September 1, 2008
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.