Breathe Easy, You've Found Me ((HUGS))

People will wonder why this blog is needed, why minority midwifery student? It's very simple actually; I was looking for this blog...but I couldn't find I created it. We all have unique experiences, and every experience, every story, can help someone else. I am a black girl from the hood at an ivy league professional school. That, alone, is reason enough to write. Somebody was looking for this blog. Someone wanted proof that what I'm doing can be done - even when you come from where we come from.

To that person especially, WELCOME.

Monday, October 27, 2008

I Never Talk About Births... What Kind of Midwifery Blog is This?

I hardly ever talk about my catches/ clinical experiences...

LadyA: Young, obese (actually she had my BMI which really bothered me), having baby #1 with family (mom, older sister who raised her while single-parent mom worked outside the home, and equally young father of baby) LadyA was on the unit when I arrived. She was induced for "post dates" at 41 weeks... and I highly suspect that she had an unfavorable cervix when they did it. In the beginning of my shift she was coping well with the contractions (she also wasn't really feeling them) She had been counseled during prenatal care about pain management and she wanted to try to avoid medications. Our unofficial policy is to explain all the pain med options with side effects, risks, and benefits on admission to labor and delivery so that the woman doesn't have to understand the risks/make these decisions in the middle of intense contractions, and then if they don't want anything we put everyone on alert to not offer anything unless the woman herself brings it up first. So she decided at admission that she wanted to try non-epidural medications first if it came to that. and she would let us know (rather than us asking her) So when the contractions got a little more intense, she started asking for an epidural but we reminded her of what she said she wanted initially. She said she changed her mind, so an epidural was placed.

So it's around 11am and she's 3cm/85% effaced/-1 station... unchanged from when she was induced early that morning. She has pitocin running at 4mU/min. Baby's heart tones start to get funky... a prolonged decel occurs, which leads to the midwife breaking her water to place an internal fetal scalp electrode, especially because it's harder to keep the baby and contractions on the monitor on fatty girls. This becomes more important when there are decelerations of the baby's heart rate because you need to determine whether they are variable (ok) or late (bad). Otherwise, it's not a good idea to break someone's bag of water at 3cm and definitely not at a -1 station.

Hours go by... still having funky decels, another one is prolonged x 4 1/2 minutes. The pit is turned off (it was at 8 by then), o2 is given again, she turns on her side... throughout the day, she has two boluses of epidural because she has a "window" of pain on her right side above the thigh that she rates between a 6 and 8. Eventually an IUPC is placed, and after that we try amniotic infusion- the 30 minutes after that gave us her most beautiful tracings of the night. But it was soon over, and back to her normal funky tracings.

The dilemma: Her contractions were not effective... MVUs of about 120... usually the pit is increased when this happens... but her baby did not like pit AT ALL... and then even with the pit off, the tracing took a long time to resume a more reassuring status.

And then, the family/nurse issues. We have a very specific guest policy concerning # of guests allowed on labor and delivery. And it's non-negotiable, unless you appeal in writing prior to arrival to the hospital. And once you select the people, you can not change them (so no taking turns) This patient had another sister who was denied entrance to the floor. It was not a pretty situation. Patient's family is arguing with the nurse, nurse is arguing back (and honestly being very rude and non-understanding about the situation which just made everything worse) and eventually the nurse is switched to another patient. The nurse was in the right, she was enforcing a policy, but her attitude was terrible. She complained to us that the patients were speaking Spanish to their family on the phone and she couldn't understand what they were saying but she just knew it was about her and her insistence that the sister couldn't come in. That was probably true as this family was very upset, even after I explained the policy to them again after the nurse left. But, come on, don't stoop to the angry person's level- you're the professional.

So anyway, after 12 hours our shift was up and we transferred care to the oncoming shift... of OBs only, no midwives on after us. When we introduced them to the patient it was obvious that a section was imminent.

LadyB came into triage a few times before being admitted. First time I sent her walking (multip with stretchy 3cm cervix looking very uncomfortable. She came back a couple hours later- no change, contractions still hovering at 7-10 minutes. I sent her home because she lived close and said she had a ride (who was there with her when I asked) and told her to eat, drink plenty of water, take a shower and a nap, etc. Told her it would probably be soon. Well she returned about 6 hours later, in active labor (6cm, contracting every 3-4mins, not able to talk through contractions) The nurses were irritated because she arrived by ambulance and obviously birth wasn't imminent. Well her ride ended up backing out and she didn't think she could walk to the hospital (her partner and children walked over) But such is life. So I admitted her, and the nurse gave her a nubain/vistaril combo (what she asked for and had with all of her previous deliveries) and she slept very peacefully between contractions and barely woke up during them. It worked great for her. She got an IV because she was GBS positive. When it was time for change of shift she was 8cm with a bulging bag and saying it was time. That's when we left.

I hate this about being a student. When the preceptor leaves, you gotta leave. I wanted to stay. She was sad we were leaving. I was shocked... well maybe not... that we were leaving when she was this close. Midwifery educators are so overworked though, so I get why they aren't as apt to put in over time. I'm hanging my hopes on the idea that real life won't be like this...

So, 12 hours, 2 patients, no catches, but a whole lotta learnin... my life as a midwifery student.


Jen said...

hey midwifery student, just curious what you've been taught is the right station to AROM? Bc most people will say -2 is fine, and certainly -1 or more as that means the head is engaged. Just wondering if people are being taught other things than that.

And that postdates induction story stinks. Another option would have been to shut the pit all together, not break her bag, monitor the baby for a whle and if it's OK send her home and start again in a few days if needed! I've done that a lot....and I'm an OB (not carrying a scalpel in my pocket!) :)

doctorjen said...

Do you get any continuity patients in your training program? I guess it's hard for me to comprehend training to be a birth attendant without taking care of at least some clients you know ahead of time, and stay for the whole labor - or at the very least follow a preceptor who is doing so, even if you don't personally know her clients. I know it's tiring to be on call, and everyone is overworked, but I can't imagine leaving a client who is 8 cms and a multip and turning her over to OBs at that point.
Do you want to come to rural IL for a month and see some clients from 36 weeks to holding a baby? :)

Ciarin said...

I see absolutely no reason why you can't AROM at -1? If the head is well applied to the cervix you can AROM at -2 although I prefer not to.

I think it is also sad that you had to leave the multip - what a bummer. If I have connected with the lady, and she's that close, i would stay :)

You should come to Arizona and play with me and my ladies!!!