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

Friday, December 26, 2008

What it feels like to grab boobs

....that was a search query in google that lead someone to my blog.

Really.

There was also a google search query "I'm 13 and want to grab some boobs". I think that is likely the same person, what do you bet?

Here are some others, which make much more sense:

Mucous plug
Oh...the mucous plug never dies, does it? There is nothing magical about it, people. Well, perhaps there is- but not for reasons that women wish it would be. The mucous plug forms at conception, sealing off the uterus from foreign substance like bacteria. It remains in place in the cervix, right in the os (cervical opening) until late pregnancy. The mucous plug either comes out in a big clump, slowing in small amounts, or not noticeable at all. Sometimes it doesn't come out until labor, seen as a large amount of bloody show. And when it comes out tells us nothing but that your body is getting ready in a normal fashion for labor. Doesn't tell us when.

Nausea before labor
Happens frequently. Its like morning sickness all over again. I've seen nausea and vomiting a lot during the labor process. Not fun for anyone.

Epidural percentage
In my opinion, it's pretty high. So many women, especially first time mothers, come in asking for the epidural before they are really in labor. They say that their ____________ (fill in the blank- sister, friend, cousin....) said they must get the epidural as soon as possible because you don't want to miss out. Or that labor is so awful that there is no way they would be able to do without (believe it or not, women do! And even plan it that way! Imagine that!)

I'd say that about 90% of the women where I work get them. I think our stats say something significantly less, like maybe 70%, so I want to know how exactly are they collecting their info. I can't remember the last women I cared for that didn't get an epidural.

As far as what it feels like to grab boobs- I can tell you that they feel like, well...boobs. Some like socks with rocks in them(where mine are heading), unnaturally firm (fake ones), or bags of sand, like Steve Carrell says in The 40 Year Old Virgin. Take which ever explanation you prefer.

Thursday, December 18, 2008

How to Handle Bad Care

I am sure some of you have already heard the lawsuit against an obstetrician who treated a woman in labor having her 5th baby horribly, so badly in fact that it caused her emotional trauma. I've written about rude and condescending things I've personally witnessed or heard about, but nothing compares to what is alleged in this particular suit.

The original story broke in the Chicago Tribune. The following comment is from Kathy:

Rebirth Nurse,

I just read
the story originally printed in the Chicago Tribune about how one doctor allegedly abused a patient because he was angry at her for not calling him before going to the hospital. (You can click on the link for the allegations, but they include denying her request for an epidural for hours, not allowing her to speak [even to ask questions], making her lie in stirrups in an extremely uncomfortable position for hours, telling her in no uncertain terms that she was going to hemorrhage, and suturing her without anesthetic.)While I am extremely upset at even the possibility of something like this happening, I wonder if there is anything that the woman or her husband could have done to stop this. Assuming all of the allegations are true, what could the woman have done while in labor to have kept this from happening? Could she have requested another doctor? Could the nurse have done something? Surely there was *something* that could have been done. While people like me can get angry at such treatment, I would like to go deeper than that and work at preventing that, rather than just "file suit afterward" if something like this happens.-Kathy

Kathy, you ask such good questions. I can answer these questions as if it happened to anyone, and what women can do in situations where they feel they are treated with a lack of respect, not given analgesia or anesthesia when requested but it would have been safe to give, or generally feel as though they are not given any choice in their care. I can't answer specifically in regards to this particular story in regards to what this woman and her husband could have done, but I think it would be helpful to discuss what any woman and her support people can do in such situations.

First off- much of what can prevent this sort of situation is education. I've written plenty on the importance of educating oneself on their provider, their philosophy, their partners and philosophies, the hospital or birth setting, and the process of labor and birth and choices available to them during that time. (Sorry, you'll have to search my archives for these posts because I am really lazy and not linking these days). Knowing what is considered "normal" labor and birth, what the policies and procedures are in your chosen birth setting, and how your provider and their covering partners "manage"or approach birth. This can help prepare you for what to expect, as well as knowing if will even be comfortable with what you desire.

In a hospital, there are always "back up" providers. Even in small community hospitals, there will always be someone else on stand-by call in case all hell breaks loose, or if the covering provider falls dead, or whatever. Larger places may even have a second provider in the hospital. So, if you do not like the provider caring for you because they are being disrespectful, performing interventions without asking permission, declining requests for pain medication, or otherwise you can always ask to have that provider take over.

But, and its a big but, is that before you get to this, start asking questions. For instance, why can't you have pain medication if you are requesting it? There may be a very good question as to why its being declined. For instance, anticipated delivery will occur in a time frame where it may not be safe for baby, or in the case of an epidural it may be because there are no anesthesiologists available at that time and you will deliver in 10 minutes. If a provider says, "You need XYZ" and starts to just do it, you have the right to say, "Can we discuss this first?" Things to ask when presented with procedures or interventions are:

  • Why is this being recommended?
  • What are the risks to myself and my baby?
  • What are the benefits?
  • What could happen if we didn't do this?
  • What are the alternatives?

Then you can ask for time to discuss it over with your support people in private. The only time I can think of where this is likely not going to happen is cases of true emergencies- like prolonged fetal bradycardia (baby's heart rate drops and doesn't come up), major maternal hemorrhage (you're bleeding out like a sieve), or the umbilical cord hangs our your vagina, for instance.

If you can not get answers to your questions, you can ask for the second provider. You can even state that you do not like how you are being spoken to if you feel its disrespectful. You can speak with your nurse as they are also your advocate. And if you don't feel like you can personally do this, have your support people ready to step in.

Remember, as the patient you have the right to informed consent, informed decision making, the ability to say no, and the right to ask for another care provider that you feel would better fit your needs and treat you safely and with respect.

As a follow up, contact the hospital's patient services/patient advocacy department, risk management, the department director (both nursing and obstetrical), or even the president/CEO- if not all of them.

This sort of stuff angers me, too, and I've been pretty fortunate not to see what was alleged in the lawsuit. I have seen things that are disrespectful, or comments that leave a woman feeling inadequate on occasion, but fortunately not often and not to the degree this lawsuit mentions. I hope my tips and thoughts are helpful.

Saturday, December 13, 2008

Thoughts on Why I Can't Get a Job

Several posts back I wrote about a doctor asked me for my assessment on whether a woman was fully dilated or had an anterior lip. I found it ironic that I was trusted enough as a CNM who happens to still work as an RN by the doctors that I work with yet none want to actually work with a CNM, let alone hire one.

This post got the following comment that I have been thinking about since:

Sounds like where I live. There used to be six or eight midwifes at the local hospitals; now we are down to two. I'd like to someday become a CNM but would anyone hire me? I'm in an isolated area and because of my husband's career can't move.And they say there is a midwife shortage? Sure...but will they let the midwives in? So much hostility - on both sides - that I think might be playing into the problem. And there really shouldn't be. We all want the same things at the heart of it, I really do believe.Would love to hear more about your thoughts on all of this.

I've heard about the midwife shortage, as well. But it's hard to believe there is one when there are midwives in many areas who can't find jobs. When I was still in school, and had to travel for my clinical sites, I met several nurses who were CNMs. Why did they still work as RNs? Same reason as me- can't find a job, can't relocate at that time.

When I was in school, most of my preceptors seemed surprised that I would not be relocating for a job. I really hate getting into all the reasons why with all these people. And I won't get into them here. And besides the several things that tie me to where I am right now, why should I leave the area and women I want to serve? I happen to really like the area I live; I actually like the hospital I work for and wish I could just stay and change my roles. It's been very cool to care for women and their families and have them come up to me in Target or the grocery store showing off their now grown baby, saying they remembered such and such thing I said or did. I even had one woman say I needed to tell her where I ended up practicing as a CNM because she was going to switch her care over to me. Why would I want to leave this?

I also happen to believe that nurse midwives are desperately needed in my area. We had a large exodus of them several years back, and not by their own doing. The hospital dumped them. Those who were pushed out our door were snatched up by a hospital about 30 miles away and they have increased birth rates at that hospital by 60%. This hospital was already the leader in birth in its region, it just didn't have any midwives until they went over. And clearly that area needed them- women wanted them.

Not surprisingly, the birth numbers at my hospital has been steadily decreasing each year.

One of the things I noticed in my both my years as an obstetrics nurse and a student midwife who did my clinical training in large city hospitals is that the large city hospital obstetrics practices had large flourishing midwifery practices. This allowed the doctors to attend to the high risk population and gynecology while the midwives did the majority of normal births. This worked well for all involved. The low risk women got superior midwifery care and those who needed more intensive obstetrical care were attended by highly skilled physicians.

In a smaller city or a community hospital, the dynamics are different. First, just the sheer numbers of women seeking regular ob/gyn care are smaller. As is the high risk population. In these areas most women go to physicians who kind of do it all. Therefore, the competition is greater because there may be a good number of providers for a smaller number of women. At least, this is how it is in my area.

Then add midwife hostility to that, and therefore difficulty finding a place to practice.

I am very close to start researching how to start my own practice. It is very overwhelming, however, to even think about. Part of my problem is being afraid of some of the powerful opposition I may be up against. But I know there is a need where I live. Women need midwives, and they have to travel to find one right now.

So those are my thoughts. For now.

