Complete previa

Every once in awhile in L&D, you have a patient come in that makes you nervous. This weekend, we had someone come in with a complete previa, and had had some bleeding a couple times at home over that last 12 hours or so. She never bled while she was at the hospital, but the on call doc ordered a sonogram to see what was going on. She was 37 weeks and some change, and they had done an amniocentesis to check lung maturity at her last doctors visit, and the lungs were immature. So they cancelled the c/s they had planned and were planning on checking maturity again in a week. Anyway, she's hanging out, and now I come on at change of shift. Both me and the prior shift nurse get to talking about the tentative plan to let her go home if the sono was fine. We were both a bit nervous and wanted to at least observe her overnight. Things can get ugly very quickly with a complete previa (placenta completely covering the cervix), and she had bled a couple times at home and was now having contractions every 3-5 minutes. Since I was the one coming on shift, I wanted to at least have IV access if she was staying because the last thing I wanted to do was have her bleed majorly, have the baby take a dive and not have IV access. Quite honestly, I was hoping they'd call for a c/s because if something did happen at 2:00 a.m., there wouldn't be an OB or anesthesiologist in house, which could make an ugly situation uglier. But, at the same time, things could be just fine. The prior nurse and I decided to give the patients doc a call, just to let her know she was here. And, much to our relief, she decided delivery would be the best bet, instead of waiting until something happened. With a previa, you never know how much blood loss you'll have. If the placenta is on the backside of the uterus, you are usually okay, but if it's in the front, where they make the incision, you can have a hemorrhage on your hands. I've seen where they've actually had to cut through the placenta to deliver the baby. Boy was that messy and scary. We started two IV sites, with 16 gauge hoses, just so if she did start to hemorrhage, we'd have to huge lines to run blood and fluids in quickly. We had 2 units on the unit and ready for use. Thankfully, the c/s went off without a hitch, the placenta was posterior and the blood loss was typical for a c/s. The baby did fine. She was breathing a little fast and was grunty working to breath, but never did need oxygen and by morning was going out to mom. I'm not usually a huge hurry-up-and-intervene-when-things-are-stable, but in this case, me and the prior nurse just had a "feeling" something would happen in the middle of the night. Now I've not been a nurse long enough to go by my instincts alone, but I think you get those feelings of foreboding for a reason. Ahh, just another day in the life of a labor nurse.

The war has begun

After one hell of an afternoon/evening/night, I am now waiting to see if all of my efforts did one bit of good in getting rid of fleas. It's overwhelming because 1.) it only takes 1 flea to reinfest, 2.) a female flea can lay up to 50 eggs 3.) the eggs are difficult to kill. I set off 3 bombs in the house, 1 on each level. They are supposed to kill the eggs, which is one of the biggest problems with fleas. I am vacuuming like a mad woman to pick up any eggs that didn't die. I also put some drops on the cats, let them stay in the garage overnight. The medicine is suppose to kill the fleas in 24 hours. I worry that because they are still alive and on the cats that somehow they will survive and take over my house again. Ugh. In preparation, I had to bag up all the kids toys (4 bags plus 3 toy boxes and 2 bins), all the baby's stuff, strip our beds and wash all bedding and blankets and rugs, turn off the pilot light to the water heater, and remove everything off my kitchen counters. After staying out of the house for 3 hours, I mopped the floors, vacuumed, wiped down the kitchen counters, dining room table, crib, and reorganized the kids toys. We decided to leave the stuffed animals in bags for awhile to make sure any fleas would starve and die. And to add to the fun, I didn't get to bed until 12:30 a.m. because Isaiah was fussing and husband decided to go to bed. Not really fair, but okay. But, then he was extra fussy and I really got 2-3 hours of sleep. And then this a.m., it took forever to relight the pilot light on the water heater so I could shower. It shouldn't have been so hard. To top it off, I work tonight, and am on call from 7-11 before my shift. I'm sure I'll be called in because I'm wiped out. I've got my last load of rugs in the dryer now, I have to rewash Clara's bedding because she peed in it at naptime (I swear she hates clean sheets because this is the only time she does this). The last thing I need to do is clean up the basement because, man, are there dead bugs everywhere. It's really disgusting. But, typing out all the things I've done in the last 24 hours makes me feel like Wonder Woman. And Wonder Woman needs a nap!

