This week, I had a great learning experience that ended with a healthy baby, but a cesarean section, making me sad, and wondering how I could have managed the labor differently. Clinical judgement is just that - judgement. Did I use good judgement? Did the doc? This was the kind of situation that I wish could be replayed with just one thing changed to see if the outcome was the same, or different. That's the thing - even if I had one thing differently, the outcome could have been exactly the same, but I will never be able to find out. Frustrating.
She was a primip (first timer) who presented in active labor around 10 AM. She labored well unmedicated until she reached about 6 cm, then got an epidural. (Epidurals are great for pain relief, but they do slow down labor. Most women don't know that, and many who do, don't care. But they do change the course of labor.) After an hour or so of rest, she was at 7 cm and I decided to rupture her bag of water, which was incredibly easy because it was ready to pop! Baby was low in her pelvis and didn’t seem to like that, showing us by lowering his heart rate to a range that made us nervous for 8-9 minutes. Her cervix changed rapidly after that, reaching at least 9 cm in less than 20 minutes. It was hard to monitor the baby's heart rate, so I put an internal monitor onto the baby's head, and still we had a difficult time keeping the baby’s HR on the monitor, probably because the baby had some head swelling. I also put in an internal pressure monitor because it was hard to monitor her contractions from the outside, and we added some saline solution to see if fluid around the baby would help his heart rate recover back up to his normal range. The nurse then called in the OB (without waiting to find out if we midwives wanted her to), and he pretty quickly decided to do a cesarean section.
As I said above, I wish I could have a “re-do.” I’d love to rewind and see what would have happened if I’d let her bag rupture on its own. I wish I had been more assertive, and seen if pushing could have helped bring the baby down. Yes, she was “only 9” cm, but that cervix was so thin, not all the way around the head, and that head was so low, so much already through it, that I think pushing may have just finished it off, and brought the baby down. She was a strong girl . . . but the baby's heart rate decelerations were making everyone nervous.
The baby came out screaming and had Apgars of 8/9 (10 is the highest!). Breastfeeding is going well. Mom is having some bleeding from her wound that we're watching closely. She's not all that upset about her cesarean, definitely not as upset as I am. Mostly, I’m beating myself up for not being more assertive and giving her a chance to see if pushing worked, and the baby tolerated it.
I did get to assist on the cesarean section, and remove the placenta. That part was cool.
Thursday, January 27, 2011
Saturday, January 22, 2011
Brief summary of my week
Lots of midwife lingo in this post. Here is a key:
IUD= intra uterine device.
TOLAC = trial of labor after cesarean section
R/O= rule out, meaning that's what we're worried about, so testing/observing to determine
SVE=sterile vaginal exam
misoprostol - a medication used to ripen a cervix, or get it ready for labor.
IOL = induction of labor, usually with pitocin.
PPROM= pre-term premature rupture of membranes (water breaking before a baby is ready, and before labor has begun)
CST= contraction stress test
NOB= new ob visit (prenatal)
PP = postpartum visit, usually at 6 weeks
Put in another IUD.
•Did complete informed consent with a patient for vaginal birth & blood transfusion.
•Learned to do SVE with my left hand – think it might be easier, somehow feels better.
•Managed 2 multiparous inductions, but no births before my shift was done.
*One was a 40+6 induction for postdates, given the option to come back next week. Fun lady. 100 mcg of misoprostol got her contracting, so I’m hoping it just kicked her into labor without further induction. When I left, she was 3 cm.
*IOL at 37+4 for G6P3002 (6 pregnancies, 3 deliveries, 2 live children) for previous fetal demise at 38 weeks. Had a great time working with her – she had LOTS of anxiety over losing this baby, guilt over inducing early, etc. Spent a lot of time with her talking about what her options were and why, and just helping her understand the whole process. Her induction was with pitocin, despite the fact that her SVE was 2 cm/50 %/-3 station because her baby had some strange variables, so it didn’t seem prudent to use misoprostol, and it doubled as a CST.
