Peer Review

So, I received an evaluation form on the medwife I work with. It's apparently part of the peer review process to maintain credentialing. Do you know how difficult it is to evaluate someone when you really have nothing nice to say? So one of the midwives and I sat down together to fill this thing out. I hated doing it - I feel like I have to be honest but on the other hand I don't want to ruin or cause trouble for someone. Those of you who have been in similar situations...your thoughts?

I'm Back....

You all have missed me haven't you?! So what's been happening...

Well, first, I have been so crazy busy with the new job and life that I just set this aside for awhile. But lately, I have been missing the blogging so decided I might come back to it for awhile :)

Next, the new job...I love it! I'm so fabulously happy to be working as a midwife but it's even better because it's a great place to work! Nothing better than liking what you do AND where you do it! But alas, nothing is perfect...there's one person I work with who I would love to see re-locate elsewhere. More on that later.

I hate to say this...it will inevitably come across wrong but...well, never stopped me before! I love private practice. Rarely am I faced with the whole trainwreck situation anymore like the residents are (if a patient comes in with no prenatal care then the residents get to care for them). You know, the whole "Hi I haven't had any prenatal care, just did crystal meth this morning, think my water has been broke for 3 days, and have no idea how far along I am". So you start to triage this patient, then having to deal with the whole fetal heart rate dropping into the 60's with each cxn, only dilated 1cm, and yes the water is broke as it is full of thick mec and rank as hell. Do I miss this sort of scenario? Uh, nooooo. And yes, this scenario actually happened to me. Want another one? Hmm, how about the grand multip who, smoking meth of course (meth is the cocktail of choice around here), shows up 8cm, no prenatal care. By the time we get her to a labor room she ruptures, thick mec, infant on the perineum. I throw on gloves (no gown - who had time??) and catch. We do prenatal labs afterwards - turns out she's HIV +. Sad, sad, sad.

What else do I love about private practice? The patients who are educated and ask questions, and don't wait for me to tell them what to do. Fantastic! I love the active participation! Of course, we still have clientele who just want to be told what to do.

What else is good? The money. I'll admit it...I hate living a simple, possession free life. I like things. I like having money to go do what I want when I want. Trips to Vegas. Trips to the Zoo (which is the kid version of Vegas). Shopping. A nice house. But also paying bills...on time no less is really damn nice. After the havoc wreaked by student loans going into repayment, graduate school, and a low-paying nursing faculty job, I am climbing out of the pit of despair financially. Woohoo!

So the job is great. Except for the medwife (that's NOT a typo). Those of you in the profession, know what I mean. She's the mini-doctor, and if that'snot bad enough, I swear she's bipolar and so does most of the office staff and hospital staff. It's not just me...no one likes her. Patients complain about her also. This could all be tolerable if she was at least good at what she does. But she's not. I dread following her on call.

Well, what else...my kids are doing well. My youngest is having a birthday soon. She wants everything Hannah Montana. I was surprised by her zest for HM because she's only 4! But I'm not complaining. At least HM is not
pregnant and keeps her clothes on. So far anyway. Thank god, she's not asking for Britney Spears stuff. Don't get me wrong, I feel very sorry for Britney Spears. That girl has lots of issues and I really hope she gets her shit together. But role model material? Uh no.

Well enough for my comeback post :) More to follow!

Personally speaking

Nothing much to report personally. Been under the weather the last couple days. I really feel at a loss for words...hmmm...

Oh, I know, work sucks...kinda. It looks like we are going to lose two students from my class. One for major attendance issues - which is a shame because I can see her being a great nurse, when she shows up. The other - I can't imagine her being a good nurse so it may be just as well if she gets tossed out. She's on strict probation for numerous issues that I won't go into here because it's really rather boring. The boss seems to be in a crabby mood lately so no one can do right - or at least this is the way I am feeling. I am finishing grading the first assignment, which was a culture paper. It's depressing - some write well but then don't address all of the criteria so they lose points. Others write almost as well as my 12 -year-old but at least address all the criteria requested. Grrr. I can't win.

