Tales Of A Labor Nurse

A Duty Of Nursing I Never Expected

2011-07-28T14:58:00.000-06:00

A few years ago, a baby died in my care.

I did everything I could. We fought hard for her life, but she died anyway.

And the parents blamed me...and sued me.

This post is hard for me to write because to this day I mourn for little "Emma." I mourn for her parents and how much they wanted her; and for the relentless, sickening, violent pain forced upon them. There is nothing like the cry of a mother who has lost her baby. Nothing in this world.

As nurses we endure endless hours of training and retraining to know what to do when a life is at stake. So many times we use that knowledge and save lives...and it all pays off. But to come to a time when everything we know is useless; to try and fight and fight and...lose. And a baby dies. And we couldn't save it. What an unsurpassable defeat. It's indescribable.

And then to learn that the mother blamed me for the death of her child. I was completely broken.

In respect for Emma and her parents, I'm not going to tell the nitty gritty details of this story. My fellow medical readers will understand when I say that it involved a velementous insertion, ruptured membranes, and blood. To those of you who don't understand: it was a rare, disastrous, often undetectable situation that went as bad as it could go, and there was not a lot that we could do.

On a side note, Emma's mother came in for an induction having had a very normal, healthy pregnancy; expecting a natural, uneventful labor; and this situation is an example of why I cringe when I hear of women claiming that home deliveries are perfectly safe. They are not. If something goes wrong in labor, often it goes very wrong, extremely quickly, and although we couldn't save Emma, most of the time we can save these babies and/or their mothers if we move quickly. If you're at home, and you have to take the time to travel to the hospital when something is wrong, most of the time it's too late. Just have your baby in a hospital and quit arguing about it.

Back to my story, the parents named me personally in their case, and accused me of atrocities...and I do mean atrocities. Not only did they think I was negligent, they accused me of killing their baby. I was dumbfounded when I read the complaint. It's amazing how a traumatic experience can skew a person's memory. They not only named me in court, but they went after my nursing license, my very means of livelihood.

I went through months of interviews with the Risk Management department of my hospital. They were extremely supportive of me, which a lot of hospitals wouldn't do. They protected me when the mother demanded a meeting with me. They provided a lawyer for me who, I must say, was the smartest lady I've ever met. I had to write pages and pages of response to the parents' "Discovery" documents to answer everything from why I asked her about pain management at admission and "terrified her," to describing my hospital's policies and my understanding of them, to why I thought I had sufficient training to do my job.

Then, once that was over, I had to appear at a deposition. 8 hours of questioning by a large panel of lawyers with a video camera 1 1/2 feet away from my face. 8 hours. They questioned me on everything from each nook and cranny of the tracing, to discussing the personality of the patient. 8 hours. It was the longest, most demeaning day of my life.

But none of this was as hard as knowing that Emma died in my care...and that her mother blamed me.

The case was dropped because neither I, nor the doctor, did anything wrong. The Board of Nursing dropped the complaint against me, finding that I upheld all that my license holds me responsible for...including trying every reasonable attempt to develop a therapeutic relationship with this patient. Even though everything was dropped, and my nursing "name" was cleared of all charges so to speak, it still doesn't heal the pain and feeling of failure I felt. And it certainly didn't heal any of the parents' pain. But perhaps it filled a purpose.

For many months I desperately asked the questions: Why in the world couldn't they see that I tried so hard? Why did they think I was so unbelievably at fault and accused me of doing things I would never dream of doing?

Since then, I've come to an understanding. It's not about me. It's about Emma. It's about the parents' unbearable challenge of dealing with their grief and very deep anger over losing their baby girl. I can understand that. If I was deemed the object of their anger and they felt they were finding release and closure by their accusations toward me, then I guess I have filled my purpose...a nursing duty that I never thought about before.

Perhaps you are a health care professional facing a legal battle, and like me, you feel overwhelmed and even unsure of how you handled the situation. Remember that hindsight is always 20/20. Don't beat yourself up looking back over your actions, knowing the outcome, and thinking, "If only I..." Did you do everything you could? Did you follow policy? Did you follow your heart? Then keep your chin up and go in there and show what you know with dignity, and be proud of your plight. Perhaps you are filling a purpose too.

Up Your Nose With A...What?

2011-06-23T05:52:00.000-06:00

As a nurse in any field, from working in the Operating Room, to tirelessly braving the Nursing Home, we all have to deal with an occasional problem. This problem is one we consciously chose to deal with from the time we carried out our first clinical day in nursing school, and the ability to deal with it can make or break any nursing or medical student who first faces it. It alone, can separate the professional from the unprofessional, the heroes from the wimps.

What could this powerful obstacle possibly be?

It's the mighty force of patient odor.

There are a lot of reasons why an otherwise sweet-smelling woman can suddenly become rank during labor. The hormones, the increased discharge. The waking up in labor at 3 in the morning and rushing to the hospital without brushing your teeth and having dry mouth from all the breathing. (He He HOOOO!) The long hours of sweating and leaking.

Don't worry. As long as you are a person who bathes, under certain circumstances you just can't help it, and we don't hold it against you. We just wash you. And if that doesn't work, we have some other tricks up our sleeves to help ourselves manage it. One trick is to sneak a tiny smear of an alcohol wipe or even some essential oil (from our "natural labor" kits) under our nose or the inside of our mask so we subtly smell peppermint instead of an undesirable odor.

A nurse friend of mine, we'll call her Maggie, was having a particularly hard time one night with a patient that unfortunately went beyond the normal limits of circumstantial odor. Even after she encouraged the patient to labor in the bathtub for a while, the smell was still unquenchable. Dismayed, my friend realized that the stench was not only coming from the patient, but her husband as well. This was no problem of a sweaty circumstance. This was a long-lived hygiene neglecting disaster. Maggie was having to battle gagging and nausea because it was so bad.

Having confided in the rest of us, Maggie was at her patient's bedside when another nurse knocked on the patient's door and asked if she had a moment. Stepping out, the nurse slipped Maggie a small bottle of Vick's Vapo-Rub, a wonderful comfort for colds, and in this case, an effective stink cover-up. New hope arising, Maggie figured that if a little under the nose was good, then a whole lot is better! This was a case for a full nostril lube-up. Desperate, she took her two forefingers, and scooped up the salve...and up her nose it went.