Tuesday, December 9, 2008

Breast Pumping

A woman I was caring for on the postpartum floor had an enormous amount of anxiety about breastfeeding. She was a first time mom, and just had herself wound so tight about whether breastfeeding was going to be successful or not. And of course, Murphy's Law was in full gear. Her baby would not latch. So we got her started with a breast pump, and I was very excited after a long explanation of how the first time a woman pumps that there may not be a whole lot that comes out but that doesn't mean she has "no milk", blah, blah, blah, to see that she filled the containers! This is such a positive reinforcement for these women, to see that their body has milk and that she is capable of giving sustenance to her baby.

When I was going on about how awesome it was she got so much milk on her first time pumping, she said, "Oh, that wasn't my first time pumping. I've been pumping for weeks."

"What?" I asked, baffled that a woman was breast pumping before she even gave birth.

"Oh, ya...I wanted to see if I had colostrum, so I have been pumping everyday for the last 3 weeks."

Oh, boy. I told her that obviously that is what helped increase her supply, but if she ever had another baby that she'd be hard pressed to find any provider that would encourage breast pumping while pregnant. It can cause premature contractions, or even premature birth, because one of the hormones involved with lactation also stimulated contractions (oxytocin).

"That must be why I always got so crampy when I was doing it," she said. She delivered her baby at 37 weeks, so she started the breast pumping around 34 weeks. Bad idea.

Wednesday, November 26, 2008

Get this...

Does this make any sense?

Everyone at work knows I am now a CNM. I've approached each and every provider and asked if they wanted to add a midwife to their roster. Each has said no. One even laughed.

So...clearly they don't want midwives...or me...or both...

But why is it then, that when I called a doctor to the room to check a woman who was clearly fully dilated (an exam is rarely needed for this in an un-epiduralized woman) and ready to push needed me to recheck his exam because she wasn't sure if there was an anterior lip or not?

The patient was fine that I rechecked her, and she was fully and +2 station. What the doctor was feeling was a wrinkle in the fetal scalp. It happened to take me all of 3 seconds to make this determination.

Mind you, this doctor was one of our family practice doctors so perhaps its because she just doesn't have a whole lot of obstetrics in her practice.

But do you see my point?

Monday, November 17, 2008

Another thing not to say to a woman in labor....

I was talking with a woman who told me that she was never going to have anymore children because her last birth experience was so horrifying that she can't even fathom putting herself through such anxiety again.

Her second child was born by c-section and in a different hospital than her first. It was an unplanned emergent c-section that sounds like it was a true stat situation. She had come to the labor floor in active labor, was hooked up to the monitor, an IV and put into a room. She was waiting for the preps for an epidural to be completed when several nurses came running in yelling orders at her to turn to her right, then her left, then on her hands and knees, and an oxygen mask was slapped on her face. She asked what this was all about, and a nurse answered, "You need to just do what we say- change your position because you are strangling your baby! Your baby's heartbeat is down because you are in the wrong position!" Despite the uterine resuscitative methods, the baby's heart rate never returned to a normal rate and she was rushed off to the OR and had her baby. He was vigorous and cried immediately, and she felt so relieved that what she had done did not harm her baby.

When she told me this, I was so saddened by those words. What a horrible thing to say to a woman in labor, leading her to believe that her baby was going to be harmed or even die because she was in the "wrong position". Basically, your baby is in distress because you are doing something wrong! Please!

When she was telling me this, I could see the fear and sadness still in her. Normally I leave my mouth shut when people tell me their birth stories because I don't want to have them feel like I am judging their experience, or challenging their beliefs in a negative way. But I felt so strongly that what was said to her needed to be corrected, I said, "I am so sorry that you had this experience. You didn't do anything wrong, you weren't harming your baby." I explained to her that baby's do drop their heart rates on occasion, sometimes because of a position that causes them to compress their cord, but it's not because the mother was doing something wrong. And sometimes no amount of position change, oxygen, IV fluids, or whatnot can not restore a normal fetal heart rate.

I was curious how long ago this was, since her feelings seemed so raw. "My son is 12," she answered. I would have thought maybe a couple of years at most, given her emotional memory.

Thursday, November 13, 2008

Midwifery in My Dreams

Because, that's the only place I can practice midwifery at this point. Hopefully this will change in the very near future, but it's not looking hopeful.

So my dreams are littered in midwifery. Many times I find myself breastfeeding babies- either my own or some random little one I find awfully cute. One of the most recent was a dream where I was in an office that looked very similar to an office I interviewed in except I had this feeling that we were out in some out of the way wooded area in another state (Indiana, or Illinois maybe...totally random). Suddenly a preceptor I worked with was laying on an office floor and needed assistance giving birth. I helped deliver the baby, a boy with lots of black curly hair, and left the room. The birth part in my dream had this weird focus on providing a lot of counterpressure to the head to preserve the perineum, yet I never inspected the perineum or labia for lacerations after the fact. This was something that panicked me when I was half asleep. How could I forget to assess for lacerations? What if she had some big tear that needed a good repair and I never even bothered to look?

Sunday, October 26, 2008

Knowledge is Power

On line with my previous post regarding knowledge of the birth process in the hospital, and just knowledge of normal birth in general, or even knowledge of what specific events have occurred during their own birth- I'm amazed at how little people know.

When I meet people, my profession frequently comes up in conversation. And this leads into various birth stories, doctor stories, nurse stories, midwife stories, medical problems. Just recently I met a couple who had a baby just days before. They were very excited to discuss the details of the labor and birth, and from what I gathered by what they were telling me, it became very obvious they really didn't know what was going on and why certain things were happening. They said they were threatened with a c-section because the woman's heart rate bottomed out requiring oxygen. The baby needed to be cared for by a NICU nurse in the regular nursery because they had to suck out the nose at birth.

For those who are labor nurses or midwives, or some other person working in the birth arena, know that neither of these things were the reason a c-section was "threatened" nor that a NICU nurse was needed to care for their baby.

How many people have a total misunderstanding of what occurs in birth, or specifically their own birth?

I think we (birth care providers in general) totally miss the boat on educating people on what is going on. Perhaps we assume that what we are explaining (if anything at all in some cases or places) makes perfect sense to those we are caring for when in fact they are not understanding or misunderstand the information. On the other hand, I've seen plenty of people not bothering in trying to educate themselves or be assertive in their care because "the doctor/midwife/nurse is the professional and knows what to do/what should happen/what I need..." the list goes on.

In order to change the care in the maternity care system in our country, we need to educate the public better. We need to educate people what actually happens on labor and delivery units across this country, and not by the daytime tv shows sensationalizing how disaster is lurking just a breath away and how technology and medicine saves the day. We need to educate the public on the normalcy of birth. When people begin to understand what is routine in many labor and delivery units, people would start to buck the system.

I don't know how this could be possible, frankly. It seems like such a daunting task. There is a small subset of people in this country who do support normal birth and want to educate the masses- and are trying their hardest to do it- but there are gobs more of those who like the system just the way it is and have stronger, louder, and more expensive voices when dealing with the public.

I feel like I am rambling now, so I'll try to wrap this up. Bottom line: knowledge is power. And it begins with knowing what went on in your own birth, and then people can start to understand more and more about the system we have right now. I think once it's obvious that much of what occurs during birth in many systems and how it goes against the normal and natural process of birth, things can change.

Sunday, October 19, 2008

Birth Plans

Oh...birth plans. Frankly, I am not sure how I feel about them. I think they can be very useful in making sure your needs and wishes are communicated to those who care for you. But, on the other hand, they can be a barrier for those who care for you because they have this preconceived notion that birth plans=hippie, crunchy women who are resistive to medical care and think that you will inevitably end up with every intervention in the book before you have a c-section.

I have seen women who have very reasonable, flexible birth plans. Like, requests that pain medication or epidurals not be offered but if it is requested or asked about they are not opposed to receiving that type of pain relief; or requests that the baby be placed right onto mom's belly or chest at birth but are ok if baby needs closer assessment immediately at birth that requires the baby being taken to the radiant warmer/resuscitator.

And then I've seen very inflexible birth plans that request things like no fetal monitoring (absolutely impossible in the hospital) which basically ask for things that are better for a home birth. These types of birth plans I have no problems with in regards to what they want or not want, but often scratch my head wondering if these couples have taken into account that they are giving birth in a hospital. As much as I feel continuous fetal monitoring or even IVs are not necessary in every birth, some hospitals have environments, protocols, etc that don't "allow" for this. I really think those who want to avoid all interventions look into alternatives to birth sites because the second you step into a hospital you give up some things, like complete control. I wish this wasn't the case, and try very hard as a nurse to let women know about informed consent and choice, but there are very few hospitals I know of that go with any request a woman has.

What really gets me though, are birth plans that are so evident that the couple did absolutely no research on birth or hospital birth. For instance, I cared for a couple recently who had a 5 page birth plan. It was a birth plan that came from an website template, likely something where you just check off what you want to include on your written plan. And what they checked for what they wanted and not wanted completely contradicted itself in some fashion. Like this:

  • I do not want an IV
  • I want an epidural as soon as possible

Ok.... it was very evident that they did not do any reading or class on childbirth ed because epidurals require an IV. There is not an anesthesiologist in the world that would place an epidural without IV access. Not to mention that you need an IV fluid bolus in preparation for an epidural because a fairly common side effect of epidurals are low blood pressure; the IV fluid bolus helps to counteract a drop in blood pressure.

