Would You Like an IUD?

I think because of the level of stress I have been feeling these days I have been experiencing some weird and vivid dreams. The most recent I just had to share; those of you who work in gynecology will get a chuckle. Or maybe you'll be horrified.

I was working as a CNM in my current clinical placement and was seeing a
young girl for an IUD placement. I had briefly reviewed her chart and saw
she had an hCG level of 238. I thought to myself, Well, that's weird
that she's getting an IUD when she is likely pregnant. But I went
ahead and put in the IUD anyhow. I was surprised at how smoothly it went
in (IUDs are not a strong skill of mine just yet) and was pleased that the young
girl was happy with it. She got up off the exam table and I asked her how
she was feeling.

"Fine," she said. And I noticed that the IUD was sitting on her
tongue. I was baffled at how this could have happened, and briefly thought
that it was too good to be true that it went in so easily. I asked her
again if she felt ok, and she said she did. This time the IUD left her
tongue and slipped into the right place, which, in my dream, was under the
tongue. She left, but I got this terribly nagging feeling that I had done
something very stupid.

I didn't like the hCG level, and on further investigation she was being
followed with hCG levels every 48 hours. It appeared that her levels were
only rising 70 points, not a good sign for a viable pregnancy. I knew that
her pregnancy was unlikely going to continue, IUD or not, but felt like a
complete ass because now it was going to appear that her miscarriage was
completely my fault. I went to my consulting doctor, my gynecologist in
real life, and told her the story. She said not to worry about it, just
about everyone made this mistake, and everything would be ok.

Oh, god, I hope to never make such blundering errors in real practice.

So, So Tired

For days I've been wondering what can I blog about? And my mind comes up blank. Well, not blank exactly, but the things that do come to mind would take some effort, and effort I do not have these days. School is wearing me out, and asking my mind to do much more than what is required is a request that will fall short. I remember hearing midwives talk about how difficult and draining school was when I first entered but always thought it wouldn't be like that for me. I was a good nursing student, and never felt stressed like the other students. Mind you, I was also around 19 or 20, so that may have played a factor given most 20 year olds don't have the same level of responsibility as a 30-something.

But, alas, those midwives weren't far from the truth at all. I've often wondered, now that I am knee deep in this stress shit, how these other midwives managed school while they cared for their children. I don't have any children, and can't even imagine adding that to my plate! I don't have that much longer to go...yet it seems so far away. If my mind ever feels light enough I will be adding to the Childbirth Education Series; let me know what topics you want me to blog about and hopefully I can come up with something in a reasonable time.

More On Being Naive

I'm not singling this comment out because it opposes the majority, but because my response requires more than the space provided in the comments section. And BTW, I like to have good natured debate here on the blog.

Ok. I'll bite. I come from a 3rd world country and have been living in the US for only 4 years so this may come off as being ignorant.But let's start with... how about stop having babies until you can provide a stable environment for your child? I understand the first one. Everyone makes mistakes. But shouldn't one learn from them? When you can't provide/secure a safe and warm place for your 4-year old daughter, then why are you having more kids?It's not like birth control is hard to come by. One can get them for free at planned parenthood or at the public health office. Maybe get some family planning counselling while you're at it. I guess I don't get it. The United States may not be the land of milk and honey as, we 3rd worlders think it is but it sure does provide one with a lot of opportunities to get back on your feet. Or at least not commit the same mistakes over and over and over.

I don't think your opinion has anything to do with being from a third world country, as many of American born and bred feel this exact same way. As a matter of fact, so did I, until I kept talking with these women and learned their stories. People fail to look at details that we, as secure and middle and upper class citizens, couldn't consider only because such details don't exist in our lives.

Specifically regarding the 27 year old in the post below, access to birth control wasn't as easy as one would think. First, she was ineligible for Medicaid in our state. Therefore, she couldn't afford care, even the reduced fee at an area clinic. So, even though Walmart (there is one locally) has two birth control pills on their $4 list of prescriptions, she couldn't afford the visit in which to get the prescription. The closest Planned Parenthood is about 30 miles away in a city where the public transportation in her city did not have routes to. And out public health department does not provide free birth control.

I guess the next logical thought would be to tell her to just not have sex, because there are no other options for her to protect against pregnancy. But, do we really have a right to tell people this? Certainly, as clinicians, we should counsel that abstinance is the only 100% effective method of birth control, and I think most people who have brain cells that rub together know this. Or perhaps she could have used a calender based method (commonly known as the rhthym method) but the most accurate ways require learning differences in cervical mucous, taking your temperature with a basal body thermometer every morning, and graphing your assessments daily. This is harder than it appears and not everyone can do it accurately. Not to mention that many people don't know of any of these methods so they wouldn't even know they could go to the library and read about it for free, let alone pay for an appointment to be counseled by a clinician. And even for those who use calender methods of birth control, the failure rate within the first year is about 25%.

