Matters of the Heart

This mornings appointment went pretty good. I had to take the kids with me, which I try my darndest not to do. I was expecting the worst, but they were actually really well behaved. It was an early appointment so the doc wasnt' running behind yet, and this appointment, really was all things I could do myself at work - listening to the baby, measuring, blood pressure and weight. So it was pretty quick. Next appointment we have another US to check the heart. They were'nt able to get a good picture of the 4 chambers last time, and especially with Clara's heart history, they want to make sure everything looks good. And of course, the heart is what I worry most about. I don't really want another surprise fetal arrythmia and heart block leading to emergency delivery (although I still would like to know if immediate delivery was really necesary. I guess is doesn't matter, because Clara's fine and that's all that matters). I'd like to be prepared. Everything else measured fine, and from what they could see of the heart, it looked fine. But again, that's what we were told with Clara and they didn't bother to recheck, thus the reason I have an new OB/GYN.

Raging hormones

I've been waiting for it and it finally happened...I had an emotional breakdown at work. We have a patient who is pregnant with twins, 20 weeks, and had a cerclage placed a week ago. (stitch in the cervix) Membranes ruptured on baby B when the doc was trying to place the cerclage. She's been hanging out with us on bedrest as we try to get her to 24 weeks and transfered to a hospital with a NICU. She has such a long way to go. Anyway, I've taken care of her every night I've worked. She's stable, hasn't started cramping, bleeding, no fever, and not really leaking any amniotic fluid anymore. Yesterday morning, I couldn't stop thinking about how unlikely she is to make it another 4 weeks without getting infected, delivering, etc. She's only a couple weeks behind me, so I get to thinking about what I would do if she were me, etc and had a hell of a time getting to sleep. Last night at the beginning of the shift, we had to move her from our antepartum room to L&D because she was cramping. It was too much for me. Even though I've taken care of her and talked with her quite a bit in the middle of the night when her mind wouldn't shut off, I couldn't take care of her. It hit too close to home, I guess. She ended up being stable within an hour. This happened when I was pregnant with my second baby. There was a patient who delivered a stillborn 34 weeker and I was 30 weeks along. I cried and cried. I wasn't so bad this time, but I couldn't stop a few selfish tears. And I think that's what they were. I feel horrible for her, and pray she does beat the odds and makes it or even has the membranes around the baby seal over. Maybe some of it was for her. But most was because I worry about this little boy growing, probably because I see all the bad things that can go wrong in pregnancy. And I am grateful it isn't me. So, until I return from maternity leave, I won't be taking care of anyone who has lost their baby, or like this mom. I'm also starting to show a bit through scrubs and we try to keep pregnant nurses away from people who have or are in the process of losing their baby b/c the last thing they need is a happy pregnant woman taking care of them.
Anyway, I'm off for the next 4 days so I plan on enjoying my time away from the hospital. I did take some belly shots a couple days ago (something I regret that I didn't do with my first 2 kids) and sometime I'll get around to posting them because I love seeing other people's bellys and seeing how they grow. Just shows you how amazing a woman's body really is.

Because I like to be prepared, sometimes way ahead of time, I did some more organizing in preparation for the little bean. I went through some of the clothes I held back to see what would be appropriate. Since this little guy is going to be a winter baby, and Jacob was summer, not much will work besides the sleepers. That's okay, though. Gives me an excuse to go shopping. I also pulled out my breast pump, baby monitors, and stuff like that to see if it still worked and left it in a corner in what will be his room.
I finished the last Harry Potter book yesterday morning. I must say that they were probably one of the best set of books I've ever read. No wonder they are so popular :) Of course, now that I've finished them so quickly, I'm at a loss of what to read next!
Over labor day weekend, we are finally having the rewiring done on our house. We bought a beautiful 100+ year old house that is in excellent shape. The lower level wiring was replaced before we bought it, but the upstairs is still the old knob-and-tube wiring. I don't know much about wiring and such, but the knob-and-tube wiring I guess isn't as safe as the new stuff. But an eletrician said it wasn't something we had to do right away because the wiring is in good shape and done right, whatever that means. Once that's done, we plan on insulating the upstairs, but that probably won't happen until spring. We'll see. It feels good to get these things done.