She stepped back into the patient's room and took a breath to speak. All at once, fire went up her nose, down her throat, out her eyeballs and stifled her words mid-sentence, "How are you do....hugghhh(gasp)...innggg?"

The amazing thing about nurses is that they are Oscar-worthy actresses. It's always about the patient. Did this nurse ever waver? Did she drop her professional air during those next moments of pain and terror? Did she ever draw attention to herself even though tears were rolling down her face and her "M's" became "B's" as she spoke? ("Don't worry about baking a bess if your bebbranes rupture.") Of course not! Not her!

But that stuff don't wash off....

Yep...she had to go home.

The Birth...Song?

2010-08-18T09:15:00.001-06:00

I have to poke some fun. I really liked this couple, but I have to give her husband the "most corney" award. Please forgive a little well-meant teasing.

I had the privilage of taking care of a sweet little couple the other day. I say "little" literally because the patient was 4ft. 14in. tall, and 110 lbs at full term pregnancy; and her firey red-headed, gotee'd husband was just as small. They were quiet-voiced, enthusiastic about the world in general, and obviously very well-read in regard to the birthing process. At the time of admission, the patient's husband told me of her desire to have a natural, non-medicated birth. Cool.

So, she labored along nicely. She was doing a beautiful job, really hanging in there well. I chuckled to myself a little as she got toward the transition phase of labor and her deep breathing turned to...well...screams. Poor thing. She'd appologize every time she screamed. What struck me as funny is that it became a sort of pattern. She'd smile, scream, appologize, smile, scream...and so on.

"I really didn't expect to scream like this!" she said to me.

Finally, her husband, tongue dripping with honey, said the awarded comment: "It's OK love, screaming is just part of the birth song."

It wouldn't have been so bad except that he kept saying it: [Contraction, scream] "Love your beautiful birth song." He'd get on the phone with some family member, "She's singing her birth song," he'd say, dreamy-eyed. After a while it became quite nauseating, and as things got a little more intense at the end, I thought she was going to rip his red beard right off his face.

Even though she had such a small frame, (sometimes this worries us labor nurses about the baby not fitting through) she delivered beautifully, quickly, and naturally. Congratulations to her.

I just have to say that if this is all a song, then I've heard some real coloraturas.

That Is The Baldest Baby I'VE Ever Seen

2010-06-28T21:52:00.001-06:00

This is a story of one of my two most embarrassing nursing moments...one that I kept a secret for a long time...because nurses are perfect, you know. Especially me. (I just have to put that in there to salvage myself. That's what I'll just keep telling myself anyway.) But here it is: me, in a complete state of vulnerability just for your enjoyment.
I was reminded today of something I did as I returned to work from an extended maternity leave after my daughter was born. I had been gone for several months to attempt being a stay-at-home-mom (which I soon found out was not the right choice for me) and was thrilled to re-enter the world of moaning women, screaming babies, and miracle beginnings of life every day. I missed it more than I ever thought I would. I jumped right back in to my previous roll on labor and delivery...but I was a "little" out of practice.

I didn't realize how much until late in my first shift back. I was skipping around all day about my patient's normal progression of labor, thrilled to be nursing again and announced to my charge nurse that I was going to start pushing with my patient. I eagerly set up the room for delivery like a good nurse, checked all the recusitation equipment, layed out my prep and pads, prepared my bag of Pit....just like I remembered I was supposed to do. And we started to push.

She was a good pusher for a prime (1st baby), and as the baby came down lower I suddenly thought to myself, "My goodness, this is the baldest baby I've ever seen."

I know all you nurses out there know exactly what was going to happen.

But my ignorance was bliss. (Or at least my forgetfulness was.)

I bubbled with delight as my patient made more and more progress, but I couldn't get over the white, bald head...and so smooth! Weird. So as I enthusiastically coached and counted, I leaned over to apply perineal pressure to further investigate this myserious presentation. A contraction came. "OK!" I coached, "take a deep breath...and GO! One...two..." I coached, pressing down and leaning close to see better. "Three...four..." I touched the white, smooth...SPLOOOOOSHH! I screamed. The patient screamed because I screamed. The dad screamed. Everybody was screaming.

It was her water bag...not the baby's head.

"It's OK! It's OK! That was just the water bag breaking. Everything is OK." I played it off as if this was just how it goes...no big deal. Nurses always scream...and are always soaked to her underwear with amniotic fluid...no big deal. (I had it in my ears!)

Ugh...

Nurses do have their "off" days. One nurse I know, who I respect for her knowlege and experience above most others, had an "off" day with a similar story. She was pushing with a patient and was in wonder at how bald the baby was. After pushing for an hour, she finally realized the baby was breech and she was looking at a little butt cheek the whole time. Afterwords she confided in me. Thinking of my own story, I comforted her by saying, "Hey, we all do it sometimes..."

"Yeah," she replied, "But I should have realized it when I thought to myself that I'd never seen a bald hispanic baby before!"

(I know it's amazing, but I have other embarrassing moments too.)

Why Do I Try?

2010-06-23T23:25:00.000-06:00

You know those patients that make you just want to beat your head against a wall? The ones that by saying a single sentence can make you wonder why you even try? Let me tell you what a patient said.

But first, you have to know her. And all you nurses: I know you know her. We all have one...maybe many. She's a frequent flyer...you know...one that comes in every other day for one reason or another. This was her 17th (Oh yes, 17th) visit to the labor and delivery unit, 10 of those visits were because she thought her water broke. We had gotten to the point of referring to her by her initials.

"A. D. is coming in again."

But it's her history that gets you. You look at her prenatal records and picture a train wreck. She's 22 years old having her 4th baby, all of which have different fathers and two of which are in the custody of the state. She has a long history of ETOH (severe alcohol abuse) and marajuana use during pregnancy. She admits to smoking 2 packs a day during this pregnancy and that's after cutting down. She has late prenatal care. In fact the only reason she came in for care this time around was because her leg was swollen and painful and she was found to be approximately 24 weeks pregnant with a DVT requiring heparin therapy. She also has Gestational Diabetes...the treatment of which she is noncompliant in following. She also is on two different antidepressants (so you picture her baby coming out looking stoned) and has a history of Bipolar Disorder and a suicide attempt. Get the picture? There's more.