Or this:

  • Please do not separate me from my baby at any time
  • It is ok to give my baby a pacifier if crying while away from me

And this:

  • I do not want any students or residents caring for me

....when you are in a teaching hospital that has structured the care delivered by utilizing residents and involves other learners at varying degrees of involvement. Now, it is completely the woman's prerogative to not have learners involved in caring for them, but it seems a little weird to me that this woman would choose to come to a teaching hospital if she didn't want residents or students.

So I guess the bottom line is that I think birth plans can be a good thing if the couple has researched birth in the setting they will deliver as well as generally educate themselves on birth. But I can totally see why birth plans end up as fodder for negativity from care providers when it's plain as day that the couple has done no research on birth at all.

Monday, October 13, 2008

Vertex

Imagine all our surprise when the baby is pulled from the mother's abdomen from a vertex position during a c-section for breech.

First of all, I'd be pissed if I were that woman.

During my most recent shift at work (remember, I am still working as an RN) I was assigned to care for the scheduled c-section patient. Things during the prep were going along just smoothly, the woman and her husband were really responding to me and I found that the anxiety level they walked in with was soon next to nothing. During my prep, I asked the resident if she wanted to scan the woman to ensure that in fact this baby was breech. She said she would, asked if I would get the bedside ultrasound machine while she went to get the attending.

A few minutes later the resident said the attending felt it wasn't necessary; his Leopold's in the office the previous day along with an ultrasound at 37 weeks (she was 39 weeks now) confirmed the breech position. For a brief second I contemplated performing Leopold's maneuvers myself but decided against it as I didn't want to overstep my RN boundaries. The resident did them, however, and I could tell she was double checking herself...but she never said anything to me about what she was feeling.

And so all goes on without a hitch. When the doctors get to the uterus I always go around to watch- I find it fascinating watching a baby emerge via vagina or abdomen- and so I parked myself towards the foot of the surgical table. The resident reaches in to grab the fetal part in the pelvis and pull it through the incision. It's a head.

The room goes quiet.

Then as usual, baby is handing over to the awaiting baby nurse and pediatrician and the father goes over to the warmer to see his baby for the first time. Baby is taken to the woman and all goes well with the suturing and closing.

We then go to the recovery area, and things continue to go without a hitch. The woman feels well, the spinal working well for her pain, and her vital signs are stable. As I am assisting her with breastfeeding the baby for the first time, the attending and resident come in. The attending is more congenial than usual, and he's got a big smile on his face.

"Well!" he booms, "That baby must have done a last minute turn."

"What do you mean?" the husband asks.

"The baby was actually in a head down position," the attending answers.

Again, silence.

The conversation moves on and the attending continues to discuss the c-section; that in fact, it was perfectly fine that they did a c-section on a baby that was vertex because, well, the baby was a little on the big side (8lbs 6 oz) and her pelvis was "questionable". I knew the pelvis thing was grasping at straws because I had reviewed all the prenatal records when doing my nursing assessment and read the physical exam section. The doctor checked "gynecoid" under pelvis type- this is the most preferable pelvis type for childbirth. The baby's size would likely not have been an issue either, as many woman give birth to 8 pound plus babies. Not to mention that 8lb 6oz is not considered "macrosomia".

After a little more discussion between the patient, her husband, and the doctor they seemed ok. They were in the middle of being excited and overwhelmed of meeting their brand new baby. I continued my recovery assessments and said nothing about the vertex thing.

When the woman was about to be transferred to postpartum, the husband said to me, "So that c-section wasn't needed, was it?"

I paused. What do I say? I was conflicted. Do I try and support the doctor by saying something vague? Do I claim ignorance? Ultimately I decide to do best- tell it like it is:

"No," I say, "It wasn't."

The husband slowly nodded, taking in what I said.

Friday, October 10, 2008

It's Official...

....you may now call me Labor Nurse, CNM.

Thursday, September 25, 2008

What Happens in a C-Section

An anonymous commenter left a comment about something that she was shocked and quite bothered by during her c-section. Here is the portion of the comment that I'd like to share:



After my husband and baby left the room and they took down the sheet, I looked
down and saw that my legs were in "frog" position and people were pushing on my
stomach and looking between my legs. I was so upset that no one told me what
they doing or gave me more privacy (the room was still full of people and I had
made it really clear I have vulnerability issues.) Is this normal practice? Do
you often see medical people doing things to c-section patients' bodies without
telling them? It seems like they should treat you the same as they do when they
do an exam or vaginal delivery.


To answer your question: yes, this is normal practice. How it was done in regards to not informing you, no that isn't normal. At least where I work. And this got me thinking about sharing with everyone what happens when you have a c-section. Seeing that 1 out of every 3 pregnant women end up with one in our country, I think it's important to have an idea of what to expect.

The following is how I've seen c-section preparation done in places where I've worked. Also, if the c-section is emergent things are just happening quickly by numerous nurses and doctors with no particular order with little explanation to what prep is going on. So just use this as a general guide and keep in mind that different hospitals do things differently and emergencies tend to blow some of the normalcy of the preparation out the window.

It usually takes two hours to "prep" someone for a c-section when it's a scheduled event. It doesn't need to because in an urgent situation (not emergent but we need to move quickly) it takes all of 20 minutes if that. But, whatever. I think the two hour prep time is to give the obstetrician and the anesthesiologist some wiggle room to run a little behind. It also makes things easier on the nurse most of the time if all she is doing is admitting you and doing all the prep stuff.

So first thing done putting the baby on the fetal monitor and getting an NST. But most nurses will just leave the woman on the monitor until you head over to the OR. An IV is started, and fluid is begun. Anesthesia likes to have lots of fluid run in before heading into surgery, so at least one liter is run in at a minimum. Paper work crap is done, like the nursing assessment, advance directives, consents, etc. A "clip" is done of the pubic area (it's better to have the nurse do than do it yourself; home razors are full of bacteria and cause microscopic nicks in the skin....a perfect set up for post-op infections, especially for the big girls who have a pannus hanging over the area to be cut.). A foley catheter is put into the bladder to make sure the bladder stays small to reduce the risk of nicking it during surgery. It also is needed after having a spinal because you'll not be able to pee for up to 18 hours post-surgery. Some places are kind and have the nurses put the catheter in after the spinal. I much prefer this because it's kinder to the woman and it's what I'd want if I was the one getting a section. But some places or doctors don't "allow" this because they are afraid that after the spinal is placed that the woman's blood pressure will plummet or the baby will nose dive and they don't want some nurse futzing around with a foley when they want to start cutting. And frankly, some nurses prefer to do it prior to going into the OR because it's one less thing they have to do once they get into the OR; the role of that nurse during the first 10 minutes in the OR are numerous because she's the one setting everything up, being asked (or told) to do 10 things at once. This is anxiety provoking to some.

There are also a lot of medications given to reduce the acid in the stomach. There is also an antibiotic given prior to going into the OR.

Once all this is done, then off to the OR. The OR is cold and warming blankets are given if needed. The woman sits on the OR table for the spinal, which usually doesn't take very long and sets in quite quickly. The nurse listens to the fetal heart rate once you are laying down, the foley catheter is placed if not done earlier, legs are strapped to the table, and then the nurse begins the surgical scrub of the belly.

At this point, the doctors will drape the belly and get into position to start the surgery. They do a test of the skin to ensure the spinal is in fact working. Typically they do this without actually telling you to really make sure you aren't thinking you feel something due to anxiety. If they get no response (and if you have any feeling left at this point you will feel it...they pinch really hard with a surgical instrument) then they get started. The support person is brought in at this point, and sits next to the woman's head. There is a big blue drape that comes up so you are shielded from what the surgeons are doing.

It doesn't take very long to get to the uterus and pull out the baby. Unless, of course, there is a lot of scar tissue from previous c-sections or abdominal surgery they have to work through. The baby is handed off to an awaiting nurse and/or pediatrician. They dry the baby, suction the airway, and hand the baby over to the support person or snuggled up to the woman if it's possible. Some places will then bring the baby to the nursery or leave the baby with the mom.

Now, during the surgery, most women fell tugging and pressure. But there should not be any pain. Some woman find the pressure very uncomfortable, especially during the expulsion of the baby because the assistant to the surgeon does a lot of pushing and leaning on the belly. And some will have an uncomfortable sensation or even nausea during the closing process when they exteriorize the uterus. This is when they literally take the uterus, tubes, and ovaries out of the pelvis while they suture the uterine incision back together. Some surgeons don't do this. Most surgeons close the uterus in two layers, which may seem like a stupid thing to mention, but if the woman hopes to have a VBAC for the next baby it's important to know this. This is detailed in the operative note, not something that anyone would mention. The risk of uterine rupture is lower with two layer closure than one layer, which is why this would be important to know in the future.

Once the abdomen is closed up, which is done in layers, the drape comes off and then the abdominal dressing is put on. This is the point when the doctor pushes on the abdomen really hard while having the woman frog legged to fish out any large blood clots in the vagina. However, unlike the anonymous commenter's experience, I've always seen the woman being told this is going to happen. There are people that are in the room but they are all busy doing whatever they need to do before they leave the OR so they really aren't paying attention to the manual expression of blood clots from the vagina.

And finally, the woman is moved over onto a stretcher or bed and wheeled to the PACU/recovery area and monitored closely for several hours. During the recovery time, breastfeeding can be initiated.

So there you have it. C-section crash course.

