Thursday, October 30, 2008

Question For All the Blog Experts...

I've seen several blogs where people say "people found my blog by searching for...X" how do you see how people find your blog? I have something that tells me who's visited my blog, but I can't tell how people find it, like what they search for and then my blog pops up? Is it something I need to add to my blog or am I just not looking in the right place?

Nursing Talk

I got a really good comment a couple days ago about nursing jargon and abbreviations, and it made me really think and smile and remember back to just a few months ago when I was learning how to "talk like a nurse" and to save my fingers when typing or writing, and since I'm a bad speller, how to save some face and just abbreviate! So I'll make a little list to maybe make reading my ramblings easier. I'm sure I'll forget something, but hopefully it will help a little!

Primip/prime - woman who this is her delivery, it is frequently her first pregnancy too. These labors usually take a little bit longer because the woman's body has never done this before. These women usually come in and have lots of questions and are really nervous, as I would be too! I like prime's because I get to really ease their worries and concerns and help them through the labor.

Multip - women who have had a baby before. Their labors are "usually" faster because their bodies have done this before. Their cervix has already stretched out once, and it just has to "remember" how to do it. They may dilate early in pregnancy and come into the hospital for delivery after walking around 2-4cm for weeks on end. They sometimes seem to get "stuck" about 4-6cm and then all of a sudden go to 10cm in about 30 minutes. As a nurse we watch them for clues that they have "made their move" and are ready to deliver. These women usually come in with fewer initial questions and depending on how their previous labors/deliveries went may be more or less nervous. Women who have only had a c-section are also considered multip's but if they had a scheduled c-section on their first baby (for breech or some other reason) and this is their first vaginal delivery, they may labor like a primip because their cervix has never dilated.

C/S - c-section. Surgical procedure to remove baby from uterus instead of pushing it out through the cervix and vagina. Women have c/s for many reasons. All the doctors I know of will do a c/s if the baby is breech. Many doctors will suggest a c/s if they think the baby may be too big to fit through the mom's pelvis. If a women attempts to deliver vaginally and she "stalls out" she will probably get a c/s, if baby goes into distress then it can be a "throw stuff around the room and get the baby out as soon as possible" c/s. Some women may choose to have a c/s simply because it takes less time and they get to pick their baby's birthday! As far as recovery, it's just like recovering from abdominal surgery ('cuz that's what it is). They haven't figured out how to get a full term baby out lapriscopically, so it's a nice straight line incision right along the bikini line. Most doctors sew up the uterus and muscle tissue, and then use staples on the skin. No sit-ups for 6-8 weeks afterwards!

AROM - artificial rupture of membranes. This is when a doctor/midwife, someone other than the baby in natural labor, breaks the bag of water surrounding the baby. This is usually one of the first steps of an induction (along with the pitocin). After the doctor breaks the water, at least at our hospital, the mom is an inpatient and not going home pregnant. Lots of women worry that breaking the water will hurt. It doesn't "hurt" any more than a regular exam. There are no nerve endings in the bag of water, so it's simply a cervical exam, with maybe a little more pressure and it may take a couple extra seconds. The cervix must be dilated enough for the doctor to at least get a finger inside of it and reach the bag of water. Usually doctors will use an "amnihook" which looks like a plastic crochet hook to simply poke a whole in the membranes. If the woman is barely dilated, they may use an "amnicot" which is like a condom that fits over one finger and has a small little point on the end to break the bag. After AROM (or after the water's broken period) women usually notice that the contractions feel "different." All the fluid that was in front of the baby's head is gone and there's not cushion between the baby's head and the cervix. Without the bag of water in the way, the baby's head is sitting right on top of the cervix and can't float back up with each contraction, and really pushes against the cervix and helps it dilate. Most women really notice that after your water breaks, with every contraction you leak a little (or a lot) of warm amniotic fluid. Some women think this feels gross, others just think it feels weird. Usually the fluid leaks for a while, then baby's head tends to act like a cork and hold it in, then as baby is delivered, all the amniotic fluid that was behind baby comes out and either makes a mess on the floor or sprays on the doctors/nurses/scrubtechs/dads who don't duck just right :)

SROM - spontaneous rupture of membranes. Same as AROM except it happens on it's own. It can happen anywhere (in bed in the middle of the night, when mom goes to the bathroom, in the WalMart parking lot...). Sometimes it's a big gush, sometimes it's just a little trickle. When you think that your water's broken on it's own, look at the clock and see what time it is, check to see what color the fluid is (usually it's clear, sometimes it can be kinda brownish), and note if it smells funny (fishy, really bad, etc). There will be a test, 'cuz those are all answers to questions we're gonna ask you when come to the hospital...

R/O SROM - rule out spontaneous rupture of membranes. This is just a way of labeling the patients who call and say they're coming to the hospital. These patients usually say "I'm leaking" or "I felt a gush." There are different tests we can do to tell if your bag of water is broken or if it's something else. The best test is to let you sit on an absorbent pad while we ask you a bunch of questions and then check to see if there's a puddle under you in 10 or 15 minutes, but if that doesn't work, we usually do an amnisure test. This is simply a vaginal swab that we put in a solution and then stick in a test strip and if there's amniotic fluid then a mark will appear on the test strip. If there's still question afte this test, we can have a doctor do what's called a "ferning" test. This is another sterile vaginal swab that is done with a speculum and is put on a microscope slide. Amniotic fluid will make a 'ferning' pattern under the microscope. The other secret is that if it "swims" under the microscope, it's not amniotic fluid, it's something else...