I am declaring War

I'm taking a mental break right now from clearing out my house. My indoor cats, INDOOR cats, are infested, covered in fleas. I am just sick over this. I'm in the process of removing all the kids toys, washing all things washable in preparation to bomb the house tonight. It's quite a daunting task. Thankfully one of my friends works at a vet clinic and is getting me some good stuff for the cats and the house. We didn't notice it until the cats were covered, and this morning, I noticed one on Clara and one on Isaiah. Everyone has their "thing" that absolutely grosses them out, like public bathrooms, outhouses, etc. Mine is apparently the thought of having fleas in my house. So, after my freak out, break down, I am recovering and waging war on these pesky little bugs. I will prevail.

Abdominal Cerclage

Last night, I took care of a patient that had an abdominal cerclage placed when she was 14 weeks. This was the first time I'd ever heard of such a thing. I obviously know about the usual cerclage, but this was different. If I understood right, it can be place before conception or afterwards. And it is permanent so she'll have to have a c-section. She'd had 2 second trimester losses, an incompetent cervix and a failed cerclage previously, so she went to a large university hospital to have an abdominal cerclage placed. Now she's 35 weeks, so apparently it works. Anyone else know much about these? I'd like to ask one of the docs about it or research it a bit, but I didn't have the time last night. It sounded like it's fairly new, and the patient said the doc who placed it said it seems to work much better at maintaining a pregnancy when there has been evidence that prior pregnancies were lost only due to cervical incompetence. I'm guessing it's a newer thing? But, like I said, I'd not heard of it. None of us working had. My imagination dreamed up this image of the doc making the incision, taking this big honkin' rope and just tying it around the lower part of the uterus, above the cervix, kinda like tying up a garbage bag. I've got a vivid imagination, but actually it sounds like that's sort of what they're doing. I'm curious to learn more.

On a side note, I remember my first patient who delivered before viability at 21 weeks. I bet I'll always remember how that night went, her doc, her name and he little son's name. She has since gone on to have another baby and she came in last night for a labor check with her 3rd baby at 38 weeks. I had bonded with them when she was hospitalized on bedrest. She had been 3 cm at her 20 week sono, and so she spent about a week or so on strict bedrest to try to get her to viability. I was just off orientation and pregnanct with Clara but not showing much through scrubs. She hadn't been contracting, denied any pain at all. She called at one point because she felt wet. Her water had broke. Her doc said to just watch her, because there wasn't much we could do. She told me she needed to have a BM, and I was filled with dread, worrying that it really wasn't stool she was feeling. So, I gave her the bedpan. She hit her call light within a minute or two and the look on her face gave it away: she was delivering. He was born alive, perfect, but not ready to be out of the womb. At first, she didn't want to see him. It was shock I think, but when she realized he was still alive and that she could keep him warm and next to her as he passed, she decided she did want to hold her son. She and her husband had about 2 hours with him. I saw her the next a.m. and they showed me pictures. We all had a cry together. I had typed up this beautiful poem I found on thick paper and had it laminated, which she still carries in her purse, which she showed me last night. I remember when she had her second son 2 years later. And it's was again great to see her pregnant and due anytime.

Postpartum

It seems I'm in a dry spell of good labor/delivery stories. Hopefully this weekend will be busy enough I can get in a couple deliveries. I'm more in my element I think, when I'm working labor than when I'm on postpartum. And on most nights, I would rather be working labor. Last night, though, I felt like I was in the right place that night. She had had a c-section with her 3rd baby at 35 weeks because he was measuring small for his gestational age and his amniotic fluid level was critically low. He came out screaming, small, and had the cord wrapped around his neck 3 times and a true knot. He's one lucky little boy. But, his lungs weren't mature, so he was on oxygen and working a bit to breathe. About 1:00 a.m., om was getting miserable: she was itchy beyond belief (something I really empathize with) was hurting and in need of pericare, plus anxious about her baby. So after about 1 1/2 hours, I get her itching under control, got an order for toradol (love that pain med), got her cleaned up and tucked into bed. She had been too uncomfortable and wiped out to actually get up out of bed for pericare. Part of it I think was earlier she had gotten up very soon after surgery and it was catching up with her. Her husband had gone home to be with their younger kids, so I spent a good deal of time talking with her. Anyway, she finally agreed that she needed to rest and decided to go to sleep. About 45minutes later, he baby is wearing out from working so hard to breathe and after a chest x-ray, we see he has a pneumothorax. So he needed to be transferred to a higher level facility. That of course sent mom over the edge and she spent a good 2 hours in the nursery with her son. It's amazing the strength mothers get when their children need them. We gave her time with her son, answered all her questions the best we could and she finally relaxed as much as possible in the moment. She even joked that her son would be able to say he got to fly in a helicopter as a newborn. He'll be fine after a couple days and she was very thankful just that we took the time to sit with her until her husband could find a sitter for their 2 other kids. Makes you realize that sometimes all it takes is a little time to make a difference to someone.