Her frequent complaints of feeling that her water broke was diagnosed as being Bacterial Vaginosis, or as we affectionately refer to it, BV. Translation: An infection causing copious green vaginal goo that stinks to high heaven and back. In some cases, you can smell it as soon as you enter the patient's room. She was given a prescription for an antibiotic for the condition...and we were all very happy.

But today she called the unit again. (She's on a first-name basis with all of us now so she just calls the unit directly and bypasses the doctor altogether.) Guess what her complaint was: "I think my water broke."

Nurse: "Is it any different than it was before?"

Patient: "No. It's the same as always."

Nurse: (Wanting to shake her) "So what makes you think that this time is any different?"

"I don't know," she replies. Pretty soon, here she comes through the door...with her messed up family and their crazy malfunctioning family dynamics...but that's another blog post.

After repeating the exam again...and it's negative again, the nurse asks her about her antibiotic.

"I never took it," she replies.

"Why ever not?" asks the nurse, thinking of the lurking stench coming from the speculum.

And here it is...that one sentence that threw us all over the edge:

"Because I thought it would hurt the baby."

Ode To The Night Nurse

2010-02-03T13:01:00.003-07:00

When I left the night shift recently, a very dear friend wisely warned me to “never forget” where I came from. You know who you are. Mind, your message was heard.

I had to leave my daughter crying tonight.

I hadn’t had time to help her with her homework, only her brothers.

Dinner was “fend for yourself.” Dishes were piled. School papers scattered, neglected.

We missed another school event tonight…Mommy has to work.

I worked last night. It was busy, stressful. I had been at work since 6:45pm the night before, worked until 7:30am and had to chart until 8:30. By the time I got home it was 9am and I still had errands to run. You can’t do ALL your shopping at 3am…when you can’t sleep at night on your days off. Places of business are very limited at that time. There were bills to pay. Sleep is only for the lucky. Once I finally lay down I fell like a rock, hard and deep. I’d overslept and the kids were home…on their own again. Struggling to “keep it down ‘cause Mom’s asleep!” So I stumbled through my shower and tried to listen to my kids tell me about their day with really nothing going on inside my head to retain anything. They could be telling me that they were shaving their head and moving to Amsterdam for all I know.

Coffee. Where’s the coffee…

My husband gets home and out the door I go. What will be in store for me tonight? A high census? Call-ins? Or worse… Will a patient’s life be in my hands tonight?

We get good at being our own resource. There’s no one there to ask for advice. No managers, no educators. We’re on our own. The Doctors are asleep in their call rooms and really don’t want to be bothered. In fact, we are so used to being barked at in the throes of half-unconsciousness that we think it’s how everybody just talks. We are given extra freedom to go with our gut…whether that’s good or bad, I don’t know.

What does the night shift do? Sometimes I feel like we are the ones who babysit the unit while the day shift is away. The night shift is an afterthought. There’s no food for sale at night because apparently night shift workers don’t eat. There’s never any meetings in the middle of the night because that would be absurd to call a meeting at 2am. (But isn’t that what you’re doing to us when you mandate us to be there at 2 in the afternoon?)

We get the crazies, the drunks, the sundowners. Nothing is ever scheduled, everything is a surprise.

The clinics aren’t open so you never know what you’re going to get. We wonder what in the world would bring you in to the Labor and Delivery unit at 3 in the morning for an aching hemorrhoid that you’ve been having trouble with for 4 days. What? Do you hear all these screaming women?? And you’re annoyed that I am in a hurry when you spend 20 minutes telling me about it? Of course I am! What about “Labor and Delivery” says a place to get my swollen butt looked at? You couldn’t wait 5 more hours to go to the clinic? I digress.

We are sleepy, but we are working hard. We are overlooked, but we are faithful. We are lonely, but united. We are irritable, but knowledgeable. We are independent, but deeply depend on each other. We work in the dark, but our humors are light. We all know what the “4am chill” is. We wake up, pep up, stay up, to try to keep up. Our stomachs are bloated, our bladders are full.

Life goes on without us, and we go on when life settles. We function in darkness, even in the daylight. Our light at the end of the tunnel is the tip of the sunrise. We have found ourselves driving into our driveways with no memory of ever driving home. And we have people’s lives in our hands like this every day.

I couldn’t do it anymore. I had to make the decision to leave the night shift because of the toll it was taking on my health. Who wants an unhealthy labor nurse? My children were suffering. In my 14 years of working nights off and on, I never really got used to it. It never became easier. I admire those of you that just have some God-given ability to do this. I don’t have it. I’ll miss you, though. The conversations that go on at night are unforgettable. You’ve made me laugh when I’ve been at my very worst. Thanks for everything, and I’ll never forget you. You truly are the “hard core” of nursing.

