A Midwife's Tale

Hello? echo

2011-12-09T14:24:00.000-07:00

Hello everyone....still here?

I've had a lot of changes since I was last here. You already know I switched practices and that continues to have been a great decision. My 'new' practice, aside from small bumps here and there, continues to be great. It's such a nice feeling to work with doctors who actually care about women's choices and aren't jerks if the woman makes a different decision than what is being recommended. It's a great feeling knowing that if I am worried about something that the doc I work with will come in, no questions asked, and evaluate. We did have some drama from the third midwife. After working with us for 2 months she took off and went to our competitors. It was a tough few weeks for me as I felt very betrayed. I struggled to get that damn knife out of my back. But I got to a place where I was able to forgive and reinstate our friendship.

We have a new midwife that started recently - and she seems to be really working out. She has a sense of humor that is like mine and we have fun working together. I think she will be around for the long term. She's a new grad but has been working for years as a L & D nurse. This wasn't important to me but was important to the doc I work for. We are getting her settled and I am thankful for the extra help cause it has been crazy busy. I had patients come with me to my new practice plus patients already there plus all the great word-of-mouth plus my ties with the birth community. Busy!

The nursing staff at the hospitals I deliver at are great, but very different environments. Hardly any idiots at these facilities so very nice to not have those struggles. They have been adjusting to midwifery care for a couple years now but with more midwives coming in and those of us who perhaps practice a little less medical, the staff have had to adjust a bit more but are doing great.

There's a practice whose docs are notoriously against any midwifery care, now hiring a midwifery service. I guess they got tired of all the transfers to our practice :p It's so hypocritical but yet, the more midwives in the area, the better!

I've become so lax in my blogging but am going to try to get back with it and get back to visiting other people's blogs! I've missed the blogging community.

I'm Still a Midwife

2011-02-01T08:20:00.002-07:00

When I last 'talked' to you guys I was contemplating leaving midwifery and had started to set some plans in motion. I was applying to school to do another specialty.

Since then, I have switched jobs! I no longer want to leave midwifery anymore :) I have a new position that is considerably closer to my home and far more supportive environment. I'm working with a wonderful midwife I have known for about 4 years. Even better, one of the midwives from the 'old' job will be joining us soon!

I miss the midwives but absolutely nothing else at my old position. Things had only gotten worse and I was thinking about taking up drinking - haha. I was gonna call it group therapy though.

I am still planning to pursue an education in another specialty, waiting to hear if I have been accepted. I feel like it's important to have a back up plan :)

That Would Be a Good Post

2010-10-24T10:58:00.002-07:00

I have had many moments where I have thought "Wow, that would make such a great blog post".

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.

Ode to the Bestie

2010-08-01T04:52:00.000-07:00

I just gotta say that my BFF rocks. She really pushes my intellectual boundaries all the time. Lovin' it! We are currently reading the same book together so we can discuss it as we move through the book. I've not ever done that and am really enjoying it.

Can't trust them multips

2010-08-01T04:00:00.000-07:00

Had a couple interesting births lately. Both were somewhat complicated with risk factors, which always makes for some excitment :p Both were multips - one having her 4th baby and the other having her 5th.

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

Jacuzzi Tub Rationale

2010-07-29T19:30:00.000-07:00

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

2010-07-27T14:10:00.000-07:00

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

2010-07-26T18:18:00.003-07:00

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

2010-07-25T19:51:00.002-07:00

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...

2010-07-24T10:47:00.002-07:00

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

2010-07-22T06:21:00.002-07:00

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

2010-07-22T06:11:00.003-07:00

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

2010-07-17T12:27:00.003-07:00

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...

Stop Living In the Past

2010-05-17T14:03:00.002-07:00

I have a patient who is living in her obstetrical past. She is a wonderful woman, very intelligent, with a pleasant sense of humor. I very much enjoy seeing her prenatally. But...

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?

I hate It When...

2010-05-17T13:57:00.002-07:00

I hate it when...

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

Transplant Evaluation and stuff

2010-05-15T09:37:00.003-07:00

My husband has been doing well considering. Energy level has improved to slightly above zilch :p

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.

Cesarean Scar

2010-05-15T09:33:00.003-07:00

I'm so woefully behind on blogging and reading blogs but will make a valiant attempt at 'catching up' on the blogosphere. While I was off tending to family, etc Navelgazing Midwife started up a new website - CesareanScar.com. I bow to her amazing skills and intuitive nature!

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.

Favorite 'duh' moment of the day

2010-05-15T09:26:00.003-07:00

It's 4am. The pager goes off.

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.

2010-05-15T09:23:00.003-07:00

I posted this cuz I think it's incredibly interesting and fascinating....

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

Latest Adventures of Nurse Crappy

2010-04-28T17:12:00.003-07:00

So yet again, I have p*ssed someone off and gotten the worst nurse there - Nurse Crappy.

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.

The Exorcist

2010-04-28T16:46:00.002-07:00

I had the privilege of witnessing a scene from the Exorcist recently - minus the vomiting of split pea soup :p

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*

Holy Cow - Babies Galore!

2010-04-26T18:19:00.003-07:00

I have been so crazy busy lately! Let me update you first on my husband's status...

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.

The Latest

2010-04-11T18:20:00.002-07:00

He's still hanging in there but we have been in the hospital for four days now. Too much longer and we will both be curled up in a ball cackling crazily. Here's th update in a nutshell....ok, maybe a large nutshell.

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.

This is NOT a typical OB patient

2010-04-11T18:13:00.001-07:00

I thought this was funny because this woman does exist. But I definitely disagree with the title - this is NOT typical!

Breathless

2010-04-03T11:19:00.002-07:00

Seems that my husband and I are both breathless but in different ways. He took the kids to the park and got out of breath just walking around leisurely. This morning he took our older daughter to play basketball at a local church. He didn't do anything but watch. Now he's exhausted and sound asleep. It seems to me he's getting worse. I'm wondering if he will have the stamina to go to his hour and a half class on Monday.

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?

Watching and Waiting

2010-04-02T12:55:00.002-07:00

My husband now weighs 224. On March 3rd, when I last talked about him, he weighed 246. He's getting so skinny. Technically his weight for his height is still overweight but he doesn't look healthy to me. He doesn't look strong anymore. He looks weak and like a man who is struggling.

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.

Update

2010-03-06T12:21:00.000-07:00

Ok, first - my husband is doing a little better. The cough is almost gone, he's maintaining his weight so far, he has a little more energy. I'm keeping a close eye on him and trying not to stress and worry about him.

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.

Achy-Breaky Heart and Pneumonia

2010-03-03T18:17:00.002-07:00

I've been quite busy lately. Work during the week and events all weekend. My husband has been under the weather for about three weeks now.

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.

No C/S for Me

2010-02-23T22:58:00.003-07:00

I had an interesting situation recently. I spoke with a woman, having her first baby, at the beginning of my call. She had been contracting all night. She opted to go into the office when it opened for a labor check. She was found to be 5-6cms so wanted to come to the hospital. Her plans were for natural childbirth.

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.

Valentine's Day Weekend

2010-02-14T08:56:00.002-07:00

HAPPY VALENTINE'S DAY!!!!!!

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.

Come and Gone

2010-02-11T11:39:00.003-07:00

The title refers to my tax refund money :p

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

Chaos

2010-02-11T11:27:00.004-07:00

I had a patient who was being induced via AROM but wasn't very active yet. My plan was to go get some dinner then be available for labor support. I had gotten a couple free tickets to our local NBA game. The plan was that my husband and older daughter would go as they both like basketball. He was gonna bring both daughters up to the hosptal to get the tickets from me and leave my younger daughter with me. I would then take her to my BFF's house, have some dinner, then go do labor support while my BFF watched my daughter. Welllll......

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!

Homebirth

2010-02-07T00:48:00.003-07:00

Does this make sense?

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.

Call Gods Suck.

2010-02-06T18:35:00.002-07:00

Call just seems to carry with it a black cloud of labors not going smoothly. And I seem to be on call with the same doc every time. Sometimes this is good and sometimes it's a freakin' stressful struggle. I have truly p*ssed off the call gods I guess. Perhaps I tried to plan something for when I was on call? Did I say the Q word one too many times? Did I try to sleep? It really doesn't take much to upset the call gods.

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

Favorite phone call

2010-02-06T06:02:00.002-07:00

It's 5am....sleeping well....pager goes off and it says "so-and-so, 3 months pregnant, possible UTI".

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.
Pt: Huh?
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.

Eh

2010-02-05T16:35:00.003-07:00

My BFF was pestering me to blog but I don't have a lot to say at this particular moment....let me see what I can come up with.

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

Busy Playing

2010-01-31T14:01:00.002-07:00

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.

Peanut

2010-01-31T11:46:00.004-07:00

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.

The Good, The Bad...

2010-01-26T18:57:00.003-07:00

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!

Why do I Get Myself Into These Things?

2010-01-23T10:21:00.002-07:00

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.

No Baby Magnet

2010-01-21T17:34:00.002-07:00

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.

How to Write a Great Blog Comment

2010-01-11T19:08:00.002-07:00

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 :)

Back in Wonderland

2010-01-10T22:48:00.003-07:00

I had an absolutely awesome birth recently. The only negative was that Nurse Crappy volunteered to take the patient. Seriously Nurse Crappy....you 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 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!

More Adventures

2010-01-05T09:04:00.002-07:00

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 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!

Adventures in Laborland

2010-01-03T12:34:00.002-07:00

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.

Avatar

2010-01-03T12:28:00.002-07:00

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.

Back to Work

2009-12-27T19:00:00.002-07:00

Well, tomorrow is back to work after being off for two weeks (the first week due to knee injury and the second week was scheduled PTO). I'm a little nervous but really feel that all will be well. I'm getting around pretty good on my knee. It gets stiff when not moving it but quickly loosens up. I would say that the knee is functioning at about 75% at this point. I do have some limitations on my range of motion (ROM), i.e. can't straighten it yet. I still am limping which causes some discomfort in other muscles and joints (especially since my ankles are some of my more troublesome joints). I will bring my crutch with me in case I need it. I'm a little nervous about sitting on the stool in the exam rooms...I'm worried that I will have trouble getting up without falling or hurting myself. I will stand when in rooms as much as possible to avoid this. The only thing I am very unsure about is first assisting for c-sections. There are none tomorrow (scheduled anyway) but on New Year's Eve there are 2! Will see how things are feeling and decide whether I can do it or not.

My knee still has puffy spots...but they are mild. I seem to have plateau'd (sp). The first week I was improving daily after the initial 2-3 days. This past week's progress has included more mobility and the ability to walk without a crutch. However, it's really been very slow progression. I have my f/u appointment on Tuesday to go over the results of the MRI and determine the POC. I suspect surgery is in my near future. I was supposed to have had the f/u last week but they rescheduled it to this week so the doctor could be present. That seems to be a huge hint that I will need surgery.

Here's hoping that all goes well tomorrow. I'm looking forward to getting back to work and to seeing my patients. I miss it all :)

Random Thoughts

2009-12-25T20:30:00.002-07:00

I want to wish everyone a Merry Christmas and a wonderful New Year. Now I feel like breaking out in song!

It's been quite busy these past few days, with preparation for Christmas, Nutcracker with my mother and the girls, making poor attempts at resting my knee. I've enjoyed the time for the most part...

Highlights (aside from the obvious of spending lots of time with my close family and friends)

-homemade fudge from my BFF
- seeing the Nutcracker
- italian christmas cookies made and decorated bymy mom, me, the kids, and my BFF

The bathtub

2009-12-18T16:27:00.002-07:00

I am so excited because I made it into the bathtub! Getting out might be a whole other blog post. And yes, I am blogging from my tub...the modern miracle of my fabulous cellphone :) I'm hoping my BFF might catch on and try buying something up to date and user useful, let alone friendly. Her phone is a piece of shite. Having a text conversation with her is like talking to a man with ADD...the conversation is all over the place and disjointed and confusing. You see, on my phone, text is laid out in chat form. Nice and organized, not to mention that I have a kkeyboard and she has some weird number/symbol/letter thing going on. Oh and no touch screen either. I'm so used to touch screen that if I use my moms crackberry, I start hitting the screen and get p*ssed off that it doesn't do anything!

Oh dear...am I rambling?

So, I got my christmas cards done. I'm off to do some christmas shopping and dinner with my BFF. I get to ride in a wheelchair - what fun!

Rumors

2009-12-17T22:19:00.002-07:00

I started a rumor that my knee was injured when Tonya Harding attacked me. I thought that was clever but likely that only people my age and older would get it. :p

I am struggling with my insurance company - I am surrounded by incompetence as well so that doesn't help. My rheum wanted to increase the dose interval on my meds which would likely require preauth as they are a bit expensive. I get a notice from my insurance that I am now required to use a specialty pharmacy instead of the ease of my local pharmacy. Ok. So I mail the Rx off to the pharmacy, like , 6-8 weeks ago. In the meantime I have some samples from my rheum to keep me going. I haven't filled any prescriptions at my local pharmacy since prior to the new RX. I get told that they can't fill it until the middle of this month....but it will be for the four syringes. Ok, I have enough samples to get by. I call back when I am supposed to and say ship my sh*t (well, maybe not in those words). They inform me that it has to be preauth'd. Uh wait...what have we been doing for past 6 weeks that you guys have had this Rx????

Ok, so I put on my patience mask and they get the ball rolling. Three days later my rheum's office calls me to let me know it's been approved. Woohoo! I go off to have my MRI done and come home to get a message from my insurance saying that my request for additional doses has been approved. Woohoo! I call the pharm to get it shipped. They promptly inform me that it can't be shipped until a week into january. Are you punking me???? Oh and it hasn't been authorized for the additional doses. But wait....did I dream the two calls saying it had? Maybe it was drug-induced wishful thinking. So the pharm chick calls my insurance to be told that the case is still pending. WTF? So I am waiting patiently...*snicker*....a couple days then will try again. It aggravates me because the increased dosing is working. Hardly any temps recently and very quick and low at that (like 99 as a high), they go away within a few minutes. My joints aren't giving me a lot of grief anymore. So aside from some fibro issues and the knee thing, I had been feeling better. Then this happens.