Random bits

Not much going on around here other than the same old stuff:

*Isaiah is still working on his teeth, although last night was back to his usual sleep pattern: asleep at 9:30, awake at 11:30 to eat, sleep until 5:00, awake again to eat and then spend the rest of the morning in bed with us. So we're pretty excited about how much sleep we got last night

* Still hate the charting tickets that are being handed out. Seeing tickets on your locker for asinine omissions just sets the tone and attitude for the rest of the shift. One found on my locker Saturday night was that I didn't fill out the first-dose education on colace. A stool softener. How petty can we get. And how much education do you really need on a stool softener?!

*Work was S-L-O-W this weekend. We have a couple orientees, which means when I'm not in charge, I have to sit back and let them do things, which is so hard to sit back and not "do". Sunday night, we only had 4 moms/baby dyads and 1 outpatients in L&D. I was in charge and had no patients for 12 hours. Very long night. Only spot of action was the labor patient G5 P3 that delivered after only 2 hours of labor. She woke up, felt a gush and thought her water broke, but it was just blood. After arriving at L&D, the girl orienting wanted me to check our her bleeding. There was a pretty good amount of blood, about the size of a large platter under her. Baby looked great, so we put a new pad under her to monitor a bit more. Five minutes later, another spot the size of a dinner plate. No history of a previa, but did deliver quickly with her last baby. So we called the doc, checked her cervix and she was 8 cm. After a nice quick delivery, the doc thought that maybe she did have a small placental abruption and that's part of the reason she went so quickly. After that, it was slow again, so I decided to read a book left by a patient a couple weeks ago called "The Shack" and managed to finish it. I didn't think it be very good, but I would whole-heartily recommend it. It's about a guy whose daughter goes missing and they find evidence she was murdered but never find her body. 4 years later, he gets a note that he thinks is from God, telling him to go back to this shack. It sound corny, but it's really very good.

*Our current Nurse manager announced she is leaving the department to head up the committee overseeing the new building construction. Mood in the department has changed.
;)

* After, oh, a week of rain we finally have sun today. Yeah! And after hearing about several people with standing water in their basements, we were glad to only have just a little seeping around one corner in our basement. Of all the things that need work in this house, it's nice to know the foundation is solid.

*Clara turns 4 tomorrow. We are taking her to a kids equivalent of a keg party: Chuck E Cheese. We're not having a huge party where we invited a bunch of her friends from daycare, but some family is coming and she'll have a good time. Its hard to believe she's 4.

The cruel world of teething

The whole process of teething seems cruel to me. I guess I don't have a better plan for how to go about getting teeth, but I don't like this system. Teeth push their way through the tender gums of a happy baby, which renders them unhappy. And in turn, unhappy parents. I'll admit, we had it pretty easy with Jacob and Clara and teething. It was actually my mom that noticed that their first tooth had come through, which was kind of embarrassing. They just never really fussed' any more than normal anyway. I guess the first round with Jacob, who was only 4 months old, he was fussier, but after that it wasn't too bad. As with everything else, Isaiah proves to be his own boy. We've been feeling a tooth under his gums on the bottom, waiting to come through. A couple nights ago, he was up, wanting to be held all night long. Fussy as a cat in a pillowcase, up every hour practically. I noticed in the morning in my half-awake state that a tooth came through on the top. Then the next day, I noticed the tooth next to it on the top coming through, and the one of the bottom. That's right, 3 teeth all at once. We figured this would happen since he's almost 9 months and hasn't gotten any teeth until now. But it's a bit miserable around here right now. We've got the whole arsenal for teething (which I'm still not sure any of these remedies really work or not) on hand: ibuprofen, tylenol, teething tablets, baby orajel, cool teethers. He's still pretty happy when he's awake, chewing on everything in sight. It's mainly when he's tired and wants to sleep that I think he's really noticing "hey, my gums hurt, I want to be held". He's hasn't been a good sleeper to begin with, and wants to be in bed with us, but now he wants to be in bed with us all night. (Although I do remember thinking he was a pretty good sleeper in the beginning.) Poor guy. Maybe they'll all come in all at once, and we'll get this whole thing over with for awhile.