Solace Dilemma

2010-01-01T18:21:00.003-07:00

When I was first finished with my training on L&D, I had my eyes opened to a very deep and serious reality of life…and labor nursing. I arrived on my shift to review my assignment and found that I would be caring for a woman who was 22 weeks along (a little more than half way.) She had learned that day that her baby had very serious brain, kidney and heart defects that weren’t “compatible with life.” The woman and her husband, having had extensive counseling by her perinatologist and physician, decided to come to our unit to induce labor to end the pregnancy. The charge nurse told me, “This baby won’t even survive labor.”
“OK,” I thought. Being relatively inexperienced at the time, I considered the anomalies so severe that this would not upset my beliefs. The baby’s life is lost. It’s hopeless to expect anything more than death; whether that occurs now at preterm induction of labor before viability, or to bear to carry this baby to term along with this grave anticipation for weeks longer and have it happen then. The latter would be too much for a person, wouldn’t it?
So, I cared for this dear woman that night. I began infusing Pitocin. I’d never cared for a woman who’s baby would be dead. I struggled so hard to know how to act. Do I smile at her when I introduce myself? Do I offer my condolences right away…or wait until it happens? Do I go on with business as normal to spare her pain? I found myself feeling very awkward. She and her husband were very numb. Their affects were as flat as ice. Who could blame them? There were no tears. Not yet.
Labor carried on quite quickly actually. In fact, very suddenly the woman was exclaiming that the baby was coming. We hadn’t monitored the baby’s heartbeat (a moot point, isn’t it?) After all, the baby would not survive labor. I called the doctor for delivery right away. But the contractions overtook the woman and I found the baby suddenly in my hands…gasping…and moving its arms and legs. I was in utter shock that the baby was alive. The father cried out, “Oh God! She’s alive!” and let out a cry that only comes from someone who is watching their child die. It’s beyond agonizing. The mother, paralyzed, was silent.
I feebly carried it to the warmer to wrap it and watched it gasp and struggle in my hands, helpless to control my own emotions. The baby’s heart beat for 20 minutes before it died. We, with all our technology…and arrogance…did not dictate or preconceive, or control, the time of death. We never will.
This couple wasn’t warned properly of what they might expect. Unfortunately, me being so inexperienced at the time didn’t help them. Of course any baby that is induced alive may be born alive, more often than not.
But what I took from this experience and held ever since is that we shouldn’t be deciding when a baby dies. That’s not our decision to make.
My nursing friend has a friend with a beautiful story. She, like the woman above was faced with certain death of her baby with life-threatening anomalies discovered at 20 weeks gestation. She was counseled to end her pregnancy and try again. But she decided not to. Her perinatologist actually told her that she needed no further prenatal care if that’s what her decision would be…that there was no need for him. She dealt with a lot of opposition about her decision to carry her pregnancy. But she just couldn’t end her baby’s life herself. She carried the baby for 20 more weeks.
Although this time was painful, knowing what would happen, she found herself bonding with her baby in utero. She played little games with her by pushing and feeling the child push and kick back in her womb. She and her husband took every opportunity to make the most of that time. When she finally went into labor, she described feeling like she knew that little girl so well, and loved her. When the baby was born, she and her husband held her for two hours until she died quietly in her arms. She says, “I feel like I sent my little angel to heaven.” She says that she will always treasure that time she had with her daughter, and she never regretted a second of that decision.
I, after caring for my patient, had to deal with my own guilt. I, after all, gave the medicine to induce labor. Does that mean that I killed that baby? No, I don’t think so. That will be between me and God. But what about my duty as a nurse? Just because a couple is doing something that I don’t agree with doesn’t mean that they don’t need care. In fact, they need it more than ever! I can’t abandon them!
This is why I have voiced my own position to my employer about these cases. My personal solution to this is to care for these dear patients that deal with such a hard time, but I won’t manage the Pitocin (or other induction agent.)
What are your thoughts? Stories?

A New Perspective

2009-12-03T12:26:00.004-07:00

I’ve been away for a while, obviously. Fate would have it that I became ill about a month ago, and I had to put aside being the nurse and had to become the patient. I haven’t been a patient since I had my children, and even then, I wasn’t sick like I was this time. Truly, I have a changed perspective on things, especially what kind of nursing care was helpful…and what wasn’t.

One thing I noticed is the moment I needed something and pushed the “nurse call button,” time slowed down. Each second was at least 10 seconds long, and each minute lasted about a half hour. I was lucky to have been in the care of fabulous nurses and aids that I never had to wait more than 5 minutes, but those 5 minutes were torture.

I also had a nurse who was very witty, high spirited, energetic, and unfortunately not very tuned in to taking me seriously. It made me feel like he didn’t think I was truly sick. Normally, I would have liked him very much. (And I want to stress that I really do think that he was a neat person.) But lying in that bed feeling awful, it was hard for me to keep up with him. I felt like I had to laugh at his jokes and be entertaining when I felt like dying. I also would go for hours without seeing him. I know that med/surg nurses are insanely busy, bless them, but, you know, check on me sometimes! He also came into my room and gave me Tylenol that another patient had asked for. Whoops! That could have been bad. Luckily it was just Tylenol. He was also late bringing in my medicine. In fact, I had to tell him it was due. But the point is this: A nurse has to be in tune with what is therapeutic to a patient at the time. Jokes have their place, but they are not always appropriate or helpful. What’s most important? Trust. A patient has to know that she is in good hands! Otherwise therapeutic progress is nil. Instead the hospital stay is more stressful on the patient than it is already. And how is a patient supposed to be “well” in that type of circumstance?

I had another nurse who was fabulous. What made her this way? She made me feel like I was her only patient. She made me feel like she was concerned about me. She anticipated my needs before I had to ask. It wasn't because she was perfect. She, like the other nurse, brought in one of my doses of medicine late, but she directly addressed it, making a plan for the next dose. She was honest about it, so I trusted her. She also knew when to let me rest, and when to have conversations with me. She paid attention.

Furthermore, I experienced the uncomfortable beds, the constant noise, the interruptions all through the night; the difficulty with maneuvering all the IV lines, cords, and whatever else, making it hard to move. I experienced the cynicism I felt when every person that entered my room had to listen to my lungs. I had to tell my story of my illness for the 400th time…and then my entire health history for the 500th time. I learned to appreciate it when an off-going nurse gave a good report to the current nurse because she/he would not ask me to repeat everything. (And I felt like they all were listening to me.)

Now don’t get me wrong. I was a good patient. I was nice to everybody. I didn’t scream when they had to restart my IV four times, and shoot saline up my nose in the middle of the night. I was appreciative of everyone just because I knew what they were going through.

Now I know more of what the patients are going through, and it will challenge the way I practice.

On My Soapbox About Epidurals vs. Natural Childbirth

2009-10-07T01:48:00.014-06:00

OK, its time to talk about epidurals.

