I'm back...

So, I have been seriously neglecting my little blog for months, but I'm back. I really need to start writing this stuff down so I don't forget everything. A lot has happened since I wrote last. I graduated nursing school and started working in a L&D department of a hospital I said I would never work in (never say never). Anyhow, I am through my orientation and I have seen so many absolutely crazy things that I could never possibly list them all here. But, I will start to write more. One thing I know for sure-- I cannot stay in this job long. I just need to get some experience and get the hell out. I don't want any of this to sink in and I don't want to pick up lots of bad habits and I'm sure that I am already acquiring a few.

Whose birth is it anyway?

Everyone has their limit. Each person will feel differently about pushing themselves to their absolute extreme-- it depends on their motivations, their past, and their beliefs. For example, I would do anything to avoid a c-section. And the only reason I would have an epidural is for a c-section. Some do not feel so strongly and pushing for 5 hours is more traumatic than a natural birth is worth. I think midwives should figure this out long before the birth to really understand their client goals.

I attended a birth last night that was a train wreck and ended in a transfer (finally). It started so well, mom coped great with dilating and made it to "complete" pretty fast. But, this is where things started going down-hill. Having an out-of-hospital birth for this mom was stepping pretty far outside of her mainstream life and I could sense that she was not very sure of her strength or very trusting of her body. She questioned everything that was happening. "What should I do... I'm not doing this right... Should I push..." etc. The last time the midwife checked her she was about 6 cm. I would guess by her reactions that she was now about 8 or 9 cm. The midwife says "follow your body," and "you can try pushing with the contractions." Do those two statements belong in the same sentence? I don't think so.

If someone is questioning whether or not to push, I feel that generally they are too much in their head. I would tell them to follow their body and not to worry because there may be a point when they will know without a doubt that they have to push and if they never feel that way that is OK too because your strong uterus will be pushing with or without your conscious effort. Every time I have heard a midwife throw out "you can push if you want" when the mom is not really in-tune with their body the mom begins to push because she thinks that is what she is supposed to be doing. And then it seems like I see a lot of swollen anterior lips or babies that don't come down after hours and hours of pushing-- like this mom. 5 hours of pushing for this poor mom and then a trip to the hospital in a state of pure exhaustion. In cases like this I think an earlier transfer would be called for. It would be good to ride in the car, be admitted, wait for the OB, be examined, get an epidural, etc. before a woman hits the point of exhaustion and apathy. Being in labor for hours, with no sleep, then pushing forever, and then ending up with a c-section... That would be awful. It would be hard to welcome that baby at that point.

And the worst part of the entire night happened at the very end. The midwife tried one last ditch effort to turn this now OP baby. It was torture for the mother who eventually was crying and saying "no, no, no, no, I can't do this, stop, I want to go to the hospital..." Why do this? That is just flat out abusive. What was this midwife trying to do-- cover her own ass by avoiding the hospital at this point more for her own reputation than for the sake of the client? Whose birth is this? Who gets to decide when enough is enough! Is a natural, out-of-hospital birth always the die-hard goal regardless of feelings or client wishes?

Compassion...

In clinical recently I had an experience that made me question (again) if I could ever work in the hospital as a L&D nurse. My preceptor and I started our day with a couple in very early labor. In fact, they probably wouldn't even be at the hospital, but the mother had SROM early that morning and was GBS positive. Per the hospital protocol, a GBS+ mother has IV antibiotics every 4 hours in labor. It’s unfortunate that primips are told to come in right away because usually with a primip you have plenty of time to get in a round of antibiotics before the birth even if they stay home until they are in active labor. Any time you come in early to the hospital your labor will be fucked with-- that you can count on. If you decide you want a hospital birth, my advice to you is to go to the hospital when you are cookin' with gas, check your own cervix before you go in. It blows my mind that people go in, scared they will be sent home (which they pretty much never do so don't worry about that) when they could check their own cervix-- its your cervix dammit!!!!