R/o PPROM at 21+1 weeks. Thankfully, did rule it out! History of PPROM at 27 weeks, and her story sounded pretty convincing, but her cervix was long and closed, and with ultrasound we could see lots of fluid on the other side.
NOB visit with a client in a drug treatment program. History of food addiction, gastric bypass (Roux-en-Y) then bowel obstruction surgery, then chronic pain, then narcotic addiction. Unplanned pregnancy. We had a long visit, then confirmed a 10 week pregnancy with ultrasound.
6 week PP visit with a woman who had PP blues/depression. Talked about self care, getting help from others, eating better! Referral for counseling.
Transfer OB visit at 24 weeks with an interesting client who wants a TOLAC. Good candidate overall.
IUD= intra uterine device.
TOLAC = trial of labor after cesarean section
R/O= rule out, meaning that's what we're worried about, so testing/observing to determine
SVE=sterile vaginal exam
misoprostol - a medication used to ripen a cervix, or get it ready for labor.
IOL = induction of labor, usually with pitocin.
PPROM= pre-term premature rupture of membranes (water breaking before a baby is ready, and before labor has begun)
CST= contraction stress test
NOB= new ob visit (prenatal)
PP = postpartum visit, usually at 6 weeks
Put in another IUD.
•Did complete informed consent with a patient for vaginal birth & blood transfusion.
•Learned to do SVE with my left hand – think it might be easier, somehow feels better.
•Managed 2 multiparous inductions, but no births before my shift was done.
*One was a 40+6 induction for postdates, given the option to come back next week. Fun lady. 100 mcg of misoprostol got her contracting, so I’m hoping it just kicked her into labor without further induction. When I left, she was 3 cm.
*IOL at 37+4 for G6P3002 (6 pregnancies, 3 deliveries, 2 live children) for previous fetal demise at 38 weeks. Had a great time working with her – she had LOTS of anxiety over losing this baby, guilt over inducing early, etc. Spent a lot of time with her talking about what her options were and why, and just helping her understand the whole process. Her induction was with pitocin, despite the fact that her SVE was 2 cm/50 %/-3 station because her baby had some strange variables, so it didn’t seem prudent to use misoprostol, and it doubled as a CST.
R/o PPROM at 21+1 weeks. Thankfully, did rule it out! History of PPROM at 27 weeks, and her story sounded pretty convincing, but her cervix was long and closed, and with ultrasound we could see lots of fluid on the other side.
NOB visit with a client in a drug treatment program. History of food addiction, gastric bypass (Roux-en-Y) then bowel obstruction surgery, then chronic pain, then narcotic addiction. Unplanned pregnancy. We had a long visit, then confirmed a 10 week pregnancy with ultrasound.
6 week PP visit with a woman who had PP blues/depression. Talked about self care, getting help from others, eating better! Referral for counseling.
Transfer OB visit at 24 weeks with an interesting client who wants a TOLAC. Good candidate overall.
Reflecting on my growth this past year
A friend of mine posted something on Facebook about feeling awkward during her clinical rotation this quarter - her very first one, doing gynecological care. My gut reaction was to reassure her and offer stories about my first clinical in order to help her see that this is a growth process, much like adolescence all over again. Here's what I wrote:
I saw your post on FB, and thought I’d just offer my experience. Remember I was NEVER a nurse, so always felt very behind in clinical. Last year, my best friend in midwifery school got to see patients on her own the first or second week. I did not. At first I felt very sad/behind/stupid/insecure/etc about it, but then realized that going slow has its advantages. First, I got to see an amazing NP in action! Second, I got to learn slowly. I think the best thing I learned, and told patients sometimes (when appropriate) is that having a student actually is advantageous for them – they get two brains instead of one, and often twice as much attention! Anyway, slowly I’ve become more and more confident during the last year. I’m now really comfortable seeing patients – at least in terms of rapport – for a variety of reasons. It’s the clinical judgement piece that takes a really long time. Some subjects I’m really comfortable with (birth control, normal prenatal visits, etc) but some I’m at a loss – mostly due to lack of experience. It’s a slow process, where you move back and forth in feeling great or feeling stupid. For at least my first three quarters of clinical I pretty much felt like an idiot most of the time. Finally, that’s not so true anymore!