Tuesday, September 23, 2008

I have no clever title for this one....

Hello, everyone.

Labor Nurse is very, very tired....

I thought that graduating would free me up, which in some sense it has, but instead of clinical and tests and papers and the like, I have work, work, and a little more work in between studying for the boards. Which, by the way, is coming up very soon. Like next week.

I am also interviewing, which is an equally tiring process. There is so much thinking involved. I wanted to leave the thinking on cruise control for a while since my brain has been in overdrive for 2 straight years but instead I have to think about call schedules, salary, benefits, midwifery support, new grad fears, malpractice insurance, and suturing perineums all on my own.

And work has been funny. Some days I work with a crew that seems genuinely happy to have me around. I even had someone tell me she'd miss me when I leave for the "big leagues". I actually wish I wasn't leaving because I do like where I work (I'm even saying this after 12+ hours of caring for an 18 year old primip at 35 weeks with pre-eclampsia on magnesium sulfate, poor pain control, high dose pitocin regime, late decels, and the inevitable failure to progress leading to a primary c-section with immediate postpartum hemorrhage requiring me to give misoprostil rectally while the girl was laying strapped to an OR table. It's not easy trying to get these pills into an orifice in which the person is laying flat on. Oh, and chorioamniotitis too!). But they don't want midwives.

That being said, I am so glad that I am where I am at. God damn, I deserve a party! Why didn't anyone throw me a party?

Thursday, September 18, 2008

Road to Nowhere

It's weird how things just pop into your head; random thoughts of things long forgotten. The other day I suddenly found myself remembering this scene:

Me, a nursing student in the mid-1990's, in a corner of a labor room. A woman pushing, her husband at her side looking very nervous and unsure. And the labor nurse and doctor at the foot of the bed, their arms crossed, discussing the woman's progress.

There may have been another student along with me, I can't remember, but I know that I was told to stay out of the way. Looking back, I see this as rude because I was quite capable of helping do little things, but I was so grateful to be in on this experience. Seeing a birth is like striking gold in nursing school.

I can't remember if the woman had an epidural or not, but I know she was left to hold her own legs while she pushed on her back. Her husband helped hold both legs but it was clearly awkward and difficult. She was clearly using every bit of strength she had in her- her face was sweaty and red, veins were bulging in her forehead, and she grunted and groaned even when not pushing.

The nurse was clearly from the old school and had seen many births in her time. I am sure that 99% of the births she attended were of a sterile, medical variety that were on timetables. The doctor was also very old school (he was the same doc that pulled me out of my mother with forceps 20 years earlier) and had a horrible bedside manner.

The thing that bothers me the most is the vision of seeing this woman, vulnerable and worn out being looked down upon by the nurse and doctor. The nurse and doctor were going back and forth on whether or not this woman could "do it". It was almost an hour into pushing. At this point the baby's head was beginning to be visible with her pushes but hadn't yet made it under the pubic bone so it would slip back when she rested. I didn't realize this was normal at the time, so I listened to what the doctor and nurse were saying with great interest. Could she "do it"? The nurse said yes, the doctor said no.

They spoke as if the woman couldn't hear them, as if she wasn't really there, or that they were looking at a zoo display behind some plexi-glass thinking that the animal behind the glass wasn't aware of being stared at. The doctor even spoke with a disgusted tone that this woman had yet to birth her baby. "Ah, this is a road to nowhere!" he said, waved his hand in frustration and stormed out of the room.

When the doctor left the room, the woman started asking if she was going to need a c-section. The nurse gave some vague answer and did some documentation while the woman went on pushing.

I don't know what the outcome was of this birth- I am sure the baby was born healthy one way or another, but whether by vaginal or c-section I don't know. But I think it is scenes like this that make me so glad there are midwives.

Saturday, September 13, 2008

My Lips Are Sealed

I wonder if I am imagining this, but I think that some of my fellow RNs view me differently now that I've graduated. Fortunately, not all of them are like this, but they seem to resent my education. They have progressively been less and less interested in having a conversation with me about anything, even non-work related stuff, and have not even acknowledged that I've finished.

Now, I would often second guess myself saying that I was just being sensitive or making this up. Until, that is, a fellow nurse said to me after I attended a delivery of her's to help ended up with a sloppy birth on part of the resident and attending. They were all fumbling around with a limp, non-vigorous baby with a nuchal cord that was still tight around the baby's neck- and she and I were holding our breath hoping they'd get their act together so we could attend to the baby. All in the end turned out ok but we talked about it briefly after the fact. I said something to the effect of, "Why didn't the resident reduce that nuchal cord?" during that conversation and she responded with a like minded statement.

And then, next time we were both at the nurse's station together she said to me, "You know, you better not go off saying stuff about what should be done at deliveries because you look like a know-it-all. So you should keep your mouth shut."

Well.

I didn't say anything because I didn't want to get into it; but I can see her point. To some, no matter what I say, it will look like I am saying what should have been done or what I would do. I have been conscious of what I say and have kept quiet as much as possible. I haven't really even discussed my up-coming boards and potential job interviews because I don't want to rile any jealous feathers.

Frankly, I don't understand this animosity towards my furthering my education and moving on in my career. I've always liked hearing of nurses moving into advanced practice- there is such a great need for it that I feel the more the merrier. Why others don't feel this way is beyond me.

Tuesday, September 9, 2008

The Dreaded Postpartum

I know you all read the celebrity gossip mags at the checkout lines at the grocery store...so the one that caught my eye today: Angelina is feared to be suffering from postpartum. Oh, really? Because she certainly is postpartum, given that she had twins not too long ago. So why is she suffering from it?

Here is a display of one of the many things that annoy me. Now, I know that what they mean to say is postpartum depression, or perhaps even the "baby blues". Postpartum encompasses the period after a woman gives birth. That's all. Perhaps "postpartum depression" couldn't fit on the cover, but baby blues could have and would have been at least a little more accurate. And I know, baby blues and postpartum depression are different things. But the general public would get the picture.

I am sure that the editors of this magazine thought they were all smart and what not for putting "postpartum" on their cover- you know, it is a technical medical term, I'm sure.

This is just as annoying as when people start talking about "epidermals".

Saturday, September 6, 2008

Hear Ye, Hear Ye!

For some reason this announcement feels very anticlimatic- but I am officially done. Graduated. Ready to take the boards.

It feels really good to not have to worry about any assignments, waking early for clinical, not sleeping for more than 24 hours at a time.

Sigh....

Saturday, August 30, 2008

Second Baby

Fortunately I haven't seen this too often, but it is something that really annoys me. It's the whole second baby syndrome. Symptoms include:

  • Over-compensating with an unusual amount of attention to the first born
  • A significant amount of gifts for the first born
  • Anxiety so thick you can slice the air with a knife when the first born comes to the hospital to meet second born
  • First born flailing and crying and generally fussing when he realizes that he is not the only one getting attention in the room
Now I know that introducing a new baby into a family can be stressful. Hell, I even remember when my brother was brought home back when I was three. I had the vague concept of a baby lurking around in the hospital, but felt a bit displaced once the realization of that baby in the house was staying. But I also don't think much fuss was made about it by either my parents or myself. Perhaps my mother would say differently, I don't know.

And I've met some women who say that they know they'll love their second baby but can't imagine how they could love another child after several years of loving their first born, especially when that is where all their attention was going for several years. Fortunately, most don't do what I witnessed during my last shift at work (on the dreaded postpartum unit).

A woman I'll call Mary gave birth to her second child, a son. Her first born, named Bobby, was 5 years old. A good age, I think, for a child to be excited and have a fairly good understanding about a new baby. When I first went in to see Mary on my morning rounds, she immediately began nervously talking about Bobby coming later that day. Bobby, you see, was refusing to acknowledge that a new baby boy was joining their family. Mary said that Bobby has been the only child in their entire family...including the extended family, and he was very spoiled. He got attention like there was no tomorrow, got things as he pleased, and Mary had even decided to stop working so that she could spend one on one time with him everyday. Apparently he could not tolerate not being with his mother. Mary was very tearful when telling me that her husband reported that Bobby had a meltdown when she didn't come home the previous night, and when it was explained to him that it was because she was in the hospital with the new baby he went into a rage that could not be calmed with candy, ice cream, toys, or a trip to the store for new toys.

You see where this was going, I'm sure.

Mary said that she and her family had spent months preparing for the very moment Bobby would walk into the hospital room and meet the baby. They decided the best approach was to have every single family member be there. So early that afternoon family started to pile into the room. There were some coordinated phone calls between Mary and her husband to say who was there, where they were sitting, and what was Bobby and the husband's ETA.

The tension in that room while they were all waiting was making me uncomfortable. And then came the knock on the door. A few held their breath as Bobby arrived. At this point I was anticipating someone place a crown on his head and roll out a red carpet. Instead everyone just squealed with delight at his arrival and gave him hugs and kisses.

Oh, it would be important to know that it was decided among the family that when Bobby arrived that the new baby be left in the crib untouched and out of the way. No one was to hold the baby until Bobby seemed "okay" with everything.

At this point I left, but needed to go back shortly after. Bobby was standing in the middle of a present pile as high as his head and surrounded with shredded wrapping paper. Just then one of the grandmothers handed him a gift and said, "And this one is from the baby."

Again, the tension and the breath-holding was at an all time high. Mary was almost in tears while she waited to see what he would do.