Deep Thoughts...by nurse lochia

I've been reading a lot of posts recently about hospital births and it is a far cry from what mother nature intended. Inductions for bogus reasons, schedule c-sections for 1st time moms for LGA and the baby comes out 7 lbs., continuous monitoring, internal monitoring, epidurals, catheters, episiotomies...I could go on. All of these are done under the pretense that birth is unsafe and a laboring woman shouldn't be left alone to labor and deliver as her body intended. Yes, there are exceptions and there can be some horrible outcomes from complications surrounding pregnancy, labor and birth. But the majority of people seem to want this. The last weeks of pregnancy are uncomfortable so people want to be induced. Labor hurts like hell and people want an epidural. Almost everyone around here is on continoius monitoring. The fetal monitor strip is like a god. If the baby doesn't look good, its off to the OR for a c-section. So people think is safer to be monitored constantly, even though research states over and over that all continous monitoring leads to is more intervention and surgical births (c-section, forceps, vaccuum). Recently a patient had a c-section for a fetal heart rate averaging 60-70 for about 30 minutes. (the nurse taking care of her was busy admitting someone and no one apparently noticed the strip for 10 minutes.) She was rushed back to the OR, delivered and the baby I guess was screaming before he was comletely out of the uterus. So you wonder, was the c-section needed? I wouldn't have wanted to wait to intervene and find out, but the questions are still there. There are people who are very strongly for the interventions and those strongly against them. I find myself wondering where exactly I stand. I love a natural birth. The kind where mom comes in, actively laboring, moving quickly into transition and the she delivers without monitors, without an IV and sometimes without a MD. I hate when some nurses shout at the mom "DONT PUSH" when she's crowning and the MD isn't here. I refuse to do that. There isn't a damn thing you can do when that head is coming out and the mom's body is telling her with every cell in her body to bear down. Who am I to argue with that? But on the other side, I also like having the interventions available. For example, a mom came in awhile back for decreased fetal movement. Slapped the monitor on and the heart rate was flat, in the 90's with frequent dips down into the 60's. Oh, she wasn't in labor and was only 33 weeks. We had her prepped and delivered by c-section within 20 minutes of having turned the fetal monitor on. That baby had a knot in the cord and was dying. Apgar scores were 1, 5, 7. The cord pH was so bad that we weren't sure how exactly this little guy made it. (He is, by the way a healthy toddler today as I work with his mother.) As much as that experience was frightening, I will admit and you can call me a monster, but it was also exciting. It was the rushing around, the adrenaline rush and the feeling like you helped "save" this baby. Now I never want or desire any kind of emergency like that. I would much rather have the rush of a laboring mother delivering quickly before any interventions can be done. Maybe its the past experience as an ICU nurse that made me an adrenaline junkie, I don't know. My birth experiences make me think about this issue all the time. With this pregnancy I get to decide to VBAC, or I could c-section. I prefer the vaginal delivery, would refuse induction, would like to move around and such, but like the epidural. I keep trying to envision going into labor, staying home until I cant take it and then arriving at the hospital in transition and having to deliver without an epidural. And right now, my plan is to delivery vaginally. But, sometimes, I think maybe I'll just have a c-section and not labor. (the Labor nurse in me screams NO everytime I think about this, but it still an option.) I don't know why I consider it because even a VBAC is safer than a c-section. I've seen comments posted that c-section is safer because of uterine rupture, but whose to say that the uterus wouldn't rupture without any uterine scar? A nurse I work has only seen 1 ruptured uterus and it was on a 1st time mon with no uterine scars. Anyway, I've rambled enough. I guess when it all comes down to it, I think we do WAY TOO MUCH INTERVENING in childbirth, but I like knowing there are interventions availabe if needed.

