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

Tuesday, April 29, 2008

Warning: Rant Ahead

Beware to those who don't feel like listening to me bitch and whine because that is what this post is going to be all about. And I'm pretty good at it.

Life just keeps getting busier and busier; my last few clinical days have been overwhelmingly busy with some really unusual things on top of a lot of women in labor who lack any coping skills or pain thresholds. I can feel the daggers coming via comments as I type; but bear with me. (Is it bear? That doesn't seem right.) When a woman becomes pregnant, doesn't she know she must feel a contraction or two? Hasn't she had at least several months to start preparing for birth, even if all she thinks is necessary is to watch A Baby Story? Even A Baby Story depicts painful contractions. Oh, I don't know... I just don't get it. Well, perhaps I get it a little bit- I'm sure these women know that labor usually equates pain but their fear just takes such hold of them they can't get past it. I could get into why it is so important to prepare for childbirth because fear and anxiety can worsen the pain, which then worsens the fears, and on and on. But when you don't realize that the fear makes things worse, I guess you don't really try to work past the fear or even realize that you should. I'm sure this seems insensitive to some of you, but after all the years I have worked in obstetrics it's just something I have never understood completely.

And speaking of A Baby Story, I was in the office the other day doing some new prenatal visits. A young girl (18 years old) and her boyfriend were full of questions based on what they have been watching on TV. Here are some examples of what they were worried about, thanks to A Baby Story:
"Will I end up with a c-section because I have small hips?"
"How long will my baby be in the NICU?"
"When the baby's heart stops because of an epidural, do they use forceps?"
"When will they take all the fluid from the baby to see if it's deformed?"
"When they take me to the operating room, do I have to be put to sleep?"

Thank you, A Baby Story. Thanks for your useful information and educating the women of our country on the realities of childbirth.

Another new prenatal visit reminded me that not everyone understands fertility and the normal menstrual cycle. A 22 year old, who had a 4 year old son, was surprised that she got pregnant. I asked if she was using any type of contraception and she said no. She went on to explain that her periods were only 2 days long so she thought she was infertile. I asked if her periods were regular, and yes, they were. But when she got pregnant with her son her periods were 5 days long and heavier; since then her periods changed to lighter, shorter periods and so she just assumed that it was abnormal and wouldn't need birth control because she was not able to get pregnant with such short periods. How was it possible that a baby could grow when she didn't have enough blood?

Sigh.

Saturday, April 19, 2008

Hospital Nurseries Never Die

After some email discussion about nursery practices with a reader, I got to wondering what people are seeing as "the norm". Every hospital I have worked has a nursery that staff an RN to oversee the duties of the nursery. The duties typically include newborn assessments and testing, bathing, and coordinating care with the attending pediatrician while ensuring nothing gets overlooked with any baby. However, despite the push for "rooming in", a concept that is not exactly new, babies always seem to find their way into the nursery for long periods of time.

One hospital I worked received newborns within the first 2 hours of life; the nurse examined the baby, bathed him, and sent him back out to his parents once they got settled into their postpartum room. Typically the labor nurse brought the baby down as the same time as the mother if it was a vaginal birth, but took the baby to the nursery sooner if the mother had a c-section. As a nurse, this set up worked quite efficiently on most days, as there were several nurseries (it was a big hospital doing most of the cities deliveries) that took turns admitting babies. Rarely was there a time that you would get two new babies at once, so a nurse could whip out a baby in 30 minutes if she was good. That time the baby was in the nursery also allowed the postpartum nurse to complete the admission on the mother.

Another hospital I worked, one with a more old school thinking, encouraged mothers to send their babies to the nursery each night. If she wanted to breastfeed her baby then it was sent out for the feeding and brought back as soon as it was done. If she didn't specify this, then the baby got bottles through the night. When the day shift came on, the nurses would start with doing all the baby vital signs and assessments before allowing the baby to leave the nursery to be with their moms. This was 12 years ago when I was a nursing assistant, and I've been back to this hospital since becoming a nurse. It hasn't changed much.

My current hospital had this spell where they tried to get rid of the nursery altogether. I was all for it, as I believe babies need to be with their mothers, except for the fact it would overload an already overworked nurse assignment. The postpartum assignments are not fairly laid out, and it gives the nurses very little juggling room as it is. Bringing the baby to the nursery for its newborn exam and bath has been made necessary on part of the postpartum assignments. There is no way to possibly do newborn exams, baths, teaching, etc while also caring for 4 other couplets. And the nursery nurse is too busy to come out to the rooms to do that stuff for the postpartum nurse. It's a terrible set up, and of course the banishing of the nursery lasted all of 2 days.