So there’s the pep talk that my friend didn’t really ask for. Maybe I just needed to do some reflecting on my own growth as a midwife, so I thank her for that.
I saw your post on FB, and thought I’d just offer my experience. Remember I was NEVER a nurse, so always felt very behind in clinical. Last year, my best friend in midwifery school got to see patients on her own the first or second week. I did not. At first I felt very sad/behind/stupid/insecure/etc about it, but then realized that going slow has its advantages. First, I got to see an amazing NP in action! Second, I got to learn slowly. I think the best thing I learned, and told patients sometimes (when appropriate) is that having a student actually is advantageous for them – they get two brains instead of one, and often twice as much attention! Anyway, slowly I’ve become more and more confident during the last year. I’m now really comfortable seeing patients – at least in terms of rapport – for a variety of reasons. It’s the clinical judgement piece that takes a really long time. Some subjects I’m really comfortable with (birth control, normal prenatal visits, etc) but some I’m at a loss – mostly due to lack of experience. It’s a slow process, where you move back and forth in feeling great or feeling stupid. For at least my first three quarters of clinical I pretty much felt like an idiot most of the time. Finally, that’s not so true anymore!
So there’s the pep talk that my friend didn’t really ask for. Maybe I just needed to do some reflecting on my own growth as a midwife, so I thank her for that.
Thursday, January 20, 2011
Typical clinic day . . . ?
I had a great clinic day yesterday. I am learning in a setting with five different midwives who are all fantastic to work with. When I got there yesterday, one of them had an IUD insertion for her first visit, so I asked if I could join in, even though I was supposed to be with another midwife. She said, "sure thing!" So we went in to consent the patient, and then had an easy and fast IUD insertion. Wonderful! I think that's the 5th one I've put in. The more I can do as a student, the better.
Then I went off to work with Midwife A. She's a really fun lady, easy to work with, and her patients love her. She was having a tough day. Something about a patient with fainting spells . . . but being that she was trying to get out of work, this somehow didn't seem quite as believable as it might under other circumstances. When I walked in, A was practically cross-eyed in trying to figure out how to deal with this client. One of the OBs was there, and they were discussing it. I'm not really sure what happened . . .
In the meantime, I took her next patient, a lovely woman who was transferring her care because she had just moved back to Washington after living in Italy for 3-ish years. She was there with her 2 year old daughter, a blond cutie who was quick to warm up to me. We had a lovely visit, doing an intake, which can take a long time. I really like long visits. I enjoy building rapport with women, learning about their lives, their medical and personal histories, etc. She told me her birth story - laboring for 3 days (really just 48 hours), and then finally having a cesarean section. At 9 centimeters! Bummer. It was an induced labor, and those always go more slowly and painfully - and I don't mean only pain in the true sense of the word, but figuratively, also. Poor thing. She wants to try to labor this time, so we discussed what that might look like. She mentioned that she got really sick of being pregnant last time at about 38 weeks. Not uncommon, but if she really wants a trial of labor, she'll have to be more patient this time! Waiting for spontaneous labor is always trying on one's patience, but it is the best thing to do if you want to have a vaginal delivery, especially after a previous cesarean section!
My next patient was a 6 week postpartum visit. Sadly, she didn't bring her baby for us to meet . . . but that's selfish on our part. :-) Her parents were visiting, so she left the baby at home with them, and with her two year old son. She seemed pretty sad. She said she'd been having some postpartum "blues" and needed some help. We talked about ways to take care of herself while also being a good mom and wife. Her husband sounds like he helps a lot when he's around, but has long working days. He encourages her to take care of herself, too, which is good. She's staying well-hydrated, but not eating much. She stopped breastfeeding after about a week because it "took too long." Her daughter is a slow eater, so she felt like that's all she was doing. Poor thing. I'm sure she's right, but the thing is that breastfeeding can help with mood by giving you good bonding time with your baby, AND by releasing hormones that make you feel good. Too late for that now. I just wish she'd known that. Anyway, she'd done some counseling the last time she had some blues during postpartum, so was happy to get referred for counseling. I hope she eats and takes good care of herself in the weeks and months to come.