Guess what my temp is right now? 99.8 F*ck.

On the lighter side of things....my husband has been a doll. The girls too. They have been very helpful, waiting on me like the Queen that I am. My bestie and my mother have also been attentive to my needs, as it should be - LOL! I have a plan in place for grocery shopping and finishing my Christmas shopping, all with injured knee.

The knee, btw, is getting better....swelling is down considerably, less painful, and I can bear some weight now. My worst fear is falling. I'm scared it will go out again. I won't know MRI results and plan of care (POC) until Christmas Eve. That sucks. My husband says it ain't right that a football player can get injured and have the MRI and follow-up immediately. I mentioned a slight difference...I'm not an athlete making millions.

Poledancing

2009-12-13T17:46:00.002-07:00

I am writing this blog post from my bed. Are you titillated by the title? Well here's the scoop. I was out dancing with my BFF and my husband. I had had quite a bit to drink but wasn't dizzy or anything like that. I'm on the dance floorwith my BFF when I lean back a bit, then have the thought that 'something just happened and I'm gonna fall'. Two seconds later I hit the floor. So, I'm all emabarrased and not really sure what happened. My BFF helps meup, and I go down again when I try to put weight on my leg. Now, sh*t be hurtin' in my knee and I know something is wrong. I manage to get up with the assistance of my BFF and husband. I'm horribly embarrased and just want to get out of there. I barely make it to the car and we head back to my BFF's place. They both start insisting I go to the ER. I respectfully and politely decline repeatedly. Really, my knee doesn't hurt that much. BTW, alcohol makes a wonderful anethestic. I get up to show them I'm ok. When I turn towards my husband, something happens in my knee again and I scream. This happens once more and they get adamant about going to the ER. You see, my drunken but sound logic was that they wouldn't do anything but x-rays and say follow up with your doc on Monday...elevate, ice, etc. I could save $125 on the co-pay by waiting until urgent care was open. But they wasn't havin' it. In fact, I think my husband was getting ticked off.

So off we go....me still very drunk and embarrassed. We get there and fortunately it isn't busy. The staff are very kind and pleasant. What can I say? I'm a funny drunk. In fact, my cell phone got into the hands of my bestieso there's some very funny video footage. So, x-rays get done, the PA sees me and says likely menisucs tear which means go home and rest it, ice, pain meds, blah blah. Gee, big surprise. So home I go....they get me all comfy as possible with ice etc. I manage to sleep for a bit then wake frequently due to pain. My alcoholic anesthestic was wearing off. So while finally deciding to take a pain pill (kinda wanted to wait until I was a bit more sober...cuz that whole stop breathing thing doesn't work for me) and researching from my cell phone on meniscus tears, I learn that this was probably already present and I just didn't recognize it for what it was. I had been having these episodes of popping in the same knee for 3-4 months now. Not painful, just weird feeling with occasional twinges of pain. I thought it was just an arthritis thing but now I know that I likely had a tear and just totally blew it out finally.

So where does the poledancing come in? I was NOT poledancing. However my BFF thinks it will be fun to see who can generate the best rumor on Facebook on how I blew out my knee. That's her first crack at it!

Tales from the Office

2009-12-10T14:53:00.003-07:00

I have a personal patient who I can't wait to catch her baby. But I am worried she'll end up delivering at home. She's a grand multip (has had more than 5 babies) with a history of fast labors. Her longest labor was 4 hours. The last couple kids have been after 1 or 2 hours. She had been feeling a little crampy so I checked her...nothing much going on. But she's making me nervous cuz the last one other time I had this patient scenario, the patient delivered at home because it went so fast. I also was worried that even if she makes it to the hospital, I won't get there in time. So I gave her my cell phone number and told her not to stalk me, just call when she goes to the hospital so I can head in to. I'm hoping she won't go into labor while I am on vacation. She's not due until after the new year.

I have another personal patient (multip) who is now past her due date. Don't really want to induce her. We are still waiting for spontaneous labor. We have a week to go until we have to talk induction (42 weeks). At least that will be right before I go on vacation. I promised my husband and children I wouldn't work on vacation. But truth be told...I probably would if any of these personal patients come in. I just don't want to miss their births.

I have another one, a primip who is also term...about 40weeks. I've been stripping her membranes the past two weeks in the hopes that she'll have her baby before I go on vacation. How did I end up with so many personal patients all due around the same time?????

I am inducing another personal patient due to blood pressure issues. She's a multip with a favorable cervix so I am hoping all goes smoothly and quickly with her. I have such a blast with her and her husband. And her daughter is such a charmer...love seeing her!

Favorite complaint - I feel like I have a bladder infection and I drink plenty of water. Comes along with a urine sample that has small ketones and nothing else. "You feel this way because you don't drink enough water." She says "But I do". I look pointedly at her McDonalds cup and ask what's in that cup? It's obviously orange whatever it is. Busted.

I did a new OB appointment with a couple from the Middle East. They have been here for 3 months. They were adorable! She was so worried because she had a miscarriage at 4 weeks the first time and is Rh negative. She didn't get Rhogam afterwards. So now she's scared for this pregnancy. Someone (family doctor I guess) has scared the crap out of her. I explain, via the translator, that she was too early for there to be any concern. I reassure her and have them both smiling and happy by the end of the visit.

6 Babies Part II

2009-12-10T14:15:00.005-07:00

So the first primip very slowly made her way to 10cms....this was after numerous position changes and using the peanut. She was also experiencing a lot of pressure and was very umcomfortable with that. She began to whine a lot. For those that know me, my tolerance for whining is minimal. I stayed out of the room as much as possible initially because none of the pep talks or support seemed to be helping her. Her family was clustered around her, offering encouragement and support. She just wasn't havin' it.

Meanwhile, the other primip was 8cms and feeling some pain. We got her epidural dosed and I broker her water. We got her settled again so I went back to dealing with the whiny primip.

The whiny primip had been pushing for awhile - some of her pushes were great and others not so much. The baby had a good bit of caput and momma had protruding ischial spines which were holding baby up a bit. I was a little concerned that she might not be able to get the baby out, especially if she continued to fight the process. After an hour and a half of pushing and slow but steady progress, we got her epidural dosed up again. I also kicked out the family except for the FOB. They were very understanding, and I kept them updated. I talked to the doc on call with me...he basically said to tell her she had 30 minutes to do something or he would come in and section her. Not the response I was wanting. She was potentially vacuumable at this point but he really needed to be the one to make that decision. I was so ticked off that he wouldn't come and evaluate. I went back to the room, where the patient was a little more settled after getting her epidural redosed, and told the patient what he had said. I could see that the caput was starting to crown. I then proceeded to talk to her as if she was my child. I told her she didn't need a section and if she would just suck it up and do the work, she could do this. I told her I wasn't letting her have a section....she was only gonna do this one way. And we got to work.

Forty minutes later, she delivered an adorable baby with a huge conehead after a 90second shoulder dystocia. Apgars were 1 min - 2, 5 min - 6, 10 min - 8, 15 min - 10. I thought I would have to change my underwear after the whole thing was said and done. It was nervewracking! The next day, I went to see her and the baby and both were doing great! Oh, and this was over an intact perieum - and the baby was close to 8 pounds!

The second primip by this time was complete and ready to push. She did a great job. We had a baby crowning fairly quickly. She also had an adorable baby after a 2 minute shoulder/body dystocia. The baby had apgars of 5-6-8. The baby weighed in at almost 9 pounds and momma just had a single periurthral tear that I threw a few stitches in. Change my pants again. Both doing very well the next day.

So two beautiful natural birthes. Then karma had to strike....and I get two shoulder dystocias.....geez.

I went home and got some rest. It's a good thing cause I was destined to be up all night on the Sunday night.

A woman came in who I had seen a few times in the office. She was 4cms in the office and was planning a trial of labor after having a c/s with her first baby. Her first baby was 9+ pounds and OP (posterior position) along with some chorio (infection in the uterus) - unfortunately a failed homebirth. She's tiny as well. Maybe 5 foot at best. I knew this baby was smaller - I estimated between 8 and 8 and a half. She was coming up on 41 weeks so was really hoping she would go into labor over the weekend. Otherwise we would be breaking her water on the following Monday.

She called me and let me know she was contracting and getting more uncomfortable. I suggested coming in. Two hours later, she finally showed up - just I am really starting to worry! Her water was broke as well, which she failed to mention to me. She was 4-5cms. So I had her walk for awhile alternating with rest. The plan was to wait until she was a little more uncomfortable then have her get in the tub. But then the baby was acting up a little - nothing major but enough that I wanted to keep an eye on the baby. Once I was happy with the baby again, we just never made it to the tub....the waterproof doppler couldn't be found so she would have to get out every 15-20 minutes for a quick listen. We decided not to bother with it. She did many position changes, with her husband on one side and me on the other. I did some massage of her back and later had her husband do some effluerage, whcih she liked. Like the other two women who birthed naturally, she was gorgeous to watch. So calm and relaxed. She was about 5-6cms, when I checked her 4 hours after the first exam. I was a little concerned about the slow progress but just tried to remind myself that labor doesn't always follow Friedman's curve.

In the meantime I caught a baby for the doc on call. This patient had a history of a precipitous labor with her first baby. She went from 5cms to 8 after walking. I broke her water, then got her in the tub. She was the type of person who never seems to be happy with anything but who knows...she was in labor after all. I found it difficult to establish a rapport with her (which is something that doesn't happen often for me) but the nurse was actually doing labor support! What a pleasant change. So I left them to it. She ended up delivering about an hour and a half after I broke her water. I was surprised as I didn't think it would take that long. So that was baby #5.

In the meantime, my other lady is continuing to do very well....seems to be getting more transitiony so I start getting a little more excited. Soon, she wants to push. I check her and she just has a small anterior lip which easily reduces with the next contraction. I tell her she can push when she feels ready. When I look at her pushing and her big belly I start worrying. I so want her to be successful. But her belly looks huge in comparison to her. But she very quickly crowns up and we have a baby! She pushed for 23 minutes. She had small periurethral tears. WOOHOO! She was so happy afterwards. I was so happy for her! Her labor from admission to delivery was about 8 hours....but anytime one has to stay awake all night labor seems long.

I left at 7am, when I went off call.

6 Babies

2009-12-10T12:04:00.002-07:00

I had a busy weekend on call not too long ago....are you ready to hear about it? Here goes...

Friday night was quiet. I had one page from triage around midnight. It was a patient having her first baby. She was initially 2-3cms then 3cms after walking for an hour. She was contracting regularly and uncomfortable with them. I ordered therapuetic rest fro her and sent her home (morphine shot - works by giving momma some rest - when she wakes the prodromal labor will either be gone or will have turned into active labor.) In hindsight, I don't really think it was prodromal labor. I think she was just in very early labor. Why do I think this you ask??? She came back around 6am Saturday morning and was 8cms!

I rush on in. The patient is doing incredibly well.....by the time I get there she's completely dilated and the baby is at a +2 station. I send the resident scurrying off (she was standing by for me) and we get done to business. The patient is doing a beautiful job of pushing her baby out. She is so calm and chats in between the contractions!?! Her boyfriend and family are all present and doing a very nice job of being supportive. I guide her through the delivery of baby #1. She does an amazing job. I repair her tear and off to go check on another patient who I admitted while on my way in.

This new patient was also a primip (first baby) and had come in since her water had broken earlier during the night. This patient was planning an epidural and I had the nurse start pitocin as she wasn't in labor. Her cervix was a fingertip/75% effaced and soft when she arrived. She was also ready to get things going. She was comfortably ensconced in her room with lots of family present. At first I thought the family would be obnoxious but as the day went by, it was the patient who was obnoxious and the family was great! :p I told her I would check on her later.

I then attempted to leave to meet my mother for some Christmas shopping. I was halfway to the mall when I got a page from a personal patient of mine. I had caught her first baby with a student midwife and had spent this pregnancy with her as well. My plan had been to catch this baby even if I wasn't on call. How nice of her to go into labor while I was on call! She's been contracting all night and her water broke a couple hours ago. I suggest she come on in as she says the contractions are now 6 minutes apart and getting stronger. I turn around and head back to the hospital. She arrives a little later and is actively laboring....although you can't tell it by looking at her! She's 5cms and doing beautifully. We get her in the tub where she labors until she's ready to deliver. She moves to the bed and pushes out a gorgeous baby #2 over an intact perineum in six minutes flat. The enitre time, she remained so calm and focused. What a beautiful birth goddess! I aways wish I could take pictures of women when they look like this...But it's so private and intimate. I just want women to see how beautiful they look when they are in the throes of labor. Anyway, she delivered only a couple hours after arriving. Nice.

I check back on my primip who is slowly but surely getting into labor. She's had a couple doses of stadol but isn't quite to the point of being ready for an epidural. She's 3cms now. I tell the nurse if she asks for more stadol again, to go ahead and let her have the epidural. No exam. After all she's been ruptured and if I don't put some specific guidelines down, some of the nurses will check patients frequently even with the water being broke. I decide to head out and try to meet my mom again.

I manage to get lunch and some shopping done with my mother. While at lunch I get a call about a new patient. This patient is also a primip who came in for a labor check. She's 4cms and crying I guess...wants an epidural. Ok, go for it.

I head back to the hospital to check on everyone. The primip on pit has an epidural and is very comfy. I check her and she's 8cms now - woohoo! The family has multiplied...there are about 12 people in the room - no exaggeration! The nurse has told them no more than four people. However, there's not a policy. It's really up to the provider. They want the soon-to-be grandparents to be there along with the FOB, which makes 5 people. I tell them that's no problem. I normally don't put any limitation unless they are interfering with the woman and her labor or if there are complications. She had meconium and so we would also have the neo and nursery nurse there as well, so it was gonna be pretty crowded.

