So much for dinner. I quickly call my husband tomake sure he's on his way to the game and my other duaghter is in the hands of my BFF. All is well.
I go do labor support for my other lady and have a rockin' natural birth with her. Then I got to stay home the rest of the night - sweet!
Sunday, February 7, 2010
Patient #1 comes in with spontaneous rupture of membranes. She's a multip, contracting every 3 minutes, mildly uncomfortable. The nurse doesn't check her.
Patient #2 comes inwith spontaneous ROM. She's a multip who is VBACing (has had three vag deliveries prior to the section). She's not contracting or complaining of any pain. She's been ruptured for 5 hours. The same nurse checks her.
Does anyone see the illogic behind this? Why wouldn't you check the patient who was contracting regularly and leave the VBAC (especially want expectant management for her!) unchecked since she isn't contracting!!!!!
Please put me out of my misery. I had a temper tantrum about it at the nurses station. One of the nurses tried to use the "well the docs want to know" logic with me. I promptly replied that the nurses ought to friggin know how to approach midwife patients. After all, I've had this very discussion with this nurse (the one who checked the one patient and not the other) in the past. AND we midwives have been at this hospital for quite some time (several years) now - you ought to have it figured out by now.
I'm becoming increasingly unhappy with the behavior and care I see from some of the staff. I had a revelation tonight. Perhaps I shouldn't be doing hospital birth anymore. Perhaps I need to be a homebirth midwife! Too bad that's not feasible in the state I live in.
Saturday, February 6, 2010
It can be quite advantageous to have this doc on though when you need lots of time for a woman's labor and you don't want to get any grief. Not so advantageous when you really need him to be there due to a crummy strip. He's very laid back :p
At 5am. Are you serious????
So I call the patient.
Me: It's the midwife on call, what can I do for you?
Pt: I'm 3 months pregnant and think I have a UTI. Is that normal?
Me: No, why don't you tell me what symptoms you have?
Pt: I just got up to go pee (and so you thought I should be awake too????) and it burned. Hardly anything came out. I also feel crampy.
Me: Sounds like a UTI. What's your pharmacy number and I will call you in an antibiotic.
Me: Your pharmacy phone number?
Pt: What do you mean?
Me: Where do you want me to call in your antibiotics to? (or did you want me to pick them up and bring them to you?)
Pt: Oh, I don't know.
Me: Do you have a phone book you can look it up in?
Pt: *slight tone of exasperation* Yeah, hold on. (right, because I'm totally inconvienencing you)
*Listening to whispered talking with her lovebug as they attempt to find the phone number of a pharmacy by the hospital.*
Pt: Ok the number is xxxxxxxxxx.
Me: Ok, I'll call it in for you. Start that today, blah blah blah.
I call the number and it's a fax machine. Motherf*ck.
Hence me sitting here on my computer griping as I had to boot my computer up and find a damn pharmacy number. Grrr.
Friday, February 5, 2010
I was irritated this morning when I received a page from a nurse, wanting to know when I was going to round. Basically, when I get there was my response. She claimed the patient was antsy to go (not a delivered patient but an antepartum patient). While that might possibly be true, this particular nurse is well-known for shoving patients out the door as soon as she can. When I am on call for the weekend (and starting early to boot), with no office hours and no patients laboring....I'm gonna round when it's damn well convenient for me! It's not like I live close to the hospital and can just whip by. :pppp
I recently had a run-in with another midwife. I was having a rough night - was up all night and the labor ended in a c/section unfortunately. I had been notified of a patient 'out there' who was 6cms but not in labor. Uh ok. She was a primip and had gotten checked in the office and wanted to go home as contractions had fizzled. She came back that night to get checked again. Nothing had changed and her contractions once again fizzled out. I started to wonder if she had some subconscious stuff going on about the hospital environment. She wanted to go home which was fine with me. She calls me about 2am (waking me from the best 45 minutes of sleep ever) and kinda wants to come back and just be admitted. Ok, sure, whatever. She's 8cms now and contracting about every 5minutes. But they aren't very strong - she's totally relaxed and barely breathing with them when she has one. We discuss options - she wants to try to get some sleep then will be ready consider AROM if labor hasn't progressed. She sleeps for about two hours, then her water breaks spontaneously. Woohoo! By this time, I have 45 minutes of my call left and I am feeling like sh*t. I call the oncoming midwife and ask her to be here at 7. She says, 'well it won't be quite 7 cuz you didn't give me enough time to shower and drive there'....blah blah blah is all I'm hearing. I say 'well, I'm not staying, she's not doing anything' but then I say 'nevermind, I won't leave until I see the whites of your eyes'.
