labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Monday, December 31, 2007

Answering With The Man In Mind

I have had several women in my last few shifts that seemed very interested in what was going on on the unit. This usually stems from them starting off in our triage room, which is essentially a throwback from the days of wards. The triage room is just one large room, one bathroom, and curtains as the only means to privacy. We do have those white noise makers, but no one ever turns them on (except me) and if they are on they mysteriously are shut off.

So anyone who enters our triage room knows they are not alone. They listen to what is going on in any one of the "bays". Typically it is family members and friends who are the most interested, given that the woman they are with is in labor and quite uncomfortable and could give two shits about anything else. When one of those laboring women starts asking questions about everyone else in the room, I find it curious.

Anyhow, I have worked some busy shifts lately, and have not been very timely to all of my nurse calls. For instance, I am in the middle of getting a mom out of bed for the first time after her c-section, and she ends up nauseous and faint while in the bathroom. My lovely nurse phone (picture a circa 1989 cell phone) that must be carried around so that everyone can keep track of my every move all shift long-including bathroom breaks...yes we are expected to answer the damn phone while sitting on the pot- rings from another of my patients room. I had help with me at this point so I could step out of the bathroom with my patient to see what the other patient needs. It's only something minor, and so I tell her that I'd be in to see her in about 10 minutes.

I get my faint c-section mother back into bed, get her settled, and head over to the woman who called me. The first thing she asks me was what was I doing. I told her I was with another patient. And she presses me for details. I tried as vaguely as possible to answer her, saying that I was with someone who wasn't feeling well.

This leads into questions about what was going on on the floor in general, how many woman did we have in labor, how many babies were already born today, etc etc. And the times I have been asked these things I wonder how much do I answer? What would violate HIPAA policy? And how often can we say, "I can't answer those questions because of HIPAA policy" before sounding like puppets for The Man?

I guess where I am going with this is that I don't necessarily think any of these questions are out of line, sans the 'what were you doing when I called?' question, but if I say that we had 3 babies born or we have one woman in labor does this constitute a HIPAA violation? My interpretation is no. I'm not divulging who came in, what their names are, any health information about those babies or women, or even what room they are in.

Yet we as nurses feel compelled to say, "I can't answer on grounds of HIPAA". And what if we give the general answer that we have one woman in labor, we then get asked, "Is it her first baby?" Many times I won't know this anyhow, but is it illegal to answer yes or no? I mean, could someone deduce who that woman is from knowing if it was her first baby? How many women come in in labor with their first baby? Thousands!

I'd like to get your opinions on this, and if you are a nurse how do you handle these questions?

Thursday, December 27, 2007

Brain Farting

For the last 2 nights I had a brilliant post idea that came to me as I fell asleep. I made mental note both times to remember what it was about. And yet all today I have searched my brain as to what it could have possibly been about. I hope I can remember what it was....

Apparently my brain goes to shit while on school break.

Tuesday, December 18, 2007

Losing My Religion

The following post was written a little while ago, and I hesitated posting it. But the crux of what I am saying here still rings true for me. I feel like there is something missing....I just don't know what. I've come up with a few theories as to why I feel like I've lost my "spunk", for lack of a better term, here on REBIRTH. It could be that school has bogged me down, it could be my disappointment in having to start REBIRTH in the first place, or it could be that I've run out of things to say. Eh... nix the last one. But because I have been thinking about what that something may be for a while now, I thought I'd post this for some feedback.


So I was talking with my husband tonight. No, that’s not the point I was going to make. We talk all the time, or shall I say he talks all the time. You’d be surprised how quiet I am compared to him.

Anyhow, so I was talking with my husband tonight and he tells me that he thinks this blog is a bad idea. He loves the blog, however, but the threats I received with the Life & Times made him change his mind about the health care blogosphere. It’s changed how I view it as well.

Something isn’t right with Rebirth. It doesn’t have the same feeling of excitement for me as Life & Times did. I enjoy writing just as much as ever, but the innocence has been taken away. It pisses me off, frankly. It’s like finding out Santa is your mother. You knew that the writing on the tags looked just like your mother’s, but it just had to be true! You heard the whisperings of Rudolph being just a cartoon, but that nose so bright is illuminating your window at night. And then, the reality sets in. Your mother bought those presents, and that half eaten apple on the front lawn next to the hoof prints in the snow was courtesy of your father…not Rudolph. Drat!

But you still get presents just the same.

My husband asked, “Why are you blogging? Why can’t you just write offline? There is no risk in that.”

“The principle of free speech,” I answer.

“There is no such thing,” he said. And I know he is right. And this pisses me off, too. Yes, I can say whatever I want here, but at the possible cost of my career. That isn’t really free, is it?

I also went on about why I started blogging in the first place, my need to get women thinking about the care they receive, ask questions, and start a revolution and the like. You know, simple stuff. I also need to vent. Writing my frustrations about my work and life seems so much easier than talking about it. Who wants to hear me talking about this all the time? It’s so much easier to write something and let it go, and those who want to read it will visit. Those who don’t have the choice not to visit.

Again, nothing is that simple.

Sunday, December 16, 2007

Rebirth of Slick


Speaking of breastfeeding, I thought I'd share a postpartum nursing secret with you all.

You know when you were exhausted after giving birth, and it's now 3AM and your baby is still fussy after 4 hours of cluster feeding (or lack of breastfeeding, or difficulty with latch.... insert breastfeeding problem here)? And then the nurse offers to take your baby to nursery so that you can get a couples hours of uninterrupted sleep?

Well, she's likely giving your baby some formula to settle him down and get him to sleep. Did you really think that when you woke 4 hours later and are told that your baby settled right down in the nursery that it was just sheer miracle? No. It wasn't. It was because he was given formula.

When I first saw this happen as a new obstetrics nurse, I was shocked. How could a nurse do this? I thought this was awfully ballsy, to say the least, and something that I would imagine could get the nurse in a lot of trouble if found out. It is never something I've done, although as I gained more experience I could understand why it was done. You've got a mom who is about to lose her mind, a baby that won't settle down and has worked himself into a fury, and a nurse who doesn't want to spend hours trying to get a crying baby onto a crying mother's breast. For those who give this secret formula feeding, it's a win-win situation. Baby's happy, mom's happy, and nurse is happy.

And for those who have allowed the nurse to take the baby to the nursery only to have him return within 20 or 30 minutes, you can rest assured that likely she didn't give him the secret formula. She probably tried rocking him, swaddling him tight, burping him, or pushing him around in the crib (for the vibration) with no success.

Friday, December 14, 2007

By The Book

I have come to the conclusion that an obstetrics nurse can handle any type of postpartum assignment so long as there aren't major breastfeeding issues to attend to. This will probably piss off a few people, but too bad. And I am not alone in feeling this. I was just having this conversation with some of my fellow staff nurses and we have agreed that breastfeeding can make or break our day.

Here's why: picture a 30-something professional woman having her first baby. She has read all the breastfeeding books, has gone to a breasfeeding class prenatally, consulted privately with a lactation specialist, and has herself completely able and ready to breastfeed once she's given birth.

Lo and behold she has her baby and immediately puts her baby to breast. It goes well and she is happy and confident. And then her baby hits the post-birth adrenaline crash and decides to sleep for hours and hours. She tries waking her baby according to all the books and lactation manuals every 2-3 hours but baby just isn't interested.

The meltdown begins....

Her nurse tries to reassure her that this is normal, and baby will nurse again. There is nothing she is doing wrong. But the books said that the baby must nurse every 2-3 hours or will lose too much weight, become jaundiced, and dehydrated. Despite reassurance, her anxiety level goes through the roof.

Finally baby latches to the breast, and in order to make sure the baby is latched properly, she pushes the top of her breast/areola down and ends up breaking the latch. She does this over and over, despite the nurse suggesting that pushing her thumbs down may be interfering with the latch. Baby becomes frustrated and frantic from the constant latching and unlatching, and so starts screaming. She starts crying.

There is such a fine line in these types of situations. As her nurse, you want her to be able to breastfeed with confidence, you want to help and reassure her, but how can you delicately say "Relax, this will work!"? And how do you get her to stop feeling guilty about her family members telling her that her baby seems hungry and how could it possibly be ok to not just give some formula?

This is so frustrating. Really. I am very pro-breastfeeding, don't get me wrong. But after 7+ years of obstetrical nursing, I've seen a lot of breastfeeding. My personal experience has lead me to believe that those who approach it with a relaxed attitude and the ability "to go with the flow" (no pun intended) do so much better from the start. The mother's who get worked up when baby hasn't nursed by the books and create an atmosphere of tension and anxiety end up with the "poor nursers".

Come to think of it, I don't ever remember assisting an 18 year old first time mother with a breast pump, or teaching her how to "finger feed", syringe feed, or use an SNS system.

Can you tell I have been working postpartum the past few shifts?

Sunday, December 9, 2007

I'm A-Scared

Because I am on winter school break now, I have been trying to pick up more hours at work. I've also finished my clinical teaching position as well, so it's really opened up my schedule until next month. I've had the chance to see a lot of my co-workers that I haven't seen much of over the last 12 weeks or so, and they've been asking me about my clinical experiences and how much longer I have to go. And I can't believe that I can say that I have less than a year to go. Less. Than. A. Year.