I check on the other primip and she's also comfy with her epidural. She's 6cms and intact bag of water. I leave her be as I am afraid that her fast progress will put me into a situation of trying to be in two places at the same time. I didn't need to worry. The first primip sitch turned into a nightmare and she wasn't gonna deliver anytime soon.

To Be Continued...

And the stupidity award goes to....

2009-12-01T06:31:00.002-07:00

The mom who left her 6-year-old alseep in the front seat of her minivan while she took her younger child into Starbucks for her caffeine fix, quite a ways away.

I was on my way to see New Moon with my mother and daughter when we came across this situation. We kinda looked at each other and looked around the parking lot. No momma in sight. We decided we had to do something, but not really sure what. Then we saw a woman come out of Starbucks and thought maybe she was the owner...nope, different vehicle. I finally told my mother to go buy the tckets and I would trek across the parking lot to the policeman parked at the empty end of this lot - it was quite a distance and likely would make me miss the beginning of the movie getting involved. But we felt like if something happened to that kid, we could have prevented it buy intervening. Then we saw momma come out and unlock the car with her keyless entry.

Hey, at least she didn't leave the keys in the car with the kid!

Chronic Pain letter

2009-11-24T07:43:00.001-07:00

Go check out this posted anonymous letter about chronic pain...It really explains a lot about what it's like to live with chronic pain.

Another day on call

2009-11-24T06:55:00.002-07:00

I had a fairly quiet call recently. I did a scheduled section with one of the docs...it was delayed a bit as a crash section had to be done first. I felt bad for the lady getting crashed. Her baby's heart rate did a couple big dips but stabilized with moderate variability. I wouldn't have sectioned her at that point. But I guess because the nurse called the doc and acted all panicky, he called it. The patient was 3-4cms and first baby so maybe he didn't want to bother with trying to let her labor. It irks me that the nurse was the one who essentially made the decision to section. The doc didn't even come to evaluate, the patient was already in the OR!

I got called in for a delivery in the wee hours of the morning. She delivered before I could get there....fast! She was 6-7cms, second baby, when she arrived. 20 minutes later...done. I got to do the placenta...what fun.

I was ticked because one of the MAs screwed up a patient's 24 hour urine. Only creatinine was ordered on it. Are you serious? Now why do you think that we might dip a hypertensive patients' urine for protein but only check her 24 hour urine for creatinine?

I got a call from my favorite nut....she's had a lot of GI issues but the GI doc won't see her because she's pregnant. What a big f*ckin' help. Anyway, she calls to let me know she's been vomiting all day. She wanted advice. Uh, go to triage for IV fluids and zofran. It's not like the first time this has happened. You know what you need to do. Why are you calling me first?

I'm looking forward to Thanksgiving and Christmas. Especially Christmas as it involves a vacation of 9 days! Woohoo. I need it. Its been since June since my last vaca...I'm burning out!

Fibro Fog

2009-11-19T07:15:00.003-07:00

I have what I now know are fibro fogs - difficulty concentrating and focusing. Here's a conversation with my husband recently...

Me: How was class?

Husband: We talked about _____ and it was really interesting. The teacher said that....wah wah wah, wah wah wah. Wah, wah, wah.....

Me: Wait, what?

Here's a conversation I had with my mother...

Me: What's been going on at work?

Mom: It's been crazy. The VP is back from Japan and on a warpath. She wah wah wah, wah wah wah. Then wah wah wah.

Me: Huh?

And here's one with a patient recently....

Me: So what seems to be the problem today?

Patient: Well, I have all this bleeding. And then I have this pain. And I want to change birth control. And....so on and so forth

Me: Wait, one thing at a time....and let me get this stuff written done.

See a trend?

Busy at day but not at night :)

2009-11-19T06:16:00.002-07:00

Favorite office encounter - I met a very sweet lady who came in for a breast complaint initially. So I ask lots of questions and when I get to the 'are you on birth control' question she says yes. She had gotten these triphasic (they have three different levels of hormones in the pill pack instead of just a steady level throughout the month) pills from planned parenthood. She couldn't remember the name but had them with her, also mentioning that she had missed 3-4 so far this pack. Nice. So I look at the pack...there's a lot of pills missing randomly. I get confused. I ask her how she's been taking these. She says she just pops one out randomly each day to take...

Umm, ok.

So, I manage to restrain myself from laughing. I explain to this less than bright star that she has to take the pills in order and no wonder she's having the issues she's having. We have a very careful lesson on how to use birth control pills and I get her all set up and send on her way.

I had lots of babies show up during the day but nothing during the night, which was nice. I had one little hispanic lady come in. Her last baby was thirteen years ago and was supposedly 4500 grams...which is around 9-14 I believe. He baby before that was 4000 grams, or about 8-13 I think. Nothing in the chart about shoulder dystocia or any problems with those deliveries. She comes in at 6-7cms and doesn't want to move from the bed or want anything for pain. I want to offer her labor support but it just feels weird sitting there so I kinda go make rounds and pop in on her. She has her daughter and her husband with her. She progresses to complete and begins to push spontaneously. And she pushes. It takes her awhile to push well, there's a lot of holding back, but then she throws herself into it. She makes good progress until the head comes out. Then we get a shoulder, which I am able to rotate out from the pubic bone. It turns into a body dystocia, meaning the body is now just stuck in her vaginal canal. We finally get the baby out, who ends up weighing in at 9-1, and doing well after initially being a little stunned. We have a borderline postpartum hemorrhage then everything stabilizes. She's intact aside from a perineal skidmark. Then the daughter says to me "oh yeah that happened with my brother and me when we were born." Hmmm, thanks for the heads up. I almost had a code yellow on this one.

Another patient was a young girl having her first baby at 42 weeks gestation. Things went smoothly, she got an epidural around 4-5cms. She continued to progress well, reaching 10cms shortly before 2pm. She labors down a bit until she feels pressure. We start her pushing at 3pm. At 4pm, she's made a little progress - the caput is descending :p I start thinking of the words of the physician from the day before (he was joking but still) "a 42-week primip? when do you wanna do the section?" I told him, to knock it off, that she would be fine :p So anywhoo, I decide to stop pushing for a bit and let her rest as well as maybe some more laboring down. The baby looks fine and she's comfortable with her epidural. We put her on her side with the peanut for half an hour, then we flip her to the other side. At 5pm, we start pushing again....the head has come down maybe a little during that time but now her pushing efforts are becoming much more effective. After she pushes for 24 minutes, we have beautiful baby weighing in at 8-14 over a second degree perineal lac. Both momma and baby were doing well! I felt tempted to call the doc and let him know we wouldn't be needing his c/s!

Another primip was sent over from the hospital for labor. She progressed well also reaching 10cms shortly after the previous patient, but felt no urge to push so laboring down was the phrase of the day. Once she began to feel pressure, the nurse checked her and says the baby is +2 (station in the pelvis with +3 being crowning). The heart rate is starting to drop with contractions, so I'm all like let's have a baby! The nurse does a few trial pushes and comes out and says she isn't pushing well. So I go in and evaluate....the patient pushes beautifully so tease the nurse for a moment and then we get down to business. Unfortunately, baby doesn't like this part of the process and we start getting some ugly strip. I ask the patient if I can cut an epis (something I have done maybe 6-7 times before - I only reserve it for this kind of scenario!) after explaining why - she says yes. So I cut a very small epis (the equivalent of a first degree lac) with very dull scissors....wow, I was ready to start gnawing on her perineum cuz the scissors were so dull...geez...oh....that sounds gross doesn't it. Anyway, she delivers with the next contraction and no extension of the epis. She has a beautiful baby weighing in at just under 7 pounds, does quite well. I repair what I broke and everyone's happy.

I am frustrated with one of the midwives...I think she's clinically depressed. I think she has a lot of personal issues. Professionally, she's had some tough call to just be starting out with. Not really sure if it's her labor management or just a black cloud following her. I remember when I was new I had a placenta cloud following me. I've tried to extend a hand but she doesn't seem interested in help. I asked her to give me a call when she was done seeing patients because I wanted to let her know what was going on with an antepartum patient so I wouldn't have to call her and wake her in the morning if there was nothing else going on. I also wanted to invite her and her kids over this weekend to hang out. She never called. So I called her and left a message...she never called me back. I'm worried about her well-being. I really hope she will be ok.

Does this make sense?

2009-11-15T20:21:00.002-07:00

So I made myself available to work regsitry today if they had a shift - although I kept my fingers crossed they wouldn't need me :p So they called me at 5 am to let me know that I was cancelled. Uh, ok. Thanks for waking me to let me know.

So that call is about par with the one from a nurse at 3 am to let me know that the antibiotics are working and the patient is afebrile (without a temp). Gee, thanks.

The kicker....I was sleeping really well...I mean really well. Like I was achieving restful sleep! Which I haven't see much of these days. Oh well, I did get lots of blogging done :)

Epidurals and trampstamps: Safety or bias?

2009-11-15T08:01:00.003-07:00

I saw this post with excerpts from an article on the Unnecesarean blog on Epidurals and Lower Back Tattoos.

Are you serious?

This has very little to do with safety and much to do with preconceived notions of women with tattoos.

Whatever.

*my statments refer to the idiots in the excerpts, NOT Jill!*

Fibromyalgia

2009-11-15T07:24:00.002-07:00

*Courtesy of WebMD* (My symptoms in red)

What is fibromyalgia?
Fibromyalgia is widespread pain in the muscles and soft tissues above and below the waist and on both sides of the body. Fibromyalgia is a syndrome-a set of symptoms that happen together but do not have a known cause. In this syndrome, the nervous system (nerves, spinal cord, and brain) is not able to control what it feels, so ordinary feelings from your muscles, joints, and soft tissues are experienced as pain. People with fibromyalgia feel pain and/or tenderness even when there is no injury or inflammation.

Fibromyalgia does not harm your muscles, joints, or organs, and there are many things you can do to control it. When it is not controlled, you may not have any energy, or you may feel depressed or have trouble sleeping. These and other symptoms can be bad enough to cause problems with your work and home life. With treatment, most people with fibromyalgia are able to continue working and participating in daily activities. Some people adjust their work duties and lifestyle if their symptoms are severe.

What causes fibromyalgia?
Experts have theories about what may cause fibromyalgia, but there is not enough evidence to support any single cause. Some think that people with fibromyalgia may have nerve cells that are too sensitive. Others think that chemicals in the brain (neurotransmitters) may be out of balance. Or it may be related to problems with the deep phase of sleep.

What are the symptoms?
The main symptom of fibromyalgia is pain in the muscles, soft tissues, back, or neck. Also certain spots on the body hurt when you press directly on them (I have 14 out of 18 - that sucks!). Experts call these tender points, but you may also hear them called trigger points.

Fibromyalgia also causes sleep problems (the past 4 months or so have been rough!) and tiredness.

Less common symptoms include headaches, morning stiffness, trouble concentrating, and irritable bowel syndrome. As with many conditions that cause chronic pain, it is common for people with fibromyalgia to have anxiety and depression. These can make you feel worse. (Also read in a pamphlet from the rheum office that one can experience bladder irritation - check, PMS, PMDD, painful perios - check, acid reflux - check, numbness and tingling sensations - check, dry eyes and/or mouth - check, 'allergies' - check)

Fibromyalgia is a long-lasting (chronic) condition with no cure. Symptoms tend to come and go. You may have times when you hurt more, followed by times when symptoms happen less often, hurt less, or are absent (remissions).

Some people find that their symptoms are worse in cold and damp weather, during times of stress, or when they try to do too much.

How is fibromyalgia diagnosed?
Doctors can find out if you have fibromyalgia based on two things. One is widespread pain, which means the pain is on both sides of your body above and below the waist. The other is tenderness in at least 11 of 18 points when they are pressed. Your doctor will also take steps to be sure you don't have other conditions that cause pain, such as rheumatoid arthritis, polymyalgia rheumatica, systemic lupus erythematosus, or other autoimmune diseases.

How is Fibromyalgia treated?
You may be able to control your symptoms with regular exercise and by finding better ways to handle stress. Good sleep habits are very important, too. If you have trouble sleeping, changes to your routine, schedule, and sleep surroundings can help. Counseling can help you cope with long-term (chronic) pain.

If your symptoms are troublesome, your doctor can prescribe medicines that help you feel better.

Symptoms of depression, such as a loss of interest in things you usually enjoy or changes in eating and sleeping habits, can often be successfully treated if you tell your doctor about them.

Some people with fibromyalgia also find complementary therapies helpful. These include acupuncture, massage, behavioral therapy, and relaxation techniques.

LMAO!

2009-11-15T06:54:00.003-07:00

I was checking out a new blog, called Uncompromised Airways (because I have so much time for this - seriously, this blogging takes away from time spent on facebook playing Mafia Wars - this is a problem) and came across this picture in a post...hilarious!

Prenatal SSRI usage

2009-11-15T06:30:00.004-07:00

I was over at Mitchsmom's blog checking out her latest posts. She had posted a link to a Medscape article entitled Prenatal SSRIs Linked to Problems in Newborns. I find mental health interesting and as a midwife I am in the position of dealing with these issues at times. We have patients suffering from depression, PTSD, bipolar, etc. I feel comfortable enough prescribing antidepressants/antianxiety meds, although not all of the midwives I work with do. But I feel even more comfortable if I have somewhere to refer these patients, and therein lies a huge issue.

My counseling of women with depression typically involves a discussion of SSRIs and third trimester use. Prior to reading this article, my discussion focused on neonatal risks. I was not aware of the possibility of preterm birth, lower 5 minute apgars, or increased risk for NICU admission.