ROL - rule out labor. Another label patients get before they come in. Usually they come in and say "I've been having contractions X minutes apart." We'll have you change into a gown, put you on the monitor and ask you a bazillion questions about when you started having contractions, how long they last, how often they happen, when you're due date is, who your doctor is, when you ate/drank last, what meds you take, what you're allergic to, if this is your first baby, etc. If you're termish (after 37 weeks) we'll usually check your cervix, let you walk, lay in bed, watch TV, etc, for an hour and then re-check your cervix. If you've changed, there's a good chance you're in labor. If you haven't really changed, well, then it's up to your doctor if you get to stay or not :)

PIH - pregnancy induced hypertension. I could do a blog just on this, 'cuz it can be a major complication of pregnancy, but just the quick and dirty version is: for some unknown reason some mom's can develop high blood pressure during pregnancy, and this can be dangerous because it restricts blood supply to the uterus and placenta and baby. If you go to the doctor and they take your blood pressure (usually sitting straight up and after walking into the office) and it's "higher than they would like" then they send you over to the hospital. We'll take you into the room, have you pee in a cup and calmly get into bed and roll to your left side. They we'll track down baby with the fetal monitor and then take your blood pressure after a few minutes. There's something magic about the left side (or any side really), but it rolls baby to the side and off the main blood vessels in your chest and abdomen, miraculously, most women's blood pressures are fine when they get to us :) Yea! We will also dip your urine to check for protein and depending on what your urine dips and what your blood pressure is we might draw labs and check different levels. PIH is just the beginning of more serious complications that can occur if it's not caught in the beginning. It's better to be safe than sorry...always!

Mec - meconium. This is the first bowel movement that your baby has. It's usually thick and black and tarry. Every baby has this at some point (hopefully soon after it's born!) When meconium can become a slight issue is when your cute little baby decides they just can't hold it anymore and poops before he or she comes out. This turns your normally clear amniotic fluid a brownish color. Whenever a doctor AROM's a patient we note the color of fluid that we see with the initial gush, and if your water breaks on it's own, we'll ask you what color fluid you saw. If we do see meconium in the fluid, there will probably be an extra baby person in the room at delivery. The thing we don't want to happen is for the baby to take a big deep breath when their head comes out and suck in a lung full of meconium fluid into their lungs. The doctor will usually take a second and suction out the baby's mouth and nose right after the head comes out before they delivery the shoulders and the rest of the baby. They might also stick a small suction catheter down the nose or mouth down into the lungs to suck out any meconium fluid that may have gotten down there. If meconium gets into the lungs it can cause an infection just like if anything gets into the lungs that isn't supposed to be there. The extra baby person really keeps a close eye on baby and the nursery nurses will also watch extra close just to make sure baby doesn't develop any breathing problems from the meconium in the first few hours. Most babies do just fine.

LEEP - Loop Electrosurgical Excision Procedure.I had to look up all the technicalities on this one myself to make sure that I explained it right. I just learned about it myself a couple weeks ago from my favorite nurse J :) A LEEP is (from the info I got and what I was told) is a type of cervical biopsy. A small wire loop is attached to an instrument (electrosurgical generator) and when scraped against your cervix during a pap smear slices off a small amount of cells that the doctor can send to the lab to have examined. Before the procedure your doctor should use some type of anesthetic to numb your cervix before he takes the cells off (but it STILL doesn't sound too comfortable to me...) and then he will probably use some anti-bleeding devices after the procedure and you should be able to go home within a few minutes after the procedure. Where a L&D nurse has any concern with a LEEP procedure is the fact that it causes scar tissue to form on the cervix from where the cells were removed. This may cause the cervix to have some problems with the cervix dilating during labor. Sometimes the cervix will dilate just a little bit and then seem to really get stuck and it may even take some manual dilatation to break the scar tissue (some people may prefer to have an epidural or some type of pain relief before this happens). After the scar tissue is broken, the cervix usually dilates normally. I believe that there is a similar procedure, LEAP, but I'm not sure what the exact difference is (something about how it's performed, maybe one uses a laser instead of a wire, I'm not 100% sure), but I do know that it gives the same results (scar tissue on the cervix).

So there's 10 new words/phrases to add to your daily vocabulary :) I'm sure I missed one or two, so ask if I spit something out you've never heard of. All you really good L&D nurses who have been doing this way longer than I have, if I explained something wrong or you have something to add that I forgot, tell me and I'll stick it in!

29 Week Cervidil X2?

I apologize ahead of time if I miss totally obvious reasoning for why this happened, but to me it just didn't make sense...

G1 29weeks presents to L&D sometime Monday afternoon for higher blood pressures and just not "feeling right." Her mom used to be a nurse in an OB's office, so of course Grandma knows "exactly" what is going on...anyway, her pressures weren't pretty (150's/100's consistently) but since it was a busy day in the office, her doc wanted us to just watch her and treat her pressures with labatalol. Her urine was dipping 4+ protein and you could tell there was some swelling going on. Labs came back "ok" not fantastic, so doc ordered a 24-hour urine to check protein, etc. So that buys her at least a 24-hour stay. She got her first dose of steroids for fetal lung development and hung out 'till Tuesday afternoon.

Tuesday, her pressures are even worse and her 24-hour urine came back with 6 GRAMS of protein. That's a lot of protein!!! The nurse had her mag set up and ready to go, but of course it was busy in the office again and it was after 1600 before a doc had a chance to come over and actually see her. She got her 2nd dose of steroids and herr 4gm mag bolus got started late Tuesday afternoon, and then the doc decides that maybe she should be delivered sometime in the future, so they order a cervidil, with mag going on a closed, thick, high 29-week primip who had a recent LEEP procedure and has tons of scar tissue. Ok...

Wednesday J and I took over. She was still closed tight, thick as anything and way, way, way, way posterior after 12hrs of cervidil. The doc that was just walking off of being on call that night didn't order pit, didn't order a c/s for this girl who's labs were continuing to get worse, no, she ordered a SECOND cervidil. Why, why, why, why? She's 29 weeks and has had a LEEP! She's on mag which STOPS contractions, and you want a cervidil? A cervidil isn't gonna do crap!!! But the doc was going off call wanted it put in, so I put it in. The next on-call doc came over and said let's see what's happened after we draw more labs and check you about 1400, after the second cervidil has been in for 6 hours and see what happens.

So for the first 7 hours of my shift, I try to talk to the poor patient who is in a Mag fog and can't concentrate and feels horrible. Like having the flu without having the flu, just nasty from the mag. Every hour check breath sounds, empty the foley bag, check reflexes and clonus and give her her 30cc of sprite. Between the hourly checks, watch a monitor with two totally flat lines running across them: one being a completely mag'd out 29 week baby and the other being a uterus that is as quiet as my non-pregnancy uterus.

