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

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."


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 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.