Then I scarfed down some lunch in about 5 minutes!
On to midwife C for the afternoon. She's been a midwife for years and years, and has amazing experience and expertise. She's done home, birth center, and hospital birth over the years. Our next client was 36 weeks pregnant, just in for her weekly checkup. Her baby sounded great, and was head down. Her belly measured well. It was a quick visit. She asked about taking a birthing class, and said she wanted to try an unmedicated labor. Good for her! But, hmmmm . . . most of the time, women (in this country) take a birth class to learn some coping techniques, and do lots of reading, and more . . . but I guess that's not true everywhere. She has a friend coming to her labor, who can hopefully act as a doula, so I hope she does well. She's young and healthy! And the epidural is there if she needs it.
Side note: When I visited a friend in Saipan last year, I observed on the L&D floor while I was there. They don't offer epidurals to everyone. It just isn't done in that hospital. Epidurals are saved for cesarean sections, or other surgeries, not for normal birth. So women there did not have that choice, so they just labored. They just did it. It was SO DIFFERENT from the way things are done in this country, generally. Now, even at most small community hospitals, epidural is offered to almost everyone. This was not the case 20 years ago . . . or even just 10 years ago. There was something really nice about women just laboring. There wasn't as much fear of the process, either. I liked it.
My last patient of the day was a woman who had gotten pregnant accidentally while using her birth control pills continuously. Well, except for that week when her prescription ran out, and she didn't have any more, and then her husband came home from a business trip . . . she's 27, and excited about this pregnancy. Her history is fascinating, though. She was morbidly obese 2.5 years ago. She had high cholesterol, high blood pressure, and a bad family history of high blood pressure and heart attacks. (Her father had a quadruple bypass at age 40!!) So she was able to qualify and get a Roux-en-Y - a version of gastric bypass surgery. And she's down to 150 pounds - less than half of her previous weight! Awesome! But then, about 4 months after her surgery, she got a bowel obstruction, which can be quite dangerous (life-threatening) so she had surgery again. All better, except for some chronic pain from nerve damage done during the surgery. Pain killers were required, and then she became addicted to them. After a year or more, she went into an inpatient treatment center and got clean. She's just finishing up her treatment now, and will continue counseling for the next year or so. She's been clean for 6 months. And now she's pregnant! Pretty intense. Baby looked great when we did the ultrasound. Wiggling around, moving, pushing against the wall of her uterus - just having a great time. I hope mommy can work out her problems and make her addiction something positive, like being a great mother, or studying to finish her degree. I think this lady has lots of potential, but I also worry about her because she's been dealing with a lot recently. Best of luck to her!
Then I went off to work with Midwife A. She's a really fun lady, easy to work with, and her patients love her. She was having a tough day. Something about a patient with fainting spells . . . but being that she was trying to get out of work, this somehow didn't seem quite as believable as it might under other circumstances. When I walked in, A was practically cross-eyed in trying to figure out how to deal with this client. One of the OBs was there, and they were discussing it. I'm not really sure what happened . . .
In the meantime, I took her next patient, a lovely woman who was transferring her care because she had just moved back to Washington after living in Italy for 3-ish years. She was there with her 2 year old daughter, a blond cutie who was quick to warm up to me. We had a lovely visit, doing an intake, which can take a long time. I really like long visits. I enjoy building rapport with women, learning about their lives, their medical and personal histories, etc. She told me her birth story - laboring for 3 days (really just 48 hours), and then finally having a cesarean section. At 9 centimeters! Bummer. It was an induced labor, and those always go more slowly and painfully - and I don't mean only pain in the true sense of the word, but figuratively, also. Poor thing. She wants to try to labor this time, so we discussed what that might look like. She mentioned that she got really sick of being pregnant last time at about 38 weeks. Not uncommon, but if she really wants a trial of labor, she'll have to be more patient this time! Waiting for spontaneous labor is always trying on one's patience, but it is the best thing to do if you want to have a vaginal delivery, especially after a previous cesarean section!