I am really excited about that, but in just a few short weeks I will be catching babies for real. I be a-scared. It's so weird that I feel confident at a birth as a nurse but the thought of being the person helping to guide a baby out into this big scary world is overwhelming. I've seen so many babies born, but now I will be at a birth in a whole different way. There is so much busy work that labor nurses do that we just don't get a chance to realize other going-on's at a birth. Yet all the same I can't wait.

Thursday, December 6, 2007

Screening Tests In Pregnancy

When a woman becomes pregnant, she is faced with making decisions about testing for fetal abnormalities. I have frequently seen women make these decisions without much thought, and end up in a quandary. (I have seen some go overboard thinking about whether they should do testing or not and drive themselves crazy with this, but not as often). The tests I am referring to are the screening tests for Down Syndrome, neural tube defects, and trisomy 18.

When I was working in an outpatient obstetrics office, it was my job to discuss the tests with the woman and give her information about the tests. Many times she would say, "I'll do whatever test is available to me" when asked if she wants it done. I really tried hard to discuss reasons why and why not to do the tests to present the full picture, but I felt that many were not listening to what I was saying.

So what tests am I talking about specifically? I am talking about screening tests done in the first and second trimester. Notice I emphasized screening, because none of these tests can diagnose a fetus with Down Syndrome, neural tube defects, or trisomy 18. They can only tell if the fetus may be at higher risk for one of the disorders.

The most common screening test is the Quad Screen. This is a blood test that is done between 14-20 weeks, but preferably between the 15-18th week. The Quad screen looks for fetuses that may be high risk for Down Syndrome, neural tube defects, and trisomy 18. It looks at 4 things in the woman's blood:

  • HCG (human chorionic gonadotropin)- this is a hormone produced by the placenta.
  • AFP (alpha-fetoprotein)- a protein released by the fetal liver.
  • Estriol- the estrogen of pregnancy produced by the placenta and fetal liver.
  • Inhibin-A- hormone produced by the placenta.

If one or a combination of these substances are abnormal (either too high or too low) may indicate a fetus at risk for one of the conditions. But, it does not detect all fetuses with these disorders, and sometimes falsely reports a fetus at risk who actually is not. This typically happens in cases with woman with a "positive" Quad screen. In other words, the sensitivity isn't 100%. Actually, the sensitivity is around 75-80%. About 2% of "negative" screens are falsely negative; or the test says the fetus is low risk but in fact does have one of the disorders. The results are reported in a ratio. For instance, it will say the Down Syndrome risk is 1:575 (which would be considered low or negative) or 1:15 (which would be considered high or positive). It will also give separate ratios for the neural tube defects and trisomy 18. This ratio is compared to the woman's age related risk. So for a 35 year old the age risk is about 1:240, but if she gets a ratio result that is lower than her age it is considered low risk.

Believe it or not, but that ultrasound you have around 18 weeks isn't just to determine the sex of your baby. It is also a screening test. The fetal survey (the second trimester ultrasound) looks at all of the fetus's organs and body parts. There are certain markers that are looked for that are associated with Down Syndrome or neural tube defects. I could go on in a separate post just about the fetal survey. I've found that not all ultrasounds are created equal; I've seen some pretty rudimentary ultrasounds and I've seen some very thorough scans. One marker seen are Echogenic foci that are bright spots seen on an organ (typically the heart) that may be associated with Down Syndrome. Sometimes the ultrasound is so sensitive that it's finding echogenic focus on organs that can't be explained, or little is known about.

A newer test, that will likely will become the standard, can be done in the first trimester that screens for Down Syndrome. Different places call this test different things, but I've heard it called Early Risk Assessment, Nuchal Translucency Screening, and First Trimester Screening. Many places only offer this to women 35 and older, or those who are high risk for having a baby with Down Syndrome. This test is done by obtaining a blood sample with an ultrasound between 10 and 14 weeks. The ultrasound measures the nuchal fold on the back of the fetal neck. The blood sample measures:

  • HCG
  • PAPP-A (pregnancy associated plasma protein-A)

Again, the results are given in a ratio and interpreted the same way as the Quad screen. One downfall to this screening test is that it can not predict neural tube defect risk, so if a woman wants a screening test for this she has to have the part of the Quad screen that looks at neural tube defects in her second trimester.

So what happens when a woman has a positive screening test? First she'll get an explanation of the results, and offered to speak with a genetic counselor. She can also chose to have a diagnostic test such as the chorionic villus sampling (CVS) or amniocentesis.

And why do I say that women do these tests that are offered without much thought? Because when the test comes back "positive" she has no clue what she wants to do. I feel that a woman should have a good idea what she would do with the information these tests are giving her. I've seen some women totally panic and freeze with fear that something is wrong, and can't come to a decision as to what she should do.

So here are some questions to consider when faced with whether or not to do these tests:

  1. Would having a child with Down Syndrome, spina bifida, or trisomy 18 change the outcome of your pregnancy?
  2. Would you feel that you could not adequately care for a child with those disorders?
  3. Would you terminate a pregnancy knowing you were carrying an affected child?
  4. Would you want to know if your child had one of these disorders so you could prepare for their care (ie, speak with specialists before the birth, align home help, decide whether to continue working)?
  5. Is not knowing in advance okay or would it create more anxiety?

I'm curious to hear how screening tests were discussed with you. I've seen some women just told that there is a test that is done and that they will be having it at that visit (so much for informed consent!). I've seen some providers tell women that they shouldn't have it done. Hopefully most are given accurate information that allows a woman to make an informed choice.

Tuesday, December 4, 2007

Leave the Uteri Alone

Consumer Reports listed cesarean sections as one of the top 10 most overused medical procedures in the United States. They cite that most common reason for c-sections is slowed labor. There is just once sentence that mentions that there are other interventions that can help speed labor and therefore divert a c-section.

I find this interesting given that not too long ago hysterectomy was one of the most overused surgical procedures in the US. Why is it that the female anatomy is the target of unnecessary treatment in many cases?

Consumer Reports is not likely going to elaborate, as they are just providing basic information. But the last statement makes it sound like there are medical interventions that are so much safer. It completely neglects that many of the interventions CR eludes to can increase the woman's chance of having a c-section. I'm wondering if there is a more detailed article for subscribers of CR, and if so, what does it say?

Monday, December 3, 2007

Mama Said Knock You Out

It looked like a scene from a horror flick. Seriously. It was awful. I've never seen a bloodier birth in my life. No one saw it coming either. I was caring for a young woman who was being induced for postdates (40 weeks 2 days.... I won't go there tonight). It was her second child, and her first was also induced. The first induction was 8 hours, which is fairly quick for a primip. This being her second child and second induction, I was anticipating a quick labor and birth. But I had pitocin going for hours and hours.

Six hours into the induction she became uncomfortable and asked for an epidural. She was 5 centimeters and so I began prepping her for anesthesia. During the few minutes I was out of the room to fetch the epidural pump and medication (because, god forbid the anesthesiologist fetch their own supplies from the room they have to walk by to get to the patient rooms) she became a wild woman. I walked back into the room to her crying hysterically, screaming for me to make it all stop; it was a huge change from what she was like minutes before, so I had a sneaking suspicion that she was likely fully dilated. I called for the MD, who verified my suspicion. Just then her water broke, and she grunted like no woman has ever grunted before.

I called out for some help, and in the meantime the fetal heart rate went to 60 and never went back up. We called for NICU in case this baby needed resuscitation. The woman sat in the bed holding her knees while she pushed (she assumed this position on her own). We were also anticipating a large baby, as her first was 9 and 1/2 lbs. As the baby's head was crowning, it was showing us the classic turtle sign that precedes shoulder dystocia.

And sure enough, that is what happened. After the usual measures to help relieve the baby's shoulders, the baby shot out like a cannon and behind him came the spray.

Now...remember this all happened so quick that I never had the chance to put on my protective gear. Normally I wear an impervious gown and mask, but all I managed this time was some gloves. So when the bloody spray came down upon us, I got soaked.

For whatever reason, I managed to turn my back as I saw the spray coming from her vagina so only the right side of my face and body got coated with blood. A big splotch hit my forehead and was quickly trickling down to my eye so I ran into the bathroom to wash off. Once things settled after the birth, I went to change my scrubs and noticed that the blood had soaked through to my bra and was caked in spots on my back.

I was thankful that none of the blood went into my eyes, nose, or mouth because I would totally be skeeved out. When I walked out of the bathroom I caught sight of the room for the first time. Blood was down the front of the doctor, behind her on the wall, over the chairs by the window, in the patient chart across the room, the neonatologist's hair was speckled red, and worst of all was the woman herself. If a birth had not happened in that room, you would think a murder occurred.

I asked the doctor what she thought that massive spray of blood was from, but she wasn't quite sure. Perhaps an abruption was occurring (hence the fetal heart rate of 60) and the blood was trapped behind the baby. That's my best guess.

As I was cleaning up this woman after the birth, she started joking with me about all the blood. She said that she was "clean"; no blood borne diseases and she wasn't a prostitute or IV drug user, she said. I said that is what they all say....but good thing nothing landed on my mucous membranes.

I felt bad for the housekeeper.

Wednesday, November 28, 2007

Firestarter

You know what totally sucks for all involved? Telling a woman that she has a sexually transmitted infection. And she's married. And she wasn't sleeping with anyone but her husband.

