Saturday, September 25, 2010

You all have to go see this post...

This is better than anything I could put together. Seriously, go and read. Notice the looks of joy on those mother's faces!
The Midwife Next Door

All of these things are implementable at any hospital- even the super busy county hospital that I work at. Patients need to be informed (first off), they need to advocate for themselves, and providers need to be willing to change how we deliver obstetric care. Unfortunately now, the only way to get these things in my state is to deliver at a birth center or at home. That makes me very sad.

Tuesday, September 14, 2010

A small joy...

I had to go to the medical library of my hospital and was happy to see a couple of books that surprised me. Penny Simpkin's The Birth Partner and The Womanly Art of Breastfeeding. The info is there!

Sunday, September 12, 2010

Their eyes are open, but they do not see...

How can you tell someone that they are missing something? That they may know so much about a subject (birth in this instance), they may well be an expert, but they are missing something. They are missing the magic, the utter joy, the orgasmic (yea, I said it) quality of birth. Over and over again I have women in my life (nurses and others) make what to my mind are radical terrible decisions. Elective primary c-sections, inductions, bottle-feeding, et. To them, my decision to have out-of-hospital birth is radical, but which is further from normal? Which takes the biggest risk? Which one has the least amount of trust in one's own body?

I just looked through an online album of a friend (someone who is very knowledgeable about birth) who had a primary elective c-section. Too posh to push. Too posh to breastfeed too as evidenced by all of the bottle-feeding pictures. I became overwhelmed with sadness. Sadness for her, she would never understand. Sadness for her baby, once again she would never understand. Why am I struck with so much pity for someone who choose this? Someone who is perfectly content with her birth experience and with her mothering choices?

I don't believe that homebirthing, breastfeeding, cosleeping, or any of the many other gentle parenting choices that I made make me a better mother. But, I do think that it make me a stronger person with a richer life. I do think that it gives my children an edge of happiness in this world that can be so difficult. I do think that it gave me an opportunity to connect to the womanly energy of the universe and of my ancestors in a way that is otherwise impossible.

What I wish is that one by one I could take the birth doubters in my life and have them sit with me through a labor. Have them rub backs, moan with a laboring woman, feel the energy of a labor that is left to progress on it's own. What would they do if they saw a baby caught by her own mother, or father? A baby born with siblings present? A baby who is left alone to transition in her mother's arms? See a mother whose face is filled with utter joy and the immense wonder at what she just did? Would the tears come then? Would they know the beauty that birth could be? Would they know what they missed?

Friday, August 20, 2010

I'm that friend...

My best friend is pregnant- yeah! She is due on my birthday- double yeah! But, I totally suck. Like seriously I'm not even sure that I should talk to her until she delivers. On the phone she asked an innocent question about how I handle working at Big County Hospital and I start to bitch and moan. I'm supposed to be the rah rah birth cheerleader and I start talking about vacuum deliveries and c/sections! What the heck is wrong with me!? She isn't even a nurse- so no terrible stories of her own! I realized what I did, but it was too late. She beat a hasty retreat and I sent her a long apologetic text promising only positive birth stories from now on... I suck. Seriously. Maybe I can blame Big County Hospital for making me jaded? I think I need some beautiful births to get my rah rah spirit back.

Thursday, August 19, 2010

The beauty of laboring down using the California Roll....

This post is specific for a mother with an epidural. Laboring down is nearly impossible for an unmedicated mom. It requires denying the urge to push and that is like trying to stop a speeding train with a feather.

Look at this animation showing the different stages of presentation....

Note all of the movement of the baby. A baby descending through the pelvis is like a key having to fit in a lock. The baby is as much of a participant in the birth as the mother, s/he is not just conked out in the uterus. The baby needs to turn her head one way, her shoulders another, and then rotate back. This doesn't necessarily happen because the mom is pushing, it happens because it is how we are made. It happens because it must.

One mistake that I think a lot of nurses may make is that they start to push a patient as soon as she is completely dilated. I feel that as long as the mom is not uncomfortable/ feeling tons of pressure than waiting for the baby to start to descend in the birth canal is very helpful. It keeps the mom off of that "pushing clock" for a little longer and it shortens the total amount of time and effort needed for her to push the baby out.

I also have theory. When a mother is nearing complete dilation and the baby descends, there is a usually a slowing down and spacing out of the contractions (in natural labor). I believe that this happens because the fundus of the uterus is empty (as the baby's bottom is now lower). I think that waiting and giving time to labor down allows the muscles in that uterus to contract back down around the baby's bottom to allow the uterus to be more of a helper during pushing. A Boggy Uterus doesn't want to contract, but a nice tight uterus contracts much more efficiently. If you wait you will see contractions that have spaced out start coming closer together. This break is God's way of giving an unmedicated mom a rest before she has to push. 

What should you do while waiting? Well, I believe that the epidural does not prevent a mother from being an active participant in the birth. Just because you have an epidural does not mean that you get to sleep throughout labor. I use a technique known as the "California Roll"- Google it and you just come up with sushi. It is sometimes called "Chicken Wing" (but that leaves an important step out). I am sure that other hospitals have different names for this, I am hoping that other nurses are already doing this. This is a great doula technique for you doulas who are attending a hospital birth.

I DO NOT like using high fowlers to labor a patient down. You do that and the baby's head is just slamming against that coccyx the whole time. You end up with a patient with terribly swollen labia, an increased risk for tearing, and a potentially swollen cervix.

1) I put the mom in a far left lateral position first- she is nearly laying on her stomach. The right leg is held up by the left stirrup, but the knee needs to be really flexed up as far as it can towards her stomach. I flip over the bottom left pad on my labor bed to support her left leg, but you can use a pillow here. This position allows her coccyx to be mobile. In a standard semi-fowlers, high-fowlers, or lithotomy position the coccyx is completely immobilized by her sitting on it! If you put a mom in this position, I want you to see how open her pelvis is, how much more room this gives the baby to descend. I leave her in this position for about 20-30 minutes.