"I don't want it!" he screamed. And this sent all the family in a scurry around the room, saying things like, "Where should we put it?" and "We need to get it out of sight!"

Are you kidding me? Really, are you kidding me? The new baby, meanwhile, laid quietly in his crib and never woke or made a peep. I sure hope that he gets used to being quiet and on the fringe of the family because clearly Bobby was calling all the shots.

Monday, August 25, 2008

Thiefery

Not sure if theifery is even a word, but it should be.

So how is it that a woman coming in for her regular prenatal visit thinks it's totally fine to permanently borrow a $700 doptone? Like, you know, we might not notice it missing?

What balls.

Friday, August 22, 2008

Hurry Up!

Actual conversation with a patient:

Patient (just turned 16 year old, 34 weeks pregnant with first baby): Do you have any children?
Me: No.
Patient: Why not?
Me: Because life has kept me very busy...you know, school and stuff.
Patient: Are you going to have children?
Me: Yes, someday.
Patient: Well, how old are you?
Me: How old do you think I am? (I always ask this when asked being I've been noticing a lot of grays on my head so I'm paranoid that I am looking old)
Patient: Like, 25?
Me: Oh, what a compliment! Actually I'm thirty-(fill in the blank)
Patient: Oh my god! You're old! You better hurry up if you want kids!
I suppose at 16, even I would have thought I was old. Funny how different our perspective changes as we get older. And I guess when you are having your first baby at 16 anything much older than that must seem pretty late to be having kids.

Monday, August 18, 2008

No Independent Thinking

Yesterday my preceptor told me that I should not have opinions. I have to laugh at this now, because clearly she hasn't really learned who I am. But at the time I couldn't believe that she said this.

The context of the conversation was about my own midwifery practice; she felt that only experienced midwives should have opinions about how they practice. I nodded and went along with this conversation because, frankly, if I disagreed it would just make matters worse. And what I walked away with was that even though I am supposed to be a safe beginning practitioner at the end of this experience, that I should just be doing everything she suggests or asks of me.

So I will, because ultimately my fate is in her hands with regards to passing and graduating. But it is frustrating when I am supposed to be setting my roots down and feel like a competent beginning midwife by the time I graduate that I still have to do things everyone else's way. I'd imagine that this is not a unique experience among student midwives; most preceptors want you to do things their way because it's what they do and it works for them. Or they think they are completely right.

Just a few weeks left.....I think I can handle it. I think....

Tuesday, August 12, 2008

Ferns






One of the coolest things, in my opinion, is amniotic ferning. Amniotic fluid, when dried, creates a fern leaf like pattern that can be seen microscopically. The presence of ferns are a strong indicator that the bag of waters has broken. Two others are looked for: pooling of water in the vagina seen on speculum exam or visualizing fluid coming from the opening of the cervix and a positive nitrizine test (pH paper turns blue).






Its incredible the number of women who come in saying their water broke when in fact they either peed or have a lot of vaginal discharge. Both are pretty common late in pregnancy. I often wonder how many have a "high leak" for days before realizing that perhaps their water broke. I'd imagine that is more common than we realize.






Either way, here is what the ferns look like. Cool, huh?

Sunday, August 3, 2008

The Job Forecast

As it appears right now, there will be no midwifery jobs out there when I graduate. Sure, there are jobs available, but I'm not moving. I live where I want to live for the rest of my life and want to provide midwifery care to the women in this area. Midwifery is limited in my area, mainly because there have been administrative cuts to midwifery practices or physicians do not want to cover CNMs for various reasons.

I've mentioned to two physicians at work from two different practices that I am available for hire. The first physician laughed. The second said she'd love to have another CNM but they just couldn't financially support one. Perhaps somewhere down the road that may open up. Who knows.

I wish that I had more courage to be an entrepreneur. I have no doubts that I'd slowly gain a steady patient base. The women my hospital lost when they closed their midwifery service would come back if a midwife was available to them. The problem with trying to open my own practice would be the politics and road blocks put up by physicians who don't want to be affiliated with a CNM. I know that there are physicians who would have no problems collaborating with CNMs, but their malpractice insurance would go up considerably or would lose their malpractice insurance policy. There is also the issue of vicarious liability, which in my opinion is ridiculous. I don't think physicians who cover CNMs should be held liable for the CNMs care and patient management. They should be responsible and liable only for the patients they care for. But that's a whole other can of worms.

So at this time, looks like I will remain working as a labor nurse after graduation. I guess this is fine initially, because I like where I work for the most part and I have a lot of student loan money to start paying back. But I've also worked so hard to become a CNM that I want to start working as one.

Tuesday, July 29, 2008

I don't get it...

Did anyone see the segment on GMA this morning about women who didn't know they were pregnant until they were giving birth? I didn't catch much of it, other than a clip of a woman who was explaining how she went to an emergency room with the complaint of terrible stomach cramping from what she contributed to the flu.

Let me just start by saying I don't get it at all. I really don't. Now, I can understand a woman not gaining weight or just a few pounds. That happens, particularly for larger women. And I can understand that many large women don't appear pregnant until much later stages due to their body habitus. I can even understand thinking you are having your periods still; some women do have vaginal bleeding in pregnancy that can be chalked up to subchorionic hematoma, friable cervix, or placenta previa. But how can you explain fetal movement? Perhaps you can pass it off as gas around 20 weeks or so, but what about 35 weeks when the fetus is causing the abdomen change shapes or pushes their body parts out with their movements?

I've only met one woman who didn't know she was pregnant until 34 weeks or something like that. She was a college student, who had bulemia and anorexia but was in complete denial about her disease. She weighed 92 pounds at 34 weeks, when I met her. The reason she even learned of her pregnancy was because she was being worked up for abnormal abdominal pain and severe gas that caused her abdomen to visibly roll and move. Huh.... go figure.

I am sure that I will meet more women in my career who don't know they are pregnant until later stages or even birth. But I don't know if I will ever understand it.

Tuesday, July 22, 2008

Ode to the Dansko

When I started my obstetrical nursing career, I found the beloved Dansko. I bought my first pair in 2000; grey nubuck clogs. The cured my lower back pain. They let my feet breathe. And they worked well with jeans and such.

I loved my Dansko clogs so much that my feet would reject any other shoe. So I had to buy more Danskos in various styles. Sandals, sport clogs, dress clogs, you name it. But the best Dansko of all was my original grey clog.

Eight years later, I still have that original pair. They are tired and worn. The leather is stretched out. The edging is worn off completely. The grey now looks hunter green, so I'm told. This must be from the various fluids that they have been exposed to. I've been finding that my feet slide too much when I walk around and have acquired another callous on my foot. As much as I didn't want to admit it, my original Danskos need to be put to sleep.

I've known this for several months now. But I couldn't bring myself to do it. I went to stores and tried on new Danskos. It just wasn't right. Maybe, just maybe, there is still some life left in them I thought. But when I wore those grey clogs to work my last shift, they just couldn't keep up.

I bought a new pair of Danskos.... well Sanita, actually. You see, Dansko contracted with Sanita for years to make their shoes. But recently, Dansko decided they were going to contract elsewhere and Sanita decided to keep making the shoes under their own name. I find that the Sanita's fit like my other Danskos; the "new" Danskos don't fit the same. So if any of you are wondering why Danskos don't fit exactly the same despite wearing your usual size, now you know why. But I digress....

My new clogs are wonderful. They fit perfectly, and feel good on my feet. They came just at the right time. And then I realized one afternoon while feeling a little poetic, the old clogs lasted my entire obstetrical nursing career. My new clogs are starting my new midwifery career. And they better last longer than eight years.

Friday, July 18, 2008

Breaking the Cycle

I've been fortunate for most of my student clinical career to have preceptors who don't subscribe to the philosophy, or at least strongly, of "I suffered and so should you". It is not unique to midwifery; I've seen it in nursing and medicine. For instance, when I was in nursing school we often heard that new grads would just have to accept night shift jobs on over-worked med-surg units because that is what those did before us. Or being the new grad on the floor meant the more senior nurses treated you like shit just because they were treated horribly as new grads. When residents were fighting to make their working hours more humane several years ago, the opposition was arguing that they worked 180 hours a week when they were residents, and so should the residents now.

In midwifery school, I knew this would likely be the case as well. Like I've said, I've been lucky to have escaped this for the most part. But it has been said to me that when my preceptors were in school, they had to do 36 and 48 hour shifts, couldn't work a job, didn't see their family for weeks at a time, well.... what exactly are you saying to me? That I should suffer like this, too? I resent this because suffering doesn't equate sound clinical education. Being sleep deprived, family deprived, life deprived does not mean I will be a better midwife. Actually, I feel quite opposite of this. When I arrive to clinical well rested, I make better clinical decisions and feel more available for the women I will care for. If I managed to have a day or two during the week that I actually got to do things just for me, or got all the housework done, I don't feel stressed about the other days being filled with school work and clinical hours. And when I get to spend time with my husband, I feel supported in what I do and all the hours I put into this. How can this not be healthy? Why should I be miserable just because those before me were?

If this attitude of requisite suffering was let go, I'd imagine we'd have more midwives. I've heard my fellow nurses say that they would consider midwifery school but don't solely because they know how horrible their experience will be. I think this is pretty counterproductive for both current midwives and future midwives. We need more midwives, so this attitude needs to change.