My clinical this semester has provided me with some extraordinary experiences in this technique. Once was with my preceptor as we examined a 30-something with numerous herpes lesions. As she lay on the exam table in lithotomy position, she burst into tears. We cultured the lesions and confirmed the diagnosis. Another was a 23 year old, fresh out of college and newly engaged. She came in complaining of an increase of vaginal discharge. It wasn't really bothering her, it just didn't "seem right". We offered her the whole work up, and chlamydia was the culprit.

But nothing compares with the 50 year old woman who just learned that her husband of 32 years was involved in some weird underground S&M ring and had a hunkering for one night stands. She wasn't having any symptoms, she just wanted to get checked out. She had several small warts on her labia. Everything else checked out fine, but needless to say, genital warts aren't fun either. They were so small she hadn't even noticed them. We applied tricholoroacetic acid (TCA) and sent her home seething. She said her next stop was the lawyer's office. She had already made an appointment.

One the other end of the spectrum, I've had a 40 year old hyperventilating in the exam room because she was petrified she was going to learn she had an STI. Based on her symptoms, it sounded like good ol' yeast. And on exam, it was classic for it. A wet mount proved good ol' Yeasty Pants was paying a visit. It took my preceptor and I a good 15 minutes convincing her that it was just yeast.

Oh, the adventures of student midwifery! I am sure the best is yet to come.

Tuesday, November 27, 2007

C-Section Rates By State

Our Bodies, Our Blog has a post linking c-section rates by state. Only a few states were listed, as c-section data can be difficult to attain. I learned that one of my alma maters has the highest c-section rate of that state. I guess I shouldn't be surprised given that there was a very low threshold for c-sections, and there were days that all we had were c-sections.

Friday, November 23, 2007

Salvation

My semester is coming to a close soon, and I have somehow managed to be ahead of my school work today. So I thought I'd allow myself to procrastinate a little bit before moving on to the next bit of work laying ahead of me.

The other day I was in a major department store, looking for a gift for my preceptor. An older woman wearing way too much make-up and large circa 1980 spectacles covering 75% of her face approaches me and asks what I was looking for. I told her that there was nothing specific, and I'd get her when I needed help. But she was one of those persistent types that wasn't going to let me go that easy.

She asks who I was shopping for, and I tell her. She launches into a story about her son who is a graduate student interning at a major media firm in Chicago. She was dropping names left and right, like I might actually know who they are (as far as I know they are the idiots putting out the lame ass McDonalds commercials). Then she asks what I am in school for. When I tell her, "nurse-midwifery", she starts cooing and squealing like a pig being thrown it's slop.

She starts telling me that there are so many jobs out there for this that I'll have no problems. I said that I think she meant nursing jobs, not nurse-midwifery jobs. She says, "No, no, nurse-midwifes (yes, she said midwifes, this is not a typo). I know there are jobs!" I begin explaining the difference, that there are tons of nursing jobs but in this area there aren't many nurse-midwife jobs available. Again she tells me I am wrong.

I began to explain the demographics of midwives in the area and the obstetrical dominance that marginalizes nurse-midwifery practice. And then I realized, why am I arguing with this saleswoman? I am happy that she thinks nurse-midwives are great and that there is a strong demand for them, but would educating her make a difference?

It made me think of the J&J nursing campaign (which, by the way, I can't stand) that was launched to the public. My understanding was the purpose was two-fold: increase the numbers of people entering the profession and help the public understand the importance of nursing. My problem with it was that you can't possibly convey what nurses do in a 30 or 60 second commercial slot without ending up with some hokey saying and little vignettes of smiling nurses holding the hand of an elderly person in a wheelchair. Is that really effective?

There has been some talk (somewhere, can't remember where) of putting a campaign out for nurse-midwifery to help the public understand what CNMs do and gain their support. But can you imagine what that spot would look like? Some midwife would be shown holding a newborn, smiling over at the mother who is sitting pretty in her hospital bed. Or some other such simplified scene. In my opinion, I find this potential campaign insulting... even more so than the J&J campaign.

The question remains: how do we strengthen the nurse-midwifery profession and have the public's support? I can't foresee this being an easy task.

Wednesday, November 21, 2007

I'm Just A Girl

I'm not kidding you guys with this at all. There is a German company that has put out the "erotic scent of a woman". They say it's not a perfume. I sure hope it doesn't smell anything like this.

Don't go opening that link at work or in any public computer. I'm giving you fair warning.

Friday, November 16, 2007

Virtual Insanity

I've been working on a paper about maternal requested cesarean delivery and to my (somewhat) surprise have found that it is likely just media hype. I think you'd have to have your head in the sand to not be aware of this phenomenon; look at all the celebrities who have had cesareans just because.

One argument I have come across is that cesarean by maternal request is a woman's right. It's her body, her baby, so she can have a cesarean if she wants. I understand the feminist philosophy behind this, but is this angle being exploited by the obstetrical field to legitimize more cesarean births? The latest stats say that 30.2% of all births were by cesarean in 2005. That is roughly 1 in 3 babies born by surgery. And depending on the state and/or hospital you look at, those numbers can be higher.

There is an article in the November issue of Bioethics regarding this issue. The framework in which the author examines this "trend" is feminist, and argues against cesarean birth by choice. I do not have access to the full article, so I am just going off the abstract. But I lean in this direction.

Whenever this topic of cesareans comes up, there is always a backlash of "if it weren't for c-sections, we'd not have the great advances in maternity care today." I agree, to a point. Absolutely there have been numerous lives saved by the advances in cesarean birth. I certainly don't see them as an "all bad" procedure. But that doesn't mean there isn't risk. The World Health Organization states that there are no improvements in perinatal mortality with cesarean rates over 15%.

But getting back to my original point, this "trend" may just be all hype. Perhaps its just the media and the celebrities playing up these c-sections. I've also read that it may be related to the obstetrical perception of more women requesting c-sections without medical need, yet studies have shown that most obstetricians receive very few requests. So in other words, the obstetrical profession is out there saying the rise of c-sections is largely related to maternal request but there isn't data to support this belief.

Virtual insanity, indeed.

Tuesday, November 13, 2007

Unbelievable

I realized that I haven't posted any google searches here on REBIRTH. The insane internet searches that bring people to my blog have not stopped with Life & Times. Oh yes, they continue to bring the strange and curious right here.

Ban doulas
Say what? (Or back in the day, I'd respond, "Word?") Are you kidding me here? Why would you want to ban doulas? Doulas are great! I even have a whole post about them. Doulas provide awesome labor support to women, can reduce the need for pain medication and epidurals, and release hospital staff to do what is unfortunately taking up too much of their time (documentation).

Secret discreet diapers
Good luck finding some, because the ones I've seen are anything but discreet. And no, I don't need them. I just know about them. I'm a nurse.

Jumping rope continuously while pregnant
And why the hell would you be doing this? Are you not uncomfortable enough?

Hide the erection
Yes, please do.

Nurse touched erection
Where did I write about erections? Because I can guarantee that it wasn't because any nurses I know (including myself, thank you very much) were going around grabbing erections that happened to be exposed throughout the unit.

Cystocele fuck
How is this possible? Anyone?

Pregnant FTM
I had to look up what FTM means. And again, when in the world was I talking about this?

Friday, November 9, 2007

Deep Cover

While teaching my first childbirth education class, I had a dad make the comment that nurses who have not been through labor and birth themselves should not teach the class, nor care for women who are in labor or postpartum. At the time it didn't bother me at all. I knew that my years of experience in obstetrical and maternity nursing more than qualified me to care for such women and their families. The nurse I was training with in the class was quite perturbed; she had several pregnancy losses and finally had her first child not too long before. This nurse had a planned c-section so she didn't experience labor and felt this dad's comments were insensitive.

Nine times out of 10, I get asked if I have children by the woman I am caring for. And most are visibly disappointed when I say, "No, I don't." I have added the comment, "But I do have several animal children" to keep them from probing any further. (You'd be surprised how many will ask why I don't have kids, when did I plan to have them, and do I even want them at all). In the past I didn't mind being asked if I had children or that some were disappointed that I don't. I know that these women who are asking that are looking for a way of connecting with me, to trust what I have to say and how I will care for them.

But you know what? I'm starting to see my fellow nurse's point of view. Does it really matter if I have children or not to properly care for women? Does my 10 years of nursing experience not count for anything? What if I was an oncology nurse? Could I not care for a woman with breast cancer because I have not experienced it personally myself? Of course not, and those thinking that I am not fully qualified to care for mothers and their babies would never pose the same expectation in any other setting.

Wednesday, November 7, 2007

Are You Gonna Go My Way?

I was caring for a young girl who was laboring beautifully. She wouldn't describe it this way, with each contraction an exclamation of how fucking awful it was....and then she would continue on text messaging. She didn't want any pain medication, but kept talking about being numb. I was confused as to what she wanted, and talked to her about her options. But she wasn't having any of it.

After a couple hours of the fucking awful contractions and text messaging (oh, and sneaking in some glances at I Love New York 2 on VH1), she said she was ready for some medication. I called for the doctor, who said, "So we'll get you an epidural."

I said something about her asking for IV medication, but the doctor turned to this young girl and said, "Do you really want to be feeling this or do you want to be numb?"

"I want to be numb."

"An epidural, it is!" exclaimed the doctor.