My next patient was a 6 week postpartum visit. Sadly, she didn't bring her baby for us to meet . . . but that's selfish on our part. :-) Her parents were visiting, so she left the baby at home with them, and with her two year old son. She seemed pretty sad. She said she'd been having some postpartum "blues" and needed some help. We talked about ways to take care of herself while also being a good mom and wife. Her husband sounds like he helps a lot when he's around, but has long working days. He encourages her to take care of herself, too, which is good. She's staying well-hydrated, but not eating much. She stopped breastfeeding after about a week because it "took too long." Her daughter is a slow eater, so she felt like that's all she was doing. Poor thing. I'm sure she's right, but the thing is that breastfeeding can help with mood by giving you good bonding time with your baby, AND by releasing hormones that make you feel good. Too late for that now. I just wish she'd known that. Anyway, she'd done some counseling the last time she had some blues during postpartum, so was happy to get referred for counseling. I hope she eats and takes good care of herself in the weeks and months to come.
Then I scarfed down some lunch in about 5 minutes!
On to midwife C for the afternoon. She's been a midwife for years and years, and has amazing experience and expertise. She's done home, birth center, and hospital birth over the years. Our next client was 36 weeks pregnant, just in for her weekly checkup. Her baby sounded great, and was head down. Her belly measured well. It was a quick visit. She asked about taking a birthing class, and said she wanted to try an unmedicated labor. Good for her! But, hmmmm . . . most of the time, women (in this country) take a birth class to learn some coping techniques, and do lots of reading, and more . . . but I guess that's not true everywhere. She has a friend coming to her labor, who can hopefully act as a doula, so I hope she does well. She's young and healthy! And the epidural is there if she needs it.
Side note: When I visited a friend in Saipan last year, I observed on the L&D floor while I was there. They don't offer epidurals to everyone. It just isn't done in that hospital. Epidurals are saved for cesarean sections, or other surgeries, not for normal birth. So women there did not have that choice, so they just labored. They just did it. It was SO DIFFERENT from the way things are done in this country, generally. Now, even at most small community hospitals, epidural is offered to almost everyone. This was not the case 20 years ago . . . or even just 10 years ago. There was something really nice about women just laboring. There wasn't as much fear of the process, either. I liked it.
My last patient of the day was a woman who had gotten pregnant accidentally while using her birth control pills continuously. Well, except for that week when her prescription ran out, and she didn't have any more, and then her husband came home from a business trip . . . she's 27, and excited about this pregnancy. Her history is fascinating, though. She was morbidly obese 2.5 years ago. She had high cholesterol, high blood pressure, and a bad family history of high blood pressure and heart attacks. (Her father had a quadruple bypass at age 40!!) So she was able to qualify and get a Roux-en-Y - a version of gastric bypass surgery. And she's down to 150 pounds - less than half of her previous weight! Awesome! But then, about 4 months after her surgery, she got a bowel obstruction, which can be quite dangerous (life-threatening) so she had surgery again. All better, except for some chronic pain from nerve damage done during the surgery. Pain killers were required, and then she became addicted to them. After a year or more, she went into an inpatient treatment center and got clean. She's just finishing up her treatment now, and will continue counseling for the next year or so. She's been clean for 6 months. And now she's pregnant! Pretty intense. Baby looked great when we did the ultrasound. Wiggling around, moving, pushing against the wall of her uterus - just having a great time. I hope mommy can work out her problems and make her addiction something positive, like being a great mother, or studying to finish her degree. I think this lady has lots of potential, but I also worry about her because she's been dealing with a lot recently. Best of luck to her!