The problem of access to mental health services is a huge one in this country and where I live. Patients without private insurance must call Magellan themselves (which is an issue sometimes - when your depressed, who wants to pick up the phone when all seems hopeless?), then they often get to wait up to 2 months for services! Once they have their initial appointment, they often are put into group therapy while being on a waitlist for one-on-one therapy. But they also get their meds managed. My personal preference is to start someone ona SSRI and then have mental health take over management of that.

We do need to carefully weigh the benefit to the mother against the risk to the fetus/neonate. This article seems to imply that as well as being in favor of the well-being of the baby as a priority. This is a slippery slope - and a source of much controversy in general - to consider that the well-being of the baby may be more important than the well-being of the mother. In a perfect world, where patients could easily get access to counseling and other forms of therapy, it would be easier to say "ok, let's not use SSRIs until baby comes". Research shows that patients will benefit from both counseling and med therapy. But the reality is that with resources severely limited, sometimes SSRIs are the only tool we have.

Rough Night

2009-11-14T06:02:00.002-07:00

I had a rough night recently. I had a patient who was having her second baby and we had a less than optimal outcome. I think it sounds like the baby will be fine in the long run. Even intially the baby was doing better. But you know how these things can weigh heavily on one's mind. These outcomes are so far and few between so makes it even more uncomfortable when they occur. Even though you know you managed appropriately, you still feel a sense of responsibility. You also get a case of the what-ifs....what if I had done this at this point...or done that....or whatever. I even called the physician at one point to come in. He reviewed the strip from home and said I didn't need him. I was very p*ssed off. Some of our docs are very difficult to get out of bed, whereas others will come, no questions asked. I also called the doc back afterwards to review the strip with me from start to finish, which he did from home. I felt better after having done that. Anyway, I got the baby out and am praying this kid is ok.

Lately I feel like a failure as a midwife. It seems like I have these occasional spells where things seem to go wrong a lot. I begin to wonder if it's me, maybe I suck. That's a really uncomfortable feeling. I also start to worry that maybe my mental clarity is not so hot. Guess that can be due to fibro. But really, when I look at whatever has happened, it seems like I made the appropriate actions but yet, just feel like I still screwed up anyway.

For example...I saw a patient quite some time ago. The patient had a reactive RPR but a negative TPPA. So that means she doesn't have syphilis. I let the patient go but chased down a doc when I had a chance later that day. I asked him if I needed to be concerned and do anything further regarding the labs. He said no, just find out if she has previously had syphilis and been treated. I figured this patient, who was a doc patient, would be ok til her next visit. We could check on it then. Maybe this is the part where I was stupid? I should have called her at her home. And I didn't document that conversation. That was definitely stupid. Anyway, so another doc sees the patient and is concerned as to why we haven't 'done anything' prior to now. She wants to send the patient to the perinatologist. I related my conversation with the previous doc and apologize for not having called the patient back at that time to further ascertain what may have caused her RPR to be reactive. But she seemed perturbed.

Causes of RPR being reactive (other than syphilis) - pregnancy, connective tissue disease, bacterial or viral infections, advanced cancer, myeloma. There may have been a couple other things but can't remember now.

Ugh.

Sex and lots of it!

2009-11-12T10:47:00.002-07:00

I saw an adorable couple in the office and have seen them several times actually. She's a couple days past her due date and we were dicussing various options and plans for the next week or so if she didn't go into labor. She said both her husband and herself were 42 weekers. I told her that it was likely she would carry that long then. But her cervix is changing - 1-2/80/-1 - so I told her for now to just focus on lots of sex and lovin' :) I kinda hope she goes into labor when I am on call...they are lots of fun!

I only caught one baby on my last call. And it was in the evening so I ain't complaining considering how crappy I have gone back to feeling since Tuesday afternoon. This particular patient, I had seen a couple times with this pregnancy and also with her pregnancy last year. She came in to L&D and was 4cms and requesting an epidural. I was at the office seeing patients so gave orders for that and said I was almost done and would be over shortly. I expected that she would have an epidural by the time I got there. Uh, no. Apparently there was a section going on and they were just finishing up. I checked her and found her to be 7/90/-1 with a BBOW. I asked her if she was sure she wanted an epidural and she was very sure! She finally got her epidural, we put her on her side to rest, and anticipated a baby soon. I was kinda hoping to make it to her second dose of antibiotics but didn't really think we would. But alas, we got close to the time so decided to break her water as her contractions were spacing out . Although, sometimes when putting a women on her side, the contractions may space out but they become stronger. However, she also wanted to get the labor over with.

I checked and she was 9/100/-1 with a very BBOW. I broke her water and figured we would have a baby very soon....and we did. She felt pushy about 20 minutes later and was complete. So she started pushing. It took her about ten minutes to get the hang of pushing again, then she moved that baby right on out. She was kinda in a squatting position....she was holding the nurse and her husband's hand to pull herself almost upright. This was very effective for her. I kinda wish we had had time to get the birth bar out for her but she was gonna deliver without it anyway. She delivered over just a small perineal ding and it was her smallest baby yet! I had told her that the baby looked small earlier in the night, maybe 7 pounds. She said "that's what you said last time and he was 7-11!" This baby was 7-2. I rock.

I admitted someone about 2:30am but no need to go in as she was a primip and wanting an epidural at 3cms (SROM). That's unusal that that happens to me! Typically if patients come in around that time, they are going natural or are a primip and 6cms who might deliver prior to 7am or etc. All of these scenarios would require me to go in. When I checked back this morning she was 4cms with spacey contractions (probably because of the epidural) so I started a little pit, then handed off to the next midwife.

Speaking of the next midwife...While I was hanging out waiting on my lady to deliver, this midwife had a personal patient of hers come in. So you would think "cool, I don't have to manage this patient and potentially be here all night - yah!" But this midwife has health issues so if she doesn't get enough rest, she ends up needing to go home to bed. Twice before she has asked me to take over in the middle of labor. Both times, they were personal patients of hers, and both were having natural childbirth so needed labor support. This left me in the awkward position of having to step in during very active, almost transitional, labor for both. Not cool. It's not fair to the patient or to me. I had never met thses women before even. Fortunately her patient this time was 9cms when she arrived and it was her 5th baby I think. So it didn't take long. But imo, either commit or don't....just plan to follow through. What I mean is...if you know you are tired or that the patient is earlier in labor and it's night time then maybe don't come at all. If you agree to come, then stay. And if you can't do that, then maybe you shouldn't be committing to patients like that. If someone comes in that is a personal patient of mine....if I agree to come in for her at that time then I consider that a committment that I will foloow her until she delivers, no matter how long that might take.

Anywhoo.

There's a doc who drives a mercedes...red....license tag says 'empuje'. He's a funny guy. Until he parked in the CNM parking spot instead of one of the many open OB spots. There are only two CNM spots....and they are compact spots. My car is not huge but nor is it a compact car. But because he didn't want to park ten feet further away, he parked in the CNM spot. Seriously. The neos have done this as well, on occasion. But it's worse because one of them drives a SUV. Geez. I have parked in the OB spot before because of either someone's big a$$ SUV or crappy parking job in the CNM spots. I ain't shy.

Quickie

2009-11-10T21:28:00.003-07:00

Ok pervs, it's not what you think! Just a short post before I head off to bed.

I was in the office and encountered some interesting and fun patients.

I have a lady who's first baby I caught last year and I am now seeing with her second child. I am eagerly looking forward to catching this baby! She brought her daughter with her, who I have not seen since her birth. She's adorable and so big! We always have a good time cutting up.

I have another lady who is pregnant with her third. She's a doll...she has RA so she and I have bonded over rheum issues :p I am hoping to catch her baby as well.

I saw a teen who has bipolar, history of substance abuse (currently smokes pot to avoid doing meth I guess), and smokes. This was my first time meeting her. She had her mother and boyfriend with her. I asked if this was his baby...was actually joking with him...he answered no then she did also. I hesitated because I thought they were joking back. Uh no. It's not his. Ooookay. Anyway, she has this fabulous bubbly personality :) I had to give her an Rx for her BV that showed up on a pap and culture done by the NP. But frankly, I didn't need the labs to make a diagnosis. I could have done it when I walked in the room. I had a flashback and thought I was at the beach. Seriously. You didn't notice that anyone????

I had another teen who I wanted to smack. I normally do quite well with teens but this one wouldn't look me in the eye, kept looking at her teen sister and giggling. Her mother would answer questions for her, even when I had my back to her and was facing the patient when I asked. The mother answered when I asked if the baby was moving lots... Uh, last time I checked mom, you weren't the pregnant 16-year-old. The patient got smartass with me when I tried to counsel her on her diet and weight gain. She flat out told me that she eats nothing but junk. I suggested some reasonable substitutes and just cutting back on the junk. She just kept giving me lip, so I just gave it right back to her. Betcha I won't see her again....until she shows up in labor as my luck would likely have it.

Saw a couple of new OBs, one of which is the sister of another patient of mine :)

Sadder news...The rheum said I have fibromyalgia along with whatever arthritic disorder I have. I wasn't hugely surprised as i suspected this was coming. But it's still a bit of an adjustment. Then, after feeling pretty decent all weekend (aside from the usual lack of sleep), I started feeling pretty crappy this afternoon to be topped off by falling about a half an hour ago. I am feeling supercrappy now. The arm of the chair practically went up my butt when it flipped out from under me.

More call recently

2009-11-09T06:03:00.002-07:00

I took over on a patient who was only 34 weeks by a third trimester ultrasound but 38 weeks by a shaky LMP. We were using the US EDC because the baby did not have the appearance of an IUGR baby, which is what it would have been had we used her shaky LMP. The patient was not exactly reliable. Her prenatal care was very hit-or-miss. She had been in the previous night for contractions, was supposed to be on pelvic and modified bedrest, but the boyfriend apparently threw her under the bus while she was in the restroom and told the triage nurse that she wasn't listening. So the triage nurse ends up sending her home after scaring the crap out of her by telling her that her baby would "live with her the rest of her life if born now". The triage nurse was none other than my BFF! Her goal was to scare the patient into being compliant. I know where she was coming from but told her that was mean!

Anyway, the patient returned with her water broke this time. She was 3cms on arrival. So we got ready to have a baby. She wanted an epidural which she got. A touch of pitocin and she delivered a short time later. Fortunately the baby came out looking more like a 36 weeker and was breastfeeding very well. She'll go home with her momma after all. And hoepfully not live with her for the rest of her momma's life. LOL!

I had another patient who I took over on and was not real happy with the management. The midwife on call never came in during the night to do labor support. The pateint had been there since late evening and had 4 doses of stadol at that time. Her labor was essentially stalled by the time I arrive that morning. She was 7-8cms. After trying everything possible and suspecting that the baby was too big and OP to boot, we sectioned her. It was totally the right call....the baby was straight OP and 8-3. Her pelvis was so little there was no way that kid was coming out of there. The doc on call (from another practice) was a little crabby when I updated him on the phone - he couldn't understand why I had waited so long to call for a section. Uh, well cause the baby looks fine and I wanted to give her every opportunity to deliver vaginally. There have been many times where other providers would have cut a patient but because we midwives understand that not every labor goes by Friedman's curve, we have gotten a vag delivery.

I had another patient who precipted (sp) - she rolled in the door and was 6-7 cms, delivered less than an hour later. She was so mad at me and th enurse because we wouldn't give any Stadol (I was willing to give her some but she delivered by the time the pharmacy had it in the system so just as well). I felt so bad because she was looking at us with these pleading eyes. Afterwards, it took her a while to smile at us (she was spanish-speaking). She did a beautiful job though pushing a big baby out!

Random stuff

2009-11-09T05:20:00.003-07:00

Call hasn't been too crazy for a change and life has been nice. Good for me but not conducive to blogging!

I had a woman come in sorta in labor recently. She was having her second baby, but it had been quite some time since the first. I had seen her in the office a couple times and we had hit it off. She's absolutely gorgeous, very intelligent, but has a husband who sounds like a bit of an a$$. From what she was telling me, he has a bit of Peter Pan syndrome going on!

Anywhoo, she came in and was initially 3/60/-2, contracting regularly. Her plans were for natural childbirth. Her first labor had only been four hours, but again, was quite some time ago. I think she had some expectations that this labor would be just as quick if not faster. I had warned her that while that might happen, not to pin her hopes on it.

The nurse sent her out walking for an hour or so, and when she returned she was 4/70/-2. So I kept her. And it was downhill from there! Well, ok, maybe not quite that bad. But it sure wasn't a smooth labor. I had the nurse send her out walking again until I could get over there from the office. Once I arrived she was alternating some walking with resting on the birth ball. She had a goofy friend with her who was very ....manic almost. She was sweet but driving me nuts and I felt like she was throwing off the vibe in the room. I really love a quiet, calm atmosphere. I realize that not every patient wants or needs that but most do. This chick was almost bouncing off the walls with excitement. And the patient was starting to feel irritated as well (shge mentioned to the nurse that she hoped her friend would go soon). The husband wasn't there, and my patient wasn't sure that she was gonna tell him yet that she was at the hospital. I was a little concerned by that as well, as I feel like the patient was anxious about how things were going to go.

I was thinking to myself 'great, what other issues can we drag into this room?' OH, and she has a history of sexual trauma. *sigh* I'm feeling those instincts kick in. Oh, and the baby was doing some strange things on the monitor. The strip would look fabulous then would do funky things. Not bad, just odd. Some of it was dehydration - she admitted to having drank very little that day and reported feeling much better with IV and oral hydration. The baby straightened out a little better as well. But there were still some oddities about the strip. I was still comfortable enough to get her off the monitor though.

After a couple hours went by, we re-checked her and she had not changed. I offered her three options...1. Go home (although due to the oddities in the heartrate I was a little uncomfy with this one), 2. Break water in the hopes of getting things going, 3. Do nothing and just wait. She opted for #2 so I broke her water and sent her out walking again. We both thought she would take off at this point.