So she arrives shortly after 7....the patient has been in the shower most of that time while I sit at the nurses station looking like a zombie. I give the midwife report and can tell she's perturbed about something. I ask what's wrong? She tells me she's disappointed that I would really leave a patient who was 8cms. I was so mad....I told her that I hadn't left had I? But that the patient isn't doing anything. She totally madfe a snap judgement without knowing the full situation. We go into the room where the patient is fresh out of the shower and very comfortable. She's smiling and chatting. Tells us the contractions seem to have petered out again. The other midwife says 'you're not in labor' and laughs. In my head I'm thinking "see? see??????". I was offended that she thought I would even leave a patient who was transitioning. This patient was 8cms but wasn't in labor. Really.
Anyway, the patient ended up delivering like 8 hours later :pppppppppppp
Sunday, January 31, 2010
Anyway, we ate yummy stuff. I remember eating the abalone calamari which was not fried but grilled I think and was delish! We also had Poke. My BFF didn't care for it as much - I guess it didn't taste like what she remembers from Hawaii. I loved it though so ate it right up. I love Ahi tuna - *drool*. Then she had ribs and I had something, but can't remember what it was. Fish I believe. And there were yummy grilled plantains! We sat by the firepit during this time. We laughed, cried, and had a fabulous time. Or so I'm told.
Next stop on the agenda, after dropping off leftovers in the fridge, was a local coffee shop. It was very cozy and the chick at the counter was very friendly. Very trendy and very gay :) Loved it! I had some coffee and a cookie, tried to sober up a bit. It didn't work. LOL.
Then we headed to the monorail thing, which I haven't ever been on. We rode that for a while, chatting, until the guy in front of us turns around and asks "Are you guys lesbians?" Turns out, Carlos is gay and new to the area. So we bonded with him for awhile and invited him to have a drink with us at some straight sports bar. So martini #5 was had along with some Perrier for hydration. I was starting to slack on water consumption. I don't normally drink this much and will try to drink lots of water and have food.....But I was feeling no pain. In fact, my kneee felt the best it has felt since I hurt it. Woohoo!
We left that bar and parted ways with gay Carlos. I got his email though to stay in touch :) We rode the rail back to where we started, grabbed a car and headed to a gay bar next. In fact it's the same bar I blew out my knee. I wanted to see if anyone remembered me - LOL! No one did. It was dead there but good music (no, I didn't dance.....but really wanted to). I had martinis' #6 and 7. I was ready to head to another gay bar to play pool but my BFF couldn't hang anymore and wanted to crash. Thus ending the night. It was so much fun and I actually remember most of it!
The next day I was just a little tired but had to run some errands with my mom....then game night with BFF, mommy, and stepdaddy. More alcohol....but at a much slower rate.
Today....payback for all that. I am tired! Will head to bed early tonight as I have to go in to help with a breech version in the morning. This will be the second one she's had. The baby flipped back to breech after the first go around. If she flips back to vertex, the plan is to induce her. I'm hoping all is successful. I don't like the idea of the induction but even worse is the idea of a c/s. Keep your fingers crossed.
They can be found in stores carrying exercise equipment, or online by doing a search for 'peanut-shaped exercise ball'. The kid is not included.
Tuesday, January 26, 2010
I had a rockin' waterbirth (oops) recently. I had seen this patient a couple times in the office and enjoyed chatting with her. Her last baby came really fast and she delivered at home, unassisted, then transported to the hospital for a repair. This time she showed up with ruptured membranse and dilated 3cms. She wasn't very uncomfortable and I opted to try and sleep just a little more, until she needed me. An hour later, the nurse calls me to say she's 6cms. Holy sh*t, what the hell was I thinking, going back to sleep?????? I rush up to the hospital and she's in the bed coping well. We get her in the tub and she moans and groans her way through her labor. She feels more pressure and wants to be checked. I check her in the tub and she hasn't changed. I tell her that likely the baby's head just needs to be readjusted and she will finish. I suggest hands and knees in the tub. She goes from side to side for awhile then tells me she has had enough. I ask her if she wants to go home - lol. Finally, she gets up on her knees and leans on the edge of the tub. Booyah. " I gotta push!"