There are so many different unique situations that have aspects that are barriers to these women. We can't start making the assumption that she should "just get on birth control" or "just stop having kids". I look at it the same way I look at women in domestic violence relationships. Many would say "just leave", but its not as easy as that.

Call me naive, but....

I realized as I was walking out of a patient's room my last shift that I have a soft spot for the underserved, the ones on the wrong side of the track, the ones that were dealt choices that all lead to nowhere. There are many nurses who have no sympathy for the women who have unstable home lives, who are 23 having their 4th baby, or homeless and pregnant. They think they should just be able to get their acts together and all will be well.

But it isn't as easy as that. Take the girl whose room I was leaving. Twenty seven years old, admitted at 27 weeks for premature rupture of membranes. No prenatal care. No stable home environment. A 4 year old she was turning over to different people every couple of days because she had no one stable to take her. I asked her why she hadn't started prenatal care. She gave me the most honest reason.

"Seeing I was homeless, going to the doctor was not on the top of my priority list when you are wondering where you'll sleep at night."

Point taken.

She was living with her mother, who is an active drug user and her apartment had a turnstile of a front door for transients. She didn't feel it was good place to have her 4 year old. She felt unsafe. So she moved in with her boyfriend's family, but because they couldn't pay the rent that was being asked of them they were kicked out. They would sleep at friends here and there, but for the most part they pitched a tent in a local park. By this time it was getting cold out at night, so they sold their car to pay for a motel for a couple of weeks. But now they didn't have any transportation, and the boyfriend had to quit his job. It took him awhile to find one he could get to by public transportation; she couldn't work because she didn't have childcare.

So, I ask those who think people like her should just get her act together, how that is possible? How does one get ahead by living on the fringe of society, homeless, wondering where you'll be keeping warm at night? When you don't have childcare, how can you work? And if you can't work, how do you pay rent? And when your days are filled with trying to secure a place to sleep that's safe and warm for your 4 year old, how do you have time to fit in a doctor's appointment?

Call me naive, but I don't see how people in these situations make it out and above.

Hiccups Take 2

I'm reposting this from Life & Times so I can be reminded of how grateful I am not to be at this clinical site anymore. No matter how tough or terrible my clinical days might be now (and trust me, there certainly have been some falling into those categories), it will never be as bad as this one was.

This clinical was so bad that I would have rather stuck nails in my eyes and bamboo shoots under my nails than go in to the office. I was not allowed access to patient medical records, was never incorporated into the visit or allowed to perform any exams, and generally was just kept in the corner of the room like some mistreated dog. I don't think this post expresses that experience exactly, but it was the only time I tried to interject in a visit while using my humor.

Hiccups

So I had all these intentions of this great post, but after allowing my brain to fizzle a bit I can't remember what it was I wanted to write about. Clearly it was not that important, but I have this nagging feeling that it was good.
Damn.
Instead, I will regale you with Tales of The Horrible Placement, or otherwise known as my primary care clinical rotation. Not only is this not my bag (remember, I feel at home when a uterus is involved) but my selected preceptor is not cut out as an educator. Perhaps I am sensitive to education because I am a nursing instructor myself. Perhaps it's because I am a really big dork who absolutely loves school. Or perhaps it's because she sucks.
Regardless of the reason, my clinical days are drawn out with Chinese torture. And so, in true Labor Nurse fashion, I decided I was going to try to make the best of it. Unfortunately, the preceptor doesn't exactly have the same sense of humor as yours truly.
We were seeing an elderly woman for her weekly follow up appointment. Needless to say, she has multiple issues. I've seen her every week that I am at this office, and find her quite endearing. She's the typical picture of independence lost: lives with her younger sister, relies on her son to take her to appointments, and generally needs daily assistance. Her faculties of the mind seem to be all there but it is clear that she does not like being the way she is. She doesn't say much but everything she does speak yells out to me: "I'm done with this life." The exasperation is evident with every answer she gives my preceptor.
As things were wrapping up and the visit almost complete, this woman gets a bone rattling case of the hiccups. "Excuse me," she would say after each hiccup. My preceptor offered her a glass of water.
"No, thank you," she replied.
And so I said in my dead pan way, "Instead we'll just scare you when you walk out the door."
The elderly woman laughed and her hiccups stopped, but my preceptor shot me a look that made it all too clear that she wasn't liking my little ditty.

Imagine That!