What's still good about work? We are getting closer and closer to OB!!!!! Meanwhile, clinicals are going well for OB and peds. I can't wait to show students the Gentle Birth Choices DVD I got recently. I'm reminding them frequently that birth is not always like what they see in the hospital (it's a county hospital which should tell you a lot about the experiences they are getting). That birth can be very different...and of course, I am always reminding them about being sensitive to the needs of the patients. They are a good group of students and are so excited to be there :)

Another shift

I worked another shift yesterday. Funny, I get cancelled then they call back at 0830 requesting me by name. Not sure if that's good or bad.

The charge nurse says "Do you wanna do postpartum? It's the easiest".

I say "sure, whatever". Normally I hate postpartum but I'm tired and she tells me its the easiest...ok...whatever.

I have no ass left...I worked it all off running with a full load of couplets (mom/baby). Grrr.

Heavy Breather

One of my new officemates is a heavy breather.

If you'll recall myself and three others get the new office to share. One of those three is part-time and only there when I am not, which is why we were paired up. Works good for me. The third officemate is funny at times and boring at other times...she talks a lot but is an incredibly intelligent woman. The third...

She is the one who is completely computer illiterate...she is the culprit also for heavy breathing.

And it's not even regular heavy breathing...it's not sighing. If it was regular, maybe I could stand it. When I have my mp3 player, it's not an issue. An atomic bomb could go off and I wouldn't hear it when I'm playing the music. But I forgot my music today...grrr....

So, everybody's in the office, it's quiet. Then big heavy breath. Then silence. Then big heavy breath.

AAAAAAAAAGGGGGGHHHHHHHHHHH! *banging my head against the wall and suppressing the urge to tell her to stop breathing*

New (to me anyway) trick for back labor and/or pain

I learned a new trick yesterday that I thought I would share...

When someone is having back pain or back labor try this...

Have them lie down flat with their knees bent. Push on their knees just below the kneecap. The midwife I worked with yesterday tried on me and on a patient. I thought it felt great (I have a lot of arthritis for a youngin' - autoimmune junk). The patient, who was having back labor, also said it helped during the contractions. Neat!

Coronavirus

While at the hospital yesterday I noticed signs here and there talking about different illnesses and encouraging handwashing. Ok, so that's pretty normal. But then I saw the sign for coronavirus...

CORONAVIRUS - my definition
-a debilitating illness following a night of drinking coronas excessively

The real definition from Wikipedia
-Coronaviruses primarily infect the upper respiratory and gastrointestinal tract of mammals and birds. Four to five different currently known strains of coronaviruses infect humans. The most publicized human coronavirus, SARS-CoV which causes SARS, has a unique pathogenesis because it causes both upper and lower respiratory tract infections and can also cause gastroenteritis. Coronaviruses are believed to cause a significant percentage of all common colds in human adults. Coronaviruses cause colds in humans primarily in the winter and early spring seasons.

A day in the life of a labor and delivery nurse

So I worked a labor and delivery shift yesterday...what a crazy day.

The unit where I worked is the same place I did my midwifery clinicals. I jumped at the chance to go back there for a couple of reasons. The first - I know for the most part how things work there - it's a familiar environment. The second reason - it's so cool to go back and see people I really liked (especially the midwives). Now, you have to understand soemthing - the nursing staff in some cases are just warm bodies. This means there are some nurses that hav no clue when it comes to caring for laboring patients. When I was there as a student midwife, I often had to be the midwife AND the nurse for my patients. For example, you couldn't count on the nurse to notify you if your patient was having lates (a type of deceleration in the baby's heart rate that indicates distress). They don't always have the knowledge they should. It's kinda scary. It's the warm body syndrome - as in any warm body will do.