1400...uric acid level has gone up from 6.5 to 7.9, platelets and liver enzymes aren't great but still "ok" for PIH, pressures are still 140's/high 90's and guess what, she's still closed, thick and high. Absolutely no change, but not surprising since she's not had ONE contraction! The doc on call wanted to know if he could come over and he couldn't.

Can we take out the cervidil and please do a section on this girl who's getting sicker before our eyes? No, the SECOND cervidil has only been in for 7-8 hours, you know the last 4 is going to change a closed/thick/high 29 week cervix that hasn't changed in the last 20 hours of cervidil. So, after the pager has been passed through two more docs, finally the nigh on-call doc comes over at J's pleading, checks her, and guess what?! She's STILL closed, thick and high! We've had to turn her mag down because she's getting toxic and baby is still a straight line across the monitor screen.

So about 2000 last night this gal gets cut, baby ways just under 1000g, but came out screaming I guess. Mom's back on l&D for at least another 24-hours on mag and I'm guessing baby's been shipped to the big children's hospital across town. The moral of the story is that this gal was sick and she wasn't getting ANY better just sitting there. What do I know, I'm just the nurse, but it seemed to me that no doc really wanted to take over and say "look, this is what needs to happen, and I'll do it." They all wanted the NEXT person in line to have to deal with it. I know it's not convenient, and I know it's a big responsibility, and I know it takes time away from the office, but what's more important, the office or a sick patient in the hospital. I don't know, I'm just the nurse.

I guess it was a crazy night on L&D, right after that 29 week section happened, the same doc that delivered a VBAC and everyone thought that baby was a girl, and it showed up with ambiguous genitalia. All the excitement and I'm already gone and didn't get to see any of it! Is it wrong to be disappointed in that?

Wednesday, October 29, 2008

More On This Subject Tomorrow

This nurse is too tired and too grouchy and too frustrated to really go in depth about her day at work. I don't think I will ever understand why some people (in this particular case doctors) do what they do when they do it. I feel like I did absolutely nothing today, got nothing really accomplished except watching my patient get sicker and sicker before my eyes and then handing her off to night shift to section 45 minutes after I left. A section that should have happened at about 0900 this morning, and by 1500 at the latest.Let's say that at times today, my line monitoring baby's heart beat was flatter than my toco line sitting on a uterus that was picking up only breathing. The toco line was at least a little jiggly! Sigh...more tomorrow when I won't blog things I'll regret later.

Bottom line is -- babies today: ZERO

Tuesday, October 28, 2008

Add Another Baby

I think everyone on the unit today would agree that today was just a day that went on forever. It wasn't bad, it just was never ending! I had an induction, multip who went from 1-"baby" in 3'50". Not too bad! Note to docs: when the nurses who are doing your induction don't start their shift 'till 0700, don't tell your patient to be there at 0630, and then when you show up at 0705, please don't be upset that she doesn't have an IV yet and that the nurse isn't just waiting around for you to AROM. I get nervous easily anyway, and when the doc is standing in the corner of the room drumming his fingers while I'm trying to start an IV and just say "good morning" to my patient that I've known all of 3 minutes, I get even more nervous! I don't think I really got my thoughts gathered 'till AFTER delivery. Oh well, live and learn.

I ended up doing a bleeding/cramping triage later on. It amazes me how the patients we as nurses think should be kept or at least sent home with somewhat BR instructions or at least maybe scheduled for high risk testing etc the doc's send home without a second thought, but the ones who really only need hydration or a vistaril are the ones who end up hanging around for 2-3 days. This poor gal was 27 weeks, had a marginal previa, was in for her second bleed in a month, an uncontrolled GDM, etc, and after I hand-held the monitor for 20 minutes the doc said "send her on home." Ok, I was thinking at least maybe steroids and some bedrest? Oh well.

I got a ROL/SROM at 1755. Really, I think we should be able to close our unit an hour-and-a-half before and after shift change, 'cuz it's crazy for a nurse to assess and admit a patient in an hour. With a full paper chart, full computer chart, doc's to call, orders to get, IV...the list goes on. And that's just with a routine patient! Throw something crazy in and it just adds to the list. It's not "hard" just time consuming. But I was out by about 1925 and shew as all fluffed, and all the charting was done for night shift. I know what it's like to pick up pieces for someone who's in a hurry, so that's my resolve as a nurse, hand a patient over more organized than when you got them :)

Tomorrow I think we signed up for the 29week PIH gal who we're gonna mag/pit (then probably section) tomorrow. That's a mess and a half right there, but hey, get it done on orientation!

Babies today: 1f
Babies total: 25M/17F = 42
Vag:19M/15F = 34
C/S: 6M2F = 8

Baby Saver

So after yesterday, I have yet ANOTHER card to add to my wallet :) My NRP card is not nestled next to my nursing license, CPR and BCLS cards. I'm aiming to have all the letters A-Z after my name soon...haha! The class really wasn't as hard as I thought it was going to be. I was all worried, but I think I could have gotten through it and done the test and gotten in all filled out in way less than the 8 hours that it took yesterday. Oh well. My one BIG question about the class was: why did they pick instructors to teach the class who have nothing to do with NRP? One of the instructors is the educator for all of Women's & Children who does NO patient care; one works Mom/Baby every once in a while and does a lot of education, and the other is the NICU manager. The NICU manager, I see that. She does NRP stuff and has done it for years, but she taught 2/9 sections! When I saw her today I told her that we voted for her to teach it ALL next time...

J thinks I should go to nights about the 16th of November. That's soon, and that's scary. I kinda like days...

Friday, October 24, 2008

1 Shift and I'm Wore Out!

So I'm not sure why I'm tired after today, it really wasn't that big of a deal. But go figure, the first/only shift I've worked since Sunday and I just totally felt like sitting on my butt and being lazy. I knew ahead of time that we had signed up for C/S, so that thought was in the back of my head. Call me picky, but C/S really aren't my favorite. I'm not really sure why, but I just feel like the nurses don't really get involved, and I sure as heck don't feel like and L&D nurse circulating a C/S. Really, I put in an IV, play secretary/scheduler for the docs/scrub techs/and anesthesia and then stand in a corner with a mask on for 45 minutes, do my little fundal checks for 2 hours and that's that. I don't feel like that is L&D nursing in the least.