Thursday, July 10, 2008

Senioritis

Do you remember when you were a senior and high school and you finally saw the light at the end of that long, tortuous tunnel? And you like stopped caring about school and homework, and even skipped to hang out at your friend's house to watch daytime talk shows and eat ice cream and fast food? You know, the senior slide?

Well, I am experiencing this as we speak. Type.

Except the cutting school thing. That's generally not well tolerated in midwifery school.

I mean, seriously, I am so mentally done. Cooked. Studying for boards? Ha! Doing writing assignments? Are you kidding me! Reading every single assigned page? Please!

I think part of it is that a friend of mine from school has already finished last month and has been set free. She even took her boards today- and passed! I can't wait to say that.

Saturday, July 5, 2008

Surprise!

My final clinical rotation is underway, and boy is it tiring. I've had several births, all very nice. They were all first babies for the mothers and all were unknown sex. I love that. Where else in life do you get a surprise like that? I can't think of any.

I had asked a couple who had decided not to find out the sex of their baby why they chose to do this. So many people find out (and often it is the only thing they care about during their fetal anatomical survey ultrasound...) that it seems like such a rarity if the birthing couple has no idea if they are having a boy or girl.

The father said, "Ok, so what do we say when the baby comes out if we already know what it is? It's a.... baby! We already know that! We want to say.... It's a boy! or It's a girl!" Very cool.

As the midwife or nurse in the room, I love to see the surprise and excitement on the faces of the family and parents when they find out what their baby is. I know it's not about me, but there really is something special that is added to the birth when things are left a surprise.

Monday, June 30, 2008

A Letter From A Doctor Who Sees the Light

I know that the internet childbirth world is all abuzz about the AMA's resolution to "outlaw" homebirth, so I wanted to share this link with you. I found it very uplifting, and hope that a reply is posted someplace.

Monday, June 23, 2008

Stretching For Damage Control? Think again.

My husband came up with a very good point about perineal manipulation during the pushing stage of labor. I was talking about how the doctors and residents, and even some nurses, can't seem to keep their hands out of a woman's vagina while she pushes. They stretch the tissues out, push posteriorly on the perineal muscles, and generally create a very swollen perineal and labial mess. I hate it. My own personal practice is very hands off and have had good results- only one second degree tear, and the rest were either intact, minor first degrees or "skidmarks" not requiring anything but time to heal.

So this is what he said, "Why don't we do that when we have to take a shit? You know, a big shit might come through your anus so maybe we should stretch it out a bit before we go just in case it could do damage." This was the cleaned up version.

Good point.... good point.

Saturday, June 21, 2008

Something Worse Than P.O.

My most recent shift I actually was coughing and gagging at a smell worse than P.O. I was working postpartum again and was attending to my final rounds of catheter bag emptying and general patient upkeep when I entered my patient's room for the ump-teenth time. But this time there was something pretty ripe about the room. I had caught the woman and her boyfriend napping and tried my best to be quiet as I made some final assessments, changed an IV bag, and then empty her catheter bag.

I saved the catheter bag for last because the boyfriend had parked the recliner right next to the side of the bed the bag was hanging on. I was hoping that he'd notice that I was moving about the room and would move out of the way. But he didn't. He just stayed right in the chair. I figured there would be enough space for me to reach and grab the bag out from between the bed and his chair, which there was, but when I went to reach for the bag I had to bend towards his feet. And here was that ripe odor.

People, I have never smelled such horrid, wretched feet in my entire life. There may have been visible fumes, but I couldn't bear to linger long enough to find out for sure. I had to breathe as shallow as possible but I still ended up coughing. It took all my might to not end up gagging as I waited for the bag to empty into my urine container. How could they not be bothered by this? You can imagine how glad I was to not have to go back in that room...ever.

Tuesday, June 17, 2008

Postpartum Sucks

Well, people, I have said this before but I will say it again. I hate working postpartum. This is the official complaint.

My "summer break" (if you want to call it that) is being spent on 12 hour shifts at work so that I can try to fill the hole of a bank account before heading back to clinical. And each and every time I go to work I end up on postpartum! My most recent response when I saw that I was assigned to the postpartum floor was, "Oh, that's just great!" This was met with a bit of silence, followed by, "Ya, we know, we know..." but being per diem makes you the low nurse on the totem pole, even if you have more experience and even attend births as the official catcher of babies.

I've wanted to say, "You know, I am much better suited to the labor floor, people... I'm going to be a midwife, for crying out loud!" But I think that might come off not so nicely. Besides, I have pissed off a few people because I am unable to work any of the summer holidays and the powers that be have allowed me to not have to work a holiday. To be fair, because I knew that this was going to ruffle some feathers if word got out, I offered to work some particular night shifts. And anyone who knows me knows how I loathe night shifts. (And I said I was going to be a midwife?) But, get this....I was told I was not needed on those night shifts. I almost fell over because they are always short on nights. So... whatever.

Friday, June 13, 2008

A Book with a Four Letter Word

So I've been reading this book called Cunt: A Declaration of Independence by Inga Muscio. First off, don't read it on public transportation if there are stuffy suburban mother's with their kids near by. They don't like that, presumably because they think you might whip out porn or something.

I find the book amusing. I haven't read the entire thing yet, and perhaps I shouldn't make a full statement on what I think yet, but it is interesting to read her take on things. I think the book is meant to be a power-enhancing liberation for women. There are some things I totally agree with, and others I wonder where she was getting her info. Like emergency contraception causes abortion.

There was one point she makes early in the book, though, that I thought was right on. She talks about the cultural belief in this country (as well as many others) that women are unclean during their periods. The mere fact that we use something called "feminine hygiene" to contain our "dirty blood" speaks volumes to how we view such a normal physiological function. We need to change our thinking about this, she says, and I agree.

Take for instance, how we deal with menarche- a girl's first period. It's a secret event, one that is, for most, treated like something that must not be overly discussed and right from the beginning girls are taught how to be discreet about such event. For anyone who has read The Red Tent, you know how differently such an event is treated. And the author talks about some woman right here in America that celebrated her daughter's menarche with a party. Soon, other mothers in the neighborhood were doing the same. What a fabulous idea. I'd imagine this is much different than what most of us have experienced.

Take my first period, for instance. It was a horrifying experience at the time, but I can laugh at it now. I knew that I would be getting my period at some point; I'd had the requisite school nurse presentation on the topic and had read several books from my mother. I was actually highly anticipating the event, only because I thought there would be some magical happenings would be sprinkled upon me and I'd suddenly be blessed with some secretive knowledge only women knew. But in reality, I just found myself staring with fear at my underwear in a school bathroom stall. And then promptly tried to ignore what I saw, and said nothing the rest of the day. At the end of the day I ran off the school bus to my house, my brother trailing behind me. My mother knew something was up, and she asked what my problem was.

"I got my period!" I exclaimed, and fell into a pile of tears. If I remember correctly, my mother tried not to crack a smile. She said something to me about the practicalities of it, how I would just simply use a pad in my underwear. Note much else was said.

My brother, having come into the house in the middle of this, listened with interest. And then, when he felt he understood what the big deal was, he yelled out with glee, "[Labor Nurse] shit her pants!"

It was awful, but I write this while laughing.

But I wonder how different this experience, as well as most of yours, would have been if we didn't view this thing as unclean.

Thursday, June 12, 2008

The Hidden Baby


I received this picture via email from someone at school, and it took me about 3 months to see the baby. I have never been able to see the hidden pictures in those magic eye posters years ago, so I guess it's no surprise that it took me as long as it did. I hope I am not the only one!


Tuesday, June 10, 2008

No Puke Zone

If there is one thing that I absolutely fear in my line of work, it's vomiting. Not vomiting while in labor, because most women in labor who puke have little in their bellies so it's not chunky, but vomiting from a virus. I absolutely dread such a thing.
When we get women in triage who need IV hydration for nausea and vomiting, I pray I do not get assigned to them. As soon as I hear that such a woman is going to be on our unit, my anxiety level shoots up ten-fold. Recently I've had a string of women at clinical who come in for this exact thing, and of course I am the one who assesses them and sits with them. I have to come in full contact with these women with the horrid viruses and I pray constantly that I do not catch what they have. I am a good hand sanitizer in general, but you can bet your last dollar that I am practically bathing in Cal-Stat and Purell before, during, and after caring for these women.
The reason for my fear and anxiety is that I am a horrible puker. I hate it more than most, I think, and even as an adult I cry. I try to bargain with the Gods and Goddesses to please just give me horrible diarrhea if I have to be sick- anything but vomiting! The mentality of just puking, getting it over with, and feeling better just doesn't jive with me. I would rather have hours of nausea and diarrhea than puke once. Frankly, I envy those who can puke like it's an aside. Like, ho-hum...I feel sick...let me puke....bluh.....ok, I'm done...what was I in the middle of saying?
This fear didn't start until I was a teenager, likely because I had had enough experience to know how much I hated it. I remember vividly one of the worst cases I had ever had: I was 22, and caught the most wretched bug that was striking people down left and right at work. It had been going through our patients (I worked with elderly at this time) and staff for a good month. I managed to stay away from just about anyone who came down with it. And then I realized that I was one of two nurses who had not become ill.
The same night I realized this, the other unaffected nurse called in sick. She was the only night shift RN, and there was no one to cover for her. So I said I would stay (oh, the days of pulling a double! I think I would die if I worked 3PM to 7AM now). Two days later, I found myself at home on New Years Eve after last minute cancellations. So I sat in front of the TV eating a pint of Ben & Jerry's Chocolate Chip Cookie Dough.
At 11PM, my stomach to feel queasy. I went to bed shortly after midnight, but my stomach felt even worse and I knew what was coming. By 1AM, I was hugging porcelain, and did so non-stop until 7AM. The following afternoon, when I finally started to feel a little better, my abs (I actually had some then) felt like I had put them through a Muscle Man competition.
So why do I tell you all this? Because I hate it so bad, that memories of that awful experience are so vivid, and because I had nothing else to write about. Oh, and it took me about 2 years to be able to eat Ben & Jerry's Chocolate Chip Cookie Dough again.

