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?

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.

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.

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.

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?

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.

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.

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?

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.