Our patients were terrific today, great couple, second baby, and finally a girl! Normal 39wk repeat C/S, but then one of the cord pH's came back nasty and last I heard baby was in the NICU getting a sepsis workup and grunting. We had a little explanation chat with mom and dad when in recovery they were saying "Oh look, she's talking to us! How cute!" Sorry, that's not talking, that's your baby trying to breath, and it's not "cute." But I think the pH was a fluke and hopefully baby will be fine by tomorrow.

Did a couple triages after our section, had a delightful meeting with the gal in charge of making sure all of our charge sheets are filled out right, etc, etc. Great afternoon :) lol. My whole family's out of town for the weekend, so it's just me and the cat! Time to catch up on some sleep and vegetate a little before my 8hr NRP class on Monday! I can't wait!! :(

Babies today: 1f
Babies total: 25M/16F = 41
Vag:19M/14F = 33
C/S: 6M2F = 8

Monday, October 20, 2008

Crazy For A Weekend!

Between the 2 12's in a row, and then babysitting last night until 2300 after I got off...I got no blogging done this weekend! Actually, for a weekend stint, it was decent. It was never crazy busy, but weekend rarely are. We had a total of 6 deliveries on my two shifts, and I did 3 of them, so 50% for me, not too bad!

Saturday morning I was excited because I got to deliver my friend from church. It was kinda fun, but it also makes you look at everything differently, and I don't know that I like that. Not only are you thinking of it in a medical way, but you're also thinking of it as "I really know this person" in brings in a whole new aspect. But good delivery, first time delivering "as a nurse" with this particular doc. They're one of those docs that us nurses sometimes roll our eyes at. At times says things that we wonder if really should be said in a delivery in front of patients. But I'm sure that I have said things maybe that shouldn't be said either, so live and learn. But this doc has earned a reputation for getting flustered. I did get some compliments from the doc through my preceptor "Wow, J, she did really good!", so that made me walk on air for a few hours at least.

After recovery A was almost over, I picked up the induction for the day that had to come back at noon after she showed up at 0700 after eating breakfast on the way for her induction. she wasn't necessarily excited when she came back after we'd already sent her home once that day. She delivered for me about 1815 though, so it all worked out ok, and I wasn't the same nurse that had sent her home in the morning so that made it a little better too. Another FP delivery, but nothing too shaky like they can be. She did have a nasty strip at times and we ended up turning the pit off, but she labored fine without it so no biggie.

Sunday it was a 37+5 weeker who SROM'd. Great delivery, and she said it was much better than her first delivery 3 years ago at a different hospital where she got a 4th degree, a vac and had "horrible nursing staff." Her poor husband said, "well, maybe one or two of them were ok" and she jumped right back in and said "no, nobody was good there." Made me a little nervous, but they were lovely and had a lovely delivery. I love it when doc's aren't in too big of a rush and let the baby sit there and really stretch out the perineum. No tears and it seems to save the baby some wear and tear too. After we moved that recovery over, all 4 of us nurses sat and stared at our board that actually had...........not one patient on it. That NEVER happens. Never, never, never, never. J said that in the 9 years she's been there she's seen the board like that maybe 3 times. So we watched football instead :)

Now I don't have to work 'till Friday!! That's what I call a good week, but by Friday I'll be ready to go back and jump back in. Guess it shows I'm still a newbie :)

Babies this weekend: 3M
Babies total: 25M/15F = 40
Vag:19M/14F = 33
C/S: 6M1F

Wednesday, October 15, 2008

No Blocks

So today I got my unblocked patient to practice all the things that all the smart nurses and mom's out there have been telling me! G4P3 age 21 was my induction stats this morning. Wowza! I'm 22, and I'm a Gzero and planning to stay that way for a while! Anyway, this gal was much more "normal" than I was expecting, and she said she'd had all 3 of her other babies unblocked and had been induced with two of them, so this wasn't a new process at all for her.

I have 100% confidence that she could have done the whole deal without me sitting in there by her bed all day, but after a few minutes of watching how the dear FOB was acting, I felt too sorry for her to leave. He sat in the recliner (all 400lbs of him), with a box of doughnuts and the comments I heard (when SportsCenter was below a dull roar) were "Want a doughnut...oh wait, you can't have one!" "Hurry up, just push and get the baby out!" "This is taking way too long, it's been 2 hours already!" "I'm tired, I've been up since 6am!" "This contraction feels good, just think that it feels good!" 'I've been waiting 20 years for this moment, hurry up already!"

So by the bed I sat really for about 5 hours. I've never done such thorough charting in my life! This gal had amazing control, and actually would fall asleep in between contractions. She was never on much pit, and got a total of 2mg of Stadol the last two hours. I was almost 100% happy with how her labor went.

Things once again seemed to fall apart right at delivery time. It was 1430 and I had taken a 2minute break after her 2nd dose of stadol and a check that said she was still about 4-5cm, to shove some food in my mouth when one of the doc's for the same group as my pt's doc finished a delivery. He was the same doc that had AROM'd for me that morning per my doc's request. J suggested that we have him check her. Now wouldn't you go figure, as I'm telling him that I had just given stadol and checked her about 15 minutes earlier and she was 5, his magic fingers appear and she's 9cm with a rim. Really? Why...

I know that's how multip's do it, and I know that's normal. But I'm sick and tired of looking like the idiot who checks her and she's 5cm and 2 minutes later when the doc's check, she's complete and has a baby 5 minutes and 1 1/2 pushes later over an intact perineum. It makes me feel like a complete moron, and I'm just sure that the docs are all getting really good impressions of this new nurse who has no idea what shes doing. I was a little surprised though even when I'm drawing up pH's and I'm trying not to cry because I'm so frustrated at myself. I know I have to get over it and know it's not my fault, that I'm always harder on myself than anyone else is and that I have to remember that I am new, and I'm NOT supposed to get it perfect every time. All those things that are easy to tell yourself after the fact but hard to remember at the time :) I know it could have happened to anyone, but why does that someone have to be me!? I should be counting my blessings that he was there to check her because once she pushed, the baby was there. I would have REALLY been in trouble if nobody had been around when she "made the move" and went from 5-complete in 10 minutes. And I should also be counting my blessings that I'm not 21 and going home with 4 kids under the age of 6. I couldn't handle that right now!

