Relax

You see how relaxed this gorilla is? (Unfortunately, it looks like it's in a zoo... which is nothing to be relaxed about but this post isn't about how much I hate zoos). I have a point to make with this, trust me.

One mistake women who want epidurals make is ignoring the importance of relaxation and comfort techniques are for labor contractions. Seems like a logical assumption to make that if you are going to get an epidural you don't really have to deal with pain and discomfort. But I've seen many a woman quite surprised that they were left without any coping skills when they were waiting for that epidural.

I know I've mentioned before that epidurals just can't happen in the blink of an eye. This is for several reasons. One is that most anesthesiologists will not administer an epidural without a blood count with a platelet level. And your 28 or 36 week CBC doesn't count. They want it from that day. So you have to wait for the lab to be drawn and results to come back. Even a stat CBC can take 30 minutes. The other thing is that you need an IV and be hydrated with a minimum of 500mL of IV fluids to hopefully counteract the common side effect of hypotension. This can also take 30 minutes, or more given how quickly and available the nursing staff are to get that IV going.

And then there is the matter of the anesthesiologist to go over risks and benefits with you, sign a consent form, and then prepare for the epidural itself. It can take 15-30 minutes to place an epidural depending on the anesthesiologists skill and your spinal anatomy. So we are talking a minimum of 45-60 minutes from the time you walk into the labor unit to get an epidural in the best cases.

Oh, and don't forget that it takes 10-20 minutes for the epidural to take some effect once it's placed. I have seen some get instant relief, but that was perhaps 3 times that I can think of.

My point to all this is that those who plan an epidural (and this post is by no means meant to be pro- or anti-epidural) is that you need to know how you will cope with your contractions. Being prepared for contractions isn't just for those women who plan to do it sans medications.

In my childbirth ed classes, I focus on relaxation techniques. I use several different types because not everyone finds each on as effective. As an educator, I find it terribly frustrating that no one really wants to do them when I present them (and then will complain on their evaluations that there wasn't enough relaxation taught! Ah!) for whatever reason. I make everyone shut their eyes to eliminate the awkwardness and fear of others watching you deep breathe, etc but some won't even do that. But I digress....

I will share some of these techniques, which I find very easy to start, that women can do to help prepare for their contractions. I've found those who find themselves some sort of relaxation they can do early in their pregnancy and consistently practice do very well with the real thing. Hypnobirthing tapes are especially effective in my personal experience.

In both relaxation techniques I describe below, find yourself in a comfortable place. It doesn't matter if you are sitting or laying down, just make sure it's a position that you can maintain throughout the exercise. You can play soothing music or white noise, or nothing at all. Completely up to you.

One relaxation uses progressive muscle relaxation. First start with slow deep breaths, as many as it takes for you to feel your body relaxed. There should be no tension in any part of your body. If you are finding that you aren't fully relaxed, focus on relaxing that part of your body with each exhalation.

Once you feel completely relaxed, tighten up a part of your body; easiest is starting with making fists. While you hold that part of your body very tight, focus on the rest of your relaxed body. You will likely need to use some sort of rhythmic type breathing to keep your body relaxed despite the tensed part. After about 30 seconds, relax your entire body. Release all the tension while taking slow deep breaths again. Then once your entire body is relaxed and you are breathing normally, tighten something else and repeat what you did the first time.

I like the next relaxation because I feel it mimics the type of relaxation needed by using real discomfort. When I do it in my class, it usually gets people talking and finally getting involved!

Get yourself a large bowl of ice water. The bowl needs to be big enough to place your hand or hands in. You'll likely need a towel as well. Then set yourself up in a comfortable position with the bowl of ice water in a place where you can easily put your hands in it without moving your entire body. Lay the towel out in a place where you will rest your hands when they are not in the bowl.

Now, for shits and giggles, the very first time you do this I want you to just place your hand(s) in the bowl for one full minute. No cheating, either. You have to keep your hand(s) in the bowl no matter how uncomfortable it is, and make sure that all you are doing is watching the clock. No TV, no music, no one talking to you. Once you've done that, remember what you were thinking and feeling during that minute you had your hand(s) in the bowl.