I tell dad to see if he can feel the baby's head when she pushes. He isn't sure....after all, he's only done this once before. I check and can feel the head getting ready to crown. I tell dad - ok, all yours! I watch as the head crowns then briefly assist with maneuvering the shoulders then baby through her legs while having dad lift the baby from her front side into her arms. It was awesome!
Saturday, January 23, 2010
The primip was on her pitocin, with the foley bulb still in, and not feeling them. I asked the nurse how much pit the patient was on and she tells me along with the fact that she keeps adjusting it down then back up based on the contractions getting too close. But the patient isn't feeling them! I explain that if she's not feeling them, then they aren't strong enough to cut off oxygen supply to baby, therefore the goal is to make them stronger. So stop turning the pit down! Later that morning, her foley bulb comes out so I check her - she's 3-4/80/-1. She's getting a little more uncomfortable and planning an epidural. I discuss breaking her water, as well as timing....do you want the epidural first or do you want to wait and see. She opts for breaking water first, which I do. She gets her epidural and gets comfy. We leave her be to rest (except when the nurse does the 'routine' vag exam after putting the foley in - after all you have sterile gloves on, why waste them by not doing an exam even though there's no indication - sheesh).
The next time I go visit her I check her with the plan of putting in an IUPC as her contractions were very erratic and the nurse was again going up and down on the pit. I opt not to put it in as the patient is now 9cms with some caput. She rests for another hour and is then 10/C/0. We try some pushing for about twenty minutes but she's not really feeling any pressure, nor is she moving the baby down. We use the peanut for 30 minutes each side. I then went off call and left her for the midwife who scheduled the induction. I had hoped she would deliver for me, so as not to leave anything for the weekend midwife. But as my BFF reminded me - a patient shouldn't be put on an artificial timeline for convienence. Good point! She delivered just under an hour after I went off call.
As I think about birth and the processes, both physiological and technological, I am gaining more insight to my own thought processes. I have learned about myself that if a woman is having natural childbirth, I will do everything I can to facilitate that with minimal use of technology (usually just doppler). However, if a woman is choosing an epidural, I have a tendency to interfere more. It's almost as if it's ok to intervene since she took that first step and got the epidural. Well, if that's ok, then it will be ok to break water....to use pitocin....etc. As Navelgazing Midwife says "you buy the ticket for the hospital, be prepared to go for the ride". I am improving on this. I can easily say that our stats are testimony to our low intervention (c/s rate 6.7%, instrumentive deliveries 1.4%) philosophy but I still feel a sense of unease at how easy it is to use interventions. Now, I will say that a vast majority of times I use them appropriately - I try to avoid the use of pitocin, etc.
I had a multip who was admitted during the night for labor and epidural. She arrived and was 3-4cms...after walking for an hour, she changed to 4cms and wanted an epidural (as she had with all her previous babies). The patient was pretty adamant about it so the midwife on did not go in. When I got report, the patient was 5cms and intact membranes. I get there and evaluate. She's contracting about every 8 minutes but is 6-7cms with a bulging bag. However the head is too high yet for me to break her water. She's made change anyway even with contractions so far apart, so reasonable to just wait and see what happens. A couple hours goes by and I re-check - she hasn't changed but the head is down a little more so I break her water. I figure she'll be ready to go in 15-30 minutes as her cervix was so incredibly thin. Couple more hours go by....sigh. She's the same even with contractions every 5-7 minutes now. Her cervix is thicker now...instead of 100 it's now about 80%. I figure the BBOW had it stretched out?
So we end up with using pitocin and the peanut which still takes some time but she eventually pushes out the baby with no catching from me. The nurse did perineal support with a cold washcloth while a very nervous but adorable dad caught the baby. The mom's epidural wasn't working well right at the end but she did a great job of staying focuses. Unfortunately, there was a retained placenta that required manual removal by the doc. On the rare occasion that this happens - I can usually grab the end of the placenta and tease it out but this one showed no sign of coming even that far. When we inspected the placenta afterwards, it was crusty with calcifications!