2 busy days, now I don't work again 'till the weekend. My friend from church is supposed to have baby #3 any day and she asked for me as her nurse. 1st time I've been "requested" by a patient! Now she's just got to deliver on a day that I'm working. What are the chances...

Babies today: 1M
Babies total: 22M/15F = 37
Vag:16M/14F = 30
C/S: 6M1F = 7

Tuesday, October 14, 2008

Add Another Baby..

So the goal from here on-out on orientation is more deliveries! It's gotten pretty standard that J and I each have our own patients now, we usually get assigned two, I get one and she gets one, and then she walks in during delivery or if I need something. So, it's a lot more of me on my own, which is really good for me. I had a different doc than the one I had all last week, and I was ok with that. This doc is a lot lower key and doesn't make me QUITE as nervous.

For the first time in a long time I had a not-so-nice strip to play with. Nothing too crazy, but we did get some pretty decent variables from about 3cm on, and it's a good thing she went from 4-complete in about 45 minutes. For a prime that wasn't too bad! It was good for me to get to work with the strip and try different things to try to get the variables to go away: turning, turning, checking, turning, fluid bolusing, turning, O2, etc. Looking back on the strip nothing really ever worked, but baby recovered great and had great variability and kept a decent baseline aside from the variables. They were a great couple, pushed for about an hour, and they were way happy with the results I think. Baby was really cute, lots of hair!

She was pretty set on an epidural from the beginning, but I tried some of the tips that eveyone's been giving me, and I think they worked ok. She got her epidural about 11am after a night of cervidal. She asked lots of questions and asked when I thought she should get it. I told her that it had to be her choice, that it was never "too late" to get it, but that if she knew she wanted it, not to "make herself" be 6cm to get it. I think she was happy with when she got it because she got good relief from it and got to really rest/sleep for about 45min-hr before things started happening all at once.

What felt like it drug on forever was the recovery. She delivered about 1510, but we didn't have an available nurse until shift change so she was 4 hrs out of recovery when I finally got to move her over. Oh well, at least I knew her legs worked!

Babies today: 1M
Babies total: 21M/15F = 36
Vag:15M/14F = 29
C/S: 6M1F

Friday, October 10, 2008

Worn Out wore me out! I don't really know why, but it was just intense from the start! My induction (I really do love inductions, I'm going to miss them when I go to nights...) was a multip, but you would never know it. Not in a million years. She was a typical "princess" that belonged to our "princess" doctor. The doctor is really good, but if she a) is in a grouchy mood b) just flat out doesn't like you or c) things don't go just her way, there is trouble ahead. Trouble started pretty quick...

The induction got there late, so I was late getting her IV started. She was freaked out about the whole induction thing, even though things were the same way with her first baby (also an induction). As we're walking into the room she asks me "Now what is this induction thing about, and how does it work" so, starting out at square one, it was like that all day. I really don't mind explaining things to my patients, in fact, I like it because it reassures me that I know what I'm doing. Anyway, but every little step in detail kinda wore me out after 12 hours. But anyway, there were no written/signed pitocin orders on the chart, so as I'm walking out of the room after getting the IV started and the patient on the monitor the doc's coming around the corner. I said, "Ah, I was just getting ready to call for pitocin orders." That started the fit about why the pit wasn't started yet. the gal had been in the hospital physically for less than 30 minutes. So, first bump in the road...

2nd bump in the road continued the pitocin battle, I was only at 8mu of pit and the gal was hypersteming. She was already having an anxiety attack because it was about 1000 and she hadn't delivered yet (she came in 2cm/60%). I had turned her pit down to about 6mu and when the doctor came over at 1030, there were only 2 contractions showing on my 7min screen. So I got the "why is her pit only at 6mu" grill from the doc, and then she called her less dilated than I just had so that ticked the patient off. It was just this ongoing battle all afternoon. We need an order to go above 20mu of pit, so I got that order, then when I called to let the doc know I was at 30mu, I got the order to keep going. Not without an IUPC, not on my nursing license! So that didn't make the doctor happy either.

I feel like a wimp, because to hear about my day it really wasn't that bad. But I don't like making docs upset, and it's too early to start developing bad reputations with them. But I gotta stand up for myself, right? Anyway, so then with a 1735 delivery, I was lucky to get out of there by about 1915. I'm pooped, and glad that I have the weekend + Monday off!

THANK YOU!!!! For all of the comments and suggestions about epidurals, pain meds, natural childbirth. Like I said, I have learned so much from hearing from both nurses who face the same situations that I do, and also from mom's who have been-there-done-it. Wow! After today, if any nurses have suggestions on getting along with doctors, and how to defend yourself/patient if a doc is going against a protocol, or even something that you just have a bad gut feeling about I would love to hear it!

Hope everyone has a GREAT weekend!

Babies today: 1M
Babies total: 20M/15F = 35
Vag:14M/14F = 28
C/S: 6M1F = 7

Thursday, October 9, 2008

Keep Teaching Me!

Wow, ok, I have been totally blown away by the awesome, amazing comments that have been left on my last couple blogs answering all my questions. I feel like I've learned more by reading comments from REAL moms who have done AMAZING things during their child's birth than I ever could have just by asking other nurses what they suggest. Thank you so much for all the tips and suggestions. I've ordered/looked up some of the books that people suggested, so now I'm really excited!

I think my perspective has totally changed on natural childbirth. I have felt like a horrible nurse standing there watching my patients "suffer" and "hurt" when I guess I can almost compare it to a good work out: no pain no gain, and how much more you appreciate something after your work for it. Not that you don't appreciate your baby immensely after you deliver no matter if you had pain meds or not, but those of you who can go without medical pain amaze me!

