Ok so we don't section all the big babies. Why? Cause we don't know how to accurately predict. And my thoughts on post partum bleeding.

So today was big baby day. A couple of 10 pounders were born out the vagina. But here is the thing, we cannot accurately predict how big the baby is going to be. Some women hide a big baby well. I am not speaking about heavy women. Many average sized women will pop out an unexpected large baby. You never can tell.

Patients always say, "how big do you think the baby is?" I always tell them I have no idea. Some Midwifes and older Docs are good at predicting. Some not so much. But there is no tool that can accurately predict. The ultrasound can be off a lb either way. But I have seen it be way way off. Also the ultra sound can measure fluid and come up low fluid but that can depend on where they measured the fluid. So none of this sh1t is a complete mathematical equation.

I had a nursing student follow me today. What I find interesting with this now is I am watching how they think. Many will want definite numbers. They will ask, "what did you get for a heart rate? How come my heart rate reading was different?" They want a recipe to follow. That is a tough one for them to get over. It was hard for me to get over.

They also want to know how I know when to check the fundus or take vital signs on the baby. I tell them the truth and it does not make them happy. The truth is I do it when I feel it is time. When I was a new nurse, I checked the clock for every 15 minutes and I would check the fundus then do baby vital signs. It was a lot of vital signs!!! Totally unnecessary. When a fundus is behaving, I check it less, when boggyish, I check it more....Baby vital signs sketchy, I check more, good vital signs, I check less.

At one point in my day, I found myself massaging the crap out of some poor woman after I shot her up with Methergine and then hemabate. I guess it was a continuous fundal check? Why? Cause the poor thing was bleeding, and bleeding, and bleeding. Massaged her uterus, gave her some methergine and hemabate after the failed oxytocin bolus that we start giving folks after delivery, and she stopped bleeding. That was good.

She was a vaginal delivery who came in in labor. She had no risk factors for a bleed. But bleed she did. If she did not stop bleeding we could have used cytotec per rectum or inserted a balloon or taken her back to the OR for a D&C. This always happens at the end of your shift. The sh1t never seems to hit the fan until the 11th hour of your shift. Then it most certainly will. I am such an optimists!

Nursing education, Graduate education, ACLS and stained glass.

That is what is on my mind. Late in August the College that I teach clinical for has some seminars for me to go to. They need to teach me how to effectively teach.

I have taught NRP for years. But teaching nursing students, I need to teach them critical thinking skills. Some of that is just going to be on the job training. But some of it is important to discuss. And I have to look at how I am teaching them. Am I doing it effectively? Could I be doing better? Certainly there is always room for improvement. Also I need to teach them how to advocate without becoming aggressive. That is a very important skill.

This semester my goal is to have no down time. If we are on the floor I want us doing something. So I have made a list of things to do during down time. One of the things is do mock NRP codes. This is easy since I have done it so much in the past. Another is practice scrubbing for the OR. Practice gown and gloving with the gloves and gowns we would have thrown out. The head scrub tech is saving these for me. I have a stock pile in my car. It is annoying the crap out of my spouse. He will get over it.

So looking forward to the new semester. Also looking forward to starting Grad school at Frontier school of midwifery. A little anxious about that. I am doing it full time. My boss at the college is wicked happy about that. I have to get a graduate degree in nursing in order to keep teaching past 5 years. I have a 5 year grace period. So she is psyched I signed up. I guess a lot of folks in the past have not jumped right into grad school. I am hoping all this thinking will help me stave off Alzheimer's. Certainly cannot hurt.

Like a complete loser I signed up to learn to teach ACLS. Why? Because I think we should have our own acls for the maternity services. We should have specific things that we need to learn and focus on. But why did I pick now to do it? Because I just didn't have enough to do! The book is sitting next to my computer. Mocking me....It has a CD too.