2) I then sit her upright in a throne position in the bed. Essentially high-fowlers, but with a big twist. The bed essentially looks like a chair and I sit the father of the baby or another family member on the bottom of the bed in between mom's feet. She is leaning forward leaning on their shoulders with her belly falling between her knees. I then tell the Dad/family member to rock left to right and front to back. I leave them there for 20-30 minutes. This also works with her leaning over a birth ball, but with an epidural I prefer to have a person there to help stabilize mom.

3) I lay her back down in a far right lateral position. The exact opposite of step one. She is there for another 20-30 minutes.

Over and over I have had tremendous results with this. I have turned OP babies, I have fixed swollen cervixes, I have gotten a cervix to dilate that hasn't dilated in 5+ hours, I have caused a very tight pelvis to open and allow baby to descend from "sky high", I have fixed asynclitic babies, and I have saved moms many an hour pushing. I even had a brow presentation once with a G1 using this technique to help baby to descend. It gives both time and and the room for a baby to move down.

The goal here is to try and mimic what an unmedicated mom would do if possible. An unmedicated mom would NEVER choose to lay in bed in a semi-fowlers position if she wasn't hooked up to a monitor. She would be up rocking her pelvis and letting her belly fall forward.

An epidural labor will never be a "normal" birth, but a good nurse/doula can try to minimize a mother's chance of ending up with a surgical (vaginal or otherwise) delivery.

Wednesday, August 18, 2010

A woman had her baby taken away for three years for refusing a c/section...

I was incredulous to read this article on a woman at a New Jersey hospital who refused to sign a pre-consent for a c/section. Here is another article on the same situation. She wanted the chance to have informed consent at the time of the surgery instead of signing her rights away before it was medically indicated. I understand completely where she is coming from. There is always time for a signature- even in the most pressing of moments there can be someone getting a signature. As long as she was informed of the risks ahead of time, she could of waited to sign until she was rolling into the OR if needed.

This hospital has a 50% c/section rate. If I was delivering there, I would probably not want to sign the c/section consent as well! It seems that your odds are just as good for an operative delivery as they are for a vaginal one! Ridonkulous!

What really pisses me off about this is that she is made out to be a "bad mother" because she didn't want her baby to be delivered via c/section. C/S really suck for moms, but they are hard on babies too. Gunky lungs, difficulty breastfeeding, spinal anesthesia, and the list goes on and on.

What this really comes down to is whether or not it is possible for someone to have "informed consent" when they sign the c/s consent in early labor. The decision for an operative delivery is taken away from the parents and given to the doctors. The doctors decide if a c/s is necessary based on their own views. Their views are based on a lot of medical training, but also on a fear of litigation. If something goes bad and the doc did a c/s it nearly will always clear him because "s/he did everything possible". How can a parent make an informed consent for a situation that hasn't even happened yet? Does it really take so long to go over the risks of surgery in early labor (but not get a patient signature) and get the signature when the need arises? Is it really that big of a deal to tell a patient the reason that we want to section them? At least then they will feel like somewhat of a participant in their birth. During a stat there are nearly always lots of hands to get the work done, is it really that hard to make getting a signature part of the work? We can get a baby out in 6 minutes at my hospital. I don't see that number being affected by the need for a signature as long as the patient was informed of the risks of a c/s in early labor.

Does refusing to sign a consent make a woman a bad mother- bad enough that her baby is taken away for 3 years? I don't think so. Heck, does having a home birth without even an OR around make a woman a bad mother? Hell no. This thinking is just part of the medicalized childbirth model that really needs to be changed.

Saturday, August 14, 2010

The down and dirty. Yeah, I'm going to say it. Poop.

I'm going to be direct, I'm going to be blunt, and I am going to sound like a nurse for a bit.

Poop. It happens. It happens everyday for all humans (hopefully!) and for all other creatures that walk or swim on this Earth. There's even a kids book about it Everyone Poops- I highly recommend this book btw for your kiddos. It helps with potty training and associated pooping on the potty anxiety.

So, why is pooping during birth such a big deal? It is really part of the natural physiology of birth. It is normal.

First, watch this animation of a vaginal birth. Recognize that something very important lies between the coccyx and that baby's head- the rectum.

As the baby's head descends, it literally squeezes out the poop from the rectum like you would squeeze toothpaste out of a tube. If there is poop there, it is coming out- it is just a mechanical thing!

Let alone when a mother is completely dilated! What is the simplest way to teach a first time mom to push out a baby? Let alone a mom with an epidural? Tell her to push just like she is pooping! Pushing out a baby and pushing out poop uses the exact same muscles. Of course, if you are using the same muscles that you use to poop with to push your baby out, there is the possibility that you may push some poop out as well. It is mechanical and normal. Heck, if I see a first timer moving poop, than I get excited! I know that she is pushing in the right spot! (Okay, I know that may sound weird to non-birth professional folks, but it is true). I am going to share one of my tricks here that other birth professionals may know. If a woman is pushing (usually a G1 here) and when I do a vaginal exam I can feel through the vaginal wall some hard stool, I will push that poop out by pushing down on the posterior wall of the vagina. This is for women with epidurals only. That hard stool can sometimes impede that baby's head as she is pushing if she is not able to push it out on her own. Soft stool just comes on it's own.

Let's talk about diarrhea during labor now. IF you go into labor on your own (this does not apply to induction) you may have loose stools for a day or two before labor begins as well as during labor itself. This is due to the release of the hormone prostaglandins which cause smooth muscle to contract. The uterus is made up of smooth muscle as are the bowel. Prostaglandins also serve the wonderful purpose of causing the cervix to soften so that it will open! If you are in active natural labor, than you may continue to have diarrhea throughout your labor. It is normal. It is your body doing what it is supposed to do to help your labor to happen. A lot of books say that "this is the body's way of cleaning out the bowels for the impending birth". They are just trying to make you think that the body is giving you a natural enema- which it kind of is, but having loose stools in early labor does not mean that you won't poop during pushing. There is a lot of feet of intestines there and there may be a lot of stool hiding.