Next question (then I'll lay this topic to rest, for awhile, so I don't bore people who read this...): 2nd time moms...from what I've seen, 2nd baby labors are a lot different than 1st baby labors, simply because your body has done it before. So, those second time moms who come in planning on getting an epidural, is it ok to really encourage them to get it before their pain is unbearable, or does that cross the line of forcing it on them. As I nurse I really do feel that it's my worst nightmare to have someone WANT pain relief/and epidural and not get it because she goes from 3cm-complete in 30 minutes. I feel the worst for the multip mom's or even prime mom's who come in very far dilated, and there's no time for an epidural and they really, really want one. So, is it best to "strongly encourage" mom's who have said they would like one at some point to get a block before it's too late, or is it better to wait until they really "need" it? Keep those suggestions and comments coming...this is way better than sitting in a seminar all day trying to learn what a book suggests! :)

Funny, I work again tomorrow and I'm actually kinda hoping for someone who might want to go without pain meds, to see if I can put into practice what everyone's been suggesting.

Wednesday, October 8, 2008

Next Question for Everyone...

Thank you for all the feedback on the natural labor posts. As a new nurse, these are the things that I'm still trying to learn, so all the feedback, ideas, thoughts are great and very, very informative.

So my next question is: What are the things that help the most if you're trying to go natural, or even if you have pain meds? What are the things that you as a laboring mom want to hear, what can I as a nurse tell you that is going to make this process what you want it to be? What things can I do to let you know that you're supported? I know labor is different for everyone, but as a general rule, what works? I told a couple of the nurses the other day when I had someone "unblocked" I feel so dumb standing by her bed saying "in through your nose, out through your mouth" "keep breathing" "good job" "you're doing great" I would think that would get old after about the 2nd contraction, and if that's all my nurse kept telling me, I think I'd rather her leave! I feel funny just standing and hovering at the bedside too, but I feel like a horrible nurse if I leave and let her lay in the bed crying on her own.

So what works, what do you want to hear, do you want me to stand beside you, do you want me to go away and come back every 15 minutes to see how you're doing? What DON'T you want me to say? Do you want me to keep offering pain meds or anything after I've offered them once or twice and you refuse them? Obviously there are things that I can't do (especially with inductions, but that's just my hospital rules, not mine), but really, what things can I offer that really help?!
So I really like this feeling of being more independent. I felt really bad for J today though, I like it I get to work "with" her instead of her just "watching" me. I really, really want to know that I can do it and that I an handle it on my own, but I like to work "with" her too. Here I go getting all mushy again...haha.

ANOTHER awesome couple today, I'm getting so lucky! It was nice to have a multip after yesterday. I was so proud of my couple yesterday though, she pushed out a >9# baby about 45 minutes after I left last night. Go her!! Anyway, great delivery today. I got to do lots more patient education, which really, honestly is when I feel like the best nurse. I love it when I know what I'm talking about and can make my patients feel calmer, relaxed and informed. This poor gal, her first delivery was slightly rocky. She had a family practice doctor, a pretty big baby, she couldn't feel to push, she got a really bad 4th degree tear, a different doc had to repair the tear (because an FP can't do it), bad mec, vac delivery, pushed for 5 hours, baby was in the NICU with lots of problems for 7 days, she was in the hospital for a while. I was impressed that she was back for another round!

You could see the fear in her eyes when she walked in this morning, and the fact that she was already 4-5cm made it more intense for her. She got a really good block, could feel to push, pushed all of 3 times, was in stirrups for 5 whole minutes. I was so proud of her. You could just see the shock and awe in everyone's eyes when this baby got to stay in the room with them and she got to hold and breastfeed within the first 20 minutes. That's the stuff you remember and why I go to work every week. When I moved her over to her postpartum room she even said, "I still can't believe this. You mean he can really sleep in here with us tonight?" Wow. That makes me excited!

After I moved her over about 1300, I really sat on my butt for the rest of the afternoon. I can say it now that I'm not at work, but I was bored! The "B"word isn't allowed in our unit. Got a triage and a long term ante toward the end of the shift, but other than that...not too exciting. But a baby is a baby, and every delivery grows my confidence level!

Babies today: 1M
Babies total: 19M/15F = 34
Vag:13M/14F = 27
C/S: 6M1F

Tuesday, October 7, 2008

Au Natural

I got a comment on one of my previous posts about a precip delivery who didn't get an epidural before she delivered and who had great control vs. some patients who I see come in who don't have such good control.

"Sometimes losing control is how a woman copes with birthing naturally.
While swearing and writhing all over the bed are annoying to you, it's the
patent's birth."

I agree totally with this statement. After going back to read my previous blog, I probably should have tried to make my point a little clearer and not come across so grouchy about it. I have nothing against someone going unblocked or without pain medicine during a delivery. In fact, I admire them! Totally, 100% admire them. They have something that a lot of people don't have: mental and physical strength and endurance!

The patients that I really, truly feel sorry for are the 1st time moms, especially, who come into labor not knowing anything about what it's going to be like. Or even worse, those who come in after doing all kinds of research on the Internet or listening to horror stories from friends and in turn come in scared spitless and with a complete unrealistic idea of how it's going to go. I think the one advice I can give to first time mom's is:

1) come in with an open mind. The best way to end up with a primary c/s is to be the mom who comes in saying she doesn't even want a saline lock. As hard as it can be, trust the nurses and the doctors who are taking care of you. They aren't out to get you, they aren't out to try and dash all your hopes and dreams, all we want is the best labor experience we can give you and above all else, a healthy mom and baby in the end.
2) Don't watch TLC's "Baby Story" and expect your labor to be just like that. According to them, you can get pregnant, have a baby and be home with your baby all in about 45 me, it doesn't really happen that way! As much as I love those kinds of shows, you have to take them with a grain of salt ;)

Back to the epidural/pain meds thing; as a labor nurse, when my patients hurt, I hurt. When I seem them crying in bed from the contractions, whether they're 1cm or 8cm, I don't want them to hurt. I wouldn't be a very good nurse if I WANTED my patients to have pain! I've seen so many mom's come in and not even really understand what an epidural is, and what they've heard about makes them totally freaked about them.

