Ode to the Bestie

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

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

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

I'm Still Such a Sucker Sometimes

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

I've known this patient for a couple years, as in providing her care during that time. She's a very large lady, close to not being able to get a weight on our office scale (tops out at 350). She's shy about her body and experiences exhaustion towards the end of pregnancy due to the extra load. I don't blame her a bit, or anyone else for that matter, for being miserable in the summer heat at the end of a pregnancy.

So here she is, term, and begging for induction. Her cervix is very favorable - 4/80/-2. It's her 4th baby. I agreed to an AROM induction.

She had a rough time with the last baby - blaming it on the pain meds she opted for with the last baby. She decided she might get an epidural this time if she needed something. Hopefully, things would go smoothly and she would just take off and birth without needing anything.

And of course, that's not how things went. She piddled around for several hours after I broke her water. She finally asked for pitocin to get things going and wanted an epidural. She was 5cms at this point, contracting sporadically. I advised her that if she was sure she wanted the epidural, to do it now so she could maintain the optimal position for it due to her size. Then we used just a 'whiff' of pitocin and she took off.

When I decided to use the pitocin, I figured I had better touch base with the doc on call with me. Which is when it hit me that the wisdom of the induction in a woman this size was not the brightestmove on my part. I felt so stupid for not having given this any thought prior to doing it, or consulting with the doc prior to now. Ugh.

But anyway, he was fine with starting pitocin....although I didn't come out and say I scheduled this. :p I was a chicken. Everything went very quickly with the labor....5 to delivered in about 3 hours (I even shut the pit off when she was freaking out, we were up to only 4mus). She didn't like the epidural either. I think she just doesn't like the transition stuff - gets very panicked and borderline hysterical.

So when I reflect on this experience, it wasn't one of my better labor managements :p

OMG

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

I had a beautiful birth recently. This little momma was having her first baby. I had met her only at a birth class recently. She came in in labor, was about 4cms, changing to 5cms after walking for an hour. She was contracting very regularly and mildly uncomfortable. She was kinda chilling in the tub, walking around, not doing a whole lot. After a few hours had gone by, I suggested checking her cervix with the possibility of breaking her water or sending her home if she wasn't changing. Unfortunately, she had not changed and did not want to go home. She agreed to getting her water broke, which we did.

Since she was fairly comfy I decided to head over to the office to see a few patients. I knew the patient would have the nurse call me when she needed me to be with her. About two hours later she was ready for me. The nurse had said that she didn't want to do anything like the tub or the birth ball. She was very opposed to moving, which was fine! I just sat with her. Finally, she seemed to be losing focus, crying instead. She asked me for something for the pain. I told her, let's check your cervix, if you are close then you just keep doing what you are doing. If not, then we'll discuss the options.

Woohoo - she was 8-9cms! So I encouraged her to get in the tub which she agreed to. However, she was unable to sit and felt better standing. She began to get more vocal after a few minutes of standing in the bathroom. Then I saw the first little pushes as she involuntarily beared (or bore down? That sounds weird too) down. Then she says "I feel something!"

She climbs into the bed and pushes, totally spontaneous, and I see a little bit of the head. Now, she was -1 station before she stood up! Woohoo - gravity rocks. She pushed her baby out in ten minutes flat :)

Private

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

So what do you think?

I Want a Healthy, Natural Childbirth...

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

Nurse Crappy at Her Finest

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

I tell Nurse Crappy - I'm in surgery as you might be able to see, and can't come either. (Perhaps the other doctor should have thought about the wisdom of breaking a mulitp's water when you won't be readily available) I tell her she better get a resident to come stand by.

They get a midwife who's in the office seeing patients to come over as well, which she misses the delivery (but the resident was there for the delivery at least - I wouldn't trust Nurse Crappy to get a patient a glass of water, let alone catch the baby).