What brought all of this up? Well, yesterday I had a patient that I was helping another nurse with. She was a G1P0 who came into triage booming in active labor. In triage she was 3cm/100/-1 and I got her into a room and got her an epidural (her choice). After she was comfortable the doc came in and checked her and AROM'ed her (this is a hospital people)- she was 6/100/0 at this point. Several hours later she was complaining of feeling a lot of pressure. I with a new LAD nurse checked her (the new nurse is checking behind me to learn the wonderful art of sterile vaginal exams). She had an AL (anterior lip)/100/+1. This was all done on her own- no pitocin. I noticed a large amount of watery stool upon this exam that the patient wasn't even aware of. I cleaned her up, and the new nurse wanted to see if the patient could push past the little lip of cervix since she was feeling a lot of pressure. I left the room to let the new nurse push her and as she pushed more stool came out, but apparently the father of the baby kept asking the mother if she had to go to the bathroom and looking really grossed out because of the poop. Now, we nurses cleaned her up. We removed the soiled chux and soiled linens from the room. He spoke Spanish and I came in and explained to him that it was his baby's head moving down that was causing the poop to push out and that his wife was doing wonderfully well. That this all was normal. I then told him that he needed to help her and tell her how beautiful she was as she birthed his baby. He looked properly chagrined and the patient seemed to like me chastising him, but she still looked embarrassed. I tried to reinforce how normal this was and praise her for doing so well, but I could tell that this would probably be something that she would remember in a negative light from this birth. I hate that.

If the idea of pooping during labor is something that you just can't handle than there are just two things that you can do. First, do NOT take Castor oil to help induce your labor. Castor oil induces labor by loosening the poop and causing the smooth muscle bowel walls to contract, the contracting of the bowels may or may not cause the uterus to contract as well. You will be having diarrhea all throughout labor if you take this. Also, taking castor oil really increases the chance that your baby will poop in utero (passing the first poop called meconium) and that is a complication that you really don't want. Second, if the poop grosses you out that much your only option is to give yourself a soap suds enema (available at any drugstore) during your early labor. It may actually speed up your labor and may keep the dreaded poop from appearing during pushing. Of course, enemas are uncomfortable and difficult to give to yourself.

What I would really hope is that you will embrace the poop as a normal part of birth. Realize that you are joining the billions of women throughout history that have pooped as they pushed their babies out. Get excited (just like us birth professional types) when the poop happens knowing that you are just that much closer to holding your baby in your arms. Educate family on the poop so that they know to expect it and how to treat you when it happens.

Everyone poops. Almost every woman poops during labor/pushing. It is NORMAL. Do not be afraid. The act of birthing a baby is a much more intimate and important event than someone just seeing you poop.

Tuesday, August 10, 2010

Breast, Bottle, or Both?

Breast, bottle, or both? Is what I am supposed to ask. A high percentage of my patients would choose "both". I don't ask that though. I ask Breast or Bottle? When the patient tells me that they want to bottle feed too, I have a long teaching moment about why it is so important to exclusively breastfeed in the hospital. There is a lot of educating my Latina moms as colostrum is not viewed as something good for the baby in most Latin cultures. There is a lot of encouraging them to "call for that pizza (aka breast milk)" every 2 hours by putting the baby to breast. There is a lot of explaining about how little a newborns stomach is (the size of a marble) and that they really don't need a huge bottle within the first 24 hours.

When I have a vaginal delivery, I always place the baby skin to skin. I always try to get that baby to latch on. I almost always call the nursery to see if I can keep the baby for longer than the hour that I am allotted to help mom to breastfeed.

Why is it that this is not the norm? I work with some awesome nurses. Really, I do. There are only a couple that wouldn't encourage a mother to breastfeed. There are a couple more that really don't care one way or the other. But, the majority really do give a shit.

I just wish our exclusive breastfeeding rates were better. Why do we even offer "both" as an option? I just don't get it.

Monday, August 9, 2010

Induced Labor May Double the Odds of a C-Section

The induction of first time moms really needs to be drastically reduced. According to this study, first time moms who had their labor induced doubled their chances of ending up in the OR. I see this cycle happen all of the time.
1) Induce a first time mom because she is at 41 weeks, or baby is estimated to be LGA, or for doctor's convenience (not so much at county though).

2) Round one of cervadil (12 hours). Potentially NPO during this phase if the nurse doesn't advocate to be able to feed the patient.

3) Round 2? of cervadil. Seriously, it happens.

4) A balloon (8 hours). Hopefully she is 4cm when we take the balloon out.

5) Pitocin.

6) More pitocin.

7) Pain and epidural. Break her water.

8) Now, she is chorio because we keep sticking our fingers and other things up her vagina. Antibiotics.

9) Internal monitors at some point.

10) Still NPO, for over 24 hours at this point. (and we wonder why the uterus doesn't want to work anymore)

11) Failure to progress (better), massive fetal decels (worse) and a trip to the OR. Another unnecessarian.

12) Honey, it wasn't your fault- it was ours.

This happens over and over. I hate it.

Wednesday, August 4, 2010

Gisele! Who woulda thunk it?

Color me shocked. Check this article out in the Huffington Post. Apparently, the supermodel Gisele gave birth to her son in a bathtub (where else would a baby be born? :D) and is now advocating breastfeeding! In an article in September's UK Harper's Bazaar, she states:

“Some people here [in the U.S.] think they don’t have to breastfeed, and I think ‘Are you going to give chemical food to your child when they are so little?’” the brainy beauty told the UK magazine. “I think there should be a worldwide law, in my opinion, that mothers should breastfeed their babies for six months.”

She backpedaled a bit in the Huffington Post article, but wow! I am impressed! Would it rock any boats to say that I AGREE with her?!?! Sure, not every mom can breastfeed, but MOST can. Sure, some babies are adopted, but there are great supplemental nursing systems out there. There is NO reason to not breastfeed your baby for at least 6 months.

Denying your baby breastmilk is just not right. The WHO agrees with Gisele and recommends breastfeeding until 2. The AAP even agrees with Gisele! Why is it so controversial that Gisele said this? Good for her for using her fame to support breastfeeding!

Long time, no post...

I know, I have been gone for a bit. A lot has been happening! I fractured my ankle (healing slowly), Bean had a birthday (5!), summer vacation, getting my house ready to sell, and OMG applying for grad school! W00t!