Saturday, June 7, 2008

How is this possible?

You know, it really irritates me when my fellow students course work completely sucks but they get decent grades. We have been finishing up the semester and have several presentations to make. I put a lot of work into my presentations, spent hours just on research alone- making sure that I use current references from respected sources, assuring that typos and grammar is correct, and my APA format is perfect.

I have always done well on my presentations, having always received full credit (ya, I'm a dork, thank you very much) and have always believed I deserved such credit.

So when the crappy students are getting passing grades when there are blatant errors in their presentations, lack of APA format or current research and data- not to mention presentations that support the medical model of care (some one poke my eyes out, please!)- I am highly insulted. If I get an A on a presentation, and the person after me has a total blow out of information but gets a B+.... how is this possible? How can the instructors justify this?

Urgh....only integration to go.... I'm done in August!

Tuesday, June 3, 2008

A Board

I recently learned that the Commonwealth of Massachusetts has legislation underway that would create a Board of Midwifery. I had no idea that this was something that was in the state legislature, and was happy to hear about it. I have not done much research on it, but from what I understand this Board would regulate all midwives in the state. This includes CNMs, CMs, and CPMs. Currently, only CNMs can practice legally in the state. If this Board legislation goes through, which apparently has made it quite far and it is looking promising, then the creation of CM and CPM licensure would follow. This would allow for women in Massachusetts to "legally" choose the women's health provider of her choice.

As you can imagine, ACOG opposes this Board. They seem to be ok with CNMs practicing under the current nursing regulation as they provide "a valuable service to our (ie, the doc's) patients" but think CMs and CPMs are under qualified to "practice medicine". Which completely boggles my mind given the fact that all midwives, CNMs, CM, and CPMs, practice midwifery. In the Act put out by ACOG, there are some talking points for physicians in Massachusetts to discuss with their local representative. They state that CPMs, also known as lay midwives according to ACOG, only need to do 10 births as an apprentice. Is this true? Again, I have not researched this, but I had thought that CPM apprentices are required to attend 100 births or something like that. That is more than CNM and CM students are required for graduation as the ACNM only requires 20 births. I admit I am completely ignorant to the educational standards of CPMs so any information you can share with me is appreciated.

Regardless, I hope that this bill makes it to law. Establishing a board of midwifery in Massachusetts would open the door to more states doing the same. Perhaps midwives throughout this country could completely cut regulatory bureaucracy that restricts their practice....I hope to see this in my career.

Saturday, May 31, 2008

Who's On First?

Woman at 37 weeks with herpes virus: "I don't really like the Valtrex."

Valtrex is frequently used for HSV suppression in pregnant women so that they hopefully they will not have any herpes lesions at the time of labor.

Me: "Are you having any reactions? Do you feel it's not working?"

Woman: "I keep having outbreaks, I wasn't having outbreaks with my other medication."

Me: "Do you currently have an outbreak?"

Woman: "Yes. But I was having outbreaks with the other medication."

Me: "So, you were having outbreaks with both medications?"

Woman: "No. Just with the old medication."

Me: "But you said you were having outbreaks with Valtrex."

Woman: "Yes, I am. But I don't like it so I haven't been taking it."

Me: "You haven't been taking any of the Valtrex?"

Woman: "I've taken it. I take it most days."

Me: "I thought you said you weren't taking it."

Woman: "Well, I am not really taking it. Usually I take it on Mondays and Tuesdays. But never on Friday, Saturday, or Sunday."

Me: "It's hard to say that the Valtrex is not working because you aren't taking it. It's not going to work when you don't take it."

Woman: "But I am taking it. Just about every day."

Me: "Ok, well....you need to take it every day. It may work to suppress the outbreaks if you take it every single day. If you are not taking it every day, as it is intended, it doesn't have a chance to be effective."

Woman: "But I have been taking it every day."

Sigh....

Friday, May 30, 2008

Quote of the Day

If the fetus you save is gay, will you still fight for its rights?


Just some food for thought.
I can not take credit for this quote...I came across it somewhere on cafepress.com

Wednesday, May 28, 2008

Stitches in the Butt

She was 17 years old, but seemed to have the mental capacity of a 6 year old. She had hid her pregnancy until she went into labor; she knew she was pregnant the entire time but was able to conceal it because of her size.

I met her at her postpartum follow up appointment. The conversation went in circles, and I was having a hard time understanding exactly what she was describing to me. Her concern was that her stitches in the butt were bothering her, and it was causing her to bleed when she moved her bowels. I found this concerning, given that her records stated that she had a first degree tear- 6 weeks later and her stitches in her rectum were causing her to bleed? This wasn't adding up.

She said that she was trying to get the stitches to heal, so she started putting "cream" on it. The cream wasn't doing anything, she said, but she thought it might just be taking some time. I told her that we would be doing an exam and would assess what was going on. When I got to the pelvic exam, I noticed that her entire bottom- perineum, labia, buttucks, and into the anus- was covered in Balmex.

Now, I know most of you are familiar with this product. It's thick, and it's white. We couldn't see anything, she was slathered in the stuff. We tried washing it off, and in the process came across an infected hair follicle in her butt crack. It started to bleed when we washed it. I think we found our culprit, I thought, but how could she have mistaken this for her stitches?

My preceptor drained the follicle, as it was full of pus and Balmex. And then just to make sure we weren't missing anything we reassessed the entire area. Everything looked fine. Once she got dressed, I tried explaining exactly what we saw, what was causing her pain and bleeding with her bowel movements. She just didn't get it. I tried explaining that her laceration and stitches were healed and I didn't see anything unusual in that area. But she insisted that she had stitches that were bleeding in her butt area. There was no convincing her otherwise.

I'm curious as to how her laceration was explained to her, or how she interpreted it. Based on my entire interaction with this 17 year old, I know she's not playing with a full deck, but it's just an interesting disconnect here.

But at least she knows not to use Balmex on herself now.

Friday, May 23, 2008

Explaining Midwifery

I have found it very frustrating trying to explain to people what a midwife is, and why a woman would chose one. When I meet people and they learn I am a student midwife, I often get questioned why am I doing it. Aren't midwives old-fashioned? Aren't they illegal? And they only do homebirth without any medications or anything, right?

ugh....

Today I went to a new electrologist (because I'm a wildebeest) who was making casual conversation. She was in her 20s and very chatty. She asked me all sorts of questions. Was I married. Did I have kids. Did I go to college. Where do I work. And I always feel like I need to answer as closely to reality as possible, which is hard for some to understand. I'm a nurse, I say, and have been for 10 years; I do work but only per diem because I went back to school for midwifery.

Her response: "You have to go to school to do that?"

She then goes on about how when she watches A Baby Story (ahhhhh!!!!!) she often wonders why some women chose a midwife, seeing that doctors are available to everyone. I said that some woman chose midwives because of the approach to birth and women's health; midwives view a women's life cycles as normal and natural that don't require a cure or treatment. We are trained to know what is normal, and what is a deviation from normal that would require physician care or consultation. And as I go on about midwifery, I notice I am totally losing her. So I wrap it up by saying, "Well, obviously I could give you a three hour dissertation on midwifery care, but I'll leave it at that." She laughs a little and moves on to telling me that college was never a thing for her.

So I am wondering what other midwives and student midwives do when asked about "what you do". When you are talking with someone who is completely clueless about midwifery, or has negative stereotypes, what do you say? How do you approach this?

Wednesday, May 21, 2008

The Bulb Syringe

My most recent clinical shift was a nightmare. I don't even know where to begin, but there is one thing that sticks out above the rest, and it is so innocuous that it makes no sense. Between multiple laboring women with so many compounding issues (like untreated STIs or domestic violence or multiple substance abuse issues) that were overwhelming, the pushy physicians who kept making their way into see our laboring women when they were not needed (and ultimately deciding one needed a c-section...which she did, but this physician was talking c-section well before there was an indication for one), and a preceptor who could not have been bothered with me, it's a bulb syringe that is pissing me off.

You see, one of the laboring women went very quickly and my preceptor was not available when delivery was imminent. So another midwife from a different practice offered to do the delivery. Phew, I wasn't going to be alone! But...perhaps I should have been. I quickly glove up and get together my supplies, which is not a whole heck of a lot. And so I stand and am ready to catch this baby when the midwife says, "Where is your bulb syringe?" and plops it into my placenta basin. I said nothing, thinking maybe she just likes having it handy. I usually leave it on the delivery table that is at the foot of the bed because I have never needed it. Not to mention my understanding was that evidence shows that normal newborn transition rarely requires assistance in clearing the airway, even when meconium is present when the baby is vigorous.

