Looking Back: Week 1 of Integration

This is pulled from my electronic journal. This is how my first week went:

Monday: L&D 8 to 11:15PM. Triaged three women in the AM with the same due date who were all post dates, 2 were teens in active labor, and the other was not in labor but wanted to check on her baby. One of the teens kept getting into it with the nurse (who was not nice to her and so I really didn't blame her) but the final straw was when she kept asking her to take her to the bathroom (she was hooked up to IV) and the nurse kept avoiding her (She admitted that she didn't like going into the patients room because the "little girl" had a "very bad attitude and an even worse mouth") and this girl just got out the bed, stood next to it and peed all over the floor. I could not believe the whole thing. I went in to talk to her and she said "I was not going to pee on myself, then she woulda left me in the bed laying in it." It was just a crazy situation. I was laughing with the nurses saying "well, welcome to integration hospital!" and they said "oh you aint seen nuthin yet!" and I thought, omg. I ended up delivering her and the other teen from the morning triages. (15 and 16yrs old) The lady who was also post dates and wanted to check on her baby was from the continent and lives with her cousin and his wife while she takes her last class here in the US. The entire rest of her family is back home. She did not want to be induced, but ended up staying for induction. She cried and cried and cried because her family back home was telling her not to be induced, to leave the baby alone and let it come on it's own. But then while she was hooked up to the monitors she was having decels, so of course we wanted to keep and induce her. I felt for this woman. Here she is, her cousin's wife dropped her off at the hospital, no one was going to be with her in labor or for the birth. She hadn't eaten since 5pm the previous day. She did not want to be induced and could recite the cascade of interventions that she was worried about, and I couldn't even pretend that it wouldn't happen. But, it was so nice to see the midwife and the doctor work together to help this woman. They are from the same part of the continent and so they came in together and talked about cultural customs and how they understood the pressure she was under. They talked about tradition vs the American way of doing things, and helped her figure out what to say to her family back home. The conversation happened in English, French, and their native tongue. The four of us in this tiny room together going over the risks/benefits of induction, still birth info, showing her the strip, asking about her needs, reassuring her that we weren't going to leave her, and just an overall understanding that were in this together. I was so happy to be able to witness it and be a part of it. She delivered vaginally the next day.

The other lady I delivered was a multip who came over from the clinic at 6cms. She was 5'2" and having her second VBAC. The baby came out fine, but then the placenta stuck. After about 30 minutes, she started to look a little shocky- basically pale, and we realized that her last H/H was like 8.9 and 25! We opened fluids, lowered the head of the bed , and called the MD stat. The MD tried to see if she could get it out (light manual removal) but couldn't (and the woman didn't have any pain med left- she was feeling everything!) and so then there was this big rush to get an interpreter phone because the doctor couldn't take her back to OR without informed consent for the anesthesia and hysterectomy she thought she might need (basically the doc felt that the placenta was probably stuck on the old c-section scar and she was going to try to really manually remove it but she would have to anaesthetise the patient, and if she couldn't get it out, she would have to have a hysterectomy) This probably would have been a lot scarier if we hadn't have just passed off the patient and went straight to our other patient who was pushing in another room! I had also done postpartum rounds during the shift, so by the time 11pm rolled around I was exhausted and ready to cry.

I was also upset that I really hadn't been prepared, like didn't have the experience of managing more than one patient at a time. Everything had to be done so fast and there were so many women to check on and strips to read and details to keep straight that I was really overwhelmed.

Tuesday: All day in the clinic connected to the hospital. Another long day. 34 patients showed up. The midwife said that it was a lot, even for her, so she called over to the hospital to ask the midwife on call if she could come help. Well she had three women in labor so she couldn't leave. I felt a little better knowing that the midwife herself felt a little flustered. I don't like how the clinic operates, but I guess this is what it's like at a high volume place. Women are given a number and called back by that number, never their names. She said this is not how midwives like to practice, afterall, this is why we went to midwifery school in the first place, to not practice this way! But this is how it is, you just have to work with it. The RNs do all the teaching- you write in the plan of the soap note what you want them to teach the woman before she leaves. You only have time to do leopolds, fundal height, and fetal heart tones. Also paps, GBS, etc.- the clinical exam stuff. Everything else, the nurses do. The MAs stay in the room with you and hand you everything so that it goes faster, and basically rush you to keep you on schedule. By the end of the day, again, I was exhausted. The midwife apologized for having to feed me to the wolves, but basically I was in shock. We both saw patients at the same time (she in her room, me in mine) and other times I saw patients with her in the room if it was something I didn't know how to do or couldn't find. It was crazy, and I did not feel like I was giving good or safe care, but I do know that I was doing the exact same thing she was doing. Also, almost every patient speaks spanish only. I swear I just can't get away from this. I'm telling myself that there's a reason this keeps happening. The only good thing is that they have multiple translators on site, and they come to you literally within a minute of asking for them, much better than those damn phones!