Lots of big news going on. ACOG has finally recommended VBAC after c/sections x2! Can you believe it? My jaw seriously hit the floor when I read this one! Does anyone on my unit know, or care? Heck no. Will this change my hospital? I don't know yet. I mentioned ACOG's new stance on VBAC's to my nurse manager and she wrote it down on her little notepad to talk with the medical director. My hospital is a pretty progressive one (in the area anyways) as we encourage women to VBAC after one c/section. I am really hoping that we will implement a new policy based on these recommendations. *fingers crossed*

Bean turned 5! He is my homebirth baby and somehow 5 just seemed like more of a milestone than 3 or 4. He will be starting kindergarten this fall. He is turning into a kid, no longer such a toddler. I really miss having a baby around, although if he had his way I would still be nursing him (he was weaned at 3) and carrying him in the sling (which I do, but man is he heavy now) all of the time. He is a mama's boy to the 9th degree! I am wondering now if I will have another baby, and that makes me sad. I am young enough, but with the dissolution of my marriage there are a lot of ducks that would need to get in a row for that to happen! *sniff* my baby is growing up!

Grad school! Is it really time for that already? I have been getting my applications together for several online midwifery programs: Frontier, Stony brook, and Univ of Cincinnati. There is a local DNP program, but I want the flexibility of an online program. As a single mom, childcare is hard to come by! Plus, I am really hopeful that I will be able to move back to my home state out West in the future. With an online program, I could continue my studies uninterrupted. Of course, there is always the issue of finding a preceptor, but I am hoping that my homebirth/ birthcenter connections will help with that. The local DNP program is lacking  out-of-hospital birth experience which is the PRIMARY reason that I am going to grad school! Why would I choose a program that will never let me see an out-of-hospital birth from a midwife's perspective? Some of the local midwives at my hospital have kind of looked down on the online programs, but they are right up there on US News and World Reports rankings of graduate midwifery programs. Frontier is 12th, Stony Brook is 28th, and Univ of Cinn is 29th! Is my local DNP program listed? Nope! The only brick and mortar school that I am interested in attending is UCSF, but that would require a BIG move and for me to be completely fluent in Spanish- which I am not yet. Anywhoo, wish me luck! There are a lot hoops to jump through to get these applications in.... Jumping through hoops is not my favorite thing in the world.

Along the education lines, I have been researching what I need to accomplish in the next year to sit for the IBLCE exam to become a lactation consultant.  I would be on Pathway one and really just need to complete a lactation course to receive my 45CEUs in lactation management. I am trying to figure out if my hospital is willing to shell out the $700 that one of these courses costs. I really hope so, because we have had 3 positions posted for L.C. in my unit for a long time. Clearly, we need more L.C.s but are they willing to pay for it?

The ankle... Le sigh. It is slowly healing. Management has finally seemed to understand that "light duty" really means I can't take care of patients. Lots and lots of paperwork though. I hate it. Really really hate it. I am so ready to labor patients again, but as long as I have to wear this boot I am stuck.

Random conversation overheard between two Attendings in the OR hallway.
Attending one: "You do circumcisions, right?"
Attending two: "Sure, the money is good."
Attending one: "I used to be so fast at them! But, then I realized that one thing that you shouldn't be fast with is a circumcision."

I really want to know the story behind that one. Poor little boys and their missing foreskins.

July. Do NOT ever, ever get sick or have a baby and go to county in July! July is when we have a whole new batch of 1st year docs start, the 3rd years become 4th years, and everything is discombobulated. July is also the start of LAD's busiest time of year. In LAD, you always need to think about what was going on 9 months ago. Well, 9 months ago the holiday season was starting, it was starting to get cold, and people were making babies!  I am dreading September and October of this year because we were snowed in so much this last winter! Holey moley, the babies are raining down! It doesn't help that we are really short nurses (not just me, but many others too). Just craziness everywhere. We did over 650 births at my hospital in July! I was out much of July completely because of my ankle, and now being back light duty it is really hard to not jump in and help.

Too random? Too much? Hopefully I will actually manage to post more than once a month now!

Tuesday, June 29, 2010


I just want to fold this guy up and carry him around in my pocket. 

Eugene R. Declercq, PhD, Professor of Maternal and Child Health, Boston University School of Public Health, presents the black and white about mortality rates in the United States.


Monday, June 14, 2010

Quote from another nurse...

"The difference between midwives and doctors is that doctors will blow up your vagina and midwives keep it together."

Isn't that the freaking truth.

Friday, June 11, 2010

I just don't trust em.

My hospital is a teaching hospital which means that we take baby docs and turn them into real docs. Of course, we have a 4 year OB/Gyn program, but my hospital also has a Family Practice program that rotates through OB. You see, if the FP is in a rural area they need to be able to deliver babies if there isn't an OB around- or so they say. My issue is that I have over and over seen the FP docs make dumb errors. Not all of them, some are actually pretty good, but enough errors that I get concerned. For example:

1) A little G1P0 that I pushed to beautifully crowning. Her perineum was generously lubed with mineral oil and I kept my fingers out of her vagina while she was pushing to prevent swelling and tissue injury. The FP doc comes in for delivery (baby is at +3 station when I call for a doc) and she delivers in 2 pushes. I am telling her to breathe, to push just a little, while they are yelling at her to push HARDER and counting to 10. I can SEE her perineum split because there is not a hand there supporting it. 3rd degree repair that this inexperienced doctor sewed up with staff looking over her shoulder. It's just not right.
2) How about the FP that missed the vagina all together and stuck his fingers up her rectum for a vaginal exam. It gets worse, but trust me you really don't want to know.
3) How about the FPs coming into my room while I am pushing my patient. Repeatedly. Seriously, stay the heck out of my room until I call for you. It makes the pt nervous to have people trooping in and out. I will call you when I need you and not a minute before.
4) Baby deceling and an FP not being able to put a scalp electrode on. Move out of the freaking way and let a nurse do it.
5) An FP nicking a bladder during a c/s or a freaking artery. OB is a SURGICAL specialty. Just because you have MD or DO after your name doesn't mean that you should be operating on people.
6) I swear the FP's want to have surgical vaginal deliveries- just so that they can practice. It feels like nearly every FP delivery they are asking for a freaking vacuum.
7) First year FP docs acting snotty towards me. Yeah, I may be a newer nurse but I know what I'm talking about when it comes to birth. Shut the heck up and learn something.
8) First year FP that breaks my baby's clavicle because she pulled up before the anterior shoulder delivered.
9) Grinding their thumb on a pt's clitoris during a vaginal exam. She doesn't have an epidural, watch your freaking thumb.
10) Taking pt after pt that is a high risk patient. Really, you don't need the PIH'er, chronic hypertensive, A2diabetic. Seriously, send that lady to an OB.