She walked for a bit, then used the ball while I rubbed her back, then rested for a bit. Time went by. By this time, her husband was there and was being a great support person. I was very pleased - he wanted to be very hands-on so I had him rubbing her back, etc. My arthritic hands can't take massage too long! Around midnight I decide to check her as she doesn't look like she is doing much. She's 5/80/-2. Great. 1cm in three hours. Not promising. I decide to go lay down for a bit.

Two hours later, feeling a little refreshed, I recheck her. She really seems to be in the same place when I watch her. That makes me nervous. And I am correct...she hasn't changed. Crap. I discuss options with her...#1 augment with pitocin or #2 continue with position changes, walking, etc. I know this isn't a big baby. Her last was 6 pounds and I really don't think this one is much bigger than that. Can't really tell what position the baby is in but believe it's not OP. Her contraction pattern and where she's feeling the most discomfort support that as well. Byt his time, I am starting to think I screwed up and should have just sent her home when she didn't change at 4cms. But oh well, now we are committed. She wants to wait a little longer before starting pit so I encourage her to try some different things. She's getting tired, which always concerns me. Her contractions are spacing out a bit.

A couple more hours goes by...minimal change in the cervical exam, maybe 5-6cms now. She and her husband are now agreeable to pit so we get it started. It starts to work very quickly and I can see the change in her behavior. The husband, nurse, and I continue to do labor support. She decides she wants some IV pain meds, of which she gets two doses before she delivers. She starts to move along nicely. Time goes by and she wants to be checked...she's 8/90/-1 - woohoo! She really starts to zip. Soon she is spontaneous bearing down so I re-check to find her 9.5cms but the last little bit of cervix is very soft and will retract easily if she just pushes with a few grunty pushes, which she does. Then it's gone and I tell her to push however she wants. She goes full force and births a beautiful little baby (and I do mean little - 5-12) in five minutes over an intact bottom. The baby has asynclitic molding...meaning the head was in her pelvis cock-eyed which was the cause of the long, drawn out labor!

Afterwards we chatted for a few minutes before I went home exhausted to my bed. She said she was thinking of asking for an epidural but thought it would be too late. I told her that it wouldn't have been, and I wouldn't have offered it to her though. My general philosophy is that if you want it, you have to ask for it. It's rare for me to offer it because I know how I was when I was having babies. I would never ask for one but when it was offered to me I took it (when I was asked in the midst of a contraction no less!). I'm very glad she delivered half an hour prior to the end of call because I had promised her I would stay until she delivered and I was f*ckin' tired!

Other random stuff...

My husband has been getting on my nerves a little lately - he hasn't been doing much at all around the house and it's p*ssing me off. I feel like I shouldn't have to do a lot of cleaning when I work all these hours. I think he should be responsible for making sure the kids don't tear up the house. We just might have to have a little talk...

I have the rheumatology appointment today. Finally. It's only been two months....geez. I hope that the fact she is so busy is a good sign. It's been a rough couple months for me with these pains, fatigue, and low-grade fevers. I hope to find out what the heck is going on and how we can go about fixing it. I would like to get to feeling better so I can start exercising and making some other changes for my health. My BFF has been very inspirational! Smoking has been gone now for 2 and a half months.

I recently had a killer hormonal migraine alomng with a sinus infection. I'm not a wuss when it comes to pain. I live with it daily and have a fairly high tolerance. But this was the worst headache I have ever had. I was in a tears a couple times because it just wouldn't stop. I was taking vicodin and tylenol with no relief. Finally, after a day and a half, I had my hsuband take me to the urgent care center where I was given toradol IM and some zofran (I was nauseated), which worked beautifully. Time to change my birth control pills! I've only had these headaches since being on YAZ. I hate to give it up because it works so well for my other issues but the headaches and the fact that my sex drive is in the toilet are just not worth it anymore. I'm gonna give Loestrin a try.

Now that you know so way intimate stuff about me, what else can I tell you?

It's not just me!

2009-10-30T16:44:00.002-07:00

I'm so happy it's not just me!!!!!

Check out Labor Nurse, CNM's post on her blog ReBirth....

I've had these issues as you all know....you can review my trials and tribulations of poor nursing care in this post about Nurse Sucky, and this post about Nurse Crappy.

I'm not alone!

Patients (patience)

2009-10-24T06:35:00.002-07:00

Here are some patients I have had recently...and their families in some cases...

18-year-old multip who has class B diabetes and hypertension - she was being induced for these reasons at 38 weeks. Trust me, that baby needed to come out...much safer out than in as momma was very non-compliant (I hate that term but appropriate in this case). She had been on insulin prior to getting pregnant. They stopped the insulin when she got pregnant and she was to do diet and exercise. I thought that sounded a little odd but whatever. She came to us late in the pregnancy because she didn't like the care she was getting from her previous doctors. Or perhaps they wanted her to do things like eat right, monitoring, etc. Low and behold, we asked the same thing. She would apparently just not show up for NSTs and things of that nature. She also comes with an overbearing mother. Her mother is very much focused on looking like someone who knows something about everything. When I met her on L&D, she informed me that her daughter has diabetes and htn....uh yeah, I kinda got that from her H&P, from the midwife who scheduled the induction. And that might be why we are checking her blood sugars periodically and told her she could only order certain foods from the menu. How's that for a clue. The mother than proceeds to ask me all kinds of questions such as...

Shouldn't she have the baby 2 hours after water breaks?
Won't she have a dry birth?
I've seen a baby with a rash because the water was broke for 6 hours (huh?)
They'll start with a low dose for the epidural right?
It goes in the spine right?

And on and on in that vein. The patron saint of patience must have been by my side as I answered all her questions that had nothing to do with the real concerns (a wbc over 17, baby sky high for even a multip, etc). And it isn't like I broke her water, it was spontaneous.

A patient came in through triage, after being seen in the office by the nurse practitioner. Her first visit with us was at 27 weeks. Then she disappeared. Now she's 36 weeks, contracting, blood pressure is up - lovely. Who needs that silly ole prenatal care - blood pressure issues are no big deal!

Another patient unfortunately had to have a c/s for CPD (this is actually a rare diagnosis - it gets tossed around a lot though). The baby was in the 9-pounder range, momma was a very large lady with a smaller pelvis :( Bad combo and unfortunate for her. We tried everything we could think of to get her dilating better and get some descent of that head, but nothing was working.

I have a momma in the office who stinks of cigarette smoke and has some very strange dreams about chihuahuas.

I have to start taking notes on things I want to blog about. I'll be thinking 'oh, I need to share this, this is good!' But now I can't remember a d*mn thing!

Paranormal Activity - one small spoiler

2009-10-23T09:23:00.003-07:00

I went and saw Paranormal Activity recently with a friend. It's been touted as the scariest movie of all time. Not so much. It was very good though - nice build of suspense. I do recommend it!

We have some paranormal activity in our house. Sometimes I see figures of little children at my bedside. They usually are whining and wanting to get in the bed. Nothing seems to make them go away...even closing my eyes and trying to go back to sleep. I sometimes am bitten while lying in my bed...even in the daylight! After the cat bites me, she seems to magically fly across the room. I hear voices late at night - in the form of sportscasters. My husband apparently can't hear the voices.

After watching the movie, I told my friend that the first time I found out that my husband was standing over me for two hours watching me sleep...his a$$ would have been gone! Anyone who knows their scary movies, knows that's a set-up for disaster! Course one might deserve what they got for pulling the stupid sh*t that the boyfriend was pulling!

Anyway, go see it!

Mommy Wars

2009-10-19T09:39:00.003-07:00

I was watching a episode of Dr Phil (yes, I admit it - I watch him) covering the debate on stay-at-home moms versus working moms. I'm sure you all can figure out which side I am on.

I found it really interesting to hear from a SAH mom who was very outspoken about her belief that women who have children and work are selfish. She stated that "if you don't have time for children, then maybe you shouldn't be having them". I would actually agree with that statement but not in the context in which she made it. She's implying that any woman who works, couldn't possibly have time to spend with her children. That a woman who works could not contribute to the health and well-being of a child. That a woman who works couldn't possibly raise a wonderful human being.

Yes, this lady was really opinionated. In fact another SAH mom stood up and said that "she does not speak for all of us!".

In general, it seemed that the SAH moms were more likely to be judgemental about working moms. I did not hear any judgements made towards women who choose to stay home. I understand that SAH moms are often undervalued. Working in the home is a career like any other. But I wonder where that defensiveness comes from. Perhaps SAH moms have had to spend so much time justifying their choice, they opt to criticize those who made a different choice.

Dr Phil mentioned some interesting statistics that over a lifetime working moms will spend 80% of the time that SAH moms do with their children. He also mentioned that children who had working moms and were in quality daycare (quality being a key word) were more likely to score higher on school readiness tests, have higher vocab, social skills, etc.

Women raising children are very likely to raise children in their values and traditions. Some women value their children above all else, including themselves. The SAH moms seem to feel that raising their children is the most important thing in their life. I can respect that.

But it's not the most important thing in my life. It's one of the most important things in my life. But my life as a woman and a human being does not begin and end with my children. I had a life before they arrived and I will continue to have a life after they grow up and move on to their own lives. I am not the type of woman who can give up myself for my children. Maybe that does make me selfish in some eyes. I like to think it makes me a better person for my children, my husband, and those around me. Because I could not be a happy person as a SAH mom. I would go insane and might take that out on my family! I love my job and am very passionate about it. Do I feel guilty at times? Sure I do. Being a midwife isn't always an easy career when you have children. But I contribute to society in a very valuable way. I also think that I contribute to my children's health and well-being. I am raising my daughters especially to be strong, beautiful women who can do whatever they want in life.

I also like to think of the women who were working moms who made huge changes throughout our history. What would one say to some of these women? You should have stayed home with your kids instead of fighting for civil rights, for freedom, for healthcare, etc. The world would be a better place had you done that. Yeah, not so much!

I really do have respect for women who choose to stay at home and make child-rearing their top priority. Not all of us can afford or choose that though. We women need to stick together and hold motherhood up, in all its forms, as a tough job and one to be greatly valued.

Fantasy Football

2009-10-19T08:44:00.003-07:00

So my husband plays fantasy football. Religiously. Four months out of the year, he's mentally not available. It's lots of fun.

My BFF sent me this video to help him pick out his players...

Tales from Officeland

2009-10-17T10:03:00.003-07:00

I had to give bad news to an adorable couple, who I was very excited to see pregnant as she is the sister of another of my patients. She was in the process of miscarrying :(
I saw a patient postpartum, who's baby I caught. She's doing very well with breastfeeding and looks great. The baby is beautiful of course. Her and her husbadn had given me a wonderful thank you card, an announcement, and a gift card - suuuweet! I love cards and gifts - they certainly aren't necessary - but are always very appreciated :p
I spoke with my favorite nut. She's the sister of a friend of mine. This friend (I sometimes have to question how much a friend she is!) sent her sister to me with the warning that she was a nut. She has mental health issues but manages them pretty well, goes to school full-time as does her partner, has a great dry sense of humor. She can drive me crazy but I admire her for being a pretty tough cookie. Anyhoo, she had been in the hospital with pain issues r/t GI issues (intentionally being vague). We were medicating her, hydrating her, and trying to figure out everything wrong with her....physically anyway. The midwife on call went to see her then came to the office and proceeded to tell me how they did a UDS on her and maybe she's a drug addict and why are we drugging this baby and why aren't the docs managing her blah blah blah. This is Ms. It's-Not-About-Us,-But-About-the-Patients. We could also call her Ms. Holier-Than-Thou. She really was p*ssing me off because of her attitude. This is 'my' patient, quit dogging her out. She may be a nut but she ain't a drug addict just because she has mental health issues. I pointed out that we had been seeing this patient since 5 weeks pregnant and not once had she presented with a complaint or request for pain meds. And she's more than halfway through the pregnancy. Back off B*tch! Anyway, she talked to one of the docs to decide what to do with her as the surgeon said no surgery and apparently the GI doc talked to the surgeon and decided he didn't need to come see her?????!!!!! WTF???? Our doc said send her home for the weekend and then refer her to the perinatologist. WTF??? Why? This is totally non-pregnant related. She needs the GI consult. So guess what I'm gonna do when I see her next week? Off to the GI doc.
I think I only said drink more water twice on one office day.
I saw a lady for what was supposed to be a new OB but apparently she had miscarried a couple days prior. She came for her appointment anyway. I sussed out the sitch and it sounded like everything was proceeding appropriately. We discussed grief. We talked about trying again and timing for that. I suggested bringing her back for a WWE in a couple weeks. She declined for religious reasons. She told me that she didn't do paps and would return when she was pregnant. Ok. Whatever. I can respect that as long a woman understands the risks and benefits of testing. I am no longer 'shocked' by out of the ordinary preferences. I'm growing so much :) Not just my a$$ either.
I saw a doctor patient (because I apparently had a slot open) who was around 29weeks complaining of low pressure, white discharge, peeing frequently, and not feeling the baby move as much for several days. It's her third baby. Um. ok. So I evaluate - lots of fluid in the vaginal vault. Did you have intercourse recently? Yep, the night before. Well, there ya go! No ROM. I explain about common discomforts of pregnancy...i.e. does it feel like the baby is going to fall out when you walk. She looks at me with shock and says yes. As if she is amazed that I know what she is talking about. I explain about pelvic floor muscles and multiple pregnancies. I put her on the monitor. Looks gorgeous. Lots of "contractions" - you know...every 30 seconds, very jagged looking. You labor nurses and midwives know what I'm getting at. Fake contractions! I palpated...not a dayum thing! Go home hun...chill. Come see your doctor next week and drive him crazy..I have enough pain-in-the-a$$es of my own.
I saw a young patient who had HELLP syndrome with her last pregnancy. She complained about having to stay in the hospital for a week after the birth, being induced, etc. She's really looking forward to doing things her way this time. I said, "If all is well, we do it your way. If all is not well, we do it our way". I hope we get to do it her way!
I saw a new OB, who is late in the pregnancy and a nut. She has schizo among other issues. I use the term 'nut' affectionately (so don't flame me, I have mentally ill people in my family and I just might be one of em!). This one was hospitalized at the beginning of the pregnancy for trying to kill herself. Her other baby died a couple months out from accidental ayphixia. And she laughed when talking about it. She said she worried that it was her fault for having the blanket in the crib. And laughed. I understand that it was likely r/t her mental status and meds but it was still creepy. It happened last year. Can anyone say social services?