My clinical site also has a nursery, but surprisingly they seem to have figured a way to keep most babies in the rooms. The only babies that seem to make it back to the nursery are those under the phototherapy lights or having their penis trimmed. The labor rooms are very big, and its set up for a nurse to do all the baby stuff right there. The drawback here is that the nurse at the delivery does all of the assessments as soon as the cord is cut. So the mom gets to hold her baby for about 5 minutes. The baby never leaves her room, but she only gets to watch her baby in the first 30 minutes or so on a warmer across the room.

In all the years I've worked obstetrics, I've yet to come up with a way that never separates the mothers and babies. The hospital systems just are not set up to accommodate this. There are so many tasky things the nurses have to do, and because there isn't enough staff to be able to do these things with the mother or without rushing I have come to believe that hospital nurseries will never die. The only way to keep mothers and babies together is to have a homebirth.

Tuesday, April 15, 2008

Shock and Fear

There's been a lot of talk in the blogosphere in the past few days about traumatic gynecological experiences. I've read stories of women who had horrible first exams, made to feel dirty, abused, and violated. There are stories of providers who are just plain inconsiderate. Or so rough that a woman who had no problems going for her exams suddenly became terrified. Some have even posted their stories here on this blog in my previous post. As a provider (or shall I say soon to be) I listen to this stories with shock and fear. Shock because I can't imagine anyone perpetrating such horrible "care"; fear because I hope to never make anyone feel remotely violated.

I've been hypersensitive at the office my last few clinical shifts, trying to be as gentle as possible. And it's not like I am not typically, but I guess what I wasn't aware of was that I wasn't aware. I assumed that women that I have cared for and performed pelvic exams on who had a difficult time keeping their knees open and their butts on the exam table despite informing them of what I was going to do before I actually did it was just a variation on the feeling that pelvic exams are just not fun. I've had women tell me upfront that they have fear and anxiety about the exam because of a past experience, and again I assumed that women would just be honest ahead of time with me about such fears and those who said nothing were likely fine.

Oh, how wrong I am.

In just one clinical day at the office, I had several women with severe anxiety in some fashion. One woman spoke so fast I had a hard time keeping up with her. I left the room feeling like I was spinning in a cloud of dust. When I went back to do the exam, she said over and over, "I am so afraid of this exam, but I force myself to do it." Another was sweating so badly that she soaked through the "hygienic" paper (that's a joke- like a thin sheet of paper will make things clean) that it disintegrated. A third was a phone call by a 60 year old woman who kept self treating for a vaginal infection that just kept getting worse; when I went into her records her last gynecological exam was in 1993. After a long discussion of her symptoms, and my explanation that I couldn't diagnose this problem over the phone and that it would be best to come in, she broke into a long story of physicians ignoring her long history of heavy bleeding that resulted in a hemoglobin level of 4 and an emergency hysterectomy. The physician covering the emergency room at the time belittled her for not having done something sooner and went on to perform an exam that left her screaming out in pain, her pleas for him to stop ignored.

So, I am asking you to tell me, as a soon to be new midwife caring for women with a wide range of gynecological histories, what things should I be doing, big or small, that would make you feel comfortable?

Thursday, April 10, 2008

Hey, I Belong Here, too!

It's been interesting being a student midwife among nurses. The nurses at my clinical site, for the most part, don't realize that I am also a labor nurse. There have been a few nurses who have taken an interest in who I am and start asking questions. The others eye me with suspicion. These nurses make me feel unwelcome; when I sit at the desk I'm often told I am in "their" workspace. They set up delivery tables without any gloves or protective equipment for me.

One incident sticks out above the others. A laboring woman is flat on her back, the monitoring devices on her belly in the same spot they've been since she got her epidural hours ago, and her baby has a deceleration. I was at a point in my clinical learning where it was difficult to switch to the student midwife from the experienced labor nurse. I was ready to jump in and start resuscitating measures but told myself to hold back a few seconds because two nurses were right there as well. The primary nurse just stands there looking at the monitor. The helper nurse says, "Think it's maternal?" Meaning, is the deceleration just a pick up of the mother's heart rate, something that the fetal monitor can do depending on its location on the abdomen, the fetal position, and if the fetus is moving. The other thing is that maternal pulse on the external fetal monitor has a different sound quality as a fetal heart rate; fetal heart rates have a galloping sounds whereas maternal pulse has a more low whooshy quality.