There is more, but really I think that you all get the idea. I hate it. I am pro midwives and would never go to an OB/Gyn unless I was high risk for some reason, but at least I know that they won't make some of these really irritating and harmful mistakes.

Now, one good thing.
1) There is one FP doc that ALWAYS writes for a liquid diet (instead of strict NPO) and for the pt to ambulate PRN. I appreciate that. He says that the research supports it, and it does. But this really is the only good thing that I can say about them.

I am NOT anti-FP docs. Heck, the primary doctor for my family is a FP DO, but I don't think that they should be delivering babies. OR, if they are going to deliver babies, they should have the same kind of constraints as CNM's and limit their practice to normal pregnancy and birth. Surgical deliveries, vaginal or otherwise should be moved to an OB, high risk pregnancies should be moved to an OB. And thats all I have to say about that.

Wednesday, June 2, 2010


A friend just told me that her fiancee makes 100k a year (actually she is my bff). He is an AC repairman....
Holy shite! I went to school for how many years? Expose myself to how many pathogens? Have literally saved how many lives?

I probably won't even make that with a freaking DNP.

Don't get me wrong. The last thing that I would want to do with my life is climb through attics in the middle of summer. My exhusband has a job that keeps him in attics and on ladders. Lord knows that is not for me. I just feel that what I do is as specialized and valuable to society as the work of an AC repairman (bless him).

Is it because nursing is still mostly women? The dichotomy between physician salaries and APN's salaries would support that. Of course, full time for me is only 36 hours a week- just three 12 hour shifts....

The feminazi in me is all bristling now. Am I overreacting?

A nice birth...

I walked in yesterday morning to my patient pushing. I always hate to have shift change in the middle of a delivery. Really, this is the thing that I hate the most out of my job in comparison with my life as a doula. As a doula, I was with my client from the time that she thought that she was in labor until many hours postpartum. But, I will admit that if it is the end of a 12 hour shift for me and I know that I have to come in the next morning, I leave if birth is not imminent.

This patient was a 19yo G1 who was being induced for PIH. After a very long induction (cervadil, followed by another cervadil, followed by a balloon, now on 34{!}mu of pitocin). She was also on magnesium sulfate for her B/P. We use Mag for two things in LAD 1) to lower high B/P in someone with PIH and 2) to stop preterm labor. Mag is a smooth muscle relaxer, the vascular system is made of smooth muscle (thus the lowering of B/P) as is the uterus (thus the stopping of contractions in a pretermer). Induction of someone on Mag for PIH is very difficult. It is a dance between having the Mag at a therapeutic level, watching the fluid ins and outs, and having the pitocin at a high enough level that the contractions are adequate to dilate a cervix which may not be ready. I was relieved though to see this little G1 push the baby to +2 with each push! Baby was sucked right back up in between ctx though. She had come a long way by this point, truly against all odds.

Her night nurse was one of my favorite nurses and her care throughout the night was perfect. I did notice a little laceration just with her pushing effort (without my hand in her vagina at all) and proceeded to lube her up with mineral oil. I kept my hands out of her vagina for pushing as she was pushing in just the right spot. I suggested that she reach down and touch the head, she did! She ASKED me for a mirror to watch the birth! She kept pushing and 46 minutes after shift change delivered a beautiful little boy! `He did great btw. After the NI nurses were done with him, I put him immediately skin to skin with mom. She was still in repair. She ended up with a 3rd degree lac which honestly, I was kind of expecting.

She really impressed me. She was adamant about breastfeeding right away, did not want baby to have a bottle at all in the hospital, initially wanted circumcision, but started to question that decision after I told them that circumcision was not recommended by the AAP. She and the FOB were just so open to suggestions. It isn't very often that I have a patient who is so informed at 19 and so open to the process.

One great thing about a patient with PIH is that I get to keep them after they deliver. They stay on L&D on Mag for 24 hours after delivery, which meant that I had her and her family all day. Even in her "Mag'ed out" state (Mag makes women loopey and out of it, like they have the flu) she was still watching the clock to make sure that she nursed her baby every one and half to two hours. Her family was really helpful with the care of the baby.

I had another delivery in my other room later that afternoon. A lovely multip easy birth, but the one that will stick with me was my little G1.

Skin to Skin after a C-Section

Truthfully, one of the things that I hate most about c/sections at my hospital is that skin to skin doesn't happen until women are many hours postpartum. Sure, we chart "skin to skin with mother" and "skin to skin with significant other", but that is basically only saying that they were able to touch the only exposed part of the baby- the face. Should that even be charted? Heck no. I was trained to chart it, but as I am learning about what kind of nurse that I want to be, I am only charting it if they are truly put skin to skin- which never happens in the OR. I saw this link at Woman to Woman Childbirth Education that showed a baby put skin to skin IN THE OR and BREASTFEEDING! Check it out...

A lot of great breastfeeding information as well. But, really HOW can I make this happen at my hospital? I would love it if the babies could go to recovery with the moms instead of being wheeled off to the nursery. I would love it if babies could be skin to skin in the OR. Of course, all of this only if baby is doing well.

Thursday, May 27, 2010

Random Compliment from an EMT

EMS and the PoPo's brought in a pregnant lady who was picked up for a drunken disorderly to my OBT. This was FIRST THING IN THE MORNING- like 7am? Seriously? You're wasted already? She reeked of alcohol and beer. She couldn't coherently answer any questions, about how far along she was, about whether or not her water had broken (her chux and pants were soaked), about ANYTHING. I was trying to assess her, and I couldn't figure out if that was amniotic fluid on the pad or urine, so I leaned over and sniffed it. Yes, I really smelled it. The EMT looked at me with saucer sized eyes and said (off to the side away from the patient), "I cannot believe that you just smelled that crack whore's chux! You are hardcore!" I said, "I'm a (insert name of hospital here) Labor and Delivery Nurse. Damn straight I'm hardcore."