Last week a woman came in having her third baby. With her other two deliveries she had delivered without any pain medication. Why? Her reasons were the same as any cross-section of laboring women who make this decision: Epidurals inhibit breastfeeding and bonding. Epidurals slow the labor process. Epidurals have risk of spinal cord injury. Epidural medications cross the placenta and get to the baby. Epidurals mean weakness. "My mother and grandmother didn't have any pain medication so by god I'm not either!" Epidurals take away the ability to push. Etc, Etc. But it seems to me that the biggest reason is that there is a common belief that giving birth without pain medication is some sort of spiritual or emotional right of passage that proves worth as a woman. As if you are less of a mother if you "cave in" and get help with the pain. And if you succeed, it's some sort of bragging right. There are even those that say they do it because it's what's best for the baby...but this just shows their ~~lack of knowlege~~ need for further research, especially coming from the counter point of view. A broader picture is in order, and if it is not sought, the literature can be a disservice to women. ~~All of the above excuses show their lack of knowlege, and the people who promote these views are doing a great disservice to women.~~

Now, don't comment back to me with "studies that prove" any of the above. I can counter you with just as many that disprove them. Anyone can prove anything they want to prove in these types of studies. They're flawed. For every woman who has one of the above troubles, there is another that doesn't. It has nothing to do with the epidural. And don't tell me that the epidural poses risk to the the baby. Childbirth causes risk to the baby! That's not a valid arguement.

But back to my story, the woman who had two natural deliveries before decided to try an epidural this time. She recieved her epidural at the time that she was feeling more pain than she wanted to. She took a nap and later visited with her loved ones during her labor. When it was time to push, she was able to wait until her sister arrived from out of town so that she wouldn't miss the birth. She pushed twice, didn't tear, and had a beautiful controlled birth.

"Oh why didn't I have an epidural for my other ones?! This has been so great!" She said this as the baby was placed to breast at 10 minutes old, having been skin to skin with her since the moment of birth.

Yes, some experiences are more difficult than this woman's. And some dramatically more so. But what a gift was brought to her by having that epidural. Consider her peaceful and controlled experience.

Regardless of what my own view on the matter is, women will choose to labor naturally and that's fine. But it shouldn't be decided upon because of one of the above reasons. The ability to give birth without drugs is as varied as the vast selection of human personalities and experience. For example, a young teenager, shallow, flighty, and inexperienced, having her first baby, told me that she wasn't going to have any drugs. I couldn't help but think that she wouldn't make it through the first five minues of strong contractions...especially because she didn't have anyone there to help support her. She was alone. She gave birth without even a peep. Then again, another woman who came to have her 3rd baby was very confident in her ability for natural childbirth. She should have been, for she was a hypnobirthing instructor--the poster child for medication-free childbirth. She'd had two natural deliveries before. Turns out, this time, she was begging for an epidural at 8 centimeters. You never know what's going to happen, or what you'll be able to tolerate. Every experience is different...even within your own experience.

My point? Don't be decieved by all the misconceptions about epidurals, and don't limit your options by closing your mind to the fact that you might need something for pain. You wouldn't go through surgery without anesthesia...so what's the difference? There is something the size of a watermelon ripping out of your body through a hole the size of a celery stick. No one is giving out awards here. Let us as a society have some common sense!

One more thing...and this is where I become a bit angry (as if you couldn't tell this is a subject that already gets me heated up.) Understand that those of us who work in labor and delivery are required to have a lot of education on the matter. We pour ourselves into education and constant improvement so that we can be of most help to you and ensure the safety of your baby. We love doing this. Most of us have been a part of many thousands of deliveries. We have seen a lot. So don't come to see us with a chip on your shoulder and intend to tell us how to do our job. Don't tell us that you don't need an IV. Don't tell us that you don't need the monitor. Don't think that because you've researched the "literature" you somehow know more about our job than we do. Because when you hinder us from doing the best that we can do, you force us to put our license on the line for you. Because when things go bad...and they do...we are all of a sudden responsible, and even legally liable for your decisions. And that's not fair. If you absolutely cannot trust us, then maybe you should consider a home birth. And I could never recommend that with a full conscience.

If you want an unmedicated delivery, then we will commit ourselves to help you, we will cheer you on, we will do everything we can do to make your experience as great as it can be, and keep you safe at the same time. At least trust us on that. And if it turns out that you need help with pain...who knows? Maybe you'll decide you LIKE the epidural.

Cheetoes and Childbirth

2009-09-10T23:56:00.006-06:00

As long as we're on the subject of false labor, I have to point out that even though we do all we can to thoroughly examine you, and ensure your safety and your understanding of when to return; on occasion, an unexpected precipitous labor can occur. Understand that we have no crystal balls to indicate when true active labor will begin, and how fast it will go. Unfortunately, we, too, are human just like you. Here is a story that will show that quite well:

When I was first training as a nurse in OB, I had one of the best teachers of the field, in my opinion, of all time. We'll call her Adrienne. Adrienne tried to show me at length the ins and outs of recognizing the difference between the "feel" of a woman in true labor and the "feel" of one who wasn't.

One night a fairly flighty hispanic 16-year-old came into the unit reporting that she thought she was in labor. She walked in with an array of followers including her fellow capricious teenage friends and an assortment of extended family members. But it wasn't the crowd of people that struck me. It was the fact that she sauntered into the exam room munching on a large bag of Cheetoes. Even after she was changed into a hospital gown and we were interviewing her for her health history, she never ceased to chomp on her obnoxious orange snack.

After a reasonable amount of time, it was determined that her cervix was not changing, and we prepared to discharge her home. We started to explain that she wasn't in labor.

"But the contractions are strong (chomp, chomp)," she was saying between Cheetoes. We gave her an exented education of what to expect in labor and when to call her doctor. As we were explaining things to her, her Spanish-speaking-only grandmother kept interrupting and gibbered off angrily in Spanish to which the girl jabbered back. The grandmother was clearly upset at us. We continued our exhaustive explanation of things to expect and when to return. The girl never stopped eating her Cheetoes.

"Is there a question we can answer that your grandma might have?" Adrienne asked politely.

"She just thinks that I'm in labor and you shouldn't send me home, (chomp, chomp)" the girl answered. "So how do I know when to come back? (chomp, chomp)" she asked, after we had just been through a long discussion of the answer.

Defeated, Adrienne answered, "Honey, when you can't eat Cheetoes anymore, come back."

So they left, the grandmother shooting us devil eyes all the way down the hallway and out the door.