And so the epidural goes in without a hitch. I suggest that maybe she could get a nap. She said she'd rather watch tv. Either was fine with me. She was happy.

But then the baby wasn't. The baby's heart rate took a nose dive. I told her to roll onto her other side as I opened up her IV fluids and put the oxygen on. She said she didn't want to. She was comfortable. I told she had to. Her mother came to my side and told her to do what I asked. And she began to complain. She would not move.

"Please, please roll onto your other side," her mother begged. I pushed the emergency light by this point and was expecting the barrage of people to come in.

And then I said something that got her to listen. "I don't care that you are comfortable. You need to get onto your other side now. Your baby's heart rate is down and moving onto your other side can help!" My tone was not nice. I felt like I was reprimanding her. Yet she listened.

After a few minutes the heart rate came back up. She looked scared behind her oxygen mask. I paused to catch her eye. "Listen," I said, "I want you to know I didn't intend to sound mean, but when the baby's heart rate goes down I need for you to help me."

This came to mind because I have been reading about birth trauma. I find myself reflecting on interactions I have had with the women I have cared for and wondering if I have made anyone feel scared or traumatized. I certainly don't think I am above it; I mean, I do work on a labor and delivery unit in a hospital... with a very medicalized approach to birth...I am part of a system that can take total control over every move. I learned labor and delivery nursing care under a medical model. I am sure that there were times I fell under the belief system of The Man. I try very hard to be the advocate for the woman I am caring for, but it is very hard to follow through with that in this environment. Hearing myself sound so authoritarian and bossy was a startling reminder of this.

This girl ended up with an emergent cesarean birth. The doctor said that no one could go in with her; hearing this pushed her into a pile of tears. I went to her side and said, "I will be with you the whole time." Once she was transferred to the OR and on the table with 6 people over her, prepping her, shouting out different things, I stood at her head. The anesthesiologist had the "gas" mask on her but big tears were streaming down her face. As the room spun in a controlled chaos, I put my hand over hers (strapped down, of course) and squeezed. For a fraction of a second I felt guilty for doing this as I watched the people who came in to help doing her abdominal prep or gowning the doctors. She hung on until the anesthesia kicked in. And I hoped that I did something to help her feel ok about what was happening.

Oh, and once she was awake in the recovery room she was text messaging again.

Tuesday, November 6, 2007

Polly (the fast version)

I've been finding that I have a soft spot for the young girls who come in with a laundry list of problems. My first real introduction to this type of girl was in my primary care rotation; an 18 year old who was essentially homeless and couldn't even scrape up enough money for tampons and had soiled every last pair of underwear she owned with her period. Most would look at their history and cast them off as losers, possibly junkies (whether or not they did drugs), without second thought. But how can a young person go so astray? Where was the positive adult influences in their lives?

Take, for instance, Polly. She's only 14 years old. She has been sexually active since she was a mere 11 years old. She said she has had up to 20 partners so far. Her first pap smear was significant for low grade lesion. A colposcopy was negative, and two repeat pap smears were still showing some atypical cells.

Remember, she's only 14.

When I walked into her exam room, Polly's eyes revealed how quickly she would retreat if things made her not feel right. I made sure to make eye contact with her, and hoped that I conveyed openness. I asked her all the usual questions, you know... all the fun gyn stuff, and then asked if she was having sex with anyone now.

"No," she said. "But I have a boyfriend." Who is 18. She'd been with him several months and he was "cool" with not having any sex with her. Polly said she was trying not to have sex and make her relationships "real". I told her I thought that was really a good decision.

As we continued to talk, I noticed that she was trying to cover her arms. It soon became obvious why: she's a cutter.

Now, I have never understood the desire to hurt oneself. I do know that the cutting itself releases endorphins, helping the person feel better. But still, I've always found crying and moping a much better way to releasing my emotions. Anyhow...to each his own....

I put a hand on her arm and asked about her cuts. Polly didn't say anything at first, likely because she was trying to come up with something. She must have realized that it would be hard to explain symmetrical cut marks that were equal distance to each other in an orderly fashion down her forearm.

She gave the typical teenage shrug, and the "I don't know". But soon she was talking about living in a group home for kids with behavioral problems, and how her father put her there because he didn't know what else to do. Her mother was a distant memory of her toddler years. It was her father, she said, who also decided she needed gynecological care, and from what she was saying he sounded like he was very much involved. He was the one to make sure she kept her follow up appointments, and hammered in how sometimes abnormal pap smears can lead to cancer if not treated properly. Polly's dad also came in to discuss with the doctor in an earlier appointment what would be the best birth control for her, because he didn't want to be the parent with "his head in the sand". And of course, he kept up on when she was due for her Depo-Provera shots.

I asked Polly if she was ok with all this, and how her dad knew about her gynecological business. She said she loved her dad, but couldn't live with him. She was glad that he didn't just "dump her off" at the group home like the other kids were. She was one of a few that had a parent who visited them regularly.

I could go on and on about all of her problems. I've barely scratched the surface here. But my fundamental question here is, what the frig happened to her? Why would this girl be making such bad decisions at such a young age? What could make such a young girl get off to such a bad start?

Friday, October 26, 2007

Smart Ideas

Want to have complete control over your teenage daughters birth control? Here’s a great idea:

Bring her to your OB/GYN and request that she be put on the vaginal ring contraceptive. This way you can assist her with its insertion and removal. You’ll make sure that it goes in on the right day, and it’s removed 3 weeks later. You can rest assured that each month she won’t get pregnant by one of her multiple partners.

The vaginal ring even comes with handy little reminder stickers for your calender! No more excuses for forgetting pills!

But…. Did it occur to anyone that she could remove it without your knowledge and put it back in when she knows you’ll be fishing around in her vagina for it? Hmm?

Thursday, October 25, 2007

Preceptor Woes

I’m still struggling to find preceptors. My current preceptor is great, except she doesn’t meet the delivery requirements for my school of at least 30 births over the semester (she does about ½ that). Otherwise my problems would be solved and I wouldn’t be in this jam I am currently in.

You see, if I can’t find a preceptor, I can’t register for classes in January. If I can’t register for the class, I lose my financial aid. Which, by the way, is the only way I can afford this last year of school. So if I lose my financial aid, I can not return to school. I’m also told that missing more than one semester kicks me out of the program, and so when the time comes to return when the heavenly preceptors fly down from heaven, I’d have to start from scratch!!!!

I am less than a year from graduation.

What a kick in the sac, as my husband would say.

Another problem is that it looks as though I am going to have to travel if I do get blessed with a preceptor. The problem being is that if I have to travel, I can’t work, and I certainly can’t afford to live away and pay my hefty mortgage here at home. I’m hoping to find some kind person who will give me a room out of the kindness of their heart.

And then there is always that worry that the kind person offering up their home to you will rape, torture, and kill you in the middle of the night. You just never know.

Ah…. Why, oh, why does this have to be so difficult? Why is it that this very profession, that claims it wants to build itself and strengthen their numbers, slams the door in your face when you are willing to become a part of it with their help?

Saturday, October 20, 2007

A Trap

Ya know, having my experience on the obstetrical side of the vagina, I've had some catching up to do (and still do!) on its gynecological end. Midwives may focus on the childbearing years of a woman's life, but she is also required to have a solid base of knowledge in gynecological care.

I've come to learn that there can be many items stuck in a vagina at any given time. You name it, it's been in there. My naivete shows here, because I had no idea. I've heard of the occasional tampon string getting lost and therefore making its removal difficult, and of course who can forget about the urban legend concerning a hot dog.

One of my more recent clinical encounters involved a girl who had something stuck in her vagina. It had been there for several days. It was now emitting a fetid odor. Before heading into the exam room, I discussed what I was supposed to do. I asked if I just put in a speculum and use ring forceps or a tenaculum to grab the item and pull it out.

To my surprise, I was told just stick my hand up there and grab it.

Ok....

So I do. I'm fishing around in there, and then my fingers come across what I think is the culprit. I say that I think I found it, and my preceptor tells me to put two fingers around it and pull. I do. It's slipping out of my fingers. I just can't get a grip on it. After several minutes of this, she says she'll give it a whirl.

As her hand is moving around in there, I can see her furrow her brow. Was I wrong? After another minute, she says, "I don't feel anything."

Well. The girl says she knows there is something in there. Just smell it! she exclaims. But because I thought I felt it, my preceptor asks for a speculum. She carefully looks around with the help of the speculum, and sure enough. Nada.

Afterwards, I felt terrible. What the hell was I grabbing and pulling on?

Friday, October 12, 2007

Stages of Labor, Part 1

When I was new to ob nursing, the most confusing and befuddling concepts were the stages and phases of labor. I couldn't keep them straight. It took me some time to get it figured out in my head, and it certainly helped when I began L&D nursing and actually witnessed the phases and stages with my very own eyes. I think the easiest way to approach this topic is with each phase/stage by itself. So I'll be talking only about the Latent Phase of the First Stage of Labor in this post.

But, to give you an overview, the stages of labor are:

  • First Stage
    • Latent Phase
    • Active Phase
    • Transition Phase
  • Second Stage
    • Pushing until birth of baby
  • Third Stage
    • Delivery of placenta
Some will even include a fourth stage, which would be the immediate postpartum period, but I'm going to skip that for now.

So on to Latent Phase labor in the first stage.....