It was urine btw. Eeew. The things I do for babies.

Teenage Pregnancy

I have seen many many teenage mothers deliver at this point. The youngest patient that I have had was 12. You read that right. Unfortunately, I have become a pro at navigating through the Child Protective Service reporting system.

I took care of a 15yo this week (the FOB was 23) and after talking about it with a couple of my friends I realize that my take on sex education of kids is probably pretty different than the norm. A lot of my friends with kids the same ages as mine, haven't even started the sex discussions yet. My feeling is that it should be an ongoing conversation, not a one time lecture.

My daughter Little Miss is 8 going on 9, the sex ed conversation probably began about 5 years ago. Seriously. Early conversations involved the homebirth of her little brother Bean. I wanted her to be there for the delivery, so I worked really hard to prepare her for the sights and sounds of birth. We read books, watched birth videos, and howled together (birth noises). My best friend was her caregiver during my labor. They made a birthday cake for Bean and watched movies. Heck I even have a picture of Little Miss in the big birth tub with me rubbing my back (my sweet little doula)! She was brought into the bedroom right at delivery. She talks about it now, but I am not sure if she really remembers or just remembers the pictures.

She has always been interested in my tampons and pads, in menstruation, and recently has been asking about body hair. I have explained the basics of sex to her in very simple terms. I have explained that her private parts are hers and no one else is to touch them. She seems to get it. She hates me talking about sex now though. She seems annoyed, but she is informed!

So now back to my 15yo patient. The conversation went like this:

Me: How old was she when she got pregnant?
Her: 14
Me: What grade is that?
Her: (lots of calculating) 8th? She is still in a grade?
Me: Yes, but I think that she is 9th now. She was in 8th when she got pregnant though. How many more grades is that than you?
Her: 6
Me: Wow, that's not much. Do you think that you could take care of a baby and still go to school everyday?
Her: I dunno (eye roll).
Me: I think that she is going to have a really hard time. Taking care of a baby is really hard. They have to be fed every 2 hours (even during the night), they cry, they need diaper changes, and constant attention. That is pretty hard work don't you think?
Her: Yeah, it does sound hard. Why would she want a baby now?
Me: I don't think that she chose to have a baby, I think that she got pregnant by accident.
Her: Wow. What are we having for dinner?

And that was the end of that conversation! This really wasn't a "sex talk", but it was part of the ongoing sex education. Sex education is about more than the mechanics of the sex act and pregnancy. Sex education IMO is about 3 simple things:
1) Respecting yourself and your potential partner
2) Respecting the responsibility of having sex
3) Respecting the responsibility that comes with parenting
 If I can get those 3 key things through to my kiddos, than I will feel like I have succeeded!

Now Bean on the other hand.... Well, the little stinker totally shocked me today. Out of the blue he told me that was going to marry Natalie (a little girl at his preschool) and that he was going to put a baby in her tummy because she didn't have a baby yet and she needed one. Oh. My. Goodness. DEEP BREATHS! He is only 4! At least he knows where babies come from? Right? He knew that babies came from a girl's tummy because of my belly cast from my pregnancy with him, let alone hearing his mother talk about birth all of the time... However, I didn't know that he knew yet that boys put the babies in the girls tummies. Le sigh. I think that it is time to start the conversation with him!

They aren't teenagers yet. That is a whole 'nother type of conversation, but I already have plans. I have LOTS of medical textbooks with LOTS of graphic pictures of all kinds of STD's. By that time I will be a midwife and I will have access to EVERY BIRTH CONTROL DEVICE KNOWN TO MAN. And of course I will have a condom stash somewhere in the house that they will know about. Do I want them to have sex as teenagers? Heck no! But, IF they do I want them to be safe and responsible.  I want them to respect themselves and their partner. I want it to be a conscious decision- not a spur of the moment impulse decision. I want them to realize that they have a choice.

Wednesday, May 26, 2010

Can a woman deliver a 10lb baby vaginally?

You betcha. A 4 foot 9 inch grandmultip being induced for A1DM, just a whiff of pit (2 hours) and a butter birth of a 10lb 3oz boy into the waiting hands of her nurse. The doc was fumbling with gloves, for some reason he thought that an unmedicated grandmultip could just not push while he gowned and gloved. Even while the nurse is telling him "just gloves!". (insert ginormous eye roll here)

Intact perineum btw. Thank you. Thank you very much. :)

Friday, May 21, 2010


It is an aspect of Labor and Delivery that isn't talked about. Miscarriage and fetal demise. There are tons of women out there who have experienced miscarriage, it is more common than we realize. For some reason, it isn't talked about. The only people who ever ask how many times that you have been pregnant are health care workers. Everyone else always asks how many kids you have. For those that have experienced a fetal loss, there is always the thought of that child that is somehow not counted, not talked about, but that you can never forget.

I have been spending a lot of time at work organizing all of our bereavement supplies. We have knitted hats, lovely sewn outfits, blankets, memory boxes, and lots of handouts to give our patients. I know that I try really hard to do my very best work when I am taking care of a mother who has a demise. Labor is an unforgettable event as it is, but when you add grief to it everything that happens to you stands out in stark contrast. What I have realized, is that my training as a doula is what has best served me in nursing to help someone die while feeling comforted (a nursing school experience) and to help a family experience the loss of a baby.

It is more than being nice or being respectful. It is being present, and being a witness. It is holding hands, while normalizing the process. It is doing everything possible to make memories for that family to keep. I take lots of pictures, make tons of hand prints/ footprints, take a lock of hair from the baby, the family keeps the baby with them as long as they wish, and I always call pastoral care. It is comforting and praying with the family. Honestly, it is the hardest thing that I do.

I have taken care of all kinds of demises at this point. 12 week miscarriages to 38 week demises for no known cause. Babies with multiple anomalies that lived for hours after birth to babies that died in utero a week before delivery. What people need to realize is that it is all the same. That 12 weeker will be just as missed as the term baby. That mother will cry just as much, will hurt just as much, and still needs just as much support. The family will feel confused, will be scared, and will need as much help as you can give.