Epidurals DON'T hurt your baby, they DON'T make your baby sleepy, I have NEVER seen someone paralyzed from an epidural (and I don't think any of our anesthesiologists have either), and they DON'T stop labor. Epidurals DO enable you to be able to rest, and maybe even enjoy your labor, they DO let your body relax and not fight the pain which in turn usually makes your labor progress at a smoother rate, they DO let you (hopefully) rest and save energy for pushing out your adorable baby instead of fighting and tensing up the entire labor.

My other little "speech" for new mom's is that if you come in 7-8cm, with you BOW broken and you don't want an epidural, more power to you. You've almost made it, I will do everything in my power to help you achieve your goal. Mom's who come in for inductions, I will STILL do everything in my power to help you achieve your goal, but I will tell you up front that it's going to be a little different being induced than if your body sends you into labor 100% on it's own time schedule. Pitocin contractions are different from "regular" and once your bag of water is broken, it's a whole NEW ballgame. At least at my hospital, if you're being induced using pitocin, I can't let you in the tub, and you're on a leash known as monitor cables. That means I can't let you walk the halls either :( Trust me, this isn't my choice, I would love to let you use the tub, walk laps in the halls, because I know that stuff works! I will never, never, never tell a patient that she "has to get an epidural." It's a free country!!! But I hurt when you hurt, and when I see you crying it makes me want to cry. I will do everything I possibly can to make sure that you have the labor experience you want, but I want you to be able to ENJOY your labor if you can, not spend most of it curled up in a ball crying because you hurt so much you can hardly breathe.

Limited Time Left...

Thank you for everyone's support after the JCAHO incident last week! I'm singing praises that I got 5 days off and a vacation to TN after that! Today the state Health Department showed up, thank goodness they went to visit Mom/Baby and not us!

So as I was leaving today, J told me, "I'm not so sure you need much time left on orientation." No! Don't tell me that yet!!! I WANT more time on orientation! I got blessed with another lovely induction couple, postdates by about a week. They were great! I was very, very, very sad when I left and she was just about complete after working for 12 hours to go from 1/50 and then work with her for 10 hours without a block and then she finally smiled again and I had to walk out the door! :( She almost got me to stay when I took the baby warmer in the room and she asked me "aren't you going to stay and help me?" No..............but I'm heading back in the AM so they're first stop on my list to go visit.

I was pretty proud of myself today, J walked into my room as I was lying my gal back after her epidural. J walked in, and 2 seconds later walked out again. That was as much as she saw of my patient for the day. I did it all on my own, talked to the doc on my own, got the epidural on my own, helped with the internals/AROM on my own...yup, I was proud of myself!

But I'm still not done with orientation, there are so many things that I personally don't feel ready for yet. I want to feel way more comfortable with the actual delivery part. I do great up until the time everything seems to crash down around me. It's a ton to focus on and try to do at once. If you take any time to stop and think it seems like you're behind in either charting, pushing, getting what the doc's crazy! I have the pieces, it's just putting them together. I haven't Mag'd someone yet, that's not something I'm crazy about doing, but I guess I have to learn it anyway. And as much as everyone on the floor hates it when I say it, I have yet to see any real emergencies. I've helped with some precip deliveries, but no "throw stuff around the room, run down the hall to the OR" emergencies. Not that I ever WANT that to happen, but I'd much rather see/do/help with it when I'm not expected to know what I'm doing than to have to deal with it for the first time when I'm really the one in charge.

And here's my question for Doctors; or anyone in that matter who has an opinion or an idea: if you have an induction scheduled, why do you make it hard on yourself? It seems like we have some docs who make their schedules crazy on purpose, and then get upset at us nurses when things all explode at once. Two induction scheduled on the same day at different hospitals, inductions scheduled at one hospital and clinic/office scheduled at a different location. It just doesn't make sense. I felt so sorry for my gal today, she was post dates, her induction was at our hospital (duh) the doctor had office at a different hospital, so didn't make it over to AROM my gal until after 1300. So this gal labored and stayed 1-2cm on 18u of pitocin for 6 hours with no change. After she was AROM'd and got an IUPC, I was getting 300+ mvu's and ended up backing down to 10mu/pit and she finally made some change. In my own little mind, it would have made more sense to a) do the induction at the hospital where you have your office hours (clear across town), or at least make it a point to AROM your induction (that takes all of 5-10 minutes) put in some internals and make sure she couldn't possibly need anything else until delivery before you take off. I know I'm still kinda new at this, but it's just a question. Answers/ideas are more than welcome!

Question #2: we have had OB hospitalists (laborists) for about a year now. I feel kinda weird asking our OB's what they think of them, so any OB's that read this blog, what's your feeling on them? I seem to have gotten mixed messages from some of the OB's at the hospital, some like them to do assists on C/S, some don't even mind if they do something like internal monitors or even an AROM in a pinch. Other's want absolutely nothing to do with them. You couldn't pay them to let a laborist touch their patient, but yet we hear about it if we interrupt office hours to ask for an IUPC, etc. I'm just wondering what other people out there think...

So no babies today, but I felt really accomplished. I hung in there with an unblocked primip for a good 10 hours, then got the smile after the epidural so I felt like I did something worthwhile today. I'll have to admit, leaving a patient at almost complete is about the worst feeling ever, but J won't let me work overtime...good thing, 'cuz I'm a sucker!

Babies today: 0
Babies total: 18M/15F = 33
Vag:12M/14F = 26
C/S: 6M1F

Wednesday, October 1, 2008

Our Friends...JCAHO

It was the middle of the afternoon that I thought I saw my whole nursing career flash before my eyes. Every hospital person knows what JCAHO is. Well they usually come at a time when I'm not working, and in school you don't have to deal with them. Guess that all changes now! The "mock" JCAHO people came around (we found out later they weren't so "fake" afterall...) and of course want to see all the units.