I'll tell it like it is: it's long and tiring for first time moms. Sometimes it can be long and tiring for moms having their second (or more) baby because of the fetal position within the pelvis. But I'm jumping ahead of myself.

Latent phase labor is when the cervix dilates from closed to 3cm. The "books" will tell you that it typically takes an average of 8 hours for this to happen. But I've seen both ends of the spectrum here. Contractions during this phase are short (less than 60 seconds) and typically begin with mild pain. On average the contractions last about 30-40 seconds long, and are spaced about every 5-10 minutes apart. Many women can talk through these contractions, or breathe easily with them. Over the course of how ever many hours latent phase labor is for any particular woman, the contractions get stronger, longer, and closer together.

As the cervix starts to open, a woman will notice some bloody show...mucous from the cervix that is mixed with bright red blood. I've seen many women get freaked out by the sight of bloody show, and my response every time is "It's lovely!" Why? Because it means your cervix is changing... something I'd imagine she'd want. Bloody show does not always present itself in this phase, so don't panic when you don't see it.

Latent phase labor is tricky. It can be confused with false labor, and vice versa. Many times when a woman presents to the L&D with a question of labor, and we are unsure of whether its false labor (some really active braxton-hicks contractions) or real labor, then we keep her for an hour or two and reevaluate her cervix. Because, remember, true labor = cervical change. The proof will be in your cervix!

And here is when it gets even trickier.... latent phase labor can occur without much cervical change. It is when contractions are regular for hours on end (and I mean hours) with no break but the cervix isn't doing diddly squat yet. This is then classified as prodromal labor, and in my opinion I'd never sign up for it. It tires these poor women out.... even though the contractions may be short and mild (in comparison to active labor contractions), when you have them non-stop for 18 or more hours all coping mechanisms have gone out the door, and the perception of pain tends to heighten. For women who end up with this prodromal labor, there are options. I've seen doctors give sleeping pills to help the women get some rest at home. I've also seen them get admitted and given an injection of morphine to put them to sleep, and I've seen them given IV fluids to either space the contractions out or give the mom a little extra "pep" to help her cope. Frequently women are scared to take any sleeping medications because they will be asleep... well, ya, that's the point...and trust me.... you'll wake up when active labor kicks in. I've seen two things happen with the sleeping medication scenario: the woman sleeps for hours and wakes rested and full of vim and vigor with a quiet uterus, or get a little bit of sleep before waking up in rip roaring labor. And yes, that medication does cross the placenta and make the baby sleepy as well.

Regardless, when latent phase labor starts, most women are excited and feel like calling everyone under the sun (at least the first time moms... ask a second time mom and she'll say screw calling people) to tell them real labor has begun. But (and I can't stress this enough) conserve your energy! Rest at home. Have light snacks. Drink lots of fluids.

As far as when you should call your doctor or midwife... ask them. Everyone has different guidelines and those guidelines can be different for each woman. So I won't be telling you that. I can tell you that from experience most healthy women do best at home during this time, and those who run to the hospital end up with more interventions because its hard for some providers to sit on their hands and let nature take its course. But again, listen to what your provider advises.

Monday, October 8, 2007

Discrimination

I have been trying really hard to abstain from using the F word on this blog.... but I'm going to blow. So here goes nothing....

What the fuck is the issue with male nurses in obstetrics? Huh? Really, why is it so taboo for a male nurse to be in a women's health area? Does it make them perverts? Are they looking for a free peep show?

Hell, no!

So why this sudden outburst? Because I have a male nursing student who has been treated like shit, that's why. My clinical group right now is an excellent bunch of students, particularly this male nursing student. He's bright, a quick learner, is personable, and seems to enjoy what he's learning. On our clinical orientation day, I asked the group if they were nervous about working with newborns and new mothers. Every one said yes, but this male student was petrified. He was afraid of how he would be received.

I told him not to worry, that these women have male physicians. So what's the difference, right? Fortunately, every woman and family he cared for really liked him. There was even one new mother who openly discussed her abusive situation with him, something she didn't do with the staff. For the most part, the postpartum and nursery nurses were fine with him as well.

Until, that is, he went to the labor and delivery unit. The hospital I do my clinical teaching at is a community hospital within a fairly good sized city. There are a lot of old school type obstetricians there (some of them were in practice when my mother had me!), and the nursing staff is well past their prime. The nurses, particularly the older ones, on this labor and delivery have scared my students shitless on occasion. They can even be snarky with me, but since I've stood up to them from the start (not to mention discussed their bad attitudes with their nurse manager and my program dean) they have been better with me.

So my usual routine is to make my student assignments on the postpartum unit first, then hit the L&D to see what is going on and what patients are ok with having a nursing student. This past clinical day I talked with a charge nurse I had never met, and was pleasantly surprised with her enthusiasm for students. She asked if there was a student available at that very moment to come down and observe a cesarean birth.

I ran back upstairs and grabbed my male student. He was so excited to get this opportunity. The charge nurse didn't bat an eye that he was a male, and she brought him back to the OR. I thought all was well and good.

Until he was suddenly back on the postpartum unit an hour later. He said the nurse caring for the c-section patient was rude, and told him to leave the OR as soon as the surgical drape was coming off. He decided he'd go wait in the PACU recovery area, but was told by this same nurse to leave. When the patient was settled in the PACU, he went back in to the room and asked if he could help do vital signs and fundal checks and what not, and was told to step out.

Apparently the charge nurse was aware of this, and suggested that he follow the pediatrician with the baby. Because the pediatrician at that point was pretty much done, there was nothing for him to do. He approached the nurse again, and she said he didn't need to see an exposed woman, especially as she was trying to breastfeed.

What the fuck? What was she thinking? That he was just trying to gawk at naked women? All she was doing was perpetuating the myth that breastfeeding is a sexual and perverse act that should be kept private. Come on!

Needless to say, the student knew why this nurse was acting this way. And he was pissed. I can't blame him. I'm just as pissed, if not more so. No one would bat an eye at a male obstetrician in that room, so why would a male nurse be an issue?

Wednesday, October 3, 2007

More on the Lonely Soldier

I am really glad to see that I am not the only one who wonders why some midwives and midwifery students adopt the medical model of birth. I think there are so many factors involved, and there is no way to easily draw a line between any of those factors. I received an email from Brittanie who asked some great questions that add to this topic. Her questions are in italics, my answer follows.

Midwifery students that do not support home birth...why? You suggest misinformation and fear of litigation, and I think you must be right.
Nurse midwifery students many times start out as labor and delivery nurses. L&D nurses are trained under the obstetrical, or medical, model of childbirth care. They are trained to view birth as inherently risky, where anything can go wrong at anytime. I work with nurses who, after 30 plus years of experience, can not see beyond this. I work with new nurses who quickly adopt the medical model. And many times, I can't blame them. It is very easy to not be able to see beyond what presents itself everyday. (Little do they realize that some of the complications they see are created out of the very things we impose in medical childbirth care).
When I was a new obstetrics nurse, I would have read my own blog and thought the person writing it was a lunatic. Homebirths? Midwives? No operating room to run to? No fetal monitoring? I was totally against it. Homebirths were for people wanting to risk their and their fetuses lives, midwives were for hippies and the indigent who could only afford second class care, c-sections were needed more often than not, and continuous monitoring was a must because that fetus could be having a deceleration at any time. I also thought that every woman would be better off delivering at a tertiary teaching hospital with a large NICU. But I was biased. My first ob nursing job was in a very large teaching hospital with a very large NICU with a very large proportion of high risk pregnancy. As a matter of fact, there was a large unit just for the high risk pregnancy women who needed to be admitted. And it was always full.
Honestly, I don't know when my opinion started to turn. I think it was gradual. When I went into labor and delivery at another large teaching hospital, laboring women were treated as incompetent sick people that were precariously teetering on the brink of disaster. The anxiety this caused me was nearly unbearable; it didn't feel right. And when I moved on to a large outpatient hospital clinic, I began to dislike how the women were thrown into this birth machine and treated like they had a disease. And so I started to question everything.
At my current job, I had a clinical preceptor who said to me, "Stop looking for the bad things. Look for the good. You'll see that there is more good to be had here if you don't go hunting for bad things!" And it made perfect sense.
I certainly believe there is a fear of litigation that drives practice. This is true for both obstetricians and midwives. However, midwives are sued less often. This is likely because they deliver evidenced based, safe care to low risk women. But when many midwives are practicing under policies set forth by the hospital or their collaborating physician or even malpractice contracts, then they have to follow rules that were put in place because of litigation fears. This point could turn into a book, so I will leave it at that. For now.

Do you think the midwifery program is another one of the culprits behind this misinformation? Are CNM midwifery programs changing?
I'm not sure that midwifery programs are the culprit per se, but certainly play a role in how new midwives view their care. So far, my program has not taught anything or even hinted at a medical model of care when it comes to childbirth. Everything that is presented to us is backed by current literature. The clinical experiences of student nurse midwives can vary greatly, however, depending on who the preceptor/mentor is. I have fellow students who are being trained by obstetricians. I often wonder how this will alter their approach. I have purposely chosen to be trained by CNMs because I want to keep my education in midwifery care.
I have no idea if CNM midwifery programs are changing. I'd imagine that they are, and hopefully in a positive way. My program is very heavily steeped in evidenced based midwifery care and political advocacy. I would imagine that nurse midwifery programs even 10 years ago didn't have these underlying focuses. But I consider this a good change.