Wednesday: similar to Tuesday, except it was all GYN/Family planning and I only had a half day, which was lovely.

Thursday: Call- similar to Monday, except I had even more PP rounds to do, and one of my births was in the birth center!!! It was actually almost a waterbirth but she had light mec on AROM and you can deliver in the tub if you have mec stained fluid. So, she delivered in the bed and something funky happened with the cord after it was cut- blood sprayed everywhere! (even though both clamps were still on) The midwife said the cord snapped, but I couldn't tell how or where. It was really nice to see a birth in the center with the woman laboring in the jacuzzi. It was so much calmer, and the midwife seemed so much more like a midwife. It was also a beautiful birth because of the woman. She was this dreadheaded woman with this dreadheaded man for a partner. She was spiritual and really into symbolism. She had prayed the whole pregnancy that this particular midwiwife would be on when she came in (the practice has 'double digits' of midwives in it, so you never know) so she was really happy to have her there. Plus she was in nursing school and wanted to go to midwifery school so she was actually happy to have me there too and we talked about what midwifery school is like. Then, her partner had a friend who was struck and killed by a truck the night before, so they had talked about how with death comes life, and her partner's best friend was having a baby at the same time in the other part of L&D. The woman was also excited that she was having her baby on MLKs birthday in this year of Obama. It was just really good energy all around. Again a room full of women of color (the nurse was from India) feeling the love. As you can see, there have been good moments mixed in with all the scariness.

But it has been scary.

I feel underprepared by my school, and this doesn't feel like IP at all. All of a sudden my hand skills at birth SUCK. And per usual, they ask me stuff I feel like I should know but dont. Plus I really miss electronic charting- writing soap notes fast has been rough. Plus I think I work too many hours. I can see myself getting burnt out here very quickly.

Early morning tomorrow, again, going to bed!

Mondays Are Always Long

My day started off with the pleasant surprise of hearing "we no longer bulb suction babies."  It was music to my ears. It has been a real struggle for me to remember to bulb suction babies on the perineum or after delivery, especially when they are already crying. 

When I arrived on L&D this morning, there was a multip near fully.  I and the midwife introduced ourselves and informed her that were going to take care of her because her doctor was in the middle of a c/section.  She was happy with that, as she was a VBAC and thought she had a better chance with us. (Even though she was already almost fully, there was still possibility for a c-section because we were worried about shoulder dystocia- her last baby was 8lbs 2oz and born by c/s after she couldn't push it past zero station... I don't know if they tried a vacuum or not... but the point is my EFW was 9lbs for this baby, and the mom agreed that it felt bigger than her last baby... so, in short, we weren't out of the woods yet.)  Her doctor popped in after finishing the c/s and stayed to help with the delivery.  This was my first time catching a baby with a doc instead of a midwife.  Mom and doc joked about how the doc said she wasn't going to get to VBAC, but the patient had insisted all along that she would wait till very close to delivery to come in and that YES, she would be having a VBAC and yes she would be able to push out this baby.  She arrived at the hospital at 8cm. :o) She said she was not getting an epidural because she wanted to be able to "push right." I love determined women!

Eventually she gave birth to a 8 pound 12oz baby over an intact perineum, without any sign of a shoulder dystocia.  This particular doc did a lot of perineal massage and puckering, which was hard for me to be get into, but it went smoothly.  The patient and doc joked some more about mom getting her way, baby latched on soon thereafter, and I cleaned up mom and headed to my other mama.

My other mama also had a "big" baby, and this time the baby did get a little stuck.  We ended up having to do McRoberts and suprapubic pressure... but didn't call it a shoulder dystocia. That happens quite a bit it seems... midwives hesitant to call SD... instead saying snug shoulders or mild shoulder, etc.  Lately it seems like often women have been completely quitting their pushing efforts after they deliver the baby's head... I have been told to put gentle downward traction on baby's head by the midwife, only for her to try it herself and see that the baby isn't coming- even in the cases where it isn't a shoulder dystocia, the body isn't coming because the mama has quit pushing!  We end up practically pulling these babies out.  This baby was also over 8 pounds.

My last patient was a woman was a nearly AMA primip I admitted but would not be delivering for a while.  She was just getting into active labor when I left: 5-6cm/80%/0 station. She had a questionable pelvic shape, so everyone began watching her closely, I look forward to seeing how it goes for her.

I then had 2 postpartum patients to round on.  Both were well and breast-feeding successfully. :o)

I've caught a lot of babies since integration started.  I usually average 2 per shift.  When I think of the suggested number of catches for competency, I am so shocked that I've surpassed them.  There are people who graduate with the number of babies I've caught... how scary! 

Today the midwife told me that the goal for my last week before spring break is for her to stop gowning and gloving up.  She expects to sit back and watch me do the deliveries... by myself... "postpartum hemorrhage, shoulder, whatever."  

No pressure.

Sigh.

