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

Saturday, May 31, 2008

Who's On First?

Woman at 37 weeks with herpes virus: "I don't really like the Valtrex."

Valtrex is frequently used for HSV suppression in pregnant women so that they hopefully they will not have any herpes lesions at the time of labor.

Me: "Are you having any reactions? Do you feel it's not working?"

Woman: "I keep having outbreaks, I wasn't having outbreaks with my other medication."

Me: "Do you currently have an outbreak?"

Woman: "Yes. But I was having outbreaks with the other medication."

Me: "So, you were having outbreaks with both medications?"

Woman: "No. Just with the old medication."

Me: "But you said you were having outbreaks with Valtrex."

Woman: "Yes, I am. But I don't like it so I haven't been taking it."

Me: "You haven't been taking any of the Valtrex?"

Woman: "I've taken it. I take it most days."

Me: "I thought you said you weren't taking it."

Woman: "Well, I am not really taking it. Usually I take it on Mondays and Tuesdays. But never on Friday, Saturday, or Sunday."

Me: "It's hard to say that the Valtrex is not working because you aren't taking it. It's not going to work when you don't take it."

Woman: "But I am taking it. Just about every day."

Me: "Ok, well....you need to take it every day. It may work to suppress the outbreaks if you take it every single day. If you are not taking it every day, as it is intended, it doesn't have a chance to be effective."

Woman: "But I have been taking it every day."

Sigh....

Friday, May 30, 2008

Quote of the Day

If the fetus you save is gay, will you still fight for its rights?


Just some food for thought.
I can not take credit for this quote...I came across it somewhere on cafepress.com

Wednesday, May 28, 2008

Stitches in the Butt

She was 17 years old, but seemed to have the mental capacity of a 6 year old. She had hid her pregnancy until she went into labor; she knew she was pregnant the entire time but was able to conceal it because of her size.

I met her at her postpartum follow up appointment. The conversation went in circles, and I was having a hard time understanding exactly what she was describing to me. Her concern was that her stitches in the butt were bothering her, and it was causing her to bleed when she moved her bowels. I found this concerning, given that her records stated that she had a first degree tear- 6 weeks later and her stitches in her rectum were causing her to bleed? This wasn't adding up.

She said that she was trying to get the stitches to heal, so she started putting "cream" on it. The cream wasn't doing anything, she said, but she thought it might just be taking some time. I told her that we would be doing an exam and would assess what was going on. When I got to the pelvic exam, I noticed that her entire bottom- perineum, labia, buttucks, and into the anus- was covered in Balmex.

Now, I know most of you are familiar with this product. It's thick, and it's white. We couldn't see anything, she was slathered in the stuff. We tried washing it off, and in the process came across an infected hair follicle in her butt crack. It started to bleed when we washed it. I think we found our culprit, I thought, but how could she have mistaken this for her stitches?

My preceptor drained the follicle, as it was full of pus and Balmex. And then just to make sure we weren't missing anything we reassessed the entire area. Everything looked fine. Once she got dressed, I tried explaining exactly what we saw, what was causing her pain and bleeding with her bowel movements. She just didn't get it. I tried explaining that her laceration and stitches were healed and I didn't see anything unusual in that area. But she insisted that she had stitches that were bleeding in her butt area. There was no convincing her otherwise.

I'm curious as to how her laceration was explained to her, or how she interpreted it. Based on my entire interaction with this 17 year old, I know she's not playing with a full deck, but it's just an interesting disconnect here.

But at least she knows not to use Balmex on herself now.

Friday, May 23, 2008

Explaining Midwifery

I have found it very frustrating trying to explain to people what a midwife is, and why a woman would chose one. When I meet people and they learn I am a student midwife, I often get questioned why am I doing it. Aren't midwives old-fashioned? Aren't they illegal? And they only do homebirth without any medications or anything, right?

ugh....

Today I went to a new electrologist (because I'm a wildebeest) who was making casual conversation. She was in her 20s and very chatty. She asked me all sorts of questions. Was I married. Did I have kids. Did I go to college. Where do I work. And I always feel like I need to answer as closely to reality as possible, which is hard for some to understand. I'm a nurse, I say, and have been for 10 years; I do work but only per diem because I went back to school for midwifery.