As a midwifery student, do you feel that your instructors/program/school are supportive of homebirth, or is this just an issue of a few of your fellow students being misinformed?
My current preceptor is supportive of homebirth, but in a fairly limited capacity. She certainly isn't as liberal as some on this, but I'm happy that she does support it. Some of my professors have done homebirth, but I haven't gone into it with them. I think that my fellow students are just having a hard time letting go of their L&D nurse mindset.

Have you talked to these students about why they are choosing midwifery instead of obstetrics?
Hell, no! Just recently a fellow student said to me, "You know, the more I get to know you the less abrasive you seem." Clearly you can tell I am outspoken in my beliefs and have rubbed some the wrong way. I think if I asked that question it would come across as an argument.

Sunday, September 30, 2007

The Lonely Soldier

I am so discouraged by the beliefs of some of my fellow midwifery students. Many of them do not believe in homebirths, VBAC’s, non-nurse midwives (such as CM’s or CPM’s), or other non-interventional childbirth. They think all births should occur in a hospital with sophisticated monitoring equipment and capabilities. What in the world are they doing in midwifery then?

One of the discussions in class led to the topic of litigation. The things coming out of some of their mouths were just repetitious dogma of ACOG and malpractice insurers. Some were saying how risky VBAC’s are, others saying so many things can go wrong at home. There were some actually accusing CM’s and CPM’s of not having a scope of practice and over stepping their boundaries by practicing medicine. Huh?

I posed the question of perception. Has the risk of uterine rupture increased with VBAC recently? No. Well, let me answer that with yes. It will increase when women who are VBAC-ing are given misoprostil. Here’s a thought: don’t give women misoprostil. Don’t mess with their labor. Again, what has changed that suddenly makes VBAC’s the devil’s labor?

The "things can go wrong at home" argument just doesn’t fly with me for reasons to not homebirth. Sure, put a high risk mother (for instance a woman with preeclampsia) in her home to labor and birth and you are asking for trouble. Put a low risk, healthy mom in her home to labor and birth and most of the time you will see a wonderful event. On the flip side, put a low risk woman in a hospital to labor and birth and watch the intervention rate sky rocket and her chance for a c-section at 30% (or higher depending on the hospital).

The other thing that bothered me was the misunderstanding of what non-nurse midwives are capable of. They are trained, skilled labor attendants. They are taught to watch for signs of possible trouble, and know their limitations (sound familiar? So do CNM’s!) and when to refer. I had no idea that there was such animosity towards what is commonly called “lay” midwives. And for the record, I don’t like the term “lay”. It doesn’t give the general public the right perception of who they are and the training and certification they have received. It makes them sound like they are a group of hippie women with armpit hair and hemp necklaces who decided to birth some babies out in a field.

Yet one more thing to make me feel like the lonely soldier fighting the seemingly impossible battle. How can things change when your colleagues don’t believe in real midwifery care?

Wednesday, September 26, 2007

P.O. vs B.O, It Still Stinks

I think it is time to repost one of the all time biggest hits from Life & Times. Hope you find a chuckle in it the second time around.


P.O. vs. B.O.

Sometimes there are women who must have a poor sense of smell or even maybe even a lack of olfactory nerves that comes into the labor unit. And she always seems to have a posse of others with the same problem.
What do you mean, you ask? I'm talking P.O. people. Think B.O. just substitute that B. And I must say I would highly prefer the B.O.
Now I usually try to remind myself that these women are in labor. Maybe they felt like they didn't have enough time to take a shower. Or maybe it began on the drive over to the hospital. I really try to cut them some slack, but it's really hard to do when the person came in for an induction and had plenty of time to shower before coming in because she wasn't in labor. And it is really hard to do when you are assisting in an exam where you end up having to revive the person going into the battlefield, if you know what I mean.
Now, nurses and doctors don't sit around the desk talking about your private parts. We see so many of them that if you walked in with a vagina on your forehead we wouldn't blink. But when we have to resort to shallow breathing and Haz-Mat suits while in the room or keeping a bottle of Febreeze handy it gets us talking.
First we make the pronouncement that yes, Virginia, there is an odor. And no, Virginia, it isn't pretty. And so we contemplate as a group, "Does she realize she stinks?" and "Does anyone else that is with her know she stinks?" If the answer is yes to the second question, then I want to know why didn't they kindly inform the woman of the stench so that she could do something about it? And then we wonder, is it infection? So depending on the doctor they may decide to do a culture but I must say it always comes back as a really bad case of stink puss. I've had one case where the stink was so bad that the baby came out smelling foul, and it persisted even after a bath. Who wants to snuggle a baby who smells like a 10 day old dead salmon?
And it also put us in a predicament. Do we want to say something? Absolutely! But how do you delicately approach such a topic with someone you just met? First off, I offer the shower or jacuzzi as a way to help with labor. This will provide a two fold bonus for all involved. It will help the woman feel better and keep the people caring for her from singeing their nose hairs. If she doesn't do this, then I start hosing her down. When I am changing the wet pads underneath her in bed, for instance, I use that little peri bottle to wash her off a bit. It doesn't work perfectly, but at least keeps the amniotic fluid and bloody show from joining in the potpourri. And when all is said and done, I push the shower. And let me tell you, for as many women who beg for a shower even before they have got out of bed for the first time after the birth there are as many who don't want anything to do with it at all. Maybe they like their stink. Perhaps it's a way for them to make a mark of where they have traveled.
Likely no one will ever tell you that you have stinky crotchitis. So do yourself a favor and take a shower if at all possible prior to coming to the hospital. Use soap. And dry well after. Put cotton underwear on. These simple steps go a long way.

Wednesday, September 19, 2007

Midwife Glasses

Today I attended my first birth as a student nurse midwife. And let me tell you how weird it is trying to stay out of the "labor nurse" mindset. As I worked with my preceptor, I found myself drifting off to the things I would be doing if I was the labor nurse. I kept wanting to silence alarms and document nursing things in the computer. I wanted to make sure all of my busy work was out of the way (filling out baby bands in advance, having an organized room, things of this nature). And then I would think...oh, wait, I don't have to worry about that! It didn't help that the real labor nurse kept trying to compare notes, asking how my hospital did things and what not.

And then came time to start birthing a baby. At this point (after 7 hours of trying not to be the labor nurse) I had managed to put my nurse midwife "glasses" on, and boy oh boy! The things I don't pay attention to! As the mom was pushing, there was this quasi-wrinkly tissue hanging out on the anterior aspect of her vagina. The first thing that came to my mind was that she had a cystocele (her bladder bulging into the vagina), but turns out it was good old fashioned vaginal rugae (vaginal folds). Huh... go figure. After all these years being an OB nurse and I never realized this before. I knew of vaginal rugae, but have never seen them kind of hanging there, being pushed forward by a baby's head.

I also got a really good look at "skidmarks". Now, many of the women I have care for have had skidmarks after a birth but I had never actually seen them in such detail. And for those of you scratching your head, thinking of poop stains in the underwear, think again. Skidmarks are used to describe tiny little abrasions that do not require suturing. It's like skinning your knee. Except on and around the perineum.

Oh, the places I will go!

Tuesday, September 18, 2007

Back To School Sale: Student Midwife Special

I'm trying to get back into the swing of things here for school. Classes started and I am swamped. I took an extra course this semester because I didn't want to be bogged down when I had a larger number of clinical hours to complete later on.

And speaking of clinical, I am happy to report that this current clinical rotation seems to be nothing like my prior clinical experience last spring. For those of you who were reading me on Life & Times last spring, you will remember my frequent whining and complaining. I had a preceptor from hell, who believed that it was not her job to teach. I was not allowed much patient contact, could not document in the patient records, and generally wanted to gouge my eyes out every slow minute that passed in that office. So I am just elated that my current preceptor, a very experienced nurse midwife, is quite the opposite. She takes the time to explain every thing she does, and was astute enough to notice how difficult it is for me to just observe. She assured me that I would be doing everything before long. Bonus points to this midwife!

However, my preceptor woes are far from over. I have yet to find anyone willing to take me as a student in January 2008. I also received a voice mail message from a midwife who had verbally agreed to take me in March 2008. The tone didn't sound good, sounded like she might be backing out. She was not available to call back until later this week, so I sit here pondering my clinical fate.

I'm also just as good as always with my procrastination skills, too. I should be entering my clinical data for school instead of blogging.

Sunday, September 16, 2007

What A Pain

Labor = Pain.

Most people would agree with that statement. There are some who have had the Labor = Ecstatic version, but seeing that is far and few between I’ll keep to the first notion.

Now, I am sure that most women realize that they will experience pain when they go into labor. I’ve discussed that some seem to be quite surprised that they have to experience pain, but I won’t go into that again. So, assuming that every woman who is due to give birth at some point in their life will have a first hand account with labor pain, I figured that it might be helpful to understand a few things about that pain.

What does labor pain come from? Well, duh, Labor Nurse, it comes from the contracting uterus and a large baby exiting your nether regions. Yup, you are right. But, it is more than that.