After-work rantings

I just realized that I'm actually having weird pregnant cravings. I didn't have that when I was pregnant with the other two munchkins. I'd just want ice cream, french toast, etc, but at different times. I just got home from work and finished off a huge helping of black grapes and a bowl of ramen noodles.
I am becoming increasingly frustrated with the hospital lately. We are short staffed and something had to be done to cover holes and take care of patients safely. So the management did some creative things. Most people work 8 hours shifts and a few nurses from day shift and nights agreed to do 3 12 hours shifts to cover 3-11, which is the shortest staffed shift. But they allowed to do 12 hours shifts have only been here at most 2 years, and a few more experienced nurses wanted to do it also but weren't allowed. Not sure why. Fine. Well, a couple nurses left from night shift and since 2 of our girls are only working 3 days instead of 4, we're short more frequently. Now they want to pull these same 2 girls off of their weekends. (We're required to do 1 weekend every 4 weeks). We're already short of weekends, expecially at night. I work a weekend-option where I work every weekend for premium pay plus 1 day during the week. I am allowed 2 weekends off a year. I put in for a weekend off before the baby comes and it was denied because there isn't enough staff. Makes sense then to pull 2 people off of their weekend. So not only do I have to work with even less staff every weekend, be in charge (oh, our 2 full-time night charge nurses are gone.) which I hate, hate, hate, and not get my weekend off I'm entitled to and cant carry over to next year. Maybe management has a brilliant plan I'm not seeing. Ugh. It's getting ugly. All I want to do is be a labor nurse and take care of labor patients, with enough staff to do it safely. Anyone got any openings?!

ACO.G guidelines for VBAC

I found a link that summarizes AC.OG guidelines for VBAC and I included it at the bottom. This was the best I could find since I'm not a member of AC.OG.

Criteria for selecting candidates for VBAC include the following: (1) one previous low-transverse cesarean delivery; (2) clinically adequate pelvis; (3) no other uterine scars or previous rupture; (4) a physician immediately available throughout active labor who is capable of monitoring labor and performing an emergency cesarean delivery; and (5) the availability of anesthesia and personnel for emergency cesarean delivery.

The following recommendations are based on good and consistent scientific evidence :
Most women with one previous cesarean delivery with a low-transverse incision are candidates for vaginal birth after cesarean delivery (VBAC) and should be counseled about VBAC and offered a trial of labor.
Epidural anesthesia may be used for VBAC.

The following recommendations are based on limited or inconsistent scientific evidence :
Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC.
The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged.

The following recommendations are based primarily on consensus and expert opinion :
Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.
After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. This discussion should be documented in the medical record.
Vaginal birth after a previous cesarean delivery is contraindicated in women with a previous classical uterine incision or extensive transfundal uterine surgery.


http://www.aafp.org/afp/20041001/practice.html

The VBAC/repeat C-section debate

I've been debating the VBAC/repeat c-section route for myself since I got pregnant, well, actually before I was even pregnant. At this time I plan on VBAC, but every once in awhile, I start to worry and think maybe a c/s would be ok. I have done extensive research on this topic and thought I'd post some of my findings to remind myself of the advantages of a vaginal birth. These figures are from 1 source, but all sources I found report about the same figures. Uterine rupture is what causes the concern for a woman wanting to labor after having a c-section. The scar tissue is weaker and the concern is that the uterus will come apart at that scar during labor. Depending on the severity of the rupture, you worry about the outcome of the baby and mother.

1. The chance of uterine rupture with 1 uterine scar is approx .6% with a .018% perimortality rate; 2 scars= 1.8% chance of uterine rupture. These risks are similar to any other unpredictable risk of labor and delivery.

2. One study found that of 17613 VBAC's attempted, only 5 had babies who died due to a uterine rupture.

3. Vaginal birth is safer than a surgical delivery. C-Section increases risk of hemorrage, adhesions, anesthetic complications, injury to fetus, etc.

4. These increase the chance of uterine rupture: induction, pregnancy/labor less than 24 months after a c-section, classic uterine incision, age above 30.

Of course each person's case is different. I am on the low risk end. I delivered my first baby vaginally with a relatively easy labor and very little pushing time, I am under 30, it's been 3 years since my c-section, my incision was the lower uterine transvere (bikini cut), and my MD will not induce labor for a VBAC. The hospital I will deliver at requires that anesthesia and the surgeon be present during the labor (sucky for them) so that surgery can be done very rapidly if a uterine rupture occurs. I work with very comptetant nurses and have full faith that they would recognize a uterine rupture if it were to occur. Now all I have to do is hope that the little bean will cooperate and be in the head down position when the time comes in about 19 weeks!