Two hours later, we received a call from the ER that an ambulance was coming with a 16-year-old who delivered at home. OMGsh, it was our girl... Just as Adrienne hung up the phone with the ER, the elevators opened with the EMTs delivering our patient. And out in front darted the vengeful grandmother with fire in her eyes. Adrienne dove under the desk and avoided the hell-hath-no-fury grandmother's gaze.

And there was our patient, being wheeled by on the gurney, with her baby in one arm and a bag of Cheetoes in the other! (Chomp! Chomp!)

False Labor on Labor Day

2009-09-07T17:04:00.006-06:00

Its the weekend. Not just any weekend...Labor Day weekend. And yet, I find myself laboring on this Labor Day...in a labor ward...how ironic. A couple of ladies came in tonight, and otherwise we were quite peaceful. But I have to mention some things about one of these particular patients because, like so many others like her who make the same mistake, she was very disappointed to find that she wasn't in labor and was sent home.

First of all, when you are frolicking down the hallway toward the labor nurse's desk to happily announce, "Hi! I'm here to have a baby!" with a big smile on your face-- that might be the first thing that lets your labor nurse suspect false labor. Let me explain: labor hurts. Sorry, I can't lie about that. In real labor, most likely you will have to stop walking during a contraction. You will not be able to talk through it. It will make your breathing change or you may be tempted to hold your breath. Real labor contractions change your mood and your ability to socialize with others. Now I am NOT saying that you won't be able to cope with it, but it will be intense enough to command control of you.

This same patient, after calling in all of her kin folk to take part in the blessed event, introduced her sister as "a doctor without a degree." I don't know what that means. But when the RN examined her cervix finding it to be one centimeter dilated and thick (50% effaced) with the baby not even in the pelvis yet, that sister exclaimed, "Well that doesn't mean anything! We're going to have a BABY!" So, the RN with two degrees explained to the patient and the doctor-without-a-degree that with a first baby, this MAY indicate that labor hasn't begun yet. The plan of care was to observe her over a period of a couple of hours, have her walk awhile, and re-examine her cervix before concluding anything. After all, labor is defined as "active cervical change."

While the nurse was explaining this, she noted contractions being traced on the monitor.
"Have you had some contractions since we've been talking?" the nurse asked to assess the patient's perception of the contractions.

"I think so!" she answered with wide eyes. "They got to 5 minutes apart at home!" However, the nurse noted no change in her behavior during these contractions...the second sign to us that might indicate false labor.

You see, typically, real labor requires painful contractions that are persistent. And if you're not sure if you're contracting, chances are that its not time to come to the hospital yet. Also, we like to see you when your contractions are painful AND about 2 or 3 minutes apart. Surprising? Well, with your first baby this is typically what we will tell you. If you've had a previous vaginal delivery, you may want to come on in when the contractions are painful regardless of the timing. Either way, PAIN is the key here.

So to tell you the end of the story, the woman and all her family followers were sent home. But, fortunately for her, she returned the next day presenting in active labor and had a beautiful birth. But sometimes these types of false contractions can continue for days or even weeks before true labor begins. If this happens to you and you are wondering if you'll know when the right time is to come in...let me tell you this: the contractions that weren't changing your cervix will change into contractions that will. You are going to feel different. You will know the difference, I promise you.

In any case, always report contractions to your doctor. Make sure they know what is going on with you and please don't go by my words alone. If you are contracting, you need to be evaluated either by phone or in person by your provider. And as always, if in doubt, come in to the hospital to be evaluated. It's better to be sent home than to find yourself in a situation you don't want to be in. Be safe.

Here's To You, Dad

2009-07-26T05:32:00.001-06:00

I mean no disrespect toward nervous expectant fathers. I just want to acknowledge you and your plight. It must be difficult being use to knowing what to do to take care of your family, your wife, your home, being the go-to guy for it all, and then having your wife go into labor and suddenly you become the novice. You just want to make it all better. I mean, that’s what you’re good at, right? You have a problem, and you solve it. Now, you have to see your wife in a terrible amount of pain (and after all, you’re the one who caused it) and you can’t make it go away. But you try to make up for that by being the hero…crashing through the doors of the labor unit announcing, “My wife is in labor!” You have made a list of every contraction she has had over the course of the last 4 hours including what time it started, and how long it lasted and present it proudly to the nurse. You carry all of the suitcases, pillows, cameras, baby books, boppies, etc. like a packhorse all the way in from the parking lot. You call all of the family and announce, “Its happening! She’s in labor!” You count, you massage, you hold up her leg, you coach, you encourage, you pant, you hold puke buckets. (Some of you even pass out.) No wonder we women love you so much!

Here’s just a couple of things that nervous fathers have done that made me chuckle:

A husband rushes out of the patient’s room announcing, “She’s shaking! I mean, she’s not turning any funny colors or anything but could someone come help her?” What I wanted to say: “Oh, that’s a relief, because if she was turning orange or polka dotted we’d be really worried.” What I did do: Rushed to the patient’s side, took vitals, checked her cervix, and reassured that shaking was completely normal in labor.

A husband exclaims, “But if you break her water how is the baby gonna breathe?” Ummm…the baby doesn’t breathe until it’s on the outside.

A husband is trying to comfort his wife through contractions. I could see the wheels turning in his head, “Now what was that they said in that class?” Her next contraction came and he started counting, “One…Two…Three…” He counted through each contraction and I could see the look of determination in his face. He felt like he was being of help so I wasn’t about to tell him that we usually save the counting for pushing. Who am I to burst his bubble? It gave him a mission. (But I don’t think it helped his wife much.)

A husband stands at his wife’s bedside as his baby is born. The doctor hands him the scissors to cut the cord and shows him just where to make the cut. We wait…he’s holds the scissors near but makes no cut. Again she tells him, “Cut right here.” Nothing. We look up at him just in time to see him fall backwards, stiff as a board, and bounces his head on the floor…still holding the scissors out in front of him poised to make the cut. He passed out cold.