Ok, now for the real thing. Make sure everything around you is comfortable, the room temperature, your position, your clothing, any background noise, etc that you find relaxing. Once you have everything, including your ice water and towel, set up, close your eyes and just take note of your body. Take slow deep breaths to get everything relaxed. Once you feel relaxed, put your hand(s) in the bowl. It may be helpful to have someone tell you when to put your hand(s) in and count that minute before you take it out. Or set a one minute timer that will beep every minute.

Now, when your hand is in the bowl, continue with deep rhythmic breathing or some type of visualization that keeps your entire body relaxed. Some people will do both, using the deep breathing while thinking of something they find comforting. If someone is with you, you can even have them add some massage or light touch if you want.

When that minute is up, take your hand(s) out and gently place it on the towel while keeping your body relaxed. You'll probably find that when you first take your hand out you'll need some deep cleansing type breaths to get everything relaxed.

Do this for a couple of rounds; increasing the number of rounds each time you do it.

Most people say that the minute spent with their hand in the ice while not doing anything to stay relaxed seemed longer than the minute when using use breathing and visualization.

Once you feel you've mastered this, add some background distraction, especially if you are having a hospital birth. I say this because you can't control the hospital environment like you can your house, and so you need to know you can stay relaxed when there is something trying to break your concentration. And let me tell you, most hospital units are noisy!

So back to that picture. The goal is to get you as relaxed as that gorilla between your contractions; and if possible, even during! It may seem like its a lot of work to be relaxed, but imagine the energy expended on writhing around with panic when a contraction comes along. That takes a whole lot more energy.

I've only touched on some very basic relaxation techniques. I also mentioned comfort measures, which refers to position changes, water therapy, birthing balls, and other things that can help a woman manage her contractions. I won't post about that right now, but there are a lot of things that can be done to help while waiting for that epidural. And believe it or not, I've seen some women decide that they are able to do without the epidural when using relaxation and what not. Imagine that!

Yay, I Rock!

Thanks to Sheriden at Enjoy Birth and Kathy from Women to Women Childbirth Education for both giving me the Excellent Award. Yay!

I am obliged to pass this along, and here is who I'd like to pass it along to:

AtYourCervix- a like minded L&D nurse and aspiring nurse midwife.

Melinda at Anything Said- because this girl is funny and I wish I could write as well as she does.

Rachel at Women's Health News- a very educated pro-everything woman blogger and medical librarian

The Business of Being Cut Off

Did anyone see the Larry King Live segment with Ricki Lake? I happened to catch it by accident while flipping through channels Friday night and was excited to be able to catch some talk about her documentary The Business of Being Born. I have not seen it yet, but know that I would enjoy it.

So what does Larry King focus on during her 15 minute segment to promote the film and discuss the maternity care in America? Her weight and her experiences being sexually abused. What the hell? I think he maybe asked one or two questions about the film, of which Ricki tried to delve into with quite a bit of detail, but was cut off at the pass quite abruptly with, "So, how did you lose the weight?" and "Would you want to see your abuser today?" or "Are you angry with your abuser?"

This film has people talking yet Larry King didn't want to. Oh, well. I think Ricki Lake is doing a fantastic job promoting this film, and the American College of Nurse Midwives is endorsing it. And like a million bloggers, as well.

My Love Hate Relationship

I have come to really loathe postpartum nursing. It’s boring. It doesn’t provide the excitement labor and delivery can bring. It’s full of sore, cracked, bleeding nipples, jaundice babies, and wacky visitors. I have become sick of listening to myself say the same things over and over with the endless teaching nurses do in postpartum.