Yesterday I taught a childbirth class, something I haven’t done in a while. I was really dreading it, quite frankly, but they needed an instructor and I needed money. The class was small, which I find makes for a better session, and they were engaged in the conversation. I didn’t feel like I was lecturing, which never feels right for a childbirth class but more often than not these couples never seem very interested. And then, a father asked, “So why is it that almost everyone talks about how they ended up needing pitocin?”

Ah-ha! My segue to the soapbox.

This question came soon after a birth video in which the woman was having regular contractions every 9 minutes apart. She had a midwife, who said to the woman when she asked if they could speed up her contractions to make the labor go quicker that she was not going to mess with a process that was working fine on its own. I love that line, because it reinforces what I want to teach, not the medical dogma on how to be a good patient while in labor.

I posed the question back at the class, using the birth from the video as an example, about how each labor is different and if progress was being made do we really need anything to make it faster or better? I got an overwhelming response, and got to talk about all the reasons they’ve heard about women “needing” pitocin. I’m always amazed at the things that they hear, like a woman needed pitocin as soon as her water broke because now the baby was in grave danger of infection. Or pitocin was needed because the woman was in active labor and having contractions every 4 minutes apart with cervical change, not the 2-3 minutes that are supposed to occur during the active labor phase.

I got to tell these couples that they had a right to make decisions for themselves, and that most decisions made in labor are not emergent. For instance, when was the decision for labor augmentation made emergent? And, if this was posed to them by their provider, that they could ask for alternatives to pitocin, not to mention a few minutes to think about their options. Ultimately, the discussed turned into their rights as patients and informed consent. Even one woman said, “So if we are being told we need something, we can say no if we disagree?”

Imagine that.

My Crazy Brain

Ya know, today I went to work and was dreading it. I have too much to do, tests to study for, reading to catch up on, clinical hours to fulfill....I just want to have a day this week I could sleep in a little, do some school work, and feel a little more on top of things.

That didn't happen.

But what I was surprised about was that once I got to work, got into the groove of my assignment, helped welcome a couple of babies into this world, I thought, Why can't my life be as simple as just going to work and coming home? What got into me to want to do more than that?

I'm just so sick of school...

I'm So Done, But Not Ready

When I entered midwifery school, I was a little reluctant of thoughts that I will have to let go of my labor nurse identity. I’ve worked hard in nursing school, and then as an RN gaining experience over the past 10 years, and I think it’s only natural to not want to give this up. Becoming a midwife, a new grad all over again, is scary. For so many reasons.

There were so many things that it took years for me to appreciate as a nurse. It took years for me to understand certain aspects of the care I was providing from a multifaceted perspective, so to speak. Coming to realize the importance and value of nursing, as opposed to just doing my job and not screwing up, isn’t something that happens overnight or with the arrival of the license. And knowing this now, as an experienced nurse, makes me fear being the new grad all over again.

However, as I gain more experience in midwifery, albeit as a (sometimes bumbling) student, I look forward to shedding my RN role and stepping into the nurse midwife role. Sometimes. When I started my midwifery clinical experiences, I had a very hard time giving up that RN role. When I was in the office, I felt terrible that an assistant was there to hold my pap smear containers and to hold out the little basin for the used speculum. I felt like I should be able to just do these things myself. And when I started my intrapartum clinical, I never asked the nurse for anything. When I wanted certain medications, for instance, I would just tell my preceptor. She would tell me to tell the nurse since she was the one to carry out the order. I think at first it went something like this:

“Um, excuse me…. would you mind, kindly, if you could, um…. hang some pitocin now?”

I think it may have come out sounding a bit like Oliver Twist asking for another bowl of broth. Even my preceptors were like, “Stop that!” and told me that I was the provider in the room…not the nurse. As I write that I realize that it may come off as “We big midwife…they little nurse!” but in fact that is not the case at all. What I needed to transition to was being the ultimately responsible provider within the team. I’ve been able to ask for things without so much guilt, and have noticed that many of the nurses have turned to me for orders, even with my preceptor there. Yet it still feels weird to say, “Send a culture on that urine, and hand two liters of D5LR over the next 4 hours”.

I’m in the final months before graduation, and I don’t know how in the world I’ll ever feel ready. I am so done with school as far as my mental state is concerned, but nervous as hell to become a new midwife. I fear that, like my nursing career, it will take more time than I’d like to feel like I’m just trying to do my job without screwing up.

Holding My Breath

One of the appeals of obstetric/maternity nursing is that very rarely are you dealing with nasty feces and vomit. Newborn poop and spit up doesn’t count as it is fairly benign. On occasion I have to clean up a woman’s poop when she pushes, but it’s only small amounts that can be quickly whisked away with the chux pads.