By the time they get to L&D we're on C/S #5 of the day, we have a bunch of triages and look, one labor patient on the board. Guess who's patient she is?! Someone sends me to go get J and have her talk to the group of 15 people standing around the nurses station in their business suits. J comes out to the desk and tells our manager, "I haven't touched that chart. Beckie's had that patient on her own 'cuz I've had my own two triages!" So now guess who gets to talk to Joint Commission?! Thank all the higher powers that be that I had just closed the chart after finishing it and all my computer charting. Pt had been here for 2 hours already, but of course Ms. Natural isn't just a put in the room and chart type of patient. Besides, the patient always comes first, so it had taken me 2 hours to even look at her chart.

I thought talking to doctors was bad? That's a joke after a JCAHO interview! And it's not just one or two people, we're sitting in the middle of the nurses station, with 3-4 JCAHO people, my manager, the M/B manager, the NICU manager, the chair of the department, the educator for the department, and about 5 other people, all looking at me, all expecting me to know that answers for everything! Good grief! When the interview person found out I was a new nurse she said "Oh good, my favorite!" I got drilled about boards, passing boards, how long I've been on orientation, what to do in a fire, patient identifiers, JCAHO safety standards, she made me give her 3 NURSING DIAGNOSES and PLAN OF CARE!!! I thought I was done with "related evidenced by..." guess not! The lady wanted to know all about my patient, how may kids, who was with her at the hospital, who was taking care of her other kids? My goodness. She looked at all my charting and asked how I "personalized it to the patient." I thought personalization of charting was kinda the whole point. Then she goes "show me the urine machine and the standardization log." First of all, that's the charge nurses' job, it's in her job description! But I was able to find what she wanted, thank goodness the log was on a bright blue clipboard!

After a good 25 minutes of drilling, she kinda smiled and said "I'm very impressed. This unit has stood out above all the rest. Congratulations, keep up the great work!" I have never breathed such a big sigh of relief. That was more intense than I don't know what. Poor J just kinda had to sit there, they weren't too interested in talking to her. After the big group left, both the manger and the "head manager" came over to me and gave me great big hugs and told me that I did a good job and they were impressed. I thought JCAHO was scary before, next year I'm telling them it's someone else's turn!

I should of known that things couldn't keep going perfectly when I sliced my thumb open snapping the top off of the darn lidocaine ampule before starting the IV at 0710...

One Of Those Days...

Today was a day from I'm not sure where...really, I'm not sure where it came from. When I first looked at the board today J and I were next to a primip who was 9/100/0 and a patient of the same doctor that I had my little "learning experience" with last week. Hmmm...but I figured it would be a fast delivery and then who knew what we'd get the rest of the day. I got report from the night nurse and was getting ready to walk into the room when there was a little discussion about assignments and J and I ended up taking one of the 2 0700 inductions for the day that another nurse had just taken back into the room. So we did a little switch, I gave my report and card to another nurse and grabbed the induction chart and walked into her room.

The couple was great, this makes 2 days in a row with totally normal, fun, interactive couples! I'm on a roll :) Baby came out great, she was adorable, big brother loved her, she was a bottle baby, it was a great morning. We even beat our time of 1109 from yesterday with a 1042 baby!

So working on an easy recovery, so we should be the perfect people to take the 1200 induction (who schedules an induction for 1200?). Then all the pieces click, this isn't just a 1200 induction, this is the family practice patient who's doctor is recently out of school, has delivered maybe 2 babies at our hospital and is the same patient who has come in during her pregnancy swearing that she had a "pulsating cord between my legs." Really, a pulsating cord between your legs? Ok...that's a first for me!

Anyway, all over her chart is "natural labor" "no epidural." Those patients are usually pretty intense, but this one could have knocked my socks off. It was an amazing delivery, I don't think I heard this woman make one peep besides some concentrated, steady, controlled breathing during her 2hrs of UC's. I stood by her bed for probably about all of those 2 hours just waiting for her to lose it and the screams to start. Nope, she'd breathe with the contractions, then be fine, chatting, talking to her 10 and 11year old daughters, watching her 18month old daughter run around the room and talking to the 2 grandmas, a grandpa and a husband in the room. Party city!

The only time I really thought I was going to get a little nervous was when I went out to get a warm blanket after we had just checked her, she was maybe 8/90/-1. The doctor had been hanging out at the hospital and had just come into the room, so I ran out for a sec and I come back in, the doctor and the dad are trying to get this girl up in stirrups and the doctor says "just pull levers 'till something moves." Wow. So I asked if she was complete, because that's when I'm used to putting patients up in stirrups. "No, she's about 8, but she's feeling pressure." Really, she's got a baby's head sitting in her vagina and no pain medicine on board!? So I kinda took over the stirrups part and remarkably the delivery went pretty well. Few seconds of shoulders after that head went "thud" (the "thud" every labor nurse knows and fears...) but nothing a little suprapubic pressure didn't fix! Baby was actually 9#9, and mom came away intact after one real push. I told her I wanted to video that labor and show it to all my 1cm thrashing in the bed people who are determined to go natural... :D

So looking at my birthdays today, the day wasn't too bad (other than that the last one was at 1901 and I left at 2000...). It was. the middle of the afternoon that I thought I saw my whole nursing career flash before my eyes

Babies today: 1M1F = 2
Babies total: 18M/15F = 33
Vag:12M/14F = 26
C/S: 6M1F

Newbie Nurse Blogger Award

So I was totally thinking about NOT blogging tonight because it's been a day from I don't know where and I have a flight for TN that leaves at like 0715 tomorrow which means I have to leave at 0530 to get to the airport on time. BUT, I decided that I had to tell at leas a few stories about today, so I got on and was checking out the blogs that I read every time I have the chance, and look what I found...

Birthday Nurse -- A new grad on L&D, and new to blogging! She creates a nifty running total of how many babies she has helped enter this world, and tells things from a new nurse point of view. Check out her blog, and help support her on her journey into labor and delivery nursing!

At Your Cervix is one of the most amazing blogs I've read, and it's probably the reason that I started writing down my stories too. It kept me awake multiple nights that I worked as a 1:1 aid this summer before passing my boards, and many nights after that. The stories are great, the author is a great writer and photographer and has a knack for teaching her readers (at least me...) tons of stuff through her blogging besides making me laugh!

She totally made my day/night!