So they chat back and forth about it likely being maternal and so Primary Nurse starts moving the external fetal monitor around the mother's belly, looking for a "better" spot for detection of the fetal heart rate. Of course she doesn't find a better spot, because it was originally in a good position.

"It's not maternal," I said, and both eyes darted over to me. "She needs to turn on her side." There are several uterine resuscitating measures for a deceleration, with a position change being the first maneuver.

"I know," said Primary Nurse. Which to me it sounded more like: "I. Know. Bitch." And yet she didn't make any move to do so.

I had this woman turn over to her left side, asked for her IV fluids to flow wide open, and asked where the oxygen mask was. Suddenly they sprang to action, and secondary nurse paged my preceptor. By the time she got there the baby recovered, and later that day this mother had a nice birth. But was all that resistance necessary?

The nurses will always defer to my preceptor when asking for the plan of care, or what supplies or medications are needed, and the preceptor will tell them to ask me to help reiterate that I am a legitimate person there. I've noticed one nurse has since included me whenever I am around, having got the clue.

What surprises me about this is how off-putting this staff can be. I guess I am spoiled where I work because I don't see this type of behavior. Perhaps there is only 2 nurses I work with that could come off this way, but they lean towards being bossy rather than rude.

Have I mentioned that I am so sick of being a student?

Tuesday, April 8, 2008

Being Reminded I'm Not This Miserable

I am finding myself so burnt out with school and clinical that I need frequent reminders to myself that things could be worse. I could be miserable, like I was in this past Thanksgiving Day post from Life & Times.