I deserve it

2009-10-14T12:32:00.003-07:00

What a rockin' night I had on call. I deserve to have a rockin' night after how the weekend went.

I caught a baby for the doc - it was a woman having her third baby. She did an amazing job at pushing out her baby and I got to use my fav spanish saying - "Si, se puerdo (sp)".

Another baby came very fast in a multip who's water I broke at 4-5cms. She delivered just over an hour later and it was so cool. She squatted and pushed the baby out with her arms wrapped around my shoulders, which meant I couldn't see as my face was in her chest....glad she was wearing a bra or I would have been breastfeeding! LOL! I had one hand underneath the baby's head and just felt the baby being born into my hand. I wish more women would birth out of the darn bed! I was so high after that birth...and it was her first natural birth as she had gotten epidurals with her two previous pregnancies then delivered half an hour later.

The third birth was in a patient who had some BP concerns so we were inducing her - second attempt. This would be her second baby, the first weighing at 9-6! I had sent her home a few days previously as cytotec had not worked to ripen her cervix, her labs, were normal, and her BPs weren't too bad. But then she started getting yucky with the BPs again so another midwife put in a foley bulb and had her come in in the morning for pitocin. Her bulb had fallen out during the night so she was 3-4/60/-2. I waited until she had been on the pit for awhile and was starting to feel crampy, then broke her water. She was 4/70/-2 at that point. She got an epidural shortly thereafter (which was her plan from the gitgo). The nurse checked her while I was finishing the previous delivery and she was 10/100/0! She moved along quickly once she got going. What ended up being so surprising about how fast she moved and only fifteen minutes of pushing was that her first baby was 10 years ago, this baby was good-sized at 8-9, and was OP! I was totally caught off guard when I saw this baby's face looking up at me, batting his eyes :)

I went home to sleep but then had to go back as two grand multips came in...neither of which delivered by morning :p

I had a stalker as well....the dayshift postpartum nurse called and paged me a minimum of 12 times in a 12 hour shift. Mostly for stupid sh*t. It was so aggravating as she seems dumber than a box of rocks. I tried to be past but frankly, it was all I could do to not be mean. Example of one conversation...

Me : Stop calling me on my cell phone and at the office, I'm trying to see patients. I don't have my cell phone on me anyway. Page me first.

RN: I did and waited an hour, you didn't call me back.

Me: You didn't page me correctly, my pager never went off. I know it's working because I just got a page from L&D - they seem to manage to get ahold of me the appropriate way.

RN: Oh, sorry.

What was she calling for this particular time? To let me know that the surgical consult wasn't going to happen until tomorrow and the patient needed to be admitted instead of 23 hour obs. That's reasonable right? Well, I had spoke to her an hour and a half previously about the patient's admission - I told her I would come by after office hours to write orders. Seriously, why are you calling me again.....arrrggghh!

Sassy Pants Mommy - I Love You!

2009-10-12T17:49:00.002-07:00

OMG, I'm in love with this chick....Her blog is f*ckin' hilarious! Go check her out but not for those with delicate sensibilities...course if you are that type, you probably aren't reading my blog!

Hematology

2009-10-12T17:44:00.002-07:00

I saw the hematologist today...got the all clear from him. He felt that all of my labs were very likely consistent with inflammation or infection. Since we have ruled out almost any possible infection (excluding weird rare sh*t), inflammation is the winner. I think I have Rheumatoid Arthritis. I see the rheum doc next month (the new one).

Weekend Part II

2009-10-12T16:12:00.002-07:00

Patient #4 delivers that morning - uneventful and well done on her part. The baby was 8-6 over an intact perineum - not bad!

I get a call from a patient (#6) who has been harassing us to induce her since 37 weeks. Because she has big babies. That's her reasoning. Oh, and she's dilated 4-5cms and keeps getting sent home from the hospital. She knows she's 4-5cms because she checks herself. And the baby's head is low and the membranes are bulging. I'm amazed and impressed as it takes most labor nurses a minimum of 6 months of practice to get this skill down. wow. In reality, she's 3-4 and the head is -2 per one of the midwives in the office last week. Her biggest babe was 10 lbs. This one isn't that big. But she's now almost 39 weeks and calling me to let me know how uncomfortable she is. I've spent more time on the phone with this patient then I do with my mother! I tell her to come in and I will see what I can do for her. When she arrives, she's actually really 4-5cms so I send her out walking while we wait for a bed to become available for her.

Patient #5 arrives...she's truly a pre-eclamptic. While BPs aren't too bad 140's over 80-90's, her labs have changed significantly in two days' time. Her cervix has also changed a little since the day before to 3-4/60/-3. So I chat with the doc and she agrees that now is the time to have a baby. It's her fourth so ought to go fairly smoothly. I decide to do some cytotec first to get her cervix really really ready....I also wasn't planning on starting an induction this late in the afternoon if it wasn't truly critical.

So I now have one delivered patient and 5 in the works. Oh, I'm lovin' life at this point!

Patient #6 progresses rapidly (it's her 5th kid) after I break her water. She gets one dose of Stadol and pushes out an adorable baby weighing in at 7-10. Not bad, she was very well controlled and did a great job. Had some placenta issues requiring the doc to come in (who was laready in the building at least) - that was the only down side.

It's time to focus on #1. She had gotten an epidural so I broke her water earlier in the afternoon. She was 4/100/-2 at that point, with some caput bulging through the cervix! Naturally, her contractions start to space out. That's about typical for how my weekend is going. So eventually I had started pitocin. When I finally went to see her again almost four hours later, I asked her if her nurse had been changing her position, because she was in the same position I had left her in. This particular nurse, we'll call her Nurse Sucky, spends lots of time charting...at the nurse's station or if she is absolutely required to be in a patient's room...ya know, like, for delivery....she starts through the whole darn delivery. Drives me insane because she pays no attention to what's going on...ya know....like fetal heart tones....shoulder dystocia in progress, etc. Nurse Sucky had not moved the patient a single time! I promptly change the patient's position and mention turning the pit up as if we might want to have a baby *dripping sarcasm here*. It's just about shift change and I have requested one of my fav night shift RNs, Beetus, to take over. I ask Nurse Sucky what the patient's most recent temp was as the baby was a little tachy and the patient had felt a little warm, not to mention her heart rate was a little tachy as well. Nurse Sucky says "I haven't checked recently, let me go do that now". Yes, go do that. I know good and well, that she probably hadn't checked one at all this shift! I look it up and low and behold she had....at 8am, almost 12 hours previously. WTF???

Nurse Sucky comes out and tells me it's 98.5...really? I'm surprised. I decide to go check her (vag exam #3 since breaking water - including the exam when I broke her water) and she's now 8/100/-1 but the caput and molding are lower. This kid is trying to come before she's completely dilated...strange. Plus she's feeling some pressure soon thereafter and is 9cms. Then we get stuck. We have adequate labor (I put in an IUPC at one point) but I know we are running out of time. Baby is looking ok but less and less happy with the process. We spend about 3 hours at 9 then 9 and a half, then a very persistent anterior lip. We change positions frequently, use the peanut, etc. The patient is pushing involuntarily the last hour and a half of that. The lip just would not go away...but the baby wanted to come...the head kept moving down. Finally I call it...call for a section but I put her into one last position - all the way on her right side with the HOB flat. I tell her I will check her one more time before we move to the OR. She's still pushing involunatrily with each contraction, despite repeated boluses on the epidural.

I check her before we get ready to move....the lip is still there but much smaller and a little further back on the head (the caput is just about crowning at this point!) so I have her push while I successfully reduce the lip. I'm so excited - she's gonna do it! I tell everyone to hold on the section and instead she delivers her baby after pushing for fifteen minutes. I did cut a small epis (the equivalent of a first degree perineal lac) due to the heart rate issues and long crowning. Baby came out kicking and screaming with a helluva lopsided molded head! Asyncliticism was the culprit for the cervix not going away. It was all very unusual because if the head is asynclitic then you usually don't get much descent of the head. It also goes to show how inaccurate non-reassuring fetal heart tones are on EFM - as the evidence tells us. But it's still very difficult to wait out a bad strip. This is another prime example of why it's bad to be induced and get epidurals sometimes. Because then you are obligated to use EFM.

Anyway, Beetus and I were very happy that she had a vag delivery. I don't think the patient truly appreciates how close she was to a section. Most OBs would have cut her long before I made the decision to do so.

Meanwhile...

Patients #2,3, and 5 are all quiet. Patient #2 was on cytotec at this point. I had stopped her pit that morning when I cam in and discovered she was NOT 4cms truly. The foley bulb must not have been all the way through her cervix. Her external os was 4 but the internal os was 1cm! So, I go home to get four hours of sleep...

...when the nurse of patient #2 calls to say she's 9cms and I need you to come. WTF??? Naturally I missed the delivery (it was her third baby). Instead the doc happened to be in house for another delivery so she caught. I was p*ssed. Turns out the nurse had checked her earlier in the night to discover she was 4, then 5 cms. She should have called me at that point. I was so mad. But I know she was just trying to let me sleep. But I told her, it's my job to be there...especially when they are planning natural childbirth!

Patient #3 and 5 are quiet so I round on postpartum and go home to take a nap. Once the pager quieted down anyway! I slept for about 2 and a half hours. I called up to L&D to see what's going on...patient #5 is 5cms but not really feeling them, says Nurse Newbie. Ok, I decide to run to the grocery store then will head to the hospital. Naturally, I get a call from Nurse Newbie an hour later....#5 is 8cms with a bulgy bag and pushy. Greeeaaatttt. I go like a bat out of hell and miss it by 2 minutes. F*ck. Apparently she did a fab job though :)

Patient #3 is all that's left and she continues to do nothing after 4 does of oral cytotec, 2 cervidils. So, cervidil #3 goes in and I leave her for the midwife who left all this for me Friday :p But I'm back on call tomorrow....I bet she's still pregnant.

Weekend in revue Part I

2009-10-12T07:23:00.003-07:00

It was a hectic weekend with lots of fires to put out. The midwife who was going off call Friday night apologized right off the bat for leaving me so many issues that needed to be dealt with. It happens to all of us at one point or another, not her fault. She literally had to makes notes to give me report.

Friday night I got to stay home even though I had 4 patients admitted at the hospital. I went to the WNBA championship game with Beetus and my older daughter, who really likes basketball. It rocked - we had such a great time, even though the hospital kept calling and paging me. I had told them that I would be unavailable except for emergencies and deliveries until halftime and the end of the game. But naturally, that message didn't make it around to everyone. The game rocked, with our team winning :) I was so exhausted though. I am in the midst of a rough week of call. I had just finished call at 7am Friday morning, only to be back on at 5pm for the weekend. By the end of the game I had such a bad headache, and my neck and shoulders were killing me.

As we leave the game, I get a call that one of the four patients, who is there for an elective induction (grumble - the patient was insistent that she was in labor and apparently refused to leave - her cervix was 1/50/-2??!!), had a foley bulb in but it fell out and she's 4cms now and wanting to get in the tub. I'm thinking "f*ck, there goes any chance of sleep". I lay down and finally drift off to sleep about 45 minutes later when another nurse pages me. Dear God, shoot me now. Another patient who is being induced with PO cytotec for GDM, hypertension, and PUPPS needs some calamine lotion and Benadryl. I'm like "are you serious???? You called me for that????" But just as well, as a hypertensive patient should not get Benadryl as it can raise BPs. I go back to sleep, anticipating that I will get a call soon to go be with the elective chick, who is planning natural childbirth (even though she so badly wanted to be induced - this wasn't her first attempt at being admitted to the hospital, and she's only 40.2). Next thing I know, it's 8am!

This was one of those times when I check my pager to make sure it is working.

I call the hospital to get updates...

-primip (#1) induction due to being 41.3 and wanting to be done - she was getting cytotec through the night...she's now 3/100/-2 and wanting something for pain and asking when she can have an epidural

-elective induction (#2) ended up taking a sleeping pill but is now on pitocin but not feeling them

-Patient #3 with GDM, htn, and PUPPS isn't doing anything yet

-Patient #4 had a foley bulb and was scheduled to come in in the morning for pitocin but actually came in, in labor, around midnight with the foley bulb having fallen out. She was 3/80/-2. She was currently comfortable with an epidural and 6-7cms.

So I get up and head on in. I forgot to mention that I was expecting a fifth patient, someone I had been seeing, to show up for re-evaluation of BP issues.

Enough for now....I want to keep everyone in suspense....will post more later.

Call recently

2009-10-03T07:00:00.002-07:00

I have been doing a lot of call recently and for the next couple weeks as well. Here are some highlights from the past couple shifts...

A call at 10pm from a patient who is a G5P3 and 37 weeks. She tells me she's been dilated 5cms for a couple weeks now and they keep sending her home from the hospital. She's tired, not sleeping (3 hours in the past three nights....exaggerate much?), and has big babies and wants to be done. She has an appointment in the morning with another midwife but is tired of being pregnant. The unspoken question? "Can you induce me tonight?". My spoken answer? "No induction until at least 39 weeks (spoken in my head - "especially not at 10pm"). We can do it then as long as your cervix is favorable (who knows if she's really 5cms)". I politely reminded her that I didn't get her pregnant and that her discomfort was not my fault. This was after listening to her complaints for about 15 minutes and trying to be emphathetic. She saw another midwife the next day with the same spiel, who asked me what I thought and I said not until 39 weeks. And she checked her....she was 3-4cms.