Her response: "You have to go to school to do that?"

She then goes on about how when she watches A Baby Story (ahhhhh!!!!!) she often wonders why some women chose a midwife, seeing that doctors are available to everyone. I said that some woman chose midwives because of the approach to birth and women's health; midwives view a women's life cycles as normal and natural that don't require a cure or treatment. We are trained to know what is normal, and what is a deviation from normal that would require physician care or consultation. And as I go on about midwifery, I notice I am totally losing her. So I wrap it up by saying, "Well, obviously I could give you a three hour dissertation on midwifery care, but I'll leave it at that." She laughs a little and moves on to telling me that college was never a thing for her.

So I am wondering what other midwives and student midwives do when asked about "what you do". When you are talking with someone who is completely clueless about midwifery, or has negative stereotypes, what do you say? How do you approach this?

Wednesday, May 21, 2008

The Bulb Syringe

My most recent clinical shift was a nightmare. I don't even know where to begin, but there is one thing that sticks out above the rest, and it is so innocuous that it makes no sense. Between multiple laboring women with so many compounding issues (like untreated STIs or domestic violence or multiple substance abuse issues) that were overwhelming, the pushy physicians who kept making their way into see our laboring women when they were not needed (and ultimately deciding one needed a c-section...which she did, but this physician was talking c-section well before there was an indication for one), and a preceptor who could not have been bothered with me, it's a bulb syringe that is pissing me off.

You see, one of the laboring women went very quickly and my preceptor was not available when delivery was imminent. So another midwife from a different practice offered to do the delivery. Phew, I wasn't going to be alone! But...perhaps I should have been. I quickly glove up and get together my supplies, which is not a whole heck of a lot. And so I stand and am ready to catch this baby when the midwife says, "Where is your bulb syringe?" and plops it into my placenta basin. I said nothing, thinking maybe she just likes having it handy. I usually leave it on the delivery table that is at the foot of the bed because I have never needed it. Not to mention my understanding was that evidence shows that normal newborn transition rarely requires assistance in clearing the airway, even when meconium is present when the baby is vigorous.

The head delivers and the midwife shoves the bulb syringe in my hand. "Suction! Suction!" she barks. I was stunned. Suctioning on the perineum? Did we time warp here? And, so like her minion I suction. Barely. The position the baby and mom were at allowed me to make it look like I was suctioning that baby good, but in fact I wasn't exactly doing nearly what she was expecting.

The rest of the birth didn't exactly go as I would have hoped (for me at least, the mom was fine) because this midwife just kept barking orders at me like I was an idiot. I kept my mouth shut and did the things I needed to do, and having attended a fair amount of deliveries at this point have come into a few ways of doing things of which she criticized profusely. It was so frustrating. Moments like these make me wish I was independent, yet I quickly remember that I don't feel quite ready and to pull in the reins.

Sunday, May 18, 2008

The Jungle and Midwives

Imagine my surprise at how the "midwife problem" of the early 20th century crept into the popular socialist novel The Jungle. For those of you not familiar with the novel, it was written in 1904 by Upton Sinclair, a socialist newspaper reporter. He did some investigative work in the meat-packing industry in Chicago at the turn of the century and was horrified by what he saw. Sinclair first began to write short pieces for a socialist paper, but the feature was not continued. But he continued to write about the lives of the meat-packing workers and ended up with The Jungle.

The story revolves around a Lithuanian family that immigrates to the United States in search of the American Dream. What they find is hardship, poverty, and horrible working conditions; as well as the establishment of worker's unions. The main character's wife becomes pregnant, and there was the dilemma of providing good care. You see, all they could really afford was a local midwife, but midwives are a sordid type and couldn't be trusted. They were considered unskilled and evil. So instead they scrape together enough money for a "man-doctor" because, as the main character believes, the "man-doctors" are respectable and can provide better care than the midwife.