Happy Thanksgiving, everyone!
In honor of the day of "thanks", I thought I'd share what I was thankful for. Actually, I am thankful for lots of things, but to keep things blog related, I am thankful I don't work at this place anymore: Big Bad City Hospital. No, not it's real name, but it might of well be as far as I'm concerned.
For whatever reason, I was talked into applying for a position at the Big Bad City Hospital by a former coworker. She said what a great place it was, everyone was great, the shifts were great, the pay was great, everything just was so great. I had been finding it difficult dealing with the management at the place I was working at the time, another of the big city hospitals, that I was intrigued. Yes, I must go work for the Big Bad City Hospital.
The interview was smooth and I was offered the job. It was a 36 hour day/night rotation. I'd have to work 1-2 night shifts per schedule. Didn't seem too bad, as I was working all three shifts at the time, and the pay was better. And just 3 shifts per week was enticing. The orientation was 12 weeks long, which was another selling point.
My first day on hospital orientation didn't feel right. I felt like I didn't belong. Every person who spoke sounded as if they were Charlie Brown's teacher. Things seemed confusing. The day felt like it would never end. The next day was on the unit.
Apparently no one was informed that I was joining the staff, and management did not ask any of the staff nurses to precept me. When I showed up on the unit I was met with suspicion. The assistant nurse manager asked one of the staff nurses to be my preceptor while I was standing right there. This nurse made it very clear that she did not want to do so, but because I was standing there said, "Fine".
I was worried at that point how this nurse would treat me, especially since I was going to be with her for 12 weeks. As it would turn out, she was very nice to me, but also very lazy. It was the other staff nurses that I had to be concerned about, because every single one of them had a stick up their ass. They were not kind, ignored me in lunch break conversations, looked down their noses at me when I asked a question, and generally were miserable.
So the 12 weeks goes by (it dragged, actually) and now I was on my own. This was my very first labor and delivery nursing job, so I was very wet behind the ears. Everything about what my job entailed gave me anxiety, and the fact that I worked with a bunch of Nurse Ratchett's made it a million times worse.
Even with 12 weeks of training, I felt like I was never going to be able to get on top of the job. During the orientation I had come to the conclusion that the amount of duties the labor nurse at this hospital was expected to perform was unsafe. They were not to call for another nurse once the delivery was going to be imminent, and something about that just didn't seem right to me. How could the nurse safely care and attend to the mother at the delivery if the baby was also her 100% responsibility? What if that baby needs resuscitation and at the same time the mother is hemorrhaging? That stuff happens, and the nurse can only deal with one of those things safely. So do you attend to the bleeding mother and give her the meds the doctors are yelling at you to give, or do you resuscitate the baby and call for the NICU? As far as I was concerned, you can't put one over the other. But I was going to have to, and I was scared.
So this scared, green labor nurse begins her shifts on her own, completely off orientation, all strings cut. And every morning as the other nurses were choosing their assignments, someone would always mark my name next to the absolutely worse patient. I never had a say in what my assignment was.
So I took care of a sick severely preeclamptic mother at 24 weeks gestation who was on a high dose of magnesium sulfate, IV labetolol, and so obese it was impossible to continuously monitor her fetus; several sets of mothers laboring with twins; a paraplegic with epilepsy who had 4 seizures during labor; and countless non-English speaking women who distrusted the white girl from the suburbs. Rarely was the patient a healthy woman with a singleton. All the other nurses took those patients. After every shift I came home and crashed, dreading the next shift. Suddenly having those luxurious 4 days off a week didn't seem like enough.
Not only were the patients difficult either personally or medically, the medical staff was rude and condescending. No matter how awful or sick my patients are, I do not want them treated the way this medical staff treated these people. Both attending and resident physicians at this hospital treated these patients like they were invisible, objects to discuss and do as they please, and generally ignore. Many a times the doc's would walk into a patient room, not introduce themselves, not even look the patient in the face, continue talking with the medical student or other resident they were with, and do as they pleased with the patient. Off came the patient's sheet, up went the johnny, and wham! Hi, nice to meet ya! Up their hand went into the patient's vagina for an exam with out even once asking or telling her what they were going to do. And after the assault... I mean "exam", they would just leave, never once telling the patient what their finding was or letting the nurse know the plan. And forget about covering them back up. They could have been flopping in the breeze in the hallway for all they cared. I was disgusted.
One of the last things I witnessed helped to push me over the edge. I was caring for a young girl having twins. She had no support with her and the father was not involved. She was difficult to care for because her pain made her a mad woman, and looking back so was her nurse because she was beside herself with the environment she was working in. When she was ready to push I wheeled her down to the OR, a protocol in place just in case the second twin decides they want to come out via c-section, by myself. The others in the room watched me struggle as I maneuvered the bed through the doorway, and then further fight with the stirrups that were to attach to the bed. She delivered both babies vaginally, and as soon as the second baby was out, the staff in the room took off. I looked around to make sure I wasn't missing someone, but no, it was just me and the patient. She was left in the stirrups with dried blood on her thighs and her johnny up around her belly. I cleaned her up and put the patient and the bed back in the right positions. She thanked me later when I was transferring her to the postpartum unit, and it further made me feel terrible about her care. I didn't feel I deserved the gratitude.
Then I just couldn't do it anymore. I woke up one morning, and made it to the shower. I noticed that even though I was through with all that I needed to do in the shower, I wasn't getting out. I just stood there, letting the hot water run over my body like a shield. And so it was decided at 6:15am: I was not ever returning. Never again. As a matter of fact, I was done with nursing.
I called the unit at 6:30am and told them I was not coming in for my 7:00am shift. Then I emailed the nurse managers and told them I was never coming back. I quit!
It was very unprofessional of me to quit the way I did, but I didn't care. I remember the friend that convinced me to work there in the first place calling me up several weeks later and telling me that I was going to regret it. "You know, it's a small world, you have no idea who'll you'll run across or whose going to be connected," she warned me. But I didn't care. As a matter of fact, I still don't care because it was the best decision I made for myself. I ended up taking a 6 week vacation, which did wonders for my mental state and for my nursing career. Obviously I did get another job in nursing, and even returned to labor and delivery. I just know that Big Bad City Hospital sucks, and the labor unit I work at now is the place I belong.

Thursday, April 3, 2008

Fathers at the Gynecologist's Office

I was doing an annual gyn visit with a girl in her young 20's and it came up in conversation that when she was 13 her father brought her to a gynecologist because of her irregular periods that were heavy and painful when they occurred. She told me that they took her aside and asked why would her father be bringing her to a gynecologist? Was there something wrong with her father? Was he molesting her?

She was quite taken aback, because this wasn't the case at all. She tried to explain this to them. Despite her denying any molestation, the physician contacted authorities and her family was investigated for abuse. Fortunately, nothing came of it, but it was a trying time for her family.

I was flabbergasted. I am sure this is not the first time such a thing has happened. Several months back I talked about Polly, who was also brought in by her father. There were some comments that suggested that perhaps Polly's father was sexually molesting her, but I never thought this was the case. Actually, I think that it's commendable that these father's are seeking medical care for their daughters gynecological problems. I'd imagine most fathers would not want to deal with such matters out of embarrassment or denial that their child is going to turn into a woman like creature.

And sure, there probably are some fathers out there that are molesting their daughters and have taken an interest in getting them birth control, or whatever, but does a father need to be investigated even when the daughter denies any abuse?