We flunked kindergarten

It's been a few weeks since Jacob started Kindergarten and he's doing fabulous. I'm amazed at how fast he's learning. I tried, but failed a bit at trying to teach him to recognize/write all his letters. In just a couple weeks, he's not only mastered recognition, he can write all the letters fairly well, AND he knows the sounds. I know, I know, that's what school is for, but I'm impressed. I guess that's what teachers do. He's also making new friends, and even gets to play with an old friend from daycare at recess, as she also goes to school here. He knows when he has homework and will sit and do it without argument. So he's doing very well. Husband and I aren't so much. We were helping him with a homework assignment a week or so ago and it had 3 letters, upper and lowercase in these little bubbles. There were 4 boxes of these letters. We thought instructions were to color all the capital P's one color, all the lowercase p's another, etc. We were so proud sending it back to school that Monday. Until we got it back Tuesday, and I noticed X's through that assignment. My mom was visiting and we couldn't figure out what was wrong. Then it dawned on me: Duh, he was supposed to color the upper and lowercase of the same letter in each box. We had him coloring the same letter and case in all four boxes. I know this explanation is hard to follow, but basically we screwed him up with that assignment. Three college degrees between the 2 of us and we complicate kindergarten homework. Oops. What makes it worse? His teacher is our neighbor. So I felt pretty dumb. He also has this key ring with letters on it that he's supposed to practice writing and sound with. Once he's "mastered" those letters, we send them back and more letters are put on the ring. And we lost it. So we're really batting 1000. He did have to bring something yesterday for show-and-tell that started with the letter "N". Not easy. "N" is a hard letter. We thought for a long time, and instead of a nickel, we sent him with a Nurse bear wearing a Name tag. Yeah, that's right, 2 "n"s for Jacob's show and tell. He had the most creative "n" object out of his class. I actually find it funny that we are so worried about not doing things right. It's like bringing your first baby home; you're so worried you'll do something wrong, but by the time the third comes along, you realize you will screw up, but they'll survive and that no one is perfect. By the time Isaiah gets to kindergarten, we'll be pros. And we'll learn how to do kindergarten assignments:)

Charting tickets

All of you nurses out there know what I mean when I say I hate charting. It sucks. Really sucks when you're busy. Charting is one reason nurses never get off on time, because when you're actually taking care of the patient, you can't chart. I mean, it would just be wrong when you're baby is taking a dive, heart tones in the crapper, and you're racing back for a c-section, for you to stop and say "hey, I have to chart all of this, so you'll have to just wait a minute". So you end up having to go back, and fill in the gaps. Plus if you have other patients, that's more charting. Charting is important anywhere, but I think? obstetrics may see more lawsuits than any other department. And lately, the charting has been, shall we say, lacking on the unit for the last several months. So, after chart audit after chart audit, the system manager decided to start holding people accountable (really, you are accountable anyway) . She came up with this "ticket" system. She'll audit charts and if your charting is perfect, you get a blue ticket. If you forgot something that a coworker or she could change, you get a yellow notice, just letting you know you forgot something. If you forgot to chart something that you have to go back and fill in, you get a red ticket. Okay, I'll go along with that. But my problem is this: these tickets are being taped to our lockers, for everyone to see. I just have a real problem with that. First, everyone makes mistakes, so lets point out to everyone who comes into the locker room (RNs, techs, secs, housekeeping, nursing students) who's made a mistake. Second, I feel like I'm in grade school. We are trained, licensed professionals and we are getting issued "tickets" . With the blue tickets, after you've collected so many, you can turn them in for a prize. Come on. Are we children or nurses?! Yes, let everyone know when they've omitted something because lately the charting has sucked, but lets do something a little more private, and let's be treated like professionals. If tickets are the only option, lets be more discreet about it. Maybe folders in everyone's mailbox. I guess I'm touchy about it. I take great pride in my charting and care, and maybe it goes back to H.S. I was a good student, so anytime anyone would see me miss a question on a test, or they did better than I did, especially in math, they'd make a big deal out of it. Maybe I'm too sensitive, but man, it irritates me. Since I work weekends, if I get a bad ticket, that puppy could be up there for 4 days before I see it. Oh well, I guess it could be worse and I don't really have a great replacement for this damn ticket system.