The day started off with me having a cervidil induction - this young lady was on her second cervidil and contracting quite a bit. She had a lower pain threshold (everybody is different and that's ok) and wanted pain meds. The midwife on asked me to check her (which is kinda flattering because the midwives normally like to check their own patients so the most of the nurses don't). The patient was 2cm dilated. We medicated the patient and let her rest. Once she woke up and started hurting again, the midwife wanted to go ahead and get the pitocin (synthetic hormone that triggers contractions) going. The patient was allowed to take a shower and then I got her on the monitor. She was having some very mild early decels (a deceleration in the heartbeat that mirrors the contractions - usually indicates head compression and is a normal finding - when they are more dilated). I started the pitocin at a very low dose and watched. The midwife came in and placed a IUPC (intrauterine pressure catheter - this midwife who was on MLOA most of my student time there is apparently a big fan of internal monitors). She was now 3cm dilated. While the midwife was inserting the IUPC, we noticed a little more blood than normal show. Hmmm...less than ten minutes after the midwife walked out of the room the baby's heart rate dropped down into the 80-90's (normal is between 110-160). So I start doing all the 'stuff' you do in the situation - flipping her position, cutting of the pit, oxygen, etc. The heart rate stays down. Three minutes into the decel I have help in the room, including the midwife. The doctor follows a couple minutes later and we going rushing off for a c/s. I took over the other laboring patient and that nurse went to do the c/s (I hadn't been oriented to their OR so opted not to go). So what was the cause of that prolonged decel in a baby that had otherwise looked absolutely fine prior to then?

Velamentous insertion, which is where the cord, instead of originating somewhere on the body of the placenta, instead originates from the edge of it.

This is an example of what a normal placenta looks like (below).

The three vessels that run between the baby and the placenta are very important to the baby's well-being. One of those vessels had likely torn thus causing the decel in the heart rate. The baby was fine fortunately - big boy weighing 8-13 and mom recovered well from the anesthesia.

So while they are off during this emergency c/s I care for a young woman who is stalled out at an anterior lip (which is like 9 and a half cm dilated). She has an eipdural. In this part of the country it seems that when women have epidurals, they get Foley catheters (a catheter left in place to continuously drain the bladder - when you have an epidural, you lose the sensation associated with a full bladder). I'm in the room introducing myself, talking to everyone, and checking all the lines she has. I notice there's no catheter so I ask the patient if the nurse had emptied her bladder since having the epidural. She says no. She had her epidural at 0700. It's now 1130 and she has had at least 2 liters of fluid since then (momma was running a temp probably related to prolonged ruptured membranes and all the fingers and IUPC that was hanging out of her vagina - well the fingers were hanging out but the vaginal exams is what I mean!). When momma runs a temp, the baby's heartrate will start go up. So bolusing her can sometimes alleviate this stress on the baby. Oxygen can help too but the nurse had not done that either. So I put in a catheter and get a whole lotta urine back, slap some oxygen on her and before you know it she's complete and numb! Her epidural was working all too well - apparently the CRNA likes to really make them numb - grrr.

The charge nurse comes up to me and says, I want you to take the new labor admission and give this patient back to the original nurse (who has the personality of a fish). I explain that I have already bonded with this patient and would like to keep her. She is concerned she will need a c/s because of the lack of progress. I gumble and think to myself "well if someone had bothered to assess her bladder and and cut the damn epidural down we might have already had a baby by now" but I am contract here so I just say "ok".

So my new patient is another primigravida (first pregnancy) who came in to triage at 5 cm - asking for an epidural. Just my luck - most of the patients I worked with as a student midwife did not want epidurals so I guess I got a little spoiled by that. So another nurse (who I do like) comes and helps me get her admitted and the epidural. She continued to labor and make good progress. She probably had her baby about an hour after I left because she was complete (10cm) at shift change. I thought for sure I was going to have a shift change baby - which kinda sucks for the nurse because then you have to stay and do paperwork. At least I do because I don't want to desert the oncoming nurse.

Teamwork is not something I see much of with these nurses. When I worked L&D in South Carolina, you always had back-up for delivery. Out here, it doesn't seem to work that way. At the big factory L&D I worked at when I first moved here and couldn't stand, you were always on your own. Same at these other places. It's weird how geographic location really does make a difference in some things.