Integration: Week 1

This is post 1 of my 14 in 14:

ETA: oh man, it didn't work... theres something wrong with the friggin formatting of my journal entries... sigh.

I'm going to repost in a new page...

Stunted. The Cure: 14 in 14

I am a stunted blogger.  

I remember searching for so long for integration blogs.  I wanted to read about what integration was like before I stepped into the fire.  I found like, one, which didn't turn out to be much about integration at all.  I had grand plans of being that blog.  "I will write it" I told myself... so that when someone else looks, they will find it.  Well, I've written hardly anything.  Maybe that's what a real integration blog looks like.... empty space.  Space where one would write if she could think.  Space where one would tell all her birth stories, and glorious tales of crazy times in L&D and the clinic, if only she could find the time.  Space where one could purge her fears and accomplishments, if she actually had time to really process them. Space where one would give helpful hints and tips, if only she could find the confidence to think she had something worth sharing.

Oh if only there were the energy.  I am now convinced that anyone who has time to maintain a blog while in integration is a wonderwoman.  So Morag should be considered SUPERwonderwoman because she's doing it while also nurturing a baby in the belly. She just finished her "integration" and I enjoyed reading about her adventures.  You'll enjoy reading from beginning to end. 

I am trying to commit to 14 posts in 14 days... basically a post a day for the rest of February.  I don't want to look back on integration and not have a record of what I did.  I have been writing about it off and on for personal use, but I want something here, too.  I'm going to de-identify some of the stuff I already wrote and post it as part of my 14 in 14.

Paperwork

I'm drowning in it.  There's a mountain of paperwork required for my class every week, and it's soooo... ugh.  There's also a massive amount of paperwork involved in being a hospital midwife, too.  It seems... outrageous!

Maybe it will be slow enough for me to write a little something more substantial later...

Thesis, What Next, Recession

I have a rare Wednesday off and lucky me I get to work on my thesis. (sarcasm, folks) I used to love it, but now I hate it.  I have a few more people to interview, that always brightens my feelings about the project. Maybe I'll start with that. Mostly I'm sick of writing, sick of reading, sick of looking at it as it barely exists.  It's also very frustrating to keep writing something that people critique so closely.  That's all I can say about it.  It's so entirely frustrating.

People in my class are starting to look for jobs.  I started a long time ago.  It's how I chose my integration site.  I picked a place I wanted to work at.  I don't think they'll be hiring this year though because they just hired someone who will start next month (she just passed her boards, yay for her)  So maybe they'll want me, maybe they wont.  Maybe I won't want them, lol.  Who knows.  My point is, I'm not really worried right now. I am actually surprised by how unworried I am.  I have never been one to be too, too worried about finding a job... I always seem to find something.  I have a large skill set and interview well.  But I'm not really looking right now because I have no idea what I want to do in 6 months.  That's so not like me.  Well, the truth is that I know exactly what I want to do (live in a cottage on the beach in the south of France) but since that's not happening, I have no idea what I want to do, lol.  The midwife who precepted me on Monday's shift gave me lots of advice (she is an alum of my school) about marketing myself and about what to do/where to work if I don't want to be a midwife right away (like if I want to be a L&D RN or a GYN only provider, etc) and about how she went about choosing where to live and making it work with her husband, etc.  It was really good to hear a midwife talk so openly about these things.  It was also good to hear a midwife say "you might not want to be a midwife right out of school if the timing isn't right, and the other options are just as good" and not be freaked, thinking OMG she doesn't think I'm ready. (She followed it all up with "You'll be ready, you're going to be great" and some side comments about how the practice likes to hire those they've trained themselves) I'm still trying to convince myself that I want to live in this area for the next few years.  As the economy flounders, I am more and more tempted to move to a place with a much lower cost of living.

The economy is really hitting poor people hard.  Every time I see the news about the bail out and where the money is going I'm infuriated.  In a whole morning of clinic I didn't have one patient with appropriate weight gain.  I had several patients who've lost weight... and they're not in the first trimester with nausea and vomiting, nor are they obese benefitting from better diets.  These are women of a normal BMI without any income or one-earner incomes of 12-16,000/year.  Women who are getting a large portion of their food from WIC. Women in the second and third trimesters, losing weight... total weight gains of 7,8,9,13 pounds over the course of a pregnancy.  Women measuring significantly "size smaller than dates" with accurate dating.  Women we must send for untrasounds they cant afford (and likely wont get) because they aren't eating enough. Women who flat out admit that they aren't eating enough.  And we ran out of our free vitamins, so we have women who have not taken witamins for 6 weeks.  I keep writing prescriptions, telling them that they can fill them for $4 at Target or Walmart.  

newFNP and lesbonurse are seeing it too.

I'm looking forward to a 3-way chat this afternoon with my girls, and for the man to come home saying "I got the job."

Monday Mornings

suck.

It came too fast. No patients on the board in L&D. This can be good or bad