Ok when I signed up it sounded like a really good idea but I am spending a lot of time making stained glass things. I have a craft fair every Wednesday. I was not expecting to sell as much as I already have. Therefore I have stained glass to work on. I really like doing it or I would have never signed up. But the craft fair runs to October. At some point it would be nice to actually make some money from this. I have invested in a tent 250 dollars, new machines for stained glass 200 (but I wanted them and this was just an excuse to buy them) and glass cost about 1.25 per handful of glass nuggets or 5-8 dollars per sheet of glass.

Here is the good news, I am having the most fun with the craft fair.

So that is a lot of balls in the air. Good thing they coincide with one another mostly. Except for the stained glass. So I should get off the computer and do something productive? Perhaps after I drink my coffee.

Favorite post of the day.

I read a lot of blogs. Most of those folks are far more entertaining than me. So this morning, I need to give accolades to Orac at Respectful insolence. He is on my side bar if you want to give it a read.

Today's topic is colon cleansing. How much is too much? Is there anything to it? Or is it just crap.....Literally. In nursing school we were taught that folks need fiber in their diet. Really, really. It helps regulate them and they will feel better. But folks don't need to get a high colonic. High hot and hell of a lot is not the prescription of choice. The concern is that these folks are wiping away useful bacteria and they could get a little dehydrated too. Any time you are vomiting or having diarrhea, you should increase you fluids.

Basically, eat good food regularly. Eat whole grains. Exercise. Drink water. Go for a walk. Wash your hands. Perhaps take a Flintstones vitamin. There is no short cut! But if you treat your body right, you will feel better and it will work better. No need to run out and get that high colonic. I am cancelling my appointment!

What is going through their mind when presented with a new baby?

In my house my Mom has loads of old stories she loves to tell. One of them was that the day my baby sister came home I took one look and said to my parents, "bring her back." They all got a chuckle out of that one. Repeatedly.

Today I am very close with my sister,surprise,surprise. Which is fortunate, I was not fond of her as a child.

Yesterday and many days, I watch the faces of little children meet their new siblings. Many parents will say, I want the baby to be in the crib when my little one comes in. Or can you bring the baby back after my little one comes in? I think they are wise women. They know that this is a huge adjustment for their little child.

One mom had presents waiting for her other children that were from the baby. One of the children looked at her belly and said, "how did the baby get them out of there?" I can see this as a favorite story to told and retold. It was very cute. Makes me think, "what is going through their little minds when presented with a new baby?"

I looked at a little face yesterday and she looked like she wanted to swallow the baby up. Many kids want to hold the sibling and sometimes parents yell at them cause they get nervous that I may just hand them over. Which I won't. But often I will unwrap the baby so we can check bands and then the new sibling and the grandparents can get a peek at what is under the wrappings. It is very funny when I unwrap the baby many folks get right up and surround the crib. Especially the grandparents. Can't say I blame them. I now announce to the room that I am going to unwrap the baby to check bands so they can get a good peek. They want to see the baby's little toes and feet. Check out the little hands. I think it may be part of their family bonding process. I don't know. But I know grandparents and small children love it so help them out. I need to check bands or do vital signs every so often anyhow.

Yesterday, the little girl looked so curious that I couldn't help but get on my knees and show her the baby up close. I think the parents were afraid I was going to let the girl hold the baby. I was not. But it gave the child a good look at the baby. She seemed mesmerized. I wonder what she was thinking? I wonder how she will feel when the baby comes home? A lot of it has to do with how the parents handle things but another part is how old the older child is? I guess you can't really help the age difference?

I interupt this blog to write a long small child story. Cause I can. It is my blog.

So I park my car near my Sister's house. She lives near the hospital. My Niece was in the back yard when I was cutting through. After my conversation with her I have now realized 1) she is way smarter than me 2) I have no defense against her 3) I might as well accept this.

She asked if she could come to my house with me. Sometimes I take her shopping and we head back to my house and watch loads of TV, eat junk food. The shopping usually consist of me buying something I need and me buying her a bunch of stuff she wants.