Friday, January 14, 2011
Differential diagnosis
For those of you not in healthcare, a list of differential diagnoses is a way of considering all of the disease/condition options that explain the symptoms that a patient describes and/or that you see during a physical exam. Last week, I got scared by one of my differentials, but was so happy I knew enough to be scared, and follow up appropriately.
My patient was a 20 year old 39-week pregnant woman. She was there for her weekly pre-natal visit. While I washed my hands, I asked her how she was. There was a long pause and a sign on the way to saying, "fine." I didn't believe her, and said so. In a nice way, of course. That's when she started to cry, and tell me about her leg and how much pain she was in. This was not something I had seen in her chart that I had reviewed on her way in, so I sat down to comfort her and hear her story.
As it turns out, her legs had been swelling, and over the course of the previous week, had increased in size considerably. One of them was not only more swollen than the other, but she was having considerable pain in the the inner thigh region. Her jeans were significantly tighter than they were the week before. She had noticed no discoloration in her leg, upper or lower, or her feet. She did not have any tingling or numbness.
Since she wanted her cervix checked, and I wanted to see this leg undressed, I left so that she could do just that. The cnm I was working with was in seeing another patient, so I left a note on her desk to come see me ASAP. I was nervous.
Back to differentials. My differential diagnosis list included:
normal (but excessive) swelling of pregnancy.
DVT (deep venous thrombosis) or in english, a blood clot.
Maybe I should have considered others, but that DVT option scared the hell out of me, so right there, I wanted proof that this was not the case. The reason they are scary is that a clot in the leg can be released at any given moment and travel to the lungs (pulmonary embolism) or the brain (brain embolism) both which can be life threatening. NOT GOOD.
I went back into the room to assess her leg. As she'd said, no discoloration. Her legs were HUGE. I measured them both . . . the painful one was significantly larger in circumference than the other, but both were very swollen. Poor thing. After her cervical exam, I had her get dressed and sent her down to radiology to get a venous ultrasound.
An hour later, the terrific news arrived. NO DVT!!!
So I sent her home to rest WITH HER FEET UP until she delivers this baby. And hydrate. No more work for her!
I followed up with her again about 5 days later. She was still pregnant, but feeling better. Thank goodness.
My patient was a 20 year old 39-week pregnant woman. She was there for her weekly pre-natal visit. While I washed my hands, I asked her how she was. There was a long pause and a sign on the way to saying, "fine." I didn't believe her, and said so. In a nice way, of course. That's when she started to cry, and tell me about her leg and how much pain she was in. This was not something I had seen in her chart that I had reviewed on her way in, so I sat down to comfort her and hear her story.
As it turns out, her legs had been swelling, and over the course of the previous week, had increased in size considerably. One of them was not only more swollen than the other, but she was having considerable pain in the the inner thigh region. Her jeans were significantly tighter than they were the week before. She had noticed no discoloration in her leg, upper or lower, or her feet. She did not have any tingling or numbness.
Since she wanted her cervix checked, and I wanted to see this leg undressed, I left so that she could do just that. The cnm I was working with was in seeing another patient, so I left a note on her desk to come see me ASAP. I was nervous.
Back to differentials. My differential diagnosis list included:
normal (but excessive) swelling of pregnancy.
DVT (deep venous thrombosis) or in english, a blood clot.
Maybe I should have considered others, but that DVT option scared the hell out of me, so right there, I wanted proof that this was not the case. The reason they are scary is that a clot in the leg can be released at any given moment and travel to the lungs (pulmonary embolism) or the brain (brain embolism) both which can be life threatening. NOT GOOD.
I went back into the room to assess her leg. As she'd said, no discoloration. Her legs were HUGE. I measured them both . . . the painful one was significantly larger in circumference than the other, but both were very swollen. Poor thing. After her cervical exam, I had her get dressed and sent her down to radiology to get a venous ultrasound.
An hour later, the terrific news arrived. NO DVT!!!
So I sent her home to rest WITH HER FEET UP until she delivers this baby. And hydrate. No more work for her!
I followed up with her again about 5 days later. She was still pregnant, but feeling better. Thank goodness.
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