So much to my dismay, my most recent shift was immersed with adult poop and vomit. I was assigned to work the triage room, so I take whatever comes walking through the door. I get report that a 32 week pregnant woman is coming in with severe nausea, vomiting, and diarrhea. And severe doesn’t even come close to describing what she was going through. This was a viral thing, and so on top of dealing with excrement of all kinds, I was also acutely paranoid that I was going to catch the virus despite my obsessive-compulsive hand washing and hand sanitizing (and pen, stethoscope, clipboard, etc etc sanitizing). If I could be offered a Haz-Mat suit when dealing with anyone with a stomach viral infection, I’d be suiting up like yesterday. This includes with my family.

After several bags of IV fluids and some zofran, she was a little better and took a nap. In the meantime, an unexpected admission came in by way of ambulance. She was an 18 year old multip who called 911 because she was having severe pressure in her pelvis like something was “trying to escape”. 911 Dispatcher instructed her not to push or sit on the toilet and sent out the paramedics.

She was writhing on the stretcher and I wondered if she was truly in labor. She was also 32 weeks, and so I prepared as quickly as I could for a delivery. A 32 week baby can just shoot out like a rocket in a multip, so you never know. Quick glance at her perineum reassured me that at least a head wasn’t sticking out or at the very least crowning.

As I am settling her in the triage room, asking her questions about what was going on, she asks for an enema.

Yes, an enema.

So I start thinking that perhaps she isn’t in labor but just severely constipated. The more we talk, the more she focuses on her bowels. The conversation goes something like this:

“Are you having any contractions?”

“No, but my belly hurts real bad when I was trying to take a shit.”

“Are you having any vaginal bleeding?”

“No. But I had a brown stain in my underwear.”

“Are you leaking any fluid out of your vagina?"

“No, nothing will come out.”

She hasn’t pooped in one day, and normally she goes 4 times a day. She was trying to go when she called 911. Somewhere there was a lack of understanding between the young girl and the 911 people, because she was really calling about her pain and difficulty with trying to move her bowels.

The physician evaluates her and finds that her rectum is full of poop. First I give a dulcolax suppository, which barely went in and crumbled in my hands. Next was an enema. This was even more difficult as the applicator tip couldn’t get past all the poop. Some how I managed to work it in there and asked her to hold in the fluid for as long as possible. I was afraid she’d spray down the bed so I had piled chux pads over the entire bed. Ten minutes later she went to the bathroom and she didn’t call for 20 minutes.

She was crying and doing a dance over the toilet; she was in so much pain but couldn’t go. When I looked, you could see her anus was dilated about 3 centimeters with a large rock of feces sitting behind it. Ouch.

She asked me to go in and pull it out.

Needless to say I could barely stand the odor in the bathroom as it was, and I knew that I’d be gagging if I had to disimpact her. But that is what I had to do. And she wanted it done in bed, so I didn’t even have the luxury of her on a toilet where it could fall into the water and somewhat mask the stench.

I put a mint in my mouth, some peppermint spirits under my nose, and did what I could do while trying to avert my eyes from what I was doing. There was easily 3 pounds of poop that came out, and that wasn’t all of it. The rest would have to come down into the rectum.

So I ask my fellow med-surg nurses…. How do you do this? How in the world do you deal with all this feces?

Think Again, Smarty

I've been listening to some talk about how obstetrical nurses don't have enough compassion for laboring women, or women who have recently given birth, if the nurse has not done so herself. I've said this before, and I will say this again: that's bullshit. While those of us can not exactly know what it feels like, we know how to care for a women who does. If it so appears that a nurse doesn't have any compassion or caring in her for a woman in labor, it has nothing to do with whether or not she's given birth. It has to do with the nurse just being in the wrong speciality, or even career, or she just plain sucks.

Now, how ridiculous would it be to have these same expectations on nurses in other fields? If this were the case, then here are some of the following implications and requirements of nurses:

• Oncology nurses must have suffered from cancer.
• Orthopedic nurses must have suffered from injury resulting in multiple fractures.
• Emergency nurses must have suffered from catastrophic trauma resulting in almost losing their life.
• GI nurses must have suffered from a bowel disease resulting in a colostomy.
• Bariatric nurses must have suffered from obesity.
• Gyn nurses must have suffered from reproductive tract disease.
• Psychiatric nurses must have been committed for mental illness.
• OR nurses must go under the knife.
• Home care nurses must have been housebound at one point in their lives.
• Hospice nurses must be dying, or have a family member dying.
• Sexual Assault Nurse Examiners (S.A.N.E) must be raped.

Get my point? It's absolutely insane to think that for a nurse to be effective in her (or his) care must know from a personal perspective what their patient is feeling.