I spoke with the couple while working on their admission paperwork and they told me they were interested in having a natural birth. The mother stated she was having some back pain, so I asked my preceptor if we could take off the monitor for awhile so the mother could move around. Of course this is never something a nurse would offer, someone would have to insist on it and they only way the will take it off is if everything is going perfect so far and there are no interventions yet.

These parents seemed unable to cope with contractions and did not seem prepared with any coping strategies. I am not suprised as I sat through the birth class offered at the hospital and its absolutely ridiculous. I made some suggestions about positions, but it seemed to me that they were not confident in there abilities, nor did the mother seem able to follow her body through the contractions. The nurse suggested getting out of bed and put a chux on the chair and said "you can sit there." Well, you may as well be strapped to the monitor because sitting up in a chair is not going to do any good! This is where a good child birth class can be very helpful, so parents have tools they feel confident in to deal with pain. This poor woman was fighting every contraction, hyperventilating, curling her toes and trying to stay in control. Its so sad, I feel there is nothing I can do at this point.

Eventually the mother took some Stadol and slept for awhile. The husband thought this would be a good time to run home to take care of their dogs. He probably did not understand the importance of his presence as my nurse and I did not spend much time doing labor support. Why that is, I don't know. We only had one patient! We could have sat in the room doing charting or been a little more encouraging, but basically nurses stay in the nurses station until 2nd stage.

The Stadol began wearing off and the doctor told us to start Pitocin at 2 by 4 every 30 minutes. I overheard the medical resident state that this order was “obnoxious.” I was glad somebody thought that was ridiculous. It makes me laugh when I see these fat, old OBs; give me a break, why are you doing this work?! You don't give a shit about women or birth or babies! This doc is the same one that nurses can tell when he checks someone when they are in the hall because women scream. Really nice... why isn't he confronted about that? That's assualt if you ask me. The whole thing is just disgusting.

This protocol was very intense for the mother and it was obvious that no one could have a natural birth with that level of Pitocin. She appeared to be in a great deal of pain and will probably not remember that day fondly even though its supposed to be one of the happiest days of a woman’s life. I have seen many natural births, but I have rarely seen anyone in this much pain especially so early in the dilation phase of labor (2-3 cm). I mean, this woman was suffering. This wasn't "pain with a purpose" this was inflicting an unnatural level of pain that the body would not be able to create on its own. The contractions were every 2-3 min. lasting 60-90 seconds and they were beyond intense, they were torture. She was grabbing the bed, holding her breath, trying to escape the pain. She was sobbing. It was horrible. And then we left the room. We went to the nurses station and paged the anesthesiologist as there is no other option at that point. I could here her sobbing and screaming from the nurses station and she was all alone. I should have stood up to my nurse and said I'm going to stay in there with her until her husband comes back, but it just didn't feel like an option. When I have stepped up and done that in the past nurses get offended like I am overstepping my bounds as a student.

My nurse and I switched to postpartum and last I had heard our patient had not progressed much past 3 centimeters dilation and the baby was beginning to have decels. Some of the nurses were calling her a c-section early in the day and that prophecy looked to be self-fulfilling. It is so unfortunate that she would probably be an “emergency” c-section for fetal distress that the doctor most likely caused by his aggressive labor management. And then they will say "thank you, thank you doctor for saving our baby."

I find the level of compassion in the physicians, nurses, and residents to be disheartening. My preceptor and I sat in the nurses’ station and paged the anesthesiologist to get an epidural right away as this seems to be the only option at this point. I don’t know if turning the Pitocin down is an option. The resident sitting in the nurses’ station seemed concerned about our patient and I said to her “it’s pretty intense and her husband isn’t here right now, he had to run home.” She turned to me and said “so,” in a way that made me think that she had never experienced pain like that, nor did she have any empathy. Compassion and empathy are very valuable qualities to have in health care providers and these skills seems undervalued in comparison to technical skills or getting a patient “delivered” as fast as possible. What happened to the nurse being the patient advocate!