I've used the word "miscarriage" here, but I have  to admit that I hate it. It implies that somehow the mother did something wrong, that she didn't carry the baby properly. I don't even really like the word "loss". It is like they left the baby somewhere- like they lost it. In medicine we use the term spontaneous abortion, but the word abortion has so many other negative connotations in our society. What it is, the word that you can and should use is "death". It is a death and it should be treated accordingly. Using the word death absolves the mother from blame, whereas every other word implies somehow that she did something wrong.  I say immediately, "I am so sorry" shortly followed by "this is not your fault, you did nothing wrong". I leave it at that, I answer questions if asked, but I really try to avoid using the above words.

I wanted to post this so that maybe if you have experienced a demise, you would know that you are not alone. That if your friend, or sister, or client has a demise you would know how to act.

Tuesday, May 18, 2010


I know that I spend a lot of time complaining about my job, but one of the best things about my hospital is that we encourage vbacs for those women who have only had one c-section. Two c/s's though? Well, you are SOL.

Yesterday we had two great vbacs! One was a woman who came in in an active labor pattern. She was already 6cm on admit, within an hour and twenty minutes she was pushing! No time for an epidural (yes she wanted one), her labs weren't even back. She had a vaginal delivery, but it was completely bungled by the resident. He allowed her vagina to explode (descriptive right?) And practically exsanguinated the baby with how he cut the cord. Baby ended up needing an IV bolus, but perked up after that. She had her vaginal birth, but her vagina is going to be very sore for a long time. Her c/s was for breech presentation btw.

The second vbac'er came in contracting, but barely. I do not know why she had her first section as she was not my patient. She did have borderline high blood pressure which was part of the reasoning in putting her on low dose pitocin (yes we pit vbacs) and her contractions were adequate (as determined via IUPC) at a mere 4mu of pitocin. She delivered vaginally too! I don't know the specifics of her birth, but I am happy that she was able to deliver vaginally.

I have to wonder though why the only hospitals in the area that allow vbacs are teaching hospitals? These doctors are taught how to manage a vbac, yet when they create a private practice they refuse to do it for fear if litigation?! Really? (Ginormous eye roll inserted here). The research supports vbac, docs are trained in it, and it is still so difficult for a woman to get one in the private world.

One of my favorite kind of births (hospital anywhoo) are when I get to be the nurse to a vbac'er. Honestly though, most of my patients don't seem as thrilled about it as I do. I wonder how many of them realize how rare it is to get an opportunity to vbac at a hospital- let alone having the hospital encourage them to vbac. As I am grinning ear to ear and telling them how amazing they are they look at me like I am a crazy lady. Well, maybe I am the crazy birth lady :).

Sunday, May 16, 2010

The beauty of extended breastfeeding....

My daughter breastfeed until 2 1/2, my son Bean nursed until he was almost 3. He is 4 almost 5 now and yesterday as he was snuggled up on my lap while we were sitting on the couch reading a book, his hand was ever so slightly resting on my breast. He said out of the blue, "Mama when I was a baby I drank milk from your boobies" while kind of giggling and pulling on one cheek like he does when he is nervous, embarrassed, or knows that he is being cute. I said "yes you did- do you remember it?" He emphatically said "Yes! It was better than the milk in the fridge!" We talked a little more about breastfeeding and all of the good that it did him. He seemed satisfied with the conversation and put his head back on my shoulder so that we could finish the story.. :) I love my munchkin!

Monday, May 10, 2010

Mother's Day!

If I couldn't be with the munchkins on Mother's Day I was so happy to be at work. I didn't have any births, I had a postpartum mother on MagSulfate and an induction, but my pod partner had a good birth. A first time mom who was PROM'ed for days (and in our high risk antepartum unit) was induced at 34 weeks. She went from 1 to 10 in 3 hours! Talk about surprised! Everything went just fine though, quick easy birth. Baby did very well, but still went to NICU because s/he was so small.

Saturday, May 8, 2010

Day as Circulator... Happy Nurses Week everyone!

I was not super thrilled to find out that I was circulating yesterday. I was missing laboring patients! It had been a few weeks since I had a day with a couple of nice births. BUT, I had a GREAT day as circulator!

First case was a primary section of a 5/3 for transverse lie. She was SROM'ed and that baby's head was stuck up in her rib cage. The CNM tried to see if the baby could be versioned, but no luck (probably because of too little fluid). Off to the OR, and shortly thereafter a beautiful baby. Mom seemed okay with everything. She understood the need for a section and understood that she could have a VBAC with her next pregnancy (at my hospital anyhow) if she liked.

Second case was a scheduled section. This would be her 3rd section and her previous two sections were done overseas and both had negative outcomes. I was really hopeful that she would be able to be awake for this birth (for the first time) and that she would be very happy with the outcome. Unfortunately, her spinal was placed by a RRNA ( a student nurse anesthetist) and it was not a good one. Was it the student's fault or just a failed spinal? I really don't know. Anesthesia had to basically put her into a twilight sleep for the birth because she felt a lot of pressure when her muscles were moved (but not when the doc was doing the incision). I didn't get a chance to talk to her in PACU once she was more alert, but I was sad that her experience was not the excellent one that I had hoped for.

Third case was a twin vaginal delivery! Yes, we take all of our twins back to the OR (eye roll). She was a gravida one with PIH who was being induced at 30 weeks. She had received two doses of betamethasone (for fetal lung development) and MULTIPLE doses of antibiotics because she was chorio at this point. She was also morbidly obese and we were very worried about having to move her to the OR table if something went wrong. The big issue (according to my hospital) with twin deliveries is that the second baby can prolapse a cord... Bleh. Guess what? She ROCKED! She pushed that first baby out with no problem, second baby was born a mere 16 minutes later! Both babies ended up in NICU, but with everything said and done this was a fantastic outcome of a not so favorable situation.

Fourth case (some tired feet at this point), was a section of a 35 weeker for severe PIH. Sitting that mom up for her spinal I saw multiple blood pressures of 200+/ 115+. I was ready for her to seize. Seriously. This baby was as little as my 30 week twins earlier. So little in fact that the NICU nurses rolled a scale into the OR to see if s/he was big enough to even go to the newborn nursery, which s/he was not. Another baby to NICU. Sigh. At least I was keeping the NI nurses in a job.