The third lady - why oh why do I get myself into these things. She had been begging for induction since 36 weeks, with numerous visits to triage and the office during that time - and phone calls late at night. She's a grand multip, with a history of one c/s followed by several VBACs, and fast labors. She's very manipulative and drives us all a little nuts. I finally agreed to do an AROM induction at 39.1 weeks - let's be honest. I just wanted to get her off my back. Oh what a sucker I am. Anyway, her cervix was 4/70/-1 so very favorable for this type of induction. I should have known how much fun this was gonna be when she showed up on the unit acting very anxious about the whole process and asking medication to calm her down. Sure, let me give you some xanax. That would have been the smart move!
I explained that I could give her some phenergan but it would make her sleepy and I was wanting her to walk after breaking her water. I offered to send her back home if she had changed her mind....she says "oh no no, I want to do this". So we do it, I break her water and send her off to walk.
Then after a bit, she wants to go smoke. Uh, no. She says she doesn't want to walk anymore, she's tired. But she'll walk if she can go outside to smoke. Uh, no. So she lays in bed and starts to harass the nurse. Apparently she tells the nurse to tell me that I need to hurry this up so she can go smoke. She tells the nurse that ' you won't like me when I don't get to smoke'. I go have a chat with her to remind her about how this proces tends to work and that it may be several hours before labor kicks in. I also remind her that she can't be nasty to the staff or to me as she asked me to do this to her. She settles back down for awhile.
Next thing I hear from the nurse is that she's hurting and wanting something for pain....she's still 4cms and contracting about the same - sporadically. It's really hard to tell with her what's going on. I discuss her with the doc on call. I want to give her just a little pitocin to get her going along with the requested meds. He laughs at me and agrees.
I share this plan with the patient who agrees if it will help her to go smoke sooner. I normally don't like to give phenergan during labor as it makes women so sleepy for so long but in this case thought it would be beneficial for her sanit and mine. I ordered Stadol and phenergan and we got the pitocin started. I headed to the office to see some patients.
After getting three pages from L&D (for various reasons) I manage to see one patient. Then the nurse pages me to let me know my patient is now 6-7cms and was 5 only minutes ago, and she's screaming. I head back to the hospital. When I arrive she's pretty out of control. We stop the pitocin (which was only on 4mu anyway) and I sit with her the remainder of her labor (approximately 45 minutes). She gets herself a little more under conrol and does well, with only occasional whining. Part of the problem was she had been pushing up until I arrived so her cervix had gotten a little swollen. She really was having a tough time and when I checked her I 'felt' why. The baby was so low in her pelvis but she was 9cms. I had her do some side-to-side positioning and she arrived at an anterior lip which I easily reduced over one contraction. She pushed the baby out two minutes later.
Then the whining started about how soon can I go smoke, I'm cramping and hurting, I want a bath, etc. I said conhrats and got the hell out of there.
Thursday, January 21, 2010
I am doing well with my physical therapy but this recent bout of rainy, wet weather has set me back a bit :p But I don't think there is surgery in the near future for me - yah!
I am getting very tired of hearing the phrase 'I don't eat that much!' in response to counseling on weight gain. That phrase is right up there with 'I drink lots of water'. I wish I had a dime everytime I heard these phrases - I would be so rich! Usually after asking a couple questions I can find out what the pitfall(s) is/are. It's usually one of three things - 1. Eating mostly junk 2. Eating too much of healthy foods 3. Eating only once or twice a day. I always try to give kudos where they have been doing things well, such as good calcium intake, then set goals for the next visit as well as encourage exercise.
I have some fun women I am seeing. One, I caught her last baby and we had really bonded with that pregnancy. I also adore her older child as well. I'm not often charmed by children (I admit, I'm just not into children - love my own but they drive me nuts sometimes) but this is one who is a doll. Anyway, I was disappointed because she opted to get her tubes tied. Well, it failed. And now we are having a third one. And the sex of the baby is a surprise! Awesome.