And then came Melissa. I cared for Melissa the day she was in labor. She was highly anxious and had no pain tolerance. Everything she felt was accompanied by dramatic outbursts. The smear of bloody show that landed in the toilet resulted in a panic attack over hemorrhaging. Despite wanting to say, “Get a grip!” I managed to actually bond with Melissa. I liked her. And her husband knew just how to handle her. Anytime her anxiety began to escalate, he would start cracking little jokes to break her concentration on whatever the “problem” was at the moment. My shift was over before she delivered.

Today I was assigned to work on postpartum, and Melissa was on my assignment. One thing I do like is that continuity and I’ve noticed that the patients I have cared for during labor seem to respond well to me on postpartum. I’m a familiar face they have come to trust.

Everything was going well for Melissa and her new son. The baby was breastfeeding like a champion, Melissa was doing spectacularly with little pain, and she and her husband both got 2 four hour stretches of sleep the night before. And she was calm as could be. I was able to see she had a sarcastic sense of humor like me (for those who don’t get sarcasm, our conversations would have sounded like arguments). They were scheduled to go home today, and she and her husband were hoping to get out as soon as they could.

After all the discharge paperwork and all the other hospital hoopla that has to occur for a mother and baby to step off hospital grounds, Melissa’s husband went to get the car seat so they could leave. I could sense something was not quite right, something that I couldn’t put a finger on.

And then it hit me.

Melissa was scared to go home with her new baby. This wasn’t your typical new mother anxiety. The thing was, Melissa had given birth to a baby girl 3 years prior. This little girl was healthy and normal, but died after an apneic (stopped breathing) spell while nursing when she was 3 weeks old. There was no known cause for this baby’s sudden death.

Melissa had felt safe in the hospital while she breastfed her new son. She felt that there were skillful eyes all around her, just in case. But there wouldn’t be a nurse or pediatrician at her side when she went home.

As I stood for a brief second thinking about this, Melissa’s eyes began to water. I looked at her, urging her without words to say how she felt. She didn’t. Instead she asked, “Could you stay in the room with me while we wait for the car seat?”

“Yes,” I answered. After a few more minutes, I said, “You’re scared to take him home, huh?”

Down came the tears. We sat across from each other while she cried. At some point I said I’d be scared too. How could a mother not be scared given the loss of her first baby? I told her that there was likely nothing that was going to make that feeling go away, but she could always remember the multiple ultrasounds and non-stress tests she had during this pregnancy that were all normal. I told her that her pediatrician wanted her to come in frequently for well baby check ups, not because they suspected her son would also die, but to help her feel reassured. Melissa nodded, saying she knew that her son was ok. She knew rationally that it was a random tragedy that her daughter died.

Her husband arrived with the car seat. She let him place the baby in it. She busied herself with last minute bags. She took a deep breath as she crossed the threshold of the door. When she saw that it was a beautiful day outside, she said, “It rained when we took Ashley home.” Then she smiled.

We hugged and said good bye. I was glad I was on postpartum today.

Problems With The Help

I know this isn't going to go over well with some, but I have reached a level of fed-up-dom that I can no longer remain quiet. So what the fuck is up with lazy ass nursing assistants?

We have several nursing assistants on our unit. They function as nursing assistants on postpartum, such as vital sign taking, bed making, call light answering, and general nurse assisting. Or so their job description entails. Some of them also are cross trained to scrub in on c-sections which is the only task they actually do completely and thoroughly.

There is a pervasive feeling amongst the nurses that we can't really ask for assistance from our nursing assistants, because, frankly, they won't help. They come up with a million and one reasons why they can't do what you are asking for. For the most part, I never bother asking. But there are times when I've worked postpartum and really needed help. Bed making is really low priority when you have other issues to be dealing with, like breastfeeding, fragile mothers, fainting mothers, discharge, pain control, you name it. That being said, I really want to get fresh sheets on the beds. Nursing assistants are supposed to take the liberty of initiating bed linen changes, or so I'm told, and so I should be able to assume that it will get done. And yet it never does. I have to purposefully ask one of them to do it; and many times it still doesn't get done. The other thing that gets me is their refusal to bring babies out of the nursery to their mothers. I mean, how difficult is that? Oh! And the other thing is if a mom calls out for supplies (like diapers) and the secretary knows the nurse is busy, she will bring it herself.... because she knows the assistant will say, "Ask the nurse to do it. I'm busy."