  • Dilation and effacement of the cervix. The opening and thinning of the cervix while a baby’s head is rammed up against it can be unpleasant.
  • Pressure of the baby within the pelvis. Imagine placing an 8 pound bowling ball in your rectum and holding it there while it is intermittently squeezed resulting in an increase in that sensation.
  • Pressure from the contracting uterus against surrounding organs. The uterus isn’t floating in its own orbit; it is smooshed against your other organs (like your bladder and intestines) and causes them to hurt, too.
  • The increase of lactic acid within the uterine muscle. Actually, the uterus is just one big muscle, and when it is exercised, so to speak, for hours and hours it will make lactic acid. It’s pretty much the same thing as an over worked bicep or quadriceps muscle if you exercise it too much.
  • And of course, the most obvious: stretching of the perineal and vaginal tissue with a descending baby. This pain has frequently been referred to as the infamous Ring Of Fire.

Another factor contributing to labor pain is your personal and cultural beliefs and experiences surrounding pain. Think back to a time in your life when you had some serious pain. How did you react to that? Did you find anything that helped you cope with it? How did that change your view of any future anticipated pain? I’ve personally found that women who have had bad experiences with pain in their past that they were unable to cope with for whatever reason have a really hard time when labor kicked in. On the other hand, women who approached previous pain with a mindset that they can deal with it one way or another have an easier time getting through contractions. I’m not saying that if you merely winced when your arm got chopped off that you can whistle through contractions; what I mean is that those who have been able to successfully tackle and mentally cope with whatever pain they’ve experienced seem to be able to accept and get through labor without losing their minds. And when I say “tackle and mentally cope”, this means that the person found something to help them. What that something was can vary considerably, and it actually doesn’t really matter. It was that they found something that was important.

Women who have a hard time coping through labor can actually make their pain worse by merely being afraid of it. Pain is heightened by fear and tension. And this turns into a self feeding cycle. You have pain, you tense up, you become afraid of what your feeling, which further increases tension, which increases the level of pain experienced…. you get the idea.

There are a few other things I think are important to address regarding pain. Since most give birth in a hospital, there are some annoying things that have to be done. First is that nurses must document pain levels. This is a standard in any area of nursing set forth by our hospital’s lovely accrediting body (JCAHO). So we have to ask what your pain level is on a scale of 1-10. If we are solely looking at how this works for documentation purposes, providing a number helps anyone looking at the chart see the progression and/or relief of pain. But it’s very annoying to ask a woman who is clearly experiencing a lot of pain, “What number would you give this pain?” Like she cares to answer. I think I’d probably answer something like, “Who the fuck cares? It hurts!” but unfortunately we need that damn number.

The other thing is that many people get caught up in what the monitor is telling us. I can’t tell you how frustrating it is to see family members staring at the monitor during a contraction and hear them say, “But honey, that one only registered a 35 on the monitor!” when she is moaning and writhing in pain. Unless the woman has an internal uterine contraction monitoring device, that monitor isn’t telling anyone shit about the pain level. Only the woman can tell us that. So stop looking at the monitor (I wish we didn’t have to use them… it would solve so many problems).

Lastly, think about the traditional definition of pain. Pain is typically defined as suffering caused by injury or illness. Labor does not signify injury or illness. It’s a normal, natural physiological process. But our society seems to forget this and equates this normal pain with pathological pain that must be treated and fixed. And so many times women jump into the whole pain, tension, fear cycle because their mind is telling them that their pain is abnormal and something must be wrong. But there isn't.

Wednesday, September 12, 2007

Ok, So Maybe You Do Like Me!

I was just reviewing some stats and saw that I was ranked in the top 25 nurse blogs by the Nursing Online Education Database. Pretty cool.

Apparently Not Everyone Likes Me

I was reminded last night of an interaction I had with a former patient. It left me feeling that I lacked something, or perhaps that I was viewed as part of something was unpleasant.

I had won sports tickets through my hospital and brought along my Dad. Before the event we were given a hearty buffet brunch. There was much fanfare for those of us lucky enough to get into the events tent and the food was good. My dad and I made our heaping plates and sat at a table to eat. My hospital had also sent along a representative. This representative was a former patient.

I cared for this woman during her office appointments. I felt that I had gotten to know her well during her prenatal visits, which was something I hoped to do with all of my patients. However, this woman was a big wig of some department within the hospital and therefore made the office staff nervous. I never felt her presence as overbearing or stiff, and remember thinking that she seemed rather young and relaxed to hold such a position. I didn’t get a chance to see her during her postpartum follow up visit and never saw her again until that day at the game.

When she approached the table she was friendly and warm. My face was towards the plate (not uncommon for those of my genetics) when she approached so I don’t think she saw that I was one of the lucky ticket winners. When I did look up and say hello, I could see the look of recognition in her face. And it didn’t look good.

She tried to pretend she had no idea who I was. She introduced herself to me and my father. I said, “Yes, we’ve met when you were pregnant with you daughter.” I smiled to convey my relaxed demeanor when seeing my patients outside of the office.

“Oh,” she replied stiffly. She was suddenly very uncomfortable and seemed to be a bit upset by my mentioning her pregnancy. There was no one else at the table but my father and I, so I didn’t believe that it was because I mentioned I knew her when she was pregnant. I didn’t mention that I cared for her, so I certainly wasn’t announcing anything involved with her care or violating the precious HIPAA laws.

Normally I would have asked how her baby was doing, what milestones they reached, but her body language said it all. She did not want to talk about anything relating to my connection to her.

I think that some would say that I was taking this all a bit too personally, but I found her response quite odd. Most patients I have cared for that I run into in the outside world seem quite happy to see a caregiver associated with a cherished event in their life. Did something happen during her birth that I was unaware of? Did she feel that we failed her? What was it about me that conjured up bad feelings?

She soon left after our quick conversation. I watched as she purposely avoided the area I sat. And I still wonder what was it that was so bad?

Thursday, September 6, 2007

Birth as an American Rite of Passage

Birth as an American Rite of Passage, Second Edition, by Robbie E. Davis-Floyd has been hyped as feminist propaganda and an eye opening must read for childbearing women. This book was first published in 1992 with the second edition following in 2004. Outside of the preface to the new edition, the book was not changed or updated. This is much to its downfall.

Davis-Floyd is an anthropologist whose life work surrounds human childbirth. She views our current system of childbirth as technology driven, under a technocratic and paternalistic model. She analyzes the need for societies and groups to have rites of passage, birth being one of these rites. She examines the history of childbirth through conceptual frameworks that changed through generations. The underlying theme in most of these frameworks is that women’s bodies are flawed. During the industrial revolution and scientific awakening, mankind began to view the body as machine. The ultimate machine is the male machine, and the female machine is the flawed or continuously faulty body. It is under this belief that drives current trends and medical approaches to childbirth.

Davis-Floyd interviewed many women during and after their pregnancies. She analyzed these interviews for underlying themes in how women view childbirth under the current medical paradigm. Surprisingly, the majority of the women wanted or at least accepted the medical approach to birth. Drat!

However, the question must be asked: is this because we are products of our culture? Are we as a society bred to believe that birth in a hospital with all the latest gadgets and procedures (of which many have no scientific evidence basis) is the best and only way? I’d say yes. How often do we hear the dogma of the medical approach to birth because it is inheritantly dangerous? Why are we ignoring the evidence that many of the dangers are technologically grounded?

Outside of this discussion, the author includes her interpretation of the medical and hospital procedures performed during childbirth starting from the wheelchair into the labor room. Because this book was originally published in 1992 many of the procedures discussed are out dated. It is still interesting to read why such things (enemas, shaves, ritual separation of mother and baby) occurred.

Because some out dated procedures remain in the book, many discredit this work as foolish drivel. I agree that the author should have updated her references and ritual analysis of hospital childbirth procedures. There certainly is enough evidence out there to continue to support her theories and analysis.

This book will not tell moms-to-be “what to expect”, but it may help in making informed choices. If you are looking for a book chock full of birth stories with benign messages, look elsewhere. There are birth stories in this book, which I found interesting, but will likely leave The Baby Story crowd unfulfilled.

Wednesday, September 5, 2007

Demands, Demands

For those who have read me back in the good ol’ days (aka Life & Times), you know one of my biggest pet peeves are those who must have an epidural yesterday. You know, labor and birth are as old as dirt so I can’t imagine any woman these days who didn’t know going into this that labor was going to hurt. Hello, people! What were you expecting?

I recently was asked (or rather, demanded) when was “my epidural was getting here?” Huh? I didn’t realize it was on order. And by the way, when you say “your epidural” you must mean the human being that was highly trained commonly known as the anesthesiologist to place said catheter? Um, ya, she will come give it to you when I can safely prepare your wussy ass for this intervention.

Ok, so I didn’t really say that. What I really said was something like this: I need to do several things to get you prepared for the epidural. First I have to start an IV and run a liter of fluid into you. However, I can only run that liter of fluid over 20-30 minutes, at the most, because too much fluid too fast can cause problems. We also have to get the results of your blood count, because an anesthesiologist will not place an epidural catheter until they know what your platelet levels are. Your labs were ordered stat so I hope to get the results in 30 minutes. I’m doing my best to move things along so you can get an epidural.

Needless to say, irony has a funny way of working itself into these sorts of situations. Well before anything was ready, this woman became fully dilated. She fought and argued that there was no way she was pushing without an epidural. “I can not do this without one!” is what she yelled. The doctor said something like, “Well, you have no choice.”