We midwives are going on a spa date - it's our Christmas present to ourselves. We are using funds from preceptorship money to pay. I am very nervous about the idea of getting a massage. I have had one professional massage three years ago and it was awful. I didn't know then that I probably had fibro. I just knew that my back and neck could be painful when touched to firmly. I told the therapist that I wanted very light massage in those areas. It wasn't light enough and I left feeling very bad. I also think I didn't tank up on water enough prior. This time I plan to be very vocal if the touch isn't gentle enough. It won't help that I will be post call and may not be rested. It will be fun to spend time with the others though :)
I've got a girls weekend to Las Vegas next month. I am very excited!!!!! My BFF, my mother, and a friend (who is a doula) will all be going. We plan to see Cirque de Soleil Love.
Monday, January 11, 2010
Sunday, January 10, 2010
She called me from triage to let me know the patient was there and was 6cms, her first baby. She had done the Bradley method but I had gotten the sense that she might not be committed when it comes done to it, when I had seen her in the office. I thought she would end up getting an epidural. Here's the convo with Nurse Crappy over the phone...
Nurse Crappy: Can she have an epidural?
Me: Did she ask for one?
Nurse Crappy: Well, no, but she asked a couple questions about epidurals.
Me: No order for an epidural then.
Nurse Crappy: Well can she have IV pain meds?
Me: No, she's going natural, studied Bradley, no pain med orders. They can call me from the back if she really wants them.
Nurse Crappy: Do you want a an IV?
Me: (while banging my head against the wall) No. Take her to the back, get her in the tub, and tell her I'm on my way.
Nurse Crappy: So no orders then?
I swear that's how the triage call went.
I arrived to find the patient in the tub. She's breathing perfect through her contractions, very calm and relaxed. She does ask me about an epidural. I tell her that she's doing so well and that I don't think she needs it. I tell her that I will do whatever she wants but don't want her to regret it afterwards. She doesn't mention it again. She does ask a little while later about IV pain meds. I talk about that option with her but again tell her that I really think she's doing a wonderful job and that she can do without if she chooses to do so. She doesn't mention it again. By this time she was lying on her side as that is where she felt most comfortable.
Fortunately, she was the only patient I had so I was able to focus all my attention on her. I did nursing care as well as labor support with her husband. I decided that Nurse Crappy wins, in this situation. She once told me that she loved midwife patients because she doesn't have to do anything....grrr. So, she didn't do anything but stick her head in the door twice...and that was too much. I've just gotten to the point where she is like fingernails on a chalkboard. I also got a much better nurse, one I very much enjoy working with, a little later.
About three hours went by and the patient wanted to be checked as she was starting to bear down a little bit, so I did. Surprise! She was supposed to be ruptured according to Nurse Crappy (and it's possible she had a leak or something). There was a large bulging bag of waters (BBOW)! And I mean bulging! She was 9cms with a very buttery cervix (meaning very soft and stretchy and very likely to melt away with a little more pressure). I asked if she wanted her water broke and she promptly said no. Not a problem. We continued to do what we were all doing.
A bit later she was really feeling more pushy so I rechecked her and she was the same. I accidently (yes, really) broke her water. She started having a contraction while I was doing the exam and my finger went through the membranes. It was a geyser. She immediately felt even more pushy. I told her to do some small grunty pushes as I anticipated that cervix would go away very quickly. A few minutes later I re-checked and she had a small lip which I easily reduced with one contraction. The baby had come down from -2 station to 0 and she began to push in earnest.
She pushed for about an hour, still lying on her side. She did try upright for a couple contractions but felt like the urge to push was less so went back to her side. She was a fantastic pusher, worked hard. She had been really worried about the 'ring of fire' or burning sensation that comes shortly before birth. She wanted to try cold compresses when the time came so I had that ready at the bedside. I asked the nurse to apply perineal support with the cold compresses while I just watched the head deliver on its own. It was so cool to be able to involve one of my fav nurses like that in the birth. She delivered an adorable baby with only a couple small periurethral tears. The baby was almost 8 pounds! And this was a petite women...very impressive.
Afterwards I told her that she was made to have babies and I hoped that she and her husband would have many. That baby came out with a perfectly round head...no molding what so ever. She was beautiful to watch laboring and birthing!