4 babies graced me with their prescence (sp) in one 24 hour call shift. All were nice births with no complications.

Had another lady who chatted with her mother the entire time she was pushing and birthing (she had an epidural). I was ready to bang my head against the wall. But she still did good - took 30 minutes to push out her OP baby.

Had a lady who came in because she had been feeling sick for three days. She was something like 30 weeks pregnant. I diagnose her with the flu and she is slightly dehydrated. I give her an Rx for oseltamavir and phenergan since she can't keep anything down. She promptly tells me that she probably won't get those filled because she doesn't have the money for the copays. I ask how much the copays are and she says it varies but the last Rx she filled cost her $4. But you can manage to scrap up money to buy cigs. She tells me that if she gets to feeling worse she'll just call an ambulance. Nice. My tax dollars at work. So why did you bother coming to see me at all and bringing your nice little flu germs with you?????

The next Move

2009-10-03T06:35:00.002-07:00

We had been looking for a new rental home this past month. My mother had been living with us and sharing the rent but when she hooked up with my stepfather, she moved out about 6-7 months ago. Unfortunately, we can't afford this house by ourself. My husband doesn't work...not because he's lazy though! He was more than willing to get a job but I want him to focus on school (he's a full-time culinary arts student). He has that bad heart and just school and family take up a lot of his energy. So my mom had agreed that she would not leave us hanging and would continue to help out. Well, I'm an independent kinda girl and don't want to continue this way. And I look at what I make monthly and wonder, where does it all go???? Anywho. We found a house right around the block from where we currently live! It's the same house even! The same amount of space, layout, etc. Just a little less upgraded. But it's $650 cheaper a month!!!!! Woohoo!!!!! So we move later this month. Now let the packing begin....ugh!

In other moves....I went and saw the FNP regarding my 'spells'. Because these spells are really getting aggravating...and very persistent. She ran a buttload of tests (some of which I would have declined had I known she was checking them - like syphillis, gonorrhea, chlamydia - really? C'mon I know I don't have STDs). Anyway, here are the significant results....for all you medical people that want to play guess the pathology...Norms are in parentheses.

Med Hx - beta thalassemia, hypothyroidism, spondylarthropathy, IBS, PMDD

Meds - levothyroxine, Yaz, folic acid, rantidine, multivitamin, zyrtec, methotrexate, humira, vicodin prn, skelaxin prn

Symptoms - Low-grade temps (normal is 97.5 area, these run anywhere from 99-100 degrees), fatigue, weakness, muscle and joint pain, shoulders and neck very painful at times especially.

WBC 12.6 (4.0-11.0) This has also been mildly elevated in the last two CBCs I have checked.
RBC 5.58 (3.7-5.4)
Hemoglobin 11.6 (11.5-16)
Hematocrit 37.9 (35-48)
MCV 68 (78-100)
MCH 20.8 (27-34)
MCHC 30.6 (31-37)
1+ Anisocytosis
2+ microcytosis
Retic count 2.0 (.5-1.5%)

Remainder of CBC WNL.

Serum iron 40 (35-175)
TIBC 412 (250-400)
% Saturation 10 (15-50)
Ferritin 368 (9-120)

CMP WNL

CRP 11.7 (<8.0)

Vitamin B12 286 (243-894)

Folate >20 (3.1-17.5)

Rheumatoid Factor <7>

ANA screen positive (negative) This has always been negative in the past
ANA titer 1:160 (<1:40)

HIV, Hep B and C all negative

Transferrin 336 (188-341)

Lyme disease negative

Urine culture negative

Thyroid panel WNL

And there you have it. Feel free to ask any questions and play detective. I have some thoughts in mind but frankly find those ideas a little scary. The FNP wants me to see a hematologist so I have that appointment scheduled for just over a week from now.

Weekend in revue

2009-09-28T11:30:00.003-07:00

I come on call Friday night to inherit an induction left over from Thursday. Great.

The patient is a 300+ pound multip with what feels like a pretty darn big baby to me, although it's hard to tell. The induction was elective and one of the other midwives gave in and scheduled her in for her call day, which was Thursday. The starting exam was 2/50/-2 and the plan was to start pitocin. IMO, this was a poor choice. I have found that multips with this kind of exam take a couple days of pit if you don't do some cervical ripening first. Bring em in the night before for a little cytotec then they are ready for pit the next day...and they will deliver the next day as well. Keep in mind, I didn't agree with doing an elective induction in the first place but casn't really say anything because I have given in to begging, pleading, crying before myself. I try very hard not to but it's difficult sometimes. Anyway, midwife #1 pits the patient all day with nothing happening. Midwife #2 comes on that night and shuts the pit off and rests the patient. Midwife #3 comes on Friday morning and breaks her water because the patient says "if you break my water, I'll take off". Sounds like a great reason to break someone's water at 2 cms. They pit her all day, she gets an epidural at one point and is 3/supposedly80/-2. She stays that exam right up until I take over at 5pm. I stop the pitocin and switch to PO cytotec x 4 doses. The next morning, before the final dose of cytotec, I check her because she is feeling pressure....yahhh!!!! She's now 5/90/-2! Woohoo....snoopy dance. We skip the final dose of cytotec and start pitocin. She delivers, 4 hours later, a chunky (10 pounds 7ounce) baby after pushing only 20 minutes. This baby was about 2 pounds bigger than her last! It was a tight tight fit...I almost had a code brown going on. But anyway, 4 midwives later we had a baby....the only midwife who didn't handle her was the on with no privileges yet!

I was frankly a little crabby that I was left with this induction. I just feel like I often have to 'clean-up' after this particular midwife. She has health issues and only works part-time because of those issues. Many times she has agreed to special a patient for labor. Then if it doesn't go quickly, I have to take over because she doesn't feel well. Then patients sometimes feel abandoned or are unhappy that they have to have me instead of 'their midwife'. It's sucky and unfair.

Anywho.

Other than a precipitous delivery earlier that morning, it was very quiet! I had a little drama with my husband and his heart Saturday night but he's fine. I had a few calls....trivial stuff....

One call was from a patient that just had been recently released from the hospital, where she was an antepartum patient. She had a low AFI and was being monitored. Well, she calls me concerned about the watery discharge she has. I advised her that she should come in to get checked out. She didn't really want to seeing as how she had just left. She wanted to wait until her appointment in the office, three days later. She never showed up. In the future, I think I will start triage phone calls with "What do you want me to tell you?". Because they usually have what they want to hear in mind already :p

Got a call from a patient with pelvic joint pain. No contractions or bleeding....just her pubic pain and hips are very painful. What did you want me to do about that on a Sunday night? Told her to get an appointment in the office and we could get her going on some physical therapy and a belly band.

And I am a Justin Timberlake fan and thought this was hilarious....it's from SNL with Beyonce. Hat tip to my BFF for showing me this....(couldn't embed so here's the link).

Justin and Beyonce Parody

One very uneventful call

2009-09-24T08:36:00.002-07:00

Wow, I had call with not a single delivery. That's unusual. Hardly any pages either....even more unusual. Maybe no one knew the baby magnet was on call!

One triage call...

"Hi I have the patient who was sent over from the office for a pre-eclampsia work-up and serial blood pressures. I sent her out to walk and when she came back her blood pressure was 175/85."

Me: Wait...what??? You sent her to walk?

Anyone see a problem here? Scary. And this nurse is also a CNM. Go figure.

Being a nurse

2009-09-22T09:23:00.002-07:00

After doing the registry shift the other day I have been thinking about what it is to be a nurse versus a midwife. I know and have known for a long time that I would never be satisfied as 'just a nurse'. It wasn't enough for me. I have been pondering why that is.

I think that working as a nurse turned out to be not at all what I thought it would be. It isn't what I tried to teach nursing students when I was still doing that. Well wait, it can be sometimes. But more often than not, nursing is about completing tasks.

There. I said it. Yes, being a nurse is about getting tasks done. With a little patient education thrown in. It seems that most nurses I work with are about getting their jobs done so they can sit at the nurse's station. I look at their interactions with doctors and midwives (myself included). Rarely is it a team approach to patient care/diagnosis/treatment. It's a doctor (or midwife) giving orders, the nurse running off to complete the orders. Rarely does a nurse make a suggestion to me. I have even asked at times, 'what do you think?'. And the response is usually "I don't know" (not always). I want to include the nurses in the POC...I try to tell them what my thoughts are and why we might be approaching a situation a certain way. Some of interested in learning but most are just like 'whatever, let me do my job so I can go home'. And god forbid I want to do something that means more work (??) for the nurse, such as intermittent auscultation, etc.

When I was in nursing school, I thought nursing would be about that team approach to healthcare. Multiple disciplines working together to achieve the best outcome for a patient. I thought everyone would be equally respected. Yes, I was d*mn naive. After all, I had no healthcare exposure prior to nursing ( Iwas a bartender!). But lets face it, nurses don't get any respect, especially not from doctors.

When I began to teach I tried to instill in nursing students this picture of what I thought nursing was supposed to be like. But really, once you get out in the 'real world', you quickly get beaten down into your place.

I always though that certain specialty areas offered more autonomy, such as L & D or the ER. And they do, but still I see the same behaviors. I don't see nurses that are willing to fight and advocate for their patients. And that's what nurses are supposed to be - patient advocates. But instead many become steamrolled by the juggernaut called healthcare. It's hard to always 'fight the power'. It wears you down quickly. Maybe that's what I am seeing where I work.

As a midwife, I have a great deal of autonomy. I can spend a lot of time with patients. I get to give the orders instead of being told what assinine things I need to go do to a patient. Maybe that's an issue for me - I am a type A personality and I like control. I am learning to give more and more of that control to patients though :)

I would love to hear thoughts from nurses and from lay people who have had nursing care that made a difference (negatively or positively) in their lives.

*Sorry about the rambling!*

Registry

2009-09-20T06:06:00.002-07:00

So due to some financial 'tightness' I decided to pick up a couple registry shifts each month. No one wants me to do this - my BFF, my husband, and my mother are all concerned that it will be too much. Well, yes, probably. But it would decrease my stress level about money and we are only talking about 24 hours a month in addition to my regular work.

I did the first shift recently and it went quite well. I was really nervous because I had not been to this particular place. You never know what your reception will be like. Some staff nurses get p*ssed because registry and travelers make big bucks. But I have had pretty good experiences in the past. The staff was very helpful and friendly. I did postpartum though, which was booorrring. It made for a very long draggy day.

I got to meet the doc that a midwife friend of mine has to work with. She's told me all kinds of horror stories about him. I've also heard stuff about him from someone else. I don't know how she stands working with him, although it may be because she is much more laid back than I am. I didn't actually meet him, just was sitting there when he came by. The words coming out of his mouth were stunning. It was all I could do to not tell him off. He obviously does not like women (and I don't mean sexually!). Apparently his wife is divorcing him and I am just not at all surprised! Agh!

Birth with Nurse Crappy

2009-09-19T11:20:00.000-07:00

I came in for a labor patient. She was 4cms and planning natural childbirth. This would be her first baby and we had met in the office a couple times.

The nurse assigned? Nurse Crappy. F*ck. I now can anticipate a long day of substandard nursing care. We start the day off with Nurse Crappy asking if she can give stadol to the patient. IV is already started with fluids going. Granted the patient came in just before I came on and the offgoing CNM gave pain med orders. I ask if the patient has tried the tub yet? Of course not. She was ready to jump start to meds. She had probably been in the room pushing an epidural already!

I got the patient in the tub, which she really liked. All is well for awhile. Then she gets out and wants to be checked. Now she's 5-6 cms with a bulgy bag. She wants to try pain meds...no problem. Gets her stadol and sleeps.

Time goes by and she wants more stadol...I suggest getting back in the tub, which she does. Then out again for a vag exam and stadol. She's 7cms with bag still intact.

Throughout this time, I only saw Nurse Crappy go in the room to immediately strap her on the monitor when the patient was back in bed. Otherwise, she sat at the desk. She gave up her other patient to another nurse. She starts asking me if I'm gonna break the patients' water. Umm, not at this point.

The patient would periodically vomit. Guess who's holding the bucket and doing clean-up? Me and the boyfriend. Now, I don't mind helping with these things but I kinda expect that the nurse will not assume that I will provide all nursing care! That's not my ultimate job. I also helped with intermittent auscultation. Also the nurses' responsibility.

Guess what else got done by me? Freshening up the linen and chux.
So anyway the patient ends up stalling at 7cms. I discuss various options with her (do nothing but positioning, ambulation,etc, add arom to the first option, or epidural then arom) and she opts for epidural and arom. I tell Nurse Crappy the plan and she says "oh ok, and then start pit?" We all start laughing and I tell her how about we see if the arom and epidural help...one intervention at a time! Geez.

So she gets her epidural and is comfy. I break her water and she's 8cms now. She throws up some more while Nurse Crappy convieniently disappears.

She progresses to complete after me reminding Nurse Crappy to flip her from side to side periodically. The end of the shift arrives but the patient isn't feeling pressure to push so the plan is to have her labor down and a new nurse (my BFF) will take over as well as the oncoming midwife.

Then the patient throws up some more and feels pressure. So I recheck her with the oncoming midwife to find the baby at +2 station. So I decide to stay and catch. We have a beautiful delivery after only pushing for half an hour, over an intact perineum (she had a nice healthy stretchy perineum).

I'm on my way home when I get a text from my BFF. She tells me that Nurse Crappy never checked a temp in the entire twelve hours!

Highlights from hell (aka office)

2009-09-18T12:31:00.001-07:00

Ok, the office isn't that bad but it sucks when you are really tired.

- I can't snap my fingers and take away your sciatica, achy back, or carpal tunnel. Don't get frustrated at me. I didn't get you pregnant.

- refrain from telling me how you wish you could just have the baby now or that the baby is ready...and you are 32 weeks along. I didn't get you pregnant.