A husband, who has been especially “heroic” during his wife’s labor is helping to hold her leg up while the baby is crowning. He is very excitedly encouraging his wife saying, “There he is, honey! I can see his head! I can’t believe it!” To our astonishment, he bends over toward the crowning head. I thought, “What is he doing? Is he trying to kiss the baby?” Then I realized he was not with us. I pulled him back to keep him from falling on the doctor and the sterile area, and he slumped to the floor. He was unconscious for the delivery. That will be a good one to write in the baby book.

A Perfect Child

2009-07-25T22:02:00.003-06:00

The time that the baby would be born was approaching. I looked at the father and couldn’t help but smile to myself. He was so nervous, so excited to have a son. He kept looking at the patient…the love of his life…so caught up in the emotions that come with having a child together. Their first child. When she was hurting he would encourage her gently and sweetly. “I love you so much,” spoken softly into her ear, “Our baby’s coming.”

The two of them-- a picture of perfect health, athletic, active, tan, mid twenties-- made me think of triathlons, and extreme sports. They were endearingly naïve, yet eager to live life. She had labored without pain medication and had held up like a fortress wall with him supporting her. Even in her most painful moments she remained sweet and mild, ever grateful for our help and advice. I found myself instantly attached and involved with this couple from the moment they arrived. I couldn’t wait for the big moment for their sakes—they were so in love with this baby together.

When the baby came out, the doctor placed it on the mother’s abdomen. The mother, breathless, embraced the baby and the couple cried, completely overtaken with joy. I tried to not intrude as I dried off the baby and changed its blankets to dry ones. All at once, the infant let out a wail, feeble and high-pitched. The sound of it made the new parents laugh with satisfaction.

“Look at his chubby little fingers!” the mother noticed with delight. The infant’s fingers were grasped around my knuckle as I listened to his chest with a stethoscope, counting the swishes for his pulse rate. I opened the chubby fingers to show the father, and ran my own finger over the single crease in the tiny palm.

“Let me take one more good look at him, here,” I said as I turned him. I couldn’t help smiling. The baby was beautiful, skin pink as a tulip, eyes like onyx—narrow and slanted. His tiny tongue, pink and pointed, protruded expectantly. “I think he’s ready to eat, Momma!”

After assisting the mother position him for breastfeeding, I turned to look at the couple. They were still high with the significance of the moment. “You have a beautiful son,” I said as I left the room-- I was completely sincere, “Congratulations.”

The doctor joined me as I started walking down the hallway. "Are you calling the nursery?" he asked.

“I’ll do that right now.”

At the nurses’ station I picked up the phone and dialed the Neonatal Nurse Practitioner.

“Hi Judy,” I said grimly, “I have a baby in labor room 4 that I need you to come and check out. It looks like he has Down’s syndrome.”

Cookie Surprise

2009-06-23T02:40:00.003-06:00

Many times, patients have brought us treats as gifts of gratitude for the care they recieved. I, as well as the majority of other nurses that I've ever met are exceeding grateful for the gesture. Having worked hard through several hours of chaos, seeing sweets on the break-room table is a welcome reward for our efforts. Usually, the physicians, nurses, and technicians swarm over the plate without ever inquiring of its origins, they were just thankful for the rush of glucose through their bloodstream to keep them going another few hours.

But there were a small number of staff who have sworn to never partake of something homeade saying, "You never know where its been!" Most of us never really heeded their words of warning. But one fateful day when reading the card attached to the plate of chocolate chip cookies that the staff had been snacking on all shift, I read the name on the bottom of the card to see what patient or staff member was so kind to go through the trouble of feeding us. To my horror the card read, "...we were very grateful that your staff is so open to promoting healthy breastfeeding practices. As a token of our thanks, please enjoy the cookies lovingly made from my own supply of breastmilk..."

Lesson learned.

A Day In The Life

2009-05-17T01:16:00.003-06:00

The following is an excerp from a short story I was working on. I had to cut this part because it was too much about the nurse's opinions and didn't help to move the story along, but I thought it would be something you might find interesting. It describes the end of a typical busy shift as an L&D nurse. Don't be too judgemental...it was a first draft. Although the story was fictional, this description is accurrate to reality....

Finally, it was almost 6:00 in the morning. I collapsed into the stiff office chair at the nurse’s station and rubbed my dry, tired eyes to attempt to focus so I could do my charting. The night had been difficult. Our maternity unit had ten labor and delivery rooms. I and 3 other nurses managed to keep them filled all night. As soon as one patient would deliver her baby, and we could transfer her out of the Labor and Delivery department, another patient would come in. It was not for trivial needs, either. They were all women in full, active, dramatic labor.

A cold front had come over the mountains from the west bringing rain. Wet, cold fronts always make women go into labor. They say that there is no evidence to prove this myth, but I know without a doubt that it’s true. I saw the weather report last night and knew that I’d better eat before I came because I would likely not get much of a break tonight. A 12-hour shift can certainly be painful, especially with no break. There’s a joke that goes around about nurses: that if we ever died and went through an autopsy, we would easily be recognized by our empty stomach, full bladder, and something about our backside being chewed.

I tried to concentrate on my task at hand but distractions made it difficult. It got to be somewhat loud on the ward with the cries of the women in the labor rooms. We had an anesthesiologist working fervently, trying to keep up with the requests for epidurals, but with so many patients in need all at once, his services were spread too thin.

Other people would probably consider us disturbed—to be able to sit at the nurse’s station casually going about our tasks and having our friendly conversations with each other—all the while surrounded by cries of agony. We are deaf to them out of callousness. It is a necessity to have such an attitude.

Only one hour left until the day shift would be here. Usually, we could get our paperwork done during the course of the shift but on nights such as these, when our patient care had been so demanding and intense, it wasn’t until we relinquish the care of our patients to our relief nurse that we could finally focus on documenting everything. So, before me sat all my notes for the night: medication dosages and vital sign figures scrawled out on a paper towel; physician orders written on the leg of my scrubs; anything else that I could scribble down in a hurry on anything I could find on a moment’s notice. Of course any good nurse masters the art of conducting her care and keeping her charting caught up throughout the shift. Unfortunately, I hadn’t been able to keep up tonight.

