Jacuzzi Tub Rationale

I admitted a patient with ruptured membranes, first baby, early labor in the middle of the night one night. I wasn't heading in yet to do labor support as the woman was very early in the labor still...but she was laboring. I left orders for expectant management and to call me when she was a little further along. Apparently the nurse didn't want the woman to get in the tub until I arrived because the head was very low in her pelvis. That's the best rationale I have ever heard to not allow a patient to get a tub. Really? Really.

I'm Still Such a Sucker Sometimes

Ok, I agreed to an induction for a patient of mine. Totally elective and the wisdom of inducing this particular patient was lost to me until there was no turning back.

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

OMG

You guys make me wanna cry. The comments from the previous post are so wonderful. It makes me not want to give up up on public blogging. Will ruminate about it a bit more.

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 :)

Private

I've been thinking about making this blog private for a while now. I talk about personal stuff on here that's pretty specific so worry that someone will figure out who I am. I think if I made this blog private, I would no longer have that stress about it. I also want to eliminate some people's desire to debate the things I say. That's not what my blog is about. It's the one place I have where I can say whatever I want and don't have to discuss the research, etc.

So what do you think?

I Want a Healthy, Natural Childbirth...

This was said in the same appointment that the women also said she would try, but wasn't promising, she wouldn't gain 70 pounds with this pregnancy like the previous ones. Uh, ok.

Nurse Crappy at Her Finest

I was told by Nurse Crappy that one of the docs I work with asked her to grab a midwife if she saw one to break his patient's water. The patient is a multip being induced because she's been 5cms for a couple weeks now. Um, ok. He's gonna be in surgery for awhile. So I go break the lady's water (with her consent of course) and get a ton of fluid. I tell Nurse Crappy "She's still 5cms but I think she's gonna go fast". I head to the OR to first assist on a scheduled section. We're just getting ready to get the baby out when Nurse Crappy comes in and says the other doctor's patient is now a rim and very pushy. Can you please come because the other doctor is in a gyn surgery and can't make it?

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).

I'm a Mini-Resident or Let Me Be Your B*tch

I was recently on postpartum during call doing rounds. The postpartum nurse (she normally works in the nursery) asks me if I will be seeing a patient who was sectioned over the weekend. I let her know that we don't do post-op rounds, the docs do their own (it's a hospital by-law kinda thing).

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."

Me?

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

Dah-da-da - Nurse Crappy returns

It's been a really long time since I have even seen Nurse Crappy, let alone had to be torutred...uh, I mean, work with her. Oh, but ye gods decided to smite me with her crappy nursing skills and personality recently.

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...