I work tomorrow and cannot wait to see what Mother's Day will bring. I am sad to be away from my kidlets on Mother's Day, but helping other mothers makes the separation bearable :).

Monday, May 3, 2010

Amnesty International Report on Maternal Health in the US

"The likelihood of a woman's dying in childbirth in the U.S. is five times as great as in Greece, four times as great as in Germany and three times as great as in Spain. Every day in the U.S., more than two women die of pregnancy-related causes, with the maternal mortality ratio doubling from 6.6 deaths per 100,000 births in 1987 to 13.3 deaths per 100,000 births in 2006."

Catching Baby

Yesterday I heard the yoodle of a push and ran into my patient's room. I threw back the covers to see a head! Quickly I put on gloves and caught the baby's body. Mama had a 2 degree tear (probably from that head coming barreling out without a helper there to slow it down), but baby was perfectly fine with 9/9 apgars. She was unmedicated and I had a gut instinct that she was getting ready to deliver 10 min earlier when I was in the room, but I didn't check her because my other patient (an induction for ancephaly) was up to the bathroom. Big mistake!I had just checked her within the last hour and she was 4-5, but paper thin. I knew that she was going to go fast. Looking back on the strip, I had one minute where I lost the baby's heartbeat. Was the baby's head out for that whole minute? I really don't know and that bothers me.

This is a perfect example of why I hate that my hospital does not follow AWHONN standards concerning nurse/patient ration. AWHONN states that all fetal demises should be one on one, that women in the active labor stage and beyond should be one on one. So clearly, there should of been two of me to take care of these two patients.

One of the things that I love about out-of-hospital birth is that your midwife is there with you. In the hospital, you really just have the monitor with you during your labor and a nurse that comes and goes. 

Btw, baby was 8lbs 3oz :). Cute little guy.

Friday, April 16, 2010

Intermediate Fetal Monitoring

AWHONN is the primary source of evidence based practice information that Women's Health nurses use. In another post I will go over all of the ways that my hospital does not follow AWHONN guidelines in our practice, but for now I would like to chit chat for a minute about Fetal Monitoring.

I just went through a 2 day long Intermediate Fetal Monitoring course and there are so many things to discuss...

First, I was struck by how over and over we were looking a strip with the baby's heartbeat in the gutter when the pertinent information given about the patient was she "just had an epidural". Seriously, over and over. Post epidural women can have a tendency to become hypotensive because the medications often used in the epidural causes vasodilation of all of the blood vessels. When mom's blood pressure drops her body automatically shunts all of her blood to HER vital organs, namely her heart and lungs and in the process stops sending the oxygenated maternal blood to the placenta. Baby's heartrate will drop correspondingly. The hypotension can often be corrected by bolusing the mother with lots of IV fluids, calling anesthesia to give ephedrine (to increase her blood pressure), giving her oxygen so that her blood is now super saturated with O2 and thereby baby gets more, and repositioning her for optimal blood flow to the baby. BUT (and here is the clincher), those things don't always work. There are times where baby can never recover after the post-epidural hypotension and the patient ends up stat'ing back to the OR. Even if baby does recover, we have almost always just stressed that baby right out into passing meconium and into a NICU attended delivery where baby can't be placed directly on mom's belly.

I was so surprised that AWHONN recognized this, but I was shocked as I looked around the room at my coworkers and they just didn't get it. Really? Are you so pro-epidural that you can't admit that sometimes it causes an emergency c-section? That it sometimes causes prolonged fetal hypoxia? That it sometimes causes babies to stress out right back to the OR? Aaarrgghh!

I was looking around the room excitedly, hoping to see someone's "holy shite I get it now" expressions. And nothing. I really try not to preach at people at work. I like my job and I like my coworkers. I just don't understand how they just don't seem to connect the dots and make the decision to be the best supporters of natural childbirth that they can be.

All of that said, I am not entirely anti-epidural. With pitocin, with c-sections, with prolonged first babies, it is a really useful intervention. I also recognize that at a busy county hospital most of our patients get pitocin, artificial rupture of membranes, and are stuck in bed for the length of their labors. Le sigh. I can see the changes that need to happen, but I have no idea how to make that possible.

One other thing about this fetal monitoring course... Who knew that doctors aren't required to take any fetal monitoring courses? They make decisions for care based on a baby's strip and yet they have never had any formal training on it. They learned from the resident the year before them, who learned from the resident the year before them, and so on back for decades. Do they have knowledge of the latest information in fetal monitoring? I think NOT. If so, we would be able to intermittently monitor most of our patients, women would be allowed to walk during labor, and their interventions would decrease. They have to take CPR and NRP, why not fetal monitoring? I think that if the course was taught by ACOG and not by AWHONN, they would be on board. They just don't want to learn beside nurses and from nurses.

First Post!

As I am new to the blogging world, please bear with me here! This blog started because of my complaining about yet another crappy birth at the large county hospital that I work at as a L&D RN. I got a suggestion from a friend (as I was bitching away) that I needed to find an outlet for "all of this negativity" as she gestured to all of me with a wave of her balanced unangsty hand. Um, okay she might be right. I have always been a journaler, but to move into blogging from journaling was a way to say to the world, "SEE, this is what REALLY happens" and maybe along the way to change things a bit.

I love birth. LOVE IT. I have a hunger deep in my spirit to be carried along on the high of a laboring woman and to feel the clap of magic as a new soul enters the room. I have two muchkins Little Miss who is 8 and Bean who is 4. Little Miss was born at a large birth center with a CNM, and surprisingly I had a terrible experience with her birth. I had a long labor with little support from my midwife. After she was born, I became a doula because I didn't want other women to feel unsupported. After attending births for several years, I started to get hungry to do MORE. To have more autonomy, to have more skills, to help fix the bad outcomes that I had observed as a doula. Along the way, I had Bean in a beautiful homebirth filled with midwives and doulas that I loved. It was empowering and wonderful. When Bean was 18 months old, I started nursing school to get my Bachelors in Nursing. Now, I am nearly a year out of school and am working in a very large county teaching hospital. I would love to be a midwife, but my kiddos need to get a bit older before I can go back to school.

All names and identifying information have been changed and/or omitted in this blog. HIPAA is not being violated.