Sunday, January 31, 2010

Busy Playing

I've been quite busy playing this weekend. I went out Friday night with my BFF and was very naughty. We started out with dinner at an awesome modern Hawaiian restaurant. I had 4 vodka martinis. I only knew this because I counted the little olive sticks the next day. I kept the olive sticks for my mother who drinks dirty vodka martinis at home....well not like, all the time....just after work and social events so maybe 6 days a week. but she totally doesn't have a problem. Really. Anyway, she was needing some little sticks for her olives and these ones were pretty darn cool.

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.


I have been asked occasionally what the 'peanut' is when I reference its use in some of my birth stories. Here's a picture...

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

The Good, The Bad...

I had a very tough situation recently (unfortunately I can't go into details here, it's a difficult case to HIPPAize). I felt traumatized by this experience and embarrassed by the care given by staff as well as professionals that were involved. If I felt so bad, I wonder how my patient felt? *sigh* It's a shame when the Bad stuff seems to outshine the Good stuff. And there's far more of the Good stuff.

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

Why do I Get Myself Into These Things?

After a really slow (not that I am complaining) week of call (for everyone) the babies returned on my last call day. One was an induction at 41.2 of a primip, who apparently insisted on having her baby already. Another midwife had put a foley bulb in her the day before then scheduled her for pitocin when I was on call. The second was an induction I scheduled because I'm into self-punishment (more on this later). The third was a spontanous laboring woman who had been admitted the night before.

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 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 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

No Baby Magnet

Hasn't been much going on lately in terms of births. One of the other midwives seems to be the baby magnet now. My last two nights on call were so quiet that I was checking my pager to be sure it was on!

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

How to Write a Great Blog Comment

I was on the Midwife Connection blog reading about Melissa's favorite comments recently. She had a link to Grammar Girl's blog on how to write a great blog comment - loved it! Go check it out :)

Sunday, January 10, 2010

Back in Wonderland

I had an absolutely awesome birth recently. The only negative was that Nurse Crappy volunteered to take the patient. Seriously Nurse haven't figured out that I can't stand you?

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 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

More Adventures

I had a 'princess' patient of another midwife. The midwife who this patient normally sees was on vaca so couldn't be called for this patients labor and birth. Bummer. Cuz I got stuck with her. She wasn't the worst I have ever cared for but definitely was up there. I had met her once previously and she left me with the impression of someone who is never happy or satisfied. That impression was upheld throughout labor and birth :p

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 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

Adventures in Laborland

I was being punished again and had my two least favorite nurses again caring for my three laboring women. I guess I need to kiss somebody's a$$ so this doesn't happen again anytime soon :p So the return of Nurse Sucky and Nurse Crappy.

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.


This is the most phenomenal movie I have ever seen. Even if you think it isn't your type of movie, it's a must see. The imagery alone is well worth it.