I've had a couple other births, one which required the doc's assistance with vacuum. The patient needing the vacuum was a total princess. Some of the midwives and my BFF call me a Princess but I'm totally not like this chick. She had an epidural and was asking the nurse to scratch her nose! And the nurse did! She was snapping out commands at her family left and right. I kept waiting for her to start cracking a whip!
Tuesday, January 5, 2010
She was planning an epidural from the very get-go. No problem. At 2cms she was crying. She hung in there until 4cms and got her epidural. Unfortunately Nurse Crappy was assigned to her. The patient complained about Nurse Crappy almost immediately. And no, I had not said a word regarding my feelings towards Nurse Crappy. Nurse Crappy really is....well...crappy.
At one point shortly after the epidural, Nurse Crappy has this conversation with me...
Nurse Crappy: Her contractions seem to have spaced out and I checked her after putting the foley in and she's still the same.
Me: (looking at the strip, which I had noticed we weren't tracing any contractions since her epidural placement) Well, we (meaning you) might need to adjust the toco as I am sure her contractions didn't stop completely.
Nurse Crappy: Well, she isn't feeling any contractions.
Me: (dumbfounded) Well, she has an epidural, of course she isn't feeling any contractions.
I walk into the room and adjust the toco and viola! Contractions. Slightly spaced out but not enough that I am concerned. I had to do this at least twice more during the course of the labor since apparently Nurse Crappy isn't capable of performing this task. I try so hard to be patient and nice to her, but dayum, she makes it hard!
Anyway, I did end up breaking her water since she didn't change after a couple hours had gone by. I told her I would come back in a couple hours to re-check her and she should get some rest. The patient says to me "I'd like to see more of you and less of her (Nurse Crappy)". What I wanted to say - "Well, we can stop the epidural and I will spend lots more time in here with you, but in the meantime I have a patient going natural who I am spending my time with." In reality I just smiled and told her I would try to get her another nurse. Which didn't happen as the board was full and everyone was loaded up.
I got tied up in my natural childbirther's room at the time I was supposed to go back and check the princess. Nurse Crappy comes in and says your other patient has summoned you. Ok, well, she didn't say that but anyway, she was wanting to see me. I informed Nurse Crappy that we are pushing in here, please go check her. Turns out, she was moving along nicely and was 8-9cms now.
At this point, I didn't really want to go in the princess' room anymore as I was tired of hearing the demands and complaints (the foley, the nurse, the bed, the IV tubing, her family, I'm hungry, etc.). Hey, this is what happens when you opt for an epidural - certain things come along with that. We discussed this in the birth strategies class that I taught and she attended. Night shift came on and I got her a fabulous nurse. The princess was feeling pressure so I told the new nurse (Nurse Wonderful) that she could check her and start pushing....call me when the baby is looking at you. :p JK! She pushed very well (I figured she would - she had a great pelvis) and delivered a cutie over a small second degree laceration.
I numbed her up prior to doing the repair as she was feeling some 'stinging'. The repair was pretty straightforward and simple but she almsot immediately starts asking how long it will take. I tell her that this is something she doesn't want me to rush!
Sunday, January 3, 2010
I am so happy because a patient who was due on this first week of January did not deliver while i was out on PTO. She and I have had such a great time - one of those really strong connections. Her cervix was 4cms and the head was down low so she came in for AROM and to have a baby. She's a grand multip with a history of fast labors...the longest was 5 hours and the shortest was 1 hour. I was happy to bring her in for a controlled induction although it was entirely her choice. I was just afraid she would not make it to the hospital, or if she did, I wouldn't get there in time to catch. We both very much wanted me to be present :) The downside to intervening versus spontaneous labor was that labor took longer than it probably would have otherwise. I had warned her that might be the case. Her labor was about 6-7 hours this time. She did a wonderful job though. This was her last baby and she finished with a perfect record of all natural births :) Nurse Sucky wasn't too bad....course the patient was off the monitor most of the time and I was there doing labor support. She was a little involved in charting on the computer during delivery. So intead of anticipating my needs (which most nurses do quite well - I'm not being egotistical or anything, they really do a great job usually), I frequently had to get her attention. Grr.
Well....more later....gotta put my knee up.