My first nursing job was no different as far as the attitude but it was a different environment. The difference was it was in a sub-acute rehab and long term care facility so those nursing assistants worked their butt off. But if you asked them to help out with something outside of their normal routine of feeding, toileting, and bathing forget it. Some of them would even accuse the nurse of being lazy and sitting on their ass for most of the shift. And there was no explaining that the reason you are sitting is because you have 20 Medicare style (AKA very long and drawn out notes so that the place would get paid) notes or that we were doing back to back med passes on those same 20 people (not sitting, but they saw the "standing around" as laziness).

So all of this flack for asking an assistant to do tasks within their job description has made me gun shy, believe it or not. I feel apprehensive asking for some help; and most of the times will just somehow do things myself.

I've even seen a nursing assistant say "Yes" very nicely to a nurse asking for help, and once the nurse walked away to go back to what she needed to get done the assistant says, "What the hell does she think I am? Her slave?" I pointed out that the nurse looked like she was busy, and what she was asking was fairly simple (walk out a discharged patient). She did end up doing what was asked, but really. Was that needed?

I just don't understand why nursing assistants get so put out by having to actually do their job. I have wanted to point out that their jobs on maternity are the cushiest nursing assisting there is. There are no bed ridden, helpless, incontinent, confused, combative, sickly patients for them to have to give bed baths, toilet, and ass-wipe. The crux of what they have to do is vital signs, bed making, handing out supplies as needed.... you get my point. It's not physically grueling work like a med-surg or nursing home can be.

* disclaimer- I know there are good nursing assistants out there. I have come across a rare one or two in my career.

In A Galaxy Far, Far Away....

.... was Labor Nurse beginning her baby catching clinicals. I have to travel out of state several hours away to even be so lucky to get this experience. But that's what happens when more local midwives don't support their profession, feel that students "harm" the atmosphere of their practice, and generally don't want to be bothered. But whatever.

I bet you are wondering if I have caught a baby yet....no. I have had some laboring women, and felt so "at home" taking care of them. My first day started out with no women whatsoever, and I was getting discouraged. I was beginning to be my pessimistic self; but once those beepers went off I felt relief that I was going to get to put my midwifery skills to action. As much as it is helpful to be a labor nurse, it is just as hindering. I found myself in triage adjusted monitors, silencing alarms, etc. And then I caught myself and had to step back. My role was to perform the assessments and physical exams, write admission notes, write orders... not to mention supporting the laboring women! (Not that labor nurses don't do this, too...it's just different when you can actually give labor support without worrying about the fetal monitor, the IVs, the continuous non-stop documentation...)

It's also weird giving "orders" to the RNs. I want to say, "Yo, sista, I'm one of you!" when they listen to my updates and plan. And how cool is it to be independent? I'm given a beeper, access to offices, lounges, and given autonomy.

Everyone has been very nice to me, which is always a huge plus, but I was forewarned that one of the midwives that will be precepting me makes students cry. Hmmm....I might have to challenge that.

Media Hype

I found this article interesting on the rising rates of cesarean sections in the US. Our Bodies, Our Blog initially drew my attention to it. I think it presents some interesting questions about how to proceed with research and clinical trials on c-section and vaginal birth. But the one thing that I want to talk about is maternal requested c-section.

Inevitably, maternal requested c-section gets cited as the reason for increasing the rates of surgical birth. And it's usually an obstetrician stating this. But, in fact, maternal requested c-section is quite rare. Yes, really. The media may lead us to believe differently, but it's generated by celebrity births (most recent celeb c-section was Christina Aguilera) that get big press. Oh, and if you want to guess who has had vaginal births, most likely it's the press reports that lack the mention of "c-section". Because, you know, they would never want to say that a celebrity gave birth vaginally.... that would be so un-cool to know that a celebrity in this day and age may have actually damaged her goods. Only heathens and us little people do that. But I digress....

