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.


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.