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 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.

Anywhoo.

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.

3 comments:

Beetus said...

Very impressive section rate. Love it!!

And thanks for the blog, was due for a fix...

Katie said...

Hello! I've read your blog and noticed you've mentioned the use of a "peanut" several times. Could you explain what that is and show a link to a website where one could be purchased? Thank you!

Ciarin said...

Katie - see post and picture :)