Back to this maternal requested crap. For example, the Listening to Mothers II study reports that most women would not choose a c-section for no medical reason even if it were offered. I had also done a literature review for a previous course in school, and could not find evidence to support maternal requested c-section as reason for the increasing rate of surgical birth. (I'd post my actual paper, but don't know how to do this.... not to mention I am sure none of you want to read my 12 page article. Plus there is always the threat of plagiarism, because the paper is that good).

There are actual websites out there by obstetricians using the "it's your body, it's your choice" advertisement for their support and practice of c-sections by maternal request without medical cause. One such site has a picture of Britney Spears as the example of those ever-wise celebrities who always do the latest and greatest of everything. If you google "maternal requested c-section" you are bound to find them. I think there is also an organization of physicians that have joined forces and organized a coalition to "save" c-sections by choice. You have to register to get to any of their supporting data, and they also use the lure of celebrities. Because, you know, Britney makes a really good role model.

Where, oh, where?

So there has been no news on Emma. What really surprises me is that this case has not made it to the news. I mean, it totally fits what the media loves to pick up on: young, pretty, married pregnant woman gone missing. It makes me wonder what the police know; like is she truly missing of her own volition? And what would make them think this? Is the real father of the baby missing as well? Did they take off somewhere together? Who knows...

Countdown to Shitting My Pants

Yes, I think we should make one of those construction paper chain countdowns til I start my next clinical, which includes baby catching, perineum stitching, and general stress and anxiety. For those who want to make that chain, you will need 9 loops; preferably pink and blue. Through in some yellow or green if it makes you happy.

I don't think I've been more nervous in my life. My mother may remember me being more nervous about other events in my life, but I certainly don't remember nerves like this. Seriously. I keep thinking of all the possible scenarios.

Dropping a baby as it emerges from its mother's womb; having an uncontrolled delivery of the head thus blowing out the mom's perineum; stitching together the labia; having mean preceptors; shaking so badly that I can't control injection of local anesthesia; being "fired" as the student nurse midwife because the family thinks I'm incompetent. The list could go on and on.

I was just talking about how I feel comfortable in my role as a labor nurse; but I realize now that there is so much I have not noticed. Like, how the perineum looks like ground beef to me no matter the degree of laceration. I understand what a first degree, second degree, etc, laceration is but to be able to determine this by assessing the actual perineum? Ya, right! Let me tell you, it doesn't look as neat and defined as texts will have you believe. As the labor nurse, I ask the doctor what degree tear the woman has and fetch them their suture. Then I go about what I need to do. There is just so much that I miss doing my "busy" work as the labor nurse. Who knows what else I've been missing!

And to think I just bought new underwear. Bad timing on my part.

To Our Loving Husbands

Dear Patient's Husband:

Thank you so kindly for showing up today at your first child's birth. How thoughtful of you to grace us all with your blessed presence despite your lack of sleep. It must have been very difficult to wake at 4am because your wife was moaning with her contractions. It must have been doubly difficult to drag yourself out of bed to drive her the few miles over to the hospital, only to wait in our triage room for an hour sitting in that really uncomfortable plastic chair.

When you heard that your wife was most certainly in labor, it was very sweet of you to offer to go home to get a nap. I am sure that it was so you could be on top of your game when the baby arrived. I realize you were very disappointed when she said she needed you there, so I found a recliner chair so that you could try to relax while supporting your wife.

I apologize that your wife and I were talking too loudly, making it difficult for you to watch the football playoff games. I was aware that your 'sshhhing' us was trying to subtly get your point across, but unfortunately your wife's needs and comfort were more important to me than whether you could hear the sport's announcers on TV.