Now, all of this is laced within several paragraphs; not much in the grand scheme of the novel. But the fact that such an "issue" even made it into a novel, which was a reflection of real life and society in the early 1900's, speaks volumes about the power in which the "midwife problem" was propagated. If I remember correctly, the coined phrase was not official until 1910, but the movement of the medical community to push out and marginalize midwives was well underway. So much so a socialist reformer who advocated for poor immigrant factory workers even knew of the "midwife problem".

Wednesday, May 14, 2008

Things Not To Say

Today I was disgusted with some of the things that were coming out of this doctor's mouth. I was caring for a woman who came in to the unit at 9 centimeters; she was huffing and puffing, screaming on occasion that this wasn't supposed to be so fast because she needed an epidural, and generally having a hard time with the fury in which her labor was taking. But after the whirlwind of her admission, and letting the dust settle, she calmed down and was impressively focused.

The doctor gowned up and started sticking his hand in her vagina, stretching her perineum like it was silly putty (I hate that). The woman started pushing but was having a hard time getting into the groove. So she wasn't really making much progress in the first 20 minutes or so. She was getting discouraged, and started outwardly doubting herself.

As I was trying to encourage her, the doctor said, "Well, this baby is much bigger than your last; she may not fit." Now, I am sure this was not the first time such words were uttered from providers. But what disgusted me so much was how it was said. It was flippant and condescending. It was so demoralizing to this woman she just crumbled into pieces, asking, "Well what do we do? Oh my god! What do we do?"

"Ah, don't worry about," he answered, "just keep pushing but do it better and stronger."

I had a hard time keeping my mouth shut, so I just turned to her and said, "There is no reason why this baby can't be born safely the way you want. I know you can do this."

And then the doctor said another phrase that I hate: "Ya, just get mad and push!" Someone needed to tape his mouth shut.

Of course, within the next ten minutes the baby was born safely vaginally, and was crying even before her feet were out. She was 8 pounds, only several ounces over her big sister.

Nitrous Oxide in Labor

I thought I would bring your attention to an excellent post over at Our Bodies, Our Blog. It discusses the use of nitrous oxide in labor, something that is not an option for women giving birth in America.

Friday, May 9, 2008

Nurse's Day Revisited

I think it's nurse's week, or nurse's day, or some such hokey celebratory crack pot. If you haven't gathered by now, I don't like nurse's day. This is what I used to think, courtesy of Life & Times:

Did you know that this week is National Nurse Week? May 6th is the official Nurse's Day but it is now a full week. I've always wondered the history of Nurse's Day. Did it come from Hallmark much like Mother's Day, Father's Day, Grandparent's Day, etc? Or did it come from an advocacy movement to make the public more aware of nursing?
I must say I have a love-hate relationship with this holiday. I love that perhaps someone will acknowledge what nurses do and what we have to offer. And I hate how hokey it all is.
My first Nurse's Day as an RN consisted of the Director of Nursing standing in the lobby of the facility handing out bandage scissors. I got to choose which color handle I wanted. I chose purple and still carry them around in my pocket at work, so it was clearly a useful gift. But I remember the look on the DON's face as she was passing these out: Ya, I know this is really cheap but it would be cheaper if we did nothing.
The next few Nurse's Day come up blank. I can't remember any of the festivities surrounding the holiday at subsequent places of employment. The only one I can remember outside of my current job was during my mental breakdown of 2002 when I decided I was all done with nursing. Of course, as you know I am still a nurse, but those 6 weeks I decided to make an impromptu mental health vacation was probably one of the better Nurse's Day festivities I've had.
Oh wait, I just remembered that I did get a plastic cup one year saying I am a valued employee. And yes, I still use it.
My current job hangs a big banner saying "Nurse's Week" at the main entrance. They offer us a free continental breakfast one day during the week, which many don't make it to for the obvious reasons: we are too busy to take the break to leave the unit.