Now, had the attending been someone else, say one of the docs who isn’t so forthright, she would have got the epidural. I have seen some who fight their body’s own natural urge to bear down so that they can get an epidural. In the time it takes to prep them, get the epidural in, and then for the time it takes to work, they could have had a baby, breastfed, and taken a nap already.

But hey, to each his own, so they say. Unfortunately for her, this woman did not get what she wanted but she did have a baby 10 minutes later, and spoke nothing of the epidural after.

p.s. before you all get your noses pushed out of joint over “wussy ass”, keep in mind that this was being asked by a woman who came in in early labor and was still able to talk and breathe easily through contractions. We originally thought she was going to be one of the women that would be sent home after having confirmed false labor.

Tuesday, September 4, 2007

Student Contact

So it’s back to school time, which means for me that I go back to being a student and a nursing instructor. My plate this coming fall will be very full. I am taking three courses and teaching a maternity clinical rotation to nursing students. Frankly, I think I would prefer to spend my time reading and knitting, but I won’t get paid or be able to graduate doing those things.

This coming semester I have given up my clinical skills lab instructing. I have worked in the skills lab for several semesters teaching new nursing students how to take pulses, blood pressures, and good body mechanics. I have taught the more senior students how to place Foley catheters and hang IV medications safely. But nothing is more amusing than teaching students who are, shall we say…. stimulated, with the skill at hand.

When a new skill is taught and practiced, students use each other as their “patients”. I was working in a practice lab, so my job is more or less just observing and supervising, and many times correcting, the students while they practice. A group of students were practicing auscultation of lung and bowel sounds, the first skill that requires them to touch skin that normally lays under clothing. You can see that some students feel uncomfortable lifting the shirt (even if it’s the back) of a fellow classmate to properly listen to their lungs. And some have no problems with it.

This particular group consisted of three young, perky 20 year old girls and one 20-something guy. When it was the male student’s turn, he was very careful with what he was doing with his hands and how he touched his classmates. The girls didn’t mind at all that their fellow male classmate could see them with their shirts half off and abdomens exposed.

The problem came up when it was the male student’s turn to be the “patient”. He took his sweet time laying down on the bed, and then moved in some strange ways that caught everyone’s attention. He was trying to hide his erection.

There was this awkward moment of stillness as we all registered what we were looking at, and there was a hesitation on the part of the girls to begin listening to his bowel sounds. The guy laid their trying to discreetly cover his groin while staring straight up at the ceiling. I told them they were all doing a good job and left the area.

I pulled a colleague aside and laughed my ass off at that poor guy. The next skill they were moving on to was body mechanics and proper transfer techniques. This requires a lot of full physical contact, and I wonder how he handled that. He never came into the practice labs for that skill.

Saturday, September 1, 2007

A Revisit of Helpful Hints

It was requested that I repost some of the things that I mentioned on Life & Times that you may find useful when preparing for a new baby. I also have the list of what to bring and not bring to the hospital somewhere, so when I find it I will post that next.

I have added more thoughts to the original post in blue.

Labor Nurse's Hints From Heloise, or Useful Shit

I have been asked here on the blog as well as at work and in my childbirth classes what a new mom should buy, read, and avoid. I list what comes to mind, but remember that this is just personal recommendations, not professional. You know, blah blah blah, don't be upset with me if you follow something and don't like it.

1. Good God, get that car seat out of the box. Do this before you are 36-37 weeks. Trust me, trying to figure out one of these contraptions on the day of discharge is no picnic, and your nurse might not be able to help you legally. People who are working within a professional role who are not car seat safety certified can not touch the car seat, and especially can not place the car seat or its base in the car for you. So read the damn manual and figure out how it works. If you are anticipating an early delivery, don't be surprised when the nurses tell you the standard car seat you have is not appropriate. Many hospitals are now testing babies that are less than 37 weeks gestation or less than 5 1/2 pounds (about 2500 grams) in car seats. The purpose of the car seat testing on babies in these categories is to make sure they do not stop breathing or drop their heart rate while in a car seat. In the rare case of a baby who "fails" the car seat test, a special flat lying seat will be required.

2. Do not place anything into the car seat that didn't come with the car seat. Believe it or not, this is a sensitive topic for some parents because they can't imagine placing a baby in the seat without one of those plush head supports or some sort of dangling entertainment from the handle. Keep in mind that if you were to get into an accident and the car seat failed, and you decide to take action against the manufacturer, and there was something attached to the seat that it didn't come with then you are out of luck. Besides, the reclined position will keep the baby's head from rolling forward (doesn't matter that their head is to the side, they can still breath and clearly its not bothering them if they are sleeping) AND those little toys could turn into a weapon in an accident. They can come loose and whip across the cabin of the car, hurting anyone present. I can't stress enough that I am not trying to be mean and make your baby uncomfortable or insinuate that you are a bad parent for buying or using car seat accessories. This one set off a few readers the first time around. It's just the recommendations of car seat manufacturers and the American Academy of Pediatrics (although don't quote me on that one, I'll have to double check that) and as a nurse I must inform parents of these safety recommendations. It is completely your choice whether or not to follow it. At my hospital, nurses have to document how the baby left the unit. For example I would have to write in the baby's chart: "Infant discharged with parents in car seat following recommended guidelines" OR "Infant discharged with parents in car seat with after market added head support. Informed parents of car seat safety guidelines, parents both verbalized understanding and stated they prefer to keep after market accessories in car seat." We even have to get the parents' signatures on this documentation (in both scenarios) to ensure that there is full understanding. Of course, when I have to document scenario #2, parents think we are writing something against them, certifying them as official bad parents. Unfortunately, in our lovely litigious society, if that family was to get in a car wreck on their way home and something terrible happened to their baby because of an after market accessory we have proof that they were aware of the guidelines and therefore the hospital is not liable.

3. Once you follow #1 & 2, go to your local fire or police department for an official car seat safety inspection. Most people, even those who read the manual, do not install the base of the car seat properly.

4. Be wary of the gimmicks. First time parents are usually the most vulnerable to this... certainly all good parents must have the Pee Pee Teepee's for their little boys, or the ultra soft and sensitive silk with woven gold fiber crib sheets. When you shop at the baby stores, look very carefully at the layout of the store. Notice that all the essential baby items (diapers, cribs, car seats, strollers) are all at different corners. This ensures that all parents coming in to shop must walk through countless aisles and sections of the nonessential but must have to look like a good parent sections. I've recently noticed that even Target has re-done their baby section and placed essential items in the back while all the cutesy non-essential stuff is placed up front.

5. Stock up on diapers. In all sizes. Don't bother with buying the newborn size. Most babies these days can go right into a size 1 diaper, and all those newborn size diapers are a waste of your money.

6. Speaking of diapers, consider having a diaper baby shower as opposed to the traditional shower where people buy useless cutesy items that you are likely never to use, or baby will never wear because its impractical, too small, or too big for the season its meant to be worn. People can bring just diapers and some can even become quite creative with it.

7. Although, probably not a good idea to plan your own baby shower (you look very greedy), but you can always drop hints.

8. Newborns do not need special lotions or other skin care products. As a matter of fact, newborns should not have anything put on their skin because it is so sensitive. Just wash the vital parts once a day (face, hands, diaper) and a tub bath just every 2-3 days.

9. Most baby needs are simple. Food, comfort, warmth. Which brings me back to #4.

10. Avoid What to Expect When You Are Expecting like the plague. Who cares that its a number one best seller for years. Its loaded with anxiety provoking sentiments like, "That twinge you feel near your groin is likely just growing pains, but it could be uterine detachment or uterine rupture and your fetus is now outside the womb tangled up in your intestines. Call your physician." One of the things that Dr. Wagner writes in his recent book Born in the USA struck me as a great piece of practical advice for pregnant mom's looking for books: if the book has the mantra "Trust your doctor" put it back; if the book has the mantra "Trust your body" then it's a keeper.

11. DO NOT, hear me, DO NOT buy a home fetal doppler. It's a waste of your money. The ones in stores almost never work. All you will hear is static and possibly the playings of alien transmissions. The dopplers in your doctors office are $600 - $800 or more dollars, which is why they work so well. Go ahead and buy the professional one if you have the money, but if you don't mind spending big bucks for something you'll use only a few times contact Tom Cruise and see if you can buy his ultrasound machine.

12. 3-D ultrasound is not better than the ultrasound your doctor or midwife has you get around 18 weeks. The ultrasound "centers" that do these 3-D ultrasounds for the hell of it are making a huge profit off you just so you get a few glimpses of your baby. What most people don't realize is that ultrasound is used for medical reasons, not just so you can find out the sex of your baby. Places that perform ultrasound for non-medical reasons are crossing the fine line of ethical "treatment".

13. Attend a non-hospital based childbirth program. You should know why.

14. Hire a doula, or ask a female friend or relative that you trust to be with you for continuous labor support. Ya, I know, Dad is going to be there, but he's likely to be scared to shit and not really know what to do. Women trained to give labor support, or even those who have gone through it seem to do a better job.

15. Get yourself a very comfortable, supportive bra without wires. Sports bras are great for those who are going to bottle feed. When you become engorged you are going to want lots of comfortable support. (And ice... ice those puppies several times a day until the engorgement is gone.) For the breastfeeding mom's, get a comfortable nursing bra without wires. Trust me, you won't want to wear that little Victoria's Secret push up.