Honesty (or lack thereof) in L&D

What an odd night last night was. It seems lately I've had quite a few patients not want to answer questions or be honest with me. They choose to stay quiet when they don't want to admit to whatever. And usually people have no problem telling me things, like the positions they find work nicely when pregnant, or that they checked there own cervix. But not lately. I had a 21 week patient last week who was high on something and wouldn't make eye contact, or admit she'd taken something. But she gave me a urine sample, so I don't know why she was hiding it. And last night, I walked out of my midnight elective induction's room to drop my consent forms off at the desk, only to find an ER RN with a patient in a stretcher. Now, they don't do that. Usually our scrub tech gets the patient, or if they think they are about to deliver, we go a-runnin' with a precip kit. But, here is this patient on a stretcher and the RN says "Dr. So-and-so said she's 6cm and 100% effaced." I thought "Sh*t, hol* f@#king hell, if she's laboring, where's her belly?" She did not even look pregnant laying on that stretcher. She was a teenager who just told her mom last week she was pregnant, and her dad found out the night before. So, yeah, they were a bit stressed. The patient really was uncooperative, too. She couldn't say when her last period was, or even how long she'd been feeling the baby move. I was just trying to get some idea of how far along she was because judging by her belly, she wasn't term. There was a doc there when she came in so he evaluated her, and couldn't get a straight answer. So he did a sono - very little fluid, approx. 32 week baby, 4cm, 100% effaced, ruptured for who knows how long. We got her admitted, got her an epidural and I proceeded to ask her all the routine admit stuff, like are you going to breast or formula feed? Circumcision? Pediatrician? etc? She said she did not plan on adoption, but she seemed irritated that I was asking her about these things. I did finally tell her gently that she had to start thinking about these things because in a few hours, she'd be a mother of a newborn baby. I also had our charge nurse who had her 1st baby at 17 go in and talk to her because I thought that might help this poor girl. She did seem to open up after that when she realized we really weren't judging her. We just wanted to make sure they were set up with everything they need. Her family was very supportive. I hope everything turns out for her and her baby. We were a bit concerned about how healthy the baby will be based on not knowing how far along she really is, how long she's been ruptured, whether or not she had oligohydramnios (too little fluid), or if the baby has any anomalies, etc. She was 10cm and at a +1 station, not pushing, but laboring down ( letting the uterus push the baby down farther, per Doc's orders) a bit when I left. I'll have to check in on her the next time I work to see how it went

Continuity of care and a 4th degree

This weekend at work wasn't too bad at all. Saturday, I had a patient come in at 3a.m. who had been in earlier with contractions but sent home. It was her first baby and she had been contracting on and off all day. She had the look and feel of a labor patient: pain, nausea, vomiting, regular contractions, pink discharge. Unfortunately, she was still only 1 cm 80% effaced. So it was the usual, watch her for awhile if she changes her cervix, admit, if not, discharge. I had hoped to give her an antiemetic, but my orders were not to unless she changes her cervix. She walked for a bit in the halls, I got her in the shower, encouraged her to change position, used the birthing ball and I rechecked her in 2 hours. I was surprised that she hadn't changed. I could have sent her home, but she was so uncomfortable and so nauseated, I thought I'd give her another hour. So an hour later, she's 3cm and 100%. Rock on. Got her admitted, zofran given, nubain given. Now it was the end of my shift so I went home to sleep. When I came back in Sunday evening, she was still there, stuck at 6 cm for the last 5 hours. The consensus was she'd end up with a c-section. She had her epidural by now. It was nice to be able to take her back as a patient, and she was glad to see me, she just had hoped to not be pregnant by this time. I recheck her in an hour and Yeah! she's 8cm. She did eventually progress to 10cm. We started pushing ( I say we because I usually end up sympathy pushing) and I noticed that she had a pretty short perineum, and I worried that she was probably going to tear pretty extensively. She brought the head down to 3+ station and the MD decided to use forceps because the baby had pretty heavy meconium fluid and was having some decelerations. She delivered a healthy baby girl, but tore a 4th degree laceration, meaning all the way through the rectum. The forceps probably didn't help, but honestly, she probably would have ended up with one regardless. I just hate to see those 4th degrees. There are people who've had a 4th degree with their first, but then opt for a c-section the second time to avoid tearing like that again. She seemed to be doing well an wasn't complaining of too much pain, but man, Ouch! When I left this a.m, she was just happy to finally have her baby and to have done it vaginally, 4th degree or no. It was a great night for me: being able to see a patient who called me her "favorite nurse" (gotta love that for the ego!) through delivery, help her get her baby to nurse well, and see the new happy family adjust to being first time parents.