In just one year I feel totally different about it. In the ten years I've been a nurse I've yet to see a national advocacy campaign that had reached the general public that isn't hokey. And what is bothering me more these days is how unprofessional some of the nurse's day things and other paraphernalia are. For instance, t-shirts with "Nurse's call the shots" or sweatpants with "RN" across the ass. Syringe pens. And my latest favorite: scrub tops with iPod pockets, c'mon! What nurse is wearing an iPod while she/he works? Oh wait...I can't believe I forgot this...I actually saw a nurse wearing one with the device sitting in the little pocket designed specifically for it. It was at my clinical site, and I almost said something.

I admit that as a new nurse I was guilty of owning a few of these items. I had a syringe pen; I remember it totally sucked. The ink was blotching and the "medication" in the syringe dried up. I even had a co-ed naked t-shirt that said something like "Nurse's stick butts" or something like that while I was in college (they were big back then, what can I say?). I guess my enthusiasm for my fledgling career needed to be expressed in hokey items.

But not any more. I cringe when I get scrubs catalogs in the mail and see Tweety Bird and Scooby Doo. I cringe even more when I see nurses wearing these scrubs, especially when they don't work in pediatrics. This shit is so unprofessional. If we want to better the profession of nursing, uplift it's image, we need to stop looking like we are wearing our teeny bopper pajamas to work. We could use nurse's day or week (or whatever we want to call the time frame) to show the public the value of nursing and that it takes a professional to do the great nursing things we do.

Wednesday, May 7, 2008

Stages of Labor, Part 2

It's been a while since I've done any childbirth ed posts, and one that was kind of left swinging in the breeze was the Stages of Labor. I talked about latent phase labor here, so go ahead and review if you want. This post will be about active phase labor.

Remember the whole phase/stage thing? It's fairly confusing. There are 3 stages of labor (4 counting the postpartum period) and within the first stage of labor are the 3 phases. Latent phase is the first, active phase follows.

Active phase labor is when things really pick up. Latent phase labor is the longest phase, typically, and once a woman reaches the active phase things really move along. Here are some signs that active phase has kicked in:

  • Suddenly contractions become so intense that talking and breathing becomes very difficult.
  • When a contraction occurs, hearing other people talk can get annoying and you need to tell them to shut up.
  • Contractions become closer together and longer in duration.
Active phase labor is defined as cervical dilation between 4-7 centimeters and contractions that are 2-3 minutes apart lasting at least 60 seconds. That being said, not everyone is text book (rarely is anyone textbook!) so don't assume this is what needs to happen. What needs to happen is cervical change, so if contractions every 5 minutes apart are causing cervical change then so be it. I've seen some providers still want to augment labor with pitocin in this situation because they've got it stuck in their head that active phase labor means contractions every 2-3 minutes apart. Plus, in theory I guess, if the woman is contracting every 5 minutes with cervical change, then getting her to contract every 2-3 minutes will make her cervix change even faster; isn't that a nice bonus (typically for the provider, sometimes for the woman if it's emphasized by the provider that she could have a quicker labor- and when such a thing is dangled in front of a woman in labor like a carrot in front of a horse who wouldn't want quicker?). But the midwifery model of care says don't fix something that isn't broke, and I agree.

I think active labor is appropriately named; not only does this stage start picking things up and becoming "active", I think it's the phase to stay active. Walk, use a tub or jacuzzi, get on a birth ball, find different positions to use during contractions. This is also the time when providers offer pain medications and epidurals (some will offer it sooner). Discussion of that in itself is several posts, so I won't go into that much now. However, pain medications and epidurals can slow a labor pattern down. This can become problematic if cervical dilation stops, and it opens up a whole can of worms. And for others these things don't effect labor. But we can never predict who is going to have their labor affected by an epidural or pain medication, so no one can advise you one way or another if you are basing your decision on that factor.

Friday, May 2, 2008

Dropping off the Cargo

This morning as I was leaving work, I noticed that the area in front of the main entrance of the hospital where patients are picked up and dropped off had several signs. The signs had clearly been there for a long time, as some were a little rusty, but I had only realized they were there until today. The signs said, "Parking For Handicapped Loading & Drop Off".

Is it me or does that not sound right? It seems to imply to me that the handicapped are cargo. Perhaps they should move these types of patients to the shipping and receiving department if that is what they think people do with the handicapped.