The head delivers and the midwife shoves the bulb syringe in my hand. "Suction! Suction!" she barks. I was stunned. Suctioning on the perineum? Did we time warp here? And, so like her minion I suction. Barely. The position the baby and mom were at allowed me to make it look like I was suctioning that baby good, but in fact I wasn't exactly doing nearly what she was expecting.

The rest of the birth didn't exactly go as I would have hoped (for me at least, the mom was fine) because this midwife just kept barking orders at me like I was an idiot. I kept my mouth shut and did the things I needed to do, and having attended a fair amount of deliveries at this point have come into a few ways of doing things of which she criticized profusely. It was so frustrating. Moments like these make me wish I was independent, yet I quickly remember that I don't feel quite ready and to pull in the reins.

Sunday, May 18, 2008

The Jungle and Midwives

Imagine my surprise at how the "midwife problem" of the early 20th century crept into the popular socialist novel The Jungle. For those of you not familiar with the novel, it was written in 1904 by Upton Sinclair, a socialist newspaper reporter. He did some investigative work in the meat-packing industry in Chicago at the turn of the century and was horrified by what he saw. Sinclair first began to write short pieces for a socialist paper, but the feature was not continued. But he continued to write about the lives of the meat-packing workers and ended up with The Jungle.

The story revolves around a Lithuanian family that immigrates to the United States in search of the American Dream. What they find is hardship, poverty, and horrible working conditions; as well as the establishment of worker's unions. The main character's wife becomes pregnant, and there was the dilemma of providing good care. You see, all they could really afford was a local midwife, but midwives are a sordid type and couldn't be trusted. They were considered unskilled and evil. So instead they scrape together enough money for a "man-doctor" because, as the main character believes, the "man-doctors" are respectable and can provide better care than the midwife.

Now, all of this is laced within several paragraphs; not much in the grand scheme of the novel. But the fact that such an "issue" even made it into a novel, which was a reflection of real life and society in the early 1900's, speaks volumes about the power in which the "midwife problem" was propagated. If I remember correctly, the coined phrase was not official until 1910, but the movement of the medical community to push out and marginalize midwives was well underway. So much so a socialist reformer who advocated for poor immigrant factory workers even knew of the "midwife problem".

Wednesday, May 14, 2008

Things Not To Say

Today I was disgusted with some of the things that were coming out of this doctor's mouth. I was caring for a woman who came in to the unit at 9 centimeters; she was huffing and puffing, screaming on occasion that this wasn't supposed to be so fast because she needed an epidural, and generally having a hard time with the fury in which her labor was taking. But after the whirlwind of her admission, and letting the dust settle, she calmed down and was impressively focused.

The doctor gowned up and started sticking his hand in her vagina, stretching her perineum like it was silly putty (I hate that). The woman started pushing but was having a hard time getting into the groove. So she wasn't really making much progress in the first 20 minutes or so. She was getting discouraged, and started outwardly doubting herself.

As I was trying to encourage her, the doctor said, "Well, this baby is much bigger than your last; she may not fit." Now, I am sure this was not the first time such words were uttered from providers. But what disgusted me so much was how it was said. It was flippant and condescending. It was so demoralizing to this woman she just crumbled into pieces, asking, "Well what do we do? Oh my god! What do we do?"

"Ah, don't worry about," he answered, "just keep pushing but do it better and stronger."

I had a hard time keeping my mouth shut, so I just turned to her and said, "There is no reason why this baby can't be born safely the way you want. I know you can do this."

And then the doctor said another phrase that I hate: "Ya, just get mad and push!" Someone needed to tape his mouth shut.

Of course, within the next ten minutes the baby was born safely vaginally, and was crying even before her feet were out. She was 8 pounds, only several ounces over her big sister.

Nitrous Oxide in Labor

I thought I would bring your attention to an excellent post over at Our Bodies, Our Blog. It discusses the use of nitrous oxide in labor, something that is not an option for women giving birth in America.

Friday, May 9, 2008

Nurse's Day Revisited

I think it's nurse's week, or nurse's day, or some such hokey celebratory crack pot. If you haven't gathered by now, I don't like nurse's day. This is what I used to think, courtesy of Life & Times:

Did you know that this week is National Nurse Week? May 6th is the official Nurse's Day but it is now a full week. I've always wondered the history of Nurse's Day. Did it come from Hallmark much like Mother's Day, Father's Day, Grandparent's Day, etc? Or did it come from an advocacy movement to make the public more aware of nursing?
I must say I have a love-hate relationship with this holiday. I love that perhaps someone will acknowledge what nurses do and what we have to offer. And I hate how hokey it all is.
My first Nurse's Day as an RN consisted of the Director of Nursing standing in the lobby of the facility handing out bandage scissors. I got to choose which color handle I wanted. I chose purple and still carry them around in my pocket at work, so it was clearly a useful gift. But I remember the look on the DON's face as she was passing these out: Ya, I know this is really cheap but it would be cheaper if we did nothing.
The next few Nurse's Day come up blank. I can't remember any of the festivities surrounding the holiday at subsequent places of employment. The only one I can remember outside of my current job was during my mental breakdown of 2002 when I decided I was all done with nursing. Of course, as you know I am still a nurse, but those 6 weeks I decided to make an impromptu mental health vacation was probably one of the better Nurse's Day festivities I've had.
Oh wait, I just remembered that I did get a plastic cup one year saying I am a valued employee. And yes, I still use it.
My current job hangs a big banner saying "Nurse's Week" at the main entrance. They offer us a free continental breakfast one day during the week, which many don't make it to for the obvious reasons: we are too busy to take the break to leave the unit.

In just one year I feel totally different about it. In the ten years I've been a nurse I've yet to see a national advocacy campaign that had reached the general public that isn't hokey. And what is bothering me more these days is how unprofessional some of the nurse's day things and other paraphernalia are. For instance, t-shirts with "Nurse's call the shots" or sweatpants with "RN" across the ass. Syringe pens. And my latest favorite: scrub tops with iPod pockets, c'mon! What nurse is wearing an iPod while she/he works? Oh wait...I can't believe I forgot this...I actually saw a nurse wearing one with the device sitting in the little pocket designed specifically for it. It was at my clinical site, and I almost said something.

I admit that as a new nurse I was guilty of owning a few of these items. I had a syringe pen; I remember it totally sucked. The ink was blotching and the "medication" in the syringe dried up. I even had a co-ed naked t-shirt that said something like "Nurse's stick butts" or something like that while I was in college (they were big back then, what can I say?). I guess my enthusiasm for my fledgling career needed to be expressed in hokey items.

But not any more. I cringe when I get scrubs catalogs in the mail and see Tweety Bird and Scooby Doo. I cringe even more when I see nurses wearing these scrubs, especially when they don't work in pediatrics. This shit is so unprofessional. If we want to better the profession of nursing, uplift it's image, we need to stop looking like we are wearing our teeny bopper pajamas to work. We could use nurse's day or week (or whatever we want to call the time frame) to show the public the value of nursing and that it takes a professional to do the great nursing things we do.

Wednesday, May 7, 2008

Stages of Labor, Part 2

It's been a while since I've done any childbirth ed posts, and one that was kind of left swinging in the breeze was the Stages of Labor. I talked about latent phase labor here, so go ahead and review if you want. This post will be about active phase labor.

Remember the whole phase/stage thing? It's fairly confusing. There are 3 stages of labor (4 counting the postpartum period) and within the first stage of labor are the 3 phases. Latent phase is the first, active phase follows.

Active phase labor is when things really pick up. Latent phase labor is the longest phase, typically, and once a woman reaches the active phase things really move along. Here are some signs that active phase has kicked in:

  • Suddenly contractions become so intense that talking and breathing becomes very difficult.
  • When a contraction occurs, hearing other people talk can get annoying and you need to tell them to shut up.
  • Contractions become closer together and longer in duration.
Active phase labor is defined as cervical dilation between 4-7 centimeters and contractions that are 2-3 minutes apart lasting at least 60 seconds. That being said, not everyone is text book (rarely is anyone textbook!) so don't assume this is what needs to happen. What needs to happen is cervical change, so if contractions every 5 minutes apart are causing cervical change then so be it. I've seen some providers still want to augment labor with pitocin in this situation because they've got it stuck in their head that active phase labor means contractions every 2-3 minutes apart. Plus, in theory I guess, if the woman is contracting every 5 minutes with cervical change, then getting her to contract every 2-3 minutes will make her cervix change even faster; isn't that a nice bonus (typically for the provider, sometimes for the woman if it's emphasized by the provider that she could have a quicker labor- and when such a thing is dangled in front of a woman in labor like a carrot in front of a horse who wouldn't want quicker?). But the midwifery model of care says don't fix something that isn't broke, and I agree.

I think active labor is appropriately named; not only does this stage start picking things up and becoming "active", I think it's the phase to stay active. Walk, use a tub or jacuzzi, get on a birth ball, find different positions to use during contractions. This is also the time when providers offer pain medications and epidurals (some will offer it sooner). Discussion of that in itself is several posts, so I won't go into that much now. However, pain medications and epidurals can slow a labor pattern down. This can become problematic if cervical dilation stops, and it opens up a whole can of worms. And for others these things don't effect labor. But we can never predict who is going to have their labor affected by an epidural or pain medication, so no one can advise you one way or another if you are basing your decision on that factor.