Today I agreed to take her on my errands to the glass warehouse and the grocery store then to my house where my Sister would pick her up later. It all sounded reasonable to me. Even though I was really tired from work.

I was doing pictures of a 17 weeker IUFD. So I am tired. But I am also grateful that my Sister is not the woman sitting in that bed today holding that dead child. Selfish maybe, but I am grateful that has not happened to my Sister. I am grateful for my Niece and Nephew and maybe just maybe that is why I said, "OK but we have to do my errands." I am sick of saying no to her. She asks every time she sees me. And what is the important things here? Is it the grocery store? No the important thing is that I carve out time to spend with my niece and nephew.

She gleefully jumps into the car seat her mother puts in my car. As soon as we drive away she says, "Aunty are we going to the toy store." I told her I had not planned on the toy store. Her retort was that she really would like to buy that bunny in a carriage toy that we looked at last time we were at the store. That was last month! How did she remember the bunny in the carriage toy? She did. So I made her this deal. We go into the store we pick out only that toy and get out of there. She agreed and she was good. She went in, we picked up the bunny in a carriage and a bubble toy for my nephew too because he was sore that he was not going with me. I couldn't do both of them today. Too much.

So I got a kick out of the fact that she remembered the bunny in carriage toy. The lady behind the desk at the toy store asked if I wanted to be on their frequent flyer program. Last month I said no, this month I rethought it and decided it might be a good idea. So I have earned a pea pod buck or some such name. I don't even know the name of the store! It is one of those fru fru stores. I call them fru fru stores because you pay too much and you know it. But you go there for 1)convenience 2)pleasant surroundings 3)helpful sales ladies 4) your fellow patrons will not scare you. All those things matter to me some days so that is when I shop there.

Also the toys that I have bought at Pea Pod last year are still intact and functional. She still has some wooden paper doll toys we bought and they are in good shape. So quality too, I guess.

We went to the glass warehouse where I get my stained glass supplies. I could never take her Brother there! She got a kick out of picking out different color nuggets of glass. She was a very good girl. She usually is really really good when she is with me. She is no fool, she knows if she is naughty I am going to bring her home. Well at least that has been the threat in the past.

At this exact moment she is on my living room floor making bracelets for her friends.

So I was going to post about 17 week fetal demises and how hard they are to get a decent photograph of, but instead I think I will focus on my Niece. More enjoyable.

Reading EFM , C-sections, Doulas and what are we going to do?

I went in today and was happy to see an old Doc. Sh1t the woman is my age but she is old in terms of medicine and obstetrics. And she is not going to stat section someone who does not need to be stat sectioned. According to Acog, if we have moderate variability and the patient in changing her cervix, it is appropriate to continue the labor baring any other complication. However, folks on the unit have gotten really weirded out about variable decels. Now it seems like variable decels are being treated like late decels and I just still have a hard time wrapping my head around that. So more folks are being sectioned than we used to. We also have a bunch of new Doctors.

So if we C-section all the women who have variables throughout their labor instead of continuing the labor, we will increase our section rate exponentially. When that occurs, since we have women who also have high risk pregnancies and many who are primips at 41, I think we are going to start injuring these people more and saving babies less. Which is a crappy thing to do. However, pregnant women do not have a safety meter on their abdomen. Which is truly too bad because it would reduce a lot of error. We are becoming victims of bad science. We need a tool to indicate well being of the laboring woman's baby. The EFM is just not all it is cracked up to be but sh1t it is all we have for the time being.

I don't think the answer is to educate the patient to advocate for themselves. I don't think a patient should be put in that situation and they don't have the medical back ground that the nurse, Doctor, Midwifes has. Some Doulas have a solid understanding but many do not. So that is tough.

I think Dona should have a test that doula's have to pass in order to be certified and then I think they will get better recognition. Childbirth educators have some certifications I think, Do clue me in if I am wrong. Perhaps medicaid should reimburse Doulas? My understanding of the literature is that having a doula does decrease the chance of c-section. I have not poured over the studies but it has never been contested by any Doctors I know or patients so I have read books but never poured over the studies about doulas. Perhaps I should put that on the to do list?