- You need to drink more water. No, soda and juice don't count. When you offer me more reasons why you can't drink more water, I'm still going to tell you to drink more water. I didn't get you pregnant.

- saw a 16-year-old who is term and really want me to be there for the birth. I wouldn't commit though. I told her she would be fine regardless of who was there. I am entitled to a life outside of work and am decreasing offers to come in on my day off to catch a baby.

I have to admit, while I was safely ensconced in the office bad sh*t was going down at the hospital. A maternal death occured - very sad situation. That hasn't happened in a couple of years. What amde it even sadder is that it was preventable. My heart goes out to the children. Good reminder not to ignore warning signs. Good reminder to also appreciate life and your loved ones!

'Down There'

2009-09-14T11:48:00.004-07:00

From Dr Lisa Masterson's website . Seriously. No, really.

Let me call my childbirth educator

2009-09-09T10:29:00.005-07:00

I had a laboring woman recently, wanting natural childbirth. Things weren't going smoothly (the baby was OP) and we had been trying multiple positions, etc in an effort to get the baby to turn. At one point, the woman is crying and begging me for something for pain. The father is arguing with her about it. He doesn't want her to have anything. We manage to keep her going and don't give her anything (although I was ready to). Time passes. No progress. Baby is still OP. Mom is getting out of control. I talk to dad about the various options including continue with position changes in the hopes that baby will turn, try the peanut, Get IV pain medication, get an epidural and put her sidelying with the peanut. Possibly pitocin if necessary. He gets upset and tells me that epidurals and pitcoin are a joke...blah blah blah. I felt like I was being very reasonable but also honest about the options. He told me he had to make a phone call...he was gonna call his childbirth educator who they had spent 10 weeks with so "I think she knows about this stuff". The 'better than you' was left off the sentence but was definitely implied. I told him to that was fine and to let me know what they needed from me. I went out to the nurses station and declared that I was done. I told the nurse to let me know what they need and I will order it but that I wasn't going back in there otherwise.

It's one thing to decline an option I offer - no problem. But no need to be an a$$ about it. And I promise that I know just as much as your childbirth educator/massage therapist/mechanic whatever.

Well anyway, I went to the patient because she was wanting to her what her options were. I asked her to give me a little more time in the tub on her hands and knees in the hopes the baby would turn. She did that very reluctantly. Then we re-checked and she was an anterior lip and the baby was changing his position. I had her wait fifteen minutes on her hands and knees then was able to reduce the anterior lip and push. She pushed for about an hour to deliver her baby into our waiting hands (dad was helping catch) over an intact perineum.

So I have mixed emotions over this experience. It's a very fine line to walk between encouraging and supporting a women's desire to go natural and her requests for pain relief. Especially when things are not going 'normally'. I think we pushed her harder than we should have. But yet I am happy (and hope she was too) that she did it naturally. But I feel like I forced it on her but not allowing pain meds/epidural. I would have had she not made any change but by that time she was so close to being ready to push I couldn't see drugging her at that point or making her numb. I'm uncomfortable also because I did what I did out of some desire to keep the peace between her and her significant other. And that's maybe not the right motivation. I don't know....gotta ponder this one a bit more.

Oh, and I got an email from the nurse that was working with us last night. She's sweet as can be, a future midwife, and a doll to work with. Apparently she was planning to give a bath to the baby (which she would have not done had the parents told her they didn't want that done) and the father got upset and threw water all over her papers. Then when another nurse later came in to check on momma, he told her she was stupid three times to her face (not sure what the context was).

Vit D and Christine Northrup

2009-09-09T10:27:00.002-07:00

Here's an interesting article about Vitamin D levels and possible relation to breast cancer among other cancers.

Prevent Breast Cancer with Vitamin D

Happy Labor Day - shout-out to nurses!

2009-09-07T13:50:00.002-07:00

Hope everyone is having a wonderful Labor day weekend. I am aside from the fever of undetermined origin that continues to nag me.

Go check out this nice shoutout to nurses on Reality Rounds' blog.

Vitamin D levels

2009-09-07T10:33:00.002-07:00

I did get my vitamin D level checked on the advice of my best friend and an anonymous poster here on my blog. Turns out it is low - 24.5. The normal range is 32-100 but it says 32 is a threshold for optimal health.

So low levels of vitamin D can be associated with increased inflammation in heart disease, arthritis, and MS. And of course, it can f*ck up your bones too. Nice.

Who would have thought that living in Arizona, you could possibly have low vit D levels????

Divorce cakes - these are fabulous!

2009-09-07T09:45:00.000-07:00

The labor from hell

2009-09-07T08:55:00.003-07:00

So the labor from hell was miserable, especially for the patient of course!

I had come in at 7am because I was scheduled to first assist for a section. I had told the off-going midwife the night before not to worry about calling me early as I would need to be there anyway. Well, she never called me at all so I assumed there were no labor patients there. Wrong! This patient, someone I had spent a lot of time in the office with and a young girl at that, had come in around 2 or 3 am. She had done the walking thing and had changed her cervix to 4/90/-2. She was planning natural childbirth. So she was admitted for expectant management.

When I arrived, the night shift nurse had just checked her because her water broke - calling her 6/90/-1. So off we go, me thionking she's gonna have her baby by lunchtime. Boy was I wrong. Even after her water breaking, she never really would contract more than every 4-6 minutes. They felt strong but progress came to a standstill. And the patient was doing a wonderful job of staying relaxed and breathing with her contractions. WTF?

I go do my section then come back to do labor support. At 10ish, I recheck her because she's feeling pressure and shaking a bit. She's the same (well, actually I would have called her 5/100/-1). That sucks. But onward and forward. We continue to try different positions, the tub, etc. At lunchtime, I have to go do another section so leave her for a bit.

After the section, come to find out the nurse had checked her and she was...any guesses? 6-7/90/-1 per the nurse. So I am feeling a little aggravated because I don't know if this is change or just the nurse feeling the same exam but calling it a little differently. I would rather have been the one to check her but the nurse said she felt like she needed to push (the patient, not the nurse) and she didn't know how long I would be in the OR. Jeez, you could have come asked me - it's not like you had to go to another part of the hospital to find me and the patient is a primip for gawdsake! My favorit expression - it ain't gonna fall out!

So more labor support, more time goes by. I blow off office hours to stay with her thinking we will have a baby in the afternoon. The patient continues to do very well (now I start questioning how well she's doing - probably because things aren't progressing!) and contractions do palp strong.

Around 5pm, I decide to check her and she's what I would call 6/90/-1 with a bag! So we break her water, again. And we continue on, thinking this will do the trick. Her contractions get a little closer together for awhile (every 3-4min) but then gradually space back out to 4-5 min. They palp strong, patient is coping well. WTF??

I start thinking about pyschological blocks. That's the only thing I can think of. Her pelvis, while a touch on the small side still feels roomy enough to birth a #6.8 baby (which is what I am estimating).

Around 6:30pm, the patient is starting to struggle to work through her contractions. We have continued to try multiple positions and the tub. I can look at her and tell she's losing it. The exam is unchanged.

I pull the patient's momma out to the hallway to chat for a bit. The patient is underage and I need to know her momma's thoughts on where to go from here. I am of the opinion that the patient needs an epidural and pitocin at this point. She hadn't wanted pitocin earlier when I suggested - not because she didn't want the interference but because she just didn't want to hurt more and she knew pit would make her hurt more. Her and her mother didn't want an epidural because they had heard too many bad stories, not because they were worried about the effects of epidural on birth. So, I talk to mom for a bit...she's not happy with the thought of an epidural but willing to consent for it if its what her daughter wants.

We go back in the room where my patient is definitely starting to lose her ability to cope. She wants the epidural. So that gets done. The nurse checks her after putting her catheter in. She's the same. Pitocin gets started and the patient is instructed to go to sleep for a bit.

We fight with the pitocin and her contraction pattern for awhile. Her contractions just didn't want to pick up. Her body was just fighting this process??

Around 11pm, I finally recheck her, thinking I will put in a IUPC because her contractions continue to be dysfunctional looking. And that's kinda my ward or good luck charm. I'll say lets go put in an IUPC and then discover the patient is too close to delivery and doesn't need it. Sure enough, the patient is 9/100/0 with a touch of caput. Woohoo!!!!!

So we wait some more....by this time I am absolutely exhausted but a friend brings me coffee which helps. Finally, around 1am, the patient is feeling a lot of pressure and feels like she needs to push. I check her and she's 10/100/+2 and the caput is crowning :p We start pushing. It only takes about 10 minutes to get the hang of it. She pushes for about an hour, finally delivering an adorable baby over a couple little dings in her bottom.

We had long crowning so the baby came out floppy initially and the labor nurse panicked (well, I think she did but she doesn't think she did) and called for nursery without taking a minute to assess and mess with the baby herself. This kinda irked me and we had some discussion about it later. She's a new nurse (maybe been doing this for about a year now) and she hasn't learned how to truly assess babies yet. I knew the baby was stunned and needed a chance to get going. Our apgars were 2 and 9, with just blow-by and stimulation to get the kid going.

Miscellaneous

2009-09-04T12:15:00.004-07:00

This is just some miscellaneous crap because I'm too tired to do a real blog post right now.

Hmmm, speaking of being too tired from work related things...Check out the blog RN Obesity Blues. This L&D nurse blogs about her life, chronic illness, women's healthcare and more. She's new to the blogosphere but very well spoken. I think she's gonna have lots to say (and hopefully it will make sense! Haha!).

I had the labor from hell recently...well, I didn't but my patient did. Will post over the weekend about that.

Going on two weeks now not feeling terribly hot. Less temps now, more nasal congestion. Husband is sick, older daughter is home sick. I think at least my daughter has the flu due to high temps. I also noticed she was growing a little curly tail, so maybe swine flu?

I'm already to role to do some registry work to pick up a few extra bucks...now just waiting to hear about a shift.

I'm glad I didn't let this blog go. I still have lots to say that just isn't appropriate for my real 'professional' identity to share.

And....ummm....well I had something else I was gonna say and just forgot it....

Oh wait, I remember...The grand total for last month - 24 babies. Am I a baby magnet or what?????

Nursing students with too much time on their hands

2009-09-02T11:53:00.001-07:00

The Laryngospasms - funny!

2009-09-02T11:44:00.001-07:00

Pushing with an Epidural

2009-09-02T09:44:00.005-07:00

"I worked with a woman whose doc said at week 10 of pregnancy that he thought she would need a c-section because of her anatomy. He induced her at week 39 to avoid big baby. Told her the baby felt BIG like 8.5. Labor moved a long. she got epidural at 4 cm, 80% -2. Was complete 7 hours later with lots of pitocin. Pushed for three hours, mostly in lithotomy position (My suggestions of side pushign shot down and laboring down too.) and doc called it. Baby didn't move past 2. Mom had been up all previous night and not eaten in 24 hours. She was toasted. Mom started pushing before she had pressure. Doc wanted coached pushing instead of laboring down. I see it all as an orchestrated c-section set up. But I don't know. So I am wondering if you have some gems up your sleeve for helping a mom with an epidural push through a "tight fitting pelvis."I feel like hands and knees or a supported drape could have been helpful, but those are not going to happen with an epidural. I don't know. Or something with one leg higher. By the way, the baby weighed 6.5. Not so big. This hospital is super management oriented, very high c-section rate. Most moms get induced. No one goes past 40 weeks."

This is a sad sad story. Now, it is possible that her pelvis was too small but in hindsight, knowing the baby was only 6-5...Hmmm, I'm inclined to think that mismanagement of labor was more likely.

Do I think she was set up for a section? Looks that way! First of all, no research supports induction for suspected macrosomia or LGA babes - in fact, these women are more likely to end up with a section!

Suggestions for pushing with an epidural? Here they are.... Everyone feel free to add any other tidbits that I may not have listed.

1. Laboring down is important - specifically with the woman on her side and a peanut wedged between her legs. This opens up the pelvis and allows baby to get in an optimal position for being born.

2. Once actually pushing - I usually have the woman push for a bit in a semi fowlers. We experiment with towel tug-of-war, using the hand grips, pulling legs back. Whatever seems to get the most out of her pushes and feels more productive to the woman.

3. I then like to flip to one side and push for about 15-20 minutes, then to the other side 15-20 minutes. I've not had this fail me once :) We can usually see a fair amount of the head after this. I then put them back into either semi-fowlers or squatting (this can be done with a birth bar - lower the foot of the bed and raise the back of the bed for support - works great for epiduralized women). Important note with squatting - the baby needs to be low in the pelvis for this position to be effective.

4. We have a baby!

There are various positions for OP babies as well. Also, hands and knees c an work for some women with epidurals - just depends on how heavy the epidural is. I had a woman who we ended up cutting the epidural off and was able to walk to the toilet with assistance after awhile, where she pushed for a bit.

I really suspect though, in the previous scenario that pushing was only a small contributing factor. I think the induction was inappropriate, coached pushing instead of waiting until mom had pressure, not allowing laboring down. Lotta things wrong in this scenario.

As an aside, Rixa has a post with references regarding this subject so go check that out on Stand and Deliver.

Privacy

2009-08-30T19:57:00.002-07:00

Ok....another rant guys.

Is it too much to friggin' ask that staff not go in and out of rooms without knocking and/or identifying themselves...especially during a delivery. I was in a delivery early this morning. The woman was pushing, she's muslim and very private. In ten minutes time, while she was pushing, 4....yes 4 staff members walked in and out of the room for various reasons. I was livid!!!!!

After the delivery was over I went to the charge nurse and raised hell....she was one of the guilty ones to have walked in that room. She apologized and promised that that issue would get addressed. I told her this happened many times before. It's very distracting when women are going natural...it sometimes interrupts their 'zone'. But even simpler, it's basic common courtesy. Knock, wait for an answer, stayt behind the curtain and say what you need. It's not that hard!