Midwifery Prenatal Clinic Rotation

I started clinical last week. I have two half days of antepartum (prenatal) clinical, and usually just one intrapartum call shift (labor and birth). For the sake of continuity and detail (and keeping with the purpose of this blog) here's what my morning of clinical was like today:

6:30/7am-Up and out the house to get to the medical campus. My clinical site is the free-ish clinic associated with the university hospital. WIC and social work are on site, which is great, especially for this population. I am supposed to arrive at 8:30, the first patient isn't until 9...but I have to look up all the patients first (ie: review their charts which, depending on how long they've been coming to the clinic, can be miles and miles long) Usually, previously, we had been able to do this step the night before at school in the computer lab, but the system is down...so I had to go to clinic early to get the info. Not fun. Know what else sucks? Half the patients will not show up...so I will end up doing half of it for nothing! *sigh* Sometimes I wing it, without looking up the patient first, but rarely, because I don't like walking into the room cold. It's bad enough that the woman already sees so many providers for her care, the least I can do is know *something* about her before I, yet another person, comes trembling in.

8:55am: My preceptor comes in to the charting room, and I give her this spiel:

"X is a 27yo G4P3003 LMP(last menstrual period) 8/1/2007 EDD(expected due date) 5/9/2008 by LMP EGA 26+5 here for her initial OB appointment. My plan today is to do a full history and physical exam, including pelvic with pap, G&C (gonorrhea and chlamydia), and pelvimetry, also FHT (fetal heart tones...ie listen to the baby's heartbeat) and Leopold's. She needs an HIV consent form, her blood drawn, a urine sample, a prescription for vitamins, and a 1hr GTT. Counseling will include nutrition, safety, and referral to WIC if appropriate."
-------------> Yes I practice this spiel...and they drill it into our heads at school.

Preceptor: What's going to be one of the most important things you do physically today since she hasn't had an ultrasound?

Me: Make sure the EGA I get by physical exam matches up with her EDD based on LMP?

Her: Yep. You got it. Are you really going to go through pelvimetry?

Me: Uhhhhnnnn no???

Her: Why not?

Me: Mmmm cause she's already given birth to 3 babies?

Her: Yeah, and were they vaginal deliveries and what size were the babies?

Me: (consulting my cheat sheet from reviewing her chart-----> and this is why you review the charts first!) 7lbs9oz, 8lbs3oz, and 8lbs1oz, all vaginal.

Her: Uh huh, meaning her pelvis is probably plenty adequate and pelvimetery can be uncomfortable! Come get me if you need me.

Then I go into the room and call the interpreter because the woman only speaks Spanish and we have an appointment with an interpreter on speaker phone. I do the exam, and, per usual, get stuck with leopold's, but everything else, including her fundus being at about the umbilicus (belly button) which is about right for her dates. So then I have to get the preceptor to help me with leopold's, and we're done.

Right now, leopold's is one of the hardest skills for me. I never, ever push in hard enough with my hands! Especially for Pawlick's grip...I hate that one...

I had 4 patients this morning. They all went about like the one above, but there's always something I end up needing help with of course. Today it was the following:

1. Couldn't find FHT for one woman: Normally, you find the fetal back and put the dop tone there, but if you have no idea where the back is (cuz your leopold's maneuvers aren't very food yet ;o) then I suggest you start with the LLQ on the woman, then start moving medially and superiorly. Also, you have to push a little harder than you think...it's doesn't work with light surface touch! Lastly, don't forget to change the angle of the wand (ie: the position you're holding it in) sometimes it won't pick up in a direct vertical angle, but if you lessen the angle a little bit you'll find it.

2. Stumbled all over the GBS explanation. Yes we learned this already in class, and yes I knew what it was...but I was trying to figure out how to explain in plain terms, and got tongue twisted. But I suggest you write out a little 3 sentence explanation of what it is and why we're testing for it, and MEMORIZE it so it's on the tip of your tongue always! I guess I could say the same for the Rh conversation...

All of the women today were past 20weeks, so I didn't have to do the bimanual sizing of the uterus, but I usually have a hard time with that, too. I couldn't tell you anterior from posterior if I tried...I did assess retroflex the other day though...

After that I go and do my own charting if I didn't complete it in the room, which I often don't because I prefer to actually be looking at the woman as we're talking instead of reading the screen and clicking yes or no as she answers...but I know that this is the luxury of being a new student with 4 patients instead of 15 for the day and that this might go out the window when my load increases...but I'll enjoy it for now!

EDIT to ADD: MISPRINT! Fundus at umbilicus = 20weeks...if her fundus was at her belly button at 27weeks she would NOT be "size equal to dates" I probably have two patients confused!