I had a lovely delivery. I had a strip with loads of variables. The Doc and myself were on the same page. We had a beautifully reactive strip when the patient was not having a contraction. With contractions, we had variable decels. So what is that? A cord. Lo and behold a nuchal cord was viewed on delivery. No surprise. Nice apgars, nice healthy baby. It was just nice.

Down the hall my buddy X had a strip that had some variables with moderate variability. Other nurses kept coming into her room to ask if she needed anything. X knows how to read the EFM. She will tell us if she needs help. She had voiced the same complaint I have had in the last year. That nurses are overreacting to a few variables. This in turn gets the patient upset and worried. The Doc gets worried and then off to the C-section room they go. This is new behavior for my workplace. I am not thrilled about it.

Now on the other hand, if you have a decel that goes over 4 minutes? I think you should have a policy of taking the patient to the OR. Why? Because if it does not come up by the time you have gotten to the OR, they very well may need a c-section quick. 99% of the time it does come up and we can slow down and decide to do a vag delivery. This is where folks are deciding to section whereas years before they would have the nurse continue the labor in the OR and/or bring her back to the labor room.

So back to the idea of having Doulas for each patient and have them covered by medical insurance. It would force more of the providers to use evidence based medicine. Why? Because the Doula would be giving the patient the latest studies. Not a bad thing? If a provider is uncomfortable with a respectful Doula who wants to discuss evidence based practice and the quality of studies, then I think that is suspicious.

A Doc recently told me, "I think it works" that was her comeback. That was her evidence. Then she walked away because I was not going to let it go. Going to have to have a chat with the chief of OB. That is what we do when Doctors misbehave. She won't walk away from the chief.

So today I thought, "why am I going to midwifery school? I don't think I can practice in this environment." Then I remembered I need the graduate degree in order to continue teaching. I don't know if I will ever actually practice midwifery in the United STates. Might be able to convince my spouse to move to Canada. He likes to ski. A lot. Maybe New Zealand? I hear they won't let American Lawyers into the country. Wise Idea.

Maternal psychosis.

This story happened a long time ago in a major city hospital far far away. Much longer than Hippa has been around. So I feel I am free to tell it.

Woman comes into the ER c/o stomach cramps. She is a big lady. Big everywhere. Maybe a gallstone? Looked like she was in wicked pain. Got her into the lower risk part of the ER. Gave her a Johhny to wear and drew some blood. The usual for every patient who graces the doors of this Establishment.

The usual questions are asked; could you be pregnant? No. What have you eaten recently? Nothing much. Have you had any trauma to the area? No. How long has this pain been bothering you? 12 hours. Gets worse then gets better then gets worse.

Then in the midst of this the woman starts bearing down like she is going to take a poop. Not strange in a city Emergency room. No amount of strange behavior is all that weird in a city Emergency room. I have seen patients just get up and shit on the gurney before so I am not shocked...Perhaps I should be?

Woman becomes quite distressed. More staff is called in since woman is really losing it now and we think she might be a danger to herself or someone else.

Low and behold out comes a baby's head from her vagina. We pull off the underwear and deliver the baby. Prior to his she had sworn up and down that she was not pregnant, she could not be pregnant. That was definitely not her problem.

After the baby comes out and we say. Look here is your baby. You were pregnant! She said, "That is not mine." We had to take the baby away because it made her very anxious. She swore up and down that was not her baby. She did not just have a baby.

Would I believe this story if I didn't see it. How could a woman be in so much denial? Is it denial or psychosis. After years and years of thinking about it and asking other folks their opinion, I have found out that this is not that uncommon. One old Doc I met as a new nurse told me, "happens all the time." He totally was not impressed with it. At the time we were talking about a woman being killed and having her baby surgically excised from her by a nutcase. The Doc was amazed that the nut job could do the operations successfully. I was amazed that he was not shocked by my ER story.

Go figure?