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

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.