I could not agree to such a high dosage of Pitocin causing more pain for the patient and more risk. If a patient has some negative consequences from the oxytocin management who is to blame, the doctor that ordered it or the nurse that carried the order out? In school it seems that we have learned we always have to double check what a doctor orders because if we give what they order and its incorrect then our license is on the line. As a nurse I wonder if you are able to question or disagree with a doctor. These are all questions I would have to answer before becoming a labor and delivery nurse.

Patient Abuse...

There was an incidence at my clinical the other day that just made me want to quit and get out of this clinical rotation stat! Here's a little synopsis of what happened:

My preceptor and I had a patient, I will call Jane, that the nurses had labeled “a pain.” She is 19 years old and a first time mother. She was married to an older man, which was also pointed out by many of the nurses, and this new family was in a lower socioeconomic status. I wouldn’t normally point out the socioeconomic status except for the fact that it seems to make a difference in the care received and the rights a patient may have.

My preceptor and I were walking down the hall to the postpartum area when this women, whom I perceived to be a nurse (from her demeanor and attire), came walking past us talking very loudly and was obviously upset. “I can’t believe this girl! I can’t believe she is going to refuse these blood tests; it’s ridiculous that she would do this to her baby! I swear if she doesn’t let us take her blood, I’m calling child protection services because this is crazy!” The patient that she was upset about was our patient for the day, Jane. Then we heard the story from the other nurses on the floor. Jane did not have much prenatal care and refused many of the standard blood draws done in pregnancy including blood typing, most likely because of her self-stated fear of needles and I think because of her being young and not understanding the implications of testing. As a result, her health care team did not know her Rh status. Blood typing will alert staff if a mother is Rh negative. If the baby is Rh positive then there are risks for future pregnancies and infants as the mothers’ body can produce antibodies against the baby.

My preceptor and I entered Jane’s room to discuss the testing with her. The nurse stood at the end of the bed to address the patient lying in bed and I sat down next to Jane. My preceptor proceeded to use scare tactics and to threaten the patient to submitting to the test. The nurse spoke in an authoritative and condescending tone as she explained the consequences to the patient. “I have to make sure you understand what you are doing. You are avoiding one poke so your baby can have at least six, do you understand? You have a choice, but you baby doesn’t—you can refuse this test, but we have a legal right to draw blood from your baby and there is nothing that you can do about that and it will take at least six pokes to complete all the tests your baby will need because we don’t have your blood type information. If you are Rh negative and your baby is Rh positive, than we to treat you or your future babies can die. If you are Rh negative and your baby is Rh positive than we can give you a shot to protect your future children. Do you understand that if do not allow us to take your blood than you will not have anymore babies!? Do you understand that?! They will die; you will not have any more children!” (I was not able to write down this exchange immediately, but this is very close to the exact exchange). I was pretty amazed as I sat there listening to this transgression as I knew that the nurse was lying about some of the information and I found the treatment of this patient to be unethical. Patients have the right to refuse. I believe that if this patient was older, more affluent, educated, or understood her rights as a patient this may not be the case. I also have a feeling that this kind of treatment is not necessarily a one time incident.

Jane didn’t say anything; she just lay in the bed with a defiant look on her face. My preceptor than left the room and I sat and tried to talk with Jane on more of a friend-to-friend level. She was very afraid of needles, so afraid in fact, that she had a natural childbirth the night before. As far as I can tell, that was the only reason she didn’t have an epidural—not because she was striving for natural childbirth, but because she was that afraid of needles. I also got the impression that Jane did not deal well with authority figures and was very, very immature for her age. I tried to understand Jane and treat her like an adult and be her friend and ally. After talking with her about the test and how we could use the smallest needle, she could squeeze my hand, and it would be over before she knew it, she was beginning to change her mind (I had realized at this point the informed refusal would not be a viable option unfortunatly). Then, in walked the irate women from the halls earlier. She introduced herself as a Pediatrician and began pretty much the same drill as my preceptor. I made a mental note to find out if this woman really was a doctor, I just couldn’t believe it. She also proceeded to try to coerce the patient with out offering the facts of the test or risks versus benefits. After her talk I followed her out of the room as she again vented about what a pain this patient was and how she couldn’t believe her and what a “psycho” she was.