I also apologize, as does your wife, for not speeding up her labor in a timely fashion. It was very disappointing for your wife to hear that she was "stuck" at 8 centimeters for 3 hours, as well. Your baby and mother nature didn't know you wanted to go back home by 2pm. Muttering under your breath, "Jesus Christ, when will this end?" doesn't really help. Perhaps next time you could try to pre-program your wife's uterus to perform in a reasonable amount of time. Even better, maybe you could try to time everything after you've had a full night's rest and have everything done with by lunch.

I greatly appreciate your assistance in getting your wife that cup of juice while the game was at a commercial. That certainly made all the difference. I look forward to caring for your family again.

Sincerely,
Labor Nurse

Nurse To The Core

I was asked by a teaching colleague, who is a Family Nurse Practitioner, what it was like to go from RN to student advanced practice nurse. I must have been shooting off vibes because I have been thinking about this. I’m having some trouble with it.

I’ve been a nurse for 10 years. I am very proud of the RN after my name, even despite the few little blips in my career. I have worked hard to gain the experience that I have, and the confidence in myself as a nurse. It has become part of my identity.

You will frequently hear nurses describe what their profession is as “just a nurse”. I’ve never said that. Ever. Because being a nurse isn’t menial. Certainly we can be viewed this way. You see nurses being portrayed as weak secondary figures in health care, being bossed around by doctors. Even the campaign (which shall remain nameless) to encourage young people to become a nurse so they can “dare to care” is demoralizing. The images show good looking young people holding the hand of the elderly, patting another on the shoulder, and pushing stretchers around a busy ER. Why aren’t they showing what we really do?

So when I think about becoming an advanced practice nurse (yes, nurse midwifery is considered an advanced practice nurse) in the not too distant future, I feel a bit sad. I will be placed in a new category. I will have a new identity. I don’t think I will ever be able to not feel like a nurse. I’ve heard some advanced practice nurses make it very clear they were “above” the RN title. I disagree. We are all nurses.

Babies, Babies Every Where

But not a nurse to be freed!

Holy shit, people. Babies were literally dropping out of the sky. Or so it appeared. Every time we turned around there was another laboring woman standing at the secretary desk.

All I have left in me today is this: holy. shit. I'm. tired.

More Than Meets The Eye

There was a young woman I met through my last clinical site that had a story that stuck with me. Emma was from England and came to the US as an au pair. She met her husband while nannying, and decided to quit the au pair business for wife-hood. I met her at her very first appointment for her first pregnancy.

Emma was very excited about becoming a mother; she obviously loved young children. The problem was her husband. He wasn't quite as thrilled. A baby would cut into his lifestyle, which included bar hopping and loose women. He was so displeased with this baby that he denied paternity.

This didn't all come out in the first visit. But during her first appointment I got the sense something wasn't right when I asked her about her husband, and then more so when I asked her the domestic violence screening. Emma denied being unsafe in her relationship but I didn't believe it. That's a hard thing to deal with because you can't help someone when they deny their problems.

During Emma's second prenatal appointment, she asked about how to get paternity testing. Her husband wanted proof he was the father. If he wasn't the father, then he wanted her to get an abortion. If he was, he was going to divorce her. Nice guy, huh?

I was surprised when this husband accompanied Emma to her third prenatal appointment. He sat quietly in the room, smiled when I said hello, and acted like any other intimidated first time father at his wife's appointment. This was just before an amniocentisis that she scheduled to determine paternity. My clinical placement was over shortly after this, and I never learned what the results were.

Until today. My previous preceptor called me today, saying that she knew I'd be interested in hearing the latest. Emma's amnio results were surprising: her husband was not the father. But this wasn't the problem. Emma has disappeared. As in missing. The only reason my preceptor knows this is because the police recently came into the office to question her about Emma. They asked if Emma expressed wanting to go back to England. Apparently the husband claims that Emma threatened to go back to England upon learning of the paternity results. Yet her parents and siblings over in England have not seen her.

My preceptor was concerned that something more sinister than just running away has happened. I wonder if my initial instinct was trying to tell me that something was going to happen, or is it just coincidence?

2008...

....the year I graduate!

Woo hoo!