What a week!

On Friday, I found out that I did not get the job I mentioned earlier - the one that pays well and is in a group practice with OBs and CNMs. I didn't think they'd offer it to me, and I was pretty sure I wouldn't take it even if they did! So that made for an easy decision.

I have no idea what I did on Saturday. Oh yeah, I went to the opening Farmer's market in my new town. Great stuff!

On Sunday, I got offered another job. This one is in a place that I would probably consider top choice, but it is only a part time position. Flattering, nevertheless. Then I helped groom the horses. Fun!

On Monday, I helped put in an IUD. More on that later. I also did a well-woman exam, including a physical, a pelvic exam, complete with PAP, and fitted her for a diaphragm. She had complained of rectal itching during the interview, but I forgot to look at her rectum for hemorrhoids. Darn it!

On Tuesday, I called one of my job offers, and told them that I wasn't ready to make a decision, and that their offer was probably not going to provide me the lifestyle to which I have become accustomed. (ha ha! - no really, it wasn't going to let me pay my bills, including at least $60K in loans!!!)

On Wednesday, my client who had her baby last week came in with a persistent headache. Not good. Her blood pressures had been up during labor, and day 1 and 2 postpartum. Now that she was day 8 postpartum, I was worried that she'd developed pre-eclampsia. Postpartum, you ask? Yes, it can happen. Remember, we don't really understand the disease, and despite the fact that we often say that it is "cured" with the birth of the baby (really the placenta), that isn't always true. We made a game plan to care for her if that was in fact the case - really that means to refer her to an OB - but when she arrived, her BP was back down to her normal range (110s over 60s) which was very reassuring, and she had no other symptoms of pre-E. Phew! For me, this was a great opportunity to use my skills of deduction and memory. What do you do to figure out if someone might have pre-E? I had to go through my list and get the information from her - some subjective (do you see bright spots in your vision? are you having any upper abdominal pain?) and some objective (is there protein in her urine?). It was a moment of realization that I've learned a bit - actually a ton - and can put it to use.

On Thursday, my IUD client returned, complaining of abdominal pain, tenderness, and cramping. She also said that she couldn't feel her IUD strings. Again, we prepared, this time for a perforated IUD. Where would we send her? First to the ultrasound or first to the OB? Should we do some testing first? When she arrived, we looked at her cervix. Yay - strings there, looking just as long as they did on Monday. Then we felt her uterus, from the outside and the inside. It felt huge! Like 16 weeks pregnant huge. She'd had a negative pregnancy test. We did an in-office ultrasound, which confirmed large uterus, no pregnancy, but we couldn't see the IUD. Is that because our ultrasound isn't strong enough? Because the IUD has migrated? Wish we knew. I also did a urine culture, a gonorrhea and chlamydia test, and a wet mount. I have to wait for the first two, as they go to the lab, but on the third, I could see lots of PMNs, a type of white blood cell, which indicates likely infection. After a consultation call to a local OB, we put her on an antibiotic for 10 days, and will plan to see her back next week. Again, I felt great about my management of her case. And worried about her!

On Friday, I called both of the women mentioned above, and they reported that they are feeling much better. Then I got called into a birth during second stage. She was laying flat on her back with her knees up by her chest. Isn't this the position we use in the hospital? Isn't the whole point of having an out-of-hospital birth to NOT be in this position? Oh well. Apparently, the midwife in charge had tried to offer a different position . . . to no avail. After watching for a while, and listening to the baby's heart rate go down after contractions (recovering quickly, I might add) and remembering that she'd been having unexplained bleeding throughout labor, I got a little nervous with the lack of progress. I suggested a different position, since that position just isn't very effective usually, and clearly was not being effective at this time. She tried hands & knees for a few pushes, and then the bleeding started again. A lot of bleeding. We got her to the birth chair, and I encouraged her to really get this baby out. She did, on the next contraction. What a momma! Her bleeding continued . . . but the baby came out crying. Good boy! It's nice to only have to worry about one of them! Pitocin given IM, and delivery of the placenta about 15 min later slowed her bleeding to almost nothing. Yay! Beautiful baby boy, 9#!

Saturday, I got a call at 0755 to head in to the birth center. Then about 0820, she told me to wait to come until we were sure this was really going to happen. Her cervix was posterior, long, thick, and closed. The baby was still floating above the pelvis. Oh well. I stayed home, had some coffee, and worked on a paper on GBS prophylaxis during labor. As it turns out, she was having crazy contractions that eventually started making change, but she took herself to the hospital for an epidural. She's 6 cm now & sleeping. The doc ruptured her membranes, and they got thick meconium. Her labor has slowed down a bit. Hopefully she'll have the VBAC she wants. Last time she only dilated to 4 cm, so she's done better this time! Best of luck to her.

Anyway, It's been an exciting week. I'm feeling oh so much more confident, like I know what I'm doing, at least most of the time. The funny thing for me is that here at the Birth Center, I am definitely the most MEDICAL of the bunch, and therefore sometimes the most conservative. I was the most nervous when that momma was bleeding and her baby was having decels. I was first to suggest antibiotics for the infection. I am first to suggest hormome methods of birth control. Why is this funny? Because until now, I've always been the most NON-MEDICAL of the group, whether it be in SNM cohort or at the other practices where I've trained. I'm usually the one opting for low or no intervention, and second-guessing myself when I choose them. I'm the one who defends the momma with the birth plan, when everyone else poo-poos it. It's great to be on the other end this time - I think it will balance me out, and I also think I am offering the folks here some new information and a new way to think about caring for our clients.