In the end, with about 20 minutes to spare, Jane did decide to go through with the blood draw. I stayed in the room with the phlebotomist as she did the draw and reassured Jane that she was doing great and the worst part was over. It turns out that woman is a Pediatrician; I just could not believe how unprofessional a doctor could be. The fact is that patient had a right to refuse that test, but she also had the right to fair and unbiased information. I feel that the correct way to address this situation would have been to present the facts about Rh factor. The facts are that 15% of the population are Rh negative and that 17% of Rh negative women who are exposed to Rh positive blood ever make antibodies. In those instances, fetal autoimmune hemoloysis can develop. Results can range anywhere from mild anemia to life-threatening conditions such as hydrops fetalis. These facts are a lot different then stating “you will never have anymore children, they will die.”

The next morning in shift report Jane’s name came up again. One of the nurses asked if she would be going home today. A nurse responded that the Pediatrician would call and find out if the babies temp was stable today and if so, then the baby could go home with its mother, if not the baby would stay and the mother would go home. Another nurse asked “why? They don’t usually do that, how unstable is the temp?” The nurse responded that the Pediatrician had to spend a bunch of time convincing the mom to have a blood draw and this was probably pay-back.

It scare the hell out of me to know that health care professionals will hold personal grudges against patients and give them different treatment as a result. Unfortunately I am sure that this kind of treatment is not that uncommon. I feel that it is very important for me as a nurse to set an example by being fair and professional in my practice. There will be times when I will not necessarily agree with decisions my patients may make regarding their care, but it is not my responsibility to force people to make decisions I think they should make. My job is to provide the facts as we know them in a fair and unbiased way so that my patients can make informed choices on their own care.

Go Red!

The God Complex...

What is it with midwives/nurses/doctors that think they know everything and you know nothing? What is it with all the egotistical health care workers out there?

I am having such a difficult time working with a midwife that takes everything personally. From a great birth, to a suggestion-- everything is a reflection of her. I get pushed down if I even bring up something new that I learned. Now I have learned that I have to keep my mouth shut. Belittling someone does not help you to be a better doctor or midwife or nurse.

I have to remember that when I am a nurse and a midwife I can still learn from the people "under" me, I can learn from everyone. I can be open to new ideas and knowledge and it doesn't necessarily mean that I am doing anything wrong. I will respect everyone, even the pee-on birth assistant.

I won't give any examples of the midwife I work with now, because I don't want to jeopardize my job yet. But, to illustrate my point I will give an example from the nurse I work with. She was demonstrating to these new parents how to take their babies temp. She explained that a rectal temp is the most accurate and this is how you do it... Later I casually mentioned that in my class at school we actually learned that axillary was the recommended way to take a child's temp until they are at least 3 years old (I didn't even explain how its actually less accurate because new babies usually have stool in their rectum, so it reads lower than it is. Nor did I mention that its actually more dangerous because you can perforate their bowel or how invasive it is or that in my conservative text book it says "axillary temps are the preferred method to rectal temps...). I didn't belittle her in front of anyone or push my idea, but her reply was "really? I didn't know that... Well, I don't even believe that because rectal is much more accurate and thats how we were taught..." and then I got the cold shoulder for awhile. Now, this is this nurses first job out of nursing school and she has been at this hospital for 10 years (in fact, I found this to be a common thread-- first job, closed minded, not evidenced-based etc...). She has no children and I bet you she has never read one book on birth or taking any childbirth classes. But, she's the expert telling new parents what to do? And she won't even open her mind to consider using axillary temps vs. rectal temps or even look it up to see the research? Wow...

Nursing School...

I am so overwhelmed right now that I haven't had time to write. In fact, I should be studying right now for a test on Wednesday, oh well... I have been to clinical two more times-- one day in the nursery and one day in postpartum. Yeah, they are all separate there. Its so funny because in their information booklet they say they practice mother-baby nursing, yeah right. Anyway, I have to come up with a project to do and it can be a scholarly paper or a project to implement a new practice at your clinical site. So, now I'm working on what I want to do, I will post my ideas when I have them and we can take a vote.