I wish so much that all I had to be responsible for is just taking care of my patients. What a novel idea! A nurse just taking care of a patient! Regrettably that is only in a perfect world. Our documentation is essential, especially now that litigation against healthcare workers is almost standard. We have to do it just to protect ourselves, let alone for information gathering and the purposes it had once had. How ironic that those who sue nurses and doctors with the purpose of forcing us to improve our care, actually cause us to spend less time at the bedside and more time having to go through tasks that take us away from our patients.

Nevertheless, I had to get everything done and clock out on time—too much overtime was prohibited and I had accrued a lot lately. I would face disciplinary action if I let myself accrue too much. My only hope this morning would be if my patients could just hold off on needing anything so that I could work uninterrupted. I was ashamed of my thoughts, but realistically, that’s what I needed.

Birth Out Of Control: Part 2 The Second Stage of Labor

2009-04-11T02:21:00.006-06:00

See Part 1 here.

The Second Stage of Labor, or the Pushing stage…always full of surprises. Women carry themselves beyond all the physical limits they ever knew they had. I am ever amazed at the power a woman can muster in herself to get through this stage. Pushing can last for hours. The longest I’ve ever seen a woman push was for 5 hours…and she did it…a beautiful vaginal birth. Of course she was so tired that she couldn’t nurse for a while. We held the baby to her breast for her, as any good nurse would do.

And here we were with my patient, whooping and whaling all the way through it. That really doesn’t bother me, I mean; anything that helps them is fine with me. I would only discourage it if it proved to be counterproductive. But she was making progress just fine. It’s the ladies in all the other rooms that were being scared out of their wits at her shrieks of torment.
I continued to help her change her positions: squatting, to side-lying, to hands and knees, to squatting again since it was her favorite position. She never ceased to claw at me. I had my hair pulled, my neck pinched, and my back ached from supporting her weight during her contractions. I continued to clean feces and urine from her perineum and I had been vomited on more than once. I had worked up a sweat by this time right along with her.

Her husband remained dutifully at her side patting her on her back and saying things like, “You have the power,” and, “Just imagine her coming out of you.” But as time passed his encouragements became less confident and by the end of the 2nd hour, he retreated to the couch.

Progress had stopped. I started losing my optimism about her being able to do this vaginally and I probably let my doubt show. The woman suddenly got angry. Screaming, “Get it out of me! I can’t do this anymore!” she reached down into somewhere deep inside of her and miraculously produced a huge powerful push with a gigantic whale, “GGGHHHHHAAAAAAAA!” The baby’s head popped around the pubic bone and stayed down low in her pelvis. I could very suddenly see the top of the baby’s head emerge between her labia.

“OK, stop pushing…breathe,” I said firmly, “we need to get the doctor in here.” I was pushing the emergency button for help. She gave me a panicked look and her face twisted into that bearing down look and a grunt escaped her throat. She couldn’t hold it…I couldn’t blame her. The baby’s head was turning and all of the sudden plowing down her birth canal. Now, understand that it’s bad form to not get the doctor there in time…especially when you’ve been pushing for two hours. But I couldn’t control the speed at which the baby was coming. Another nurse came rushing in to find me holding the top of the baby’s head, trying to keep it from exploding out and tearing her to shreds. The patient was screaming so loud that no one in the room could hear any directions. Her arms and legs extended straight out, and were locked that way. There was no moving her. She wasn’t even taking a breath, just a loud, long scream, with curses, and, “GET IT OUT!!!!”

Her husband took this opportunity to prepare himself for the birth. He started taking off his clothes. He stripped down to his skivvies and waited. Quite a mystery.

The doctor raced in. When I saw that he was ready to reach in and catch, I let go of the baby’s head to ready the stirrups. I disconnected the bottom of the bed and bent over to put it aside. Just as I did that, the woman sat up, gave one more good holler, and out came the baby in one slithering thrust. I barely caught the slippery baby in my hands…juggling it…almost dropping it. Still bent over, holding the sputtering baby, I looked behind me at the doctor. “Good catch,” he said without a hint of a smile. He handed me a clamp and a scissor. He was quite a dry-humored fellow.

In the end, I guess it was a beautiful birth. My patient’s expectations were met. (Everything except the “no pushing” request, but that could not be helped.) I looked at the couple as she admired her newborn and the father smeared amniotic fluid and vernix so romantically over his bare chest (still a mystery.) No thanks were offered to me, no indication that my efforts were at all noticed or appreciated. I hope she was happy with her care. I’ll never know, but I do have the fingernail marks on my neck to remind me that I did everything I could to support her…and I can be satisfied with that.

Birth Out Of Control: Part 1

2009-04-09T05:12:00.008-06:00

“Good luck,” she wished me with a furrowed brow when she had finished giving me report on the patient she had cared for all day. I was to take over for the next 12 hours. You know you’re in trouble when all the day shift nurses look at you with pity in their eyes when they see which patient has been assigned to you. After all, 12 hours can be a very long time when you are forced to spend it with a not so amiable person.

I gathered my wits about me, took a deep breath, and walked toward the door of my patient’s room from which loud, femininely unbecoming moans could be heard from far down the hallway. I gently entered the room. The day shift nurse had warned me but it was still a bit of a shock. There was my patient in the bed, naked on all fours, making a growl-like sound with her contraction, her backside facing the door. She wasn't a small woman, either. I politely introduced myself and offered complements on how well she was doing. As I was talking, neither she, nor her husband acknowledged that I was speaking…so I just shut my mouth and quietly supported her.

As time slowly passed, I felt it apparent that I was not to leave the room. So I gently made suggestions for position changes and relaxation methods. To pass the time, I found myself wondering how this couple found each other. A very unlikely couple they were. She was 43 years old. Her short hair was curly and coarse…and dark…not unlike pubic hair. She had matching strays adorning her upper lip and chin. Her voice was harsh and low-pitched. Her lips were dry and had several layers of cracking skin sloughing off, and a thick paste of yellow smoothed the crevices between her teeth. Her breath confirmed that it had been housed there for a while. I encouraged her to labor in a hot tub for a while…not only because of the calming effects, but also to relieve the smell she emitted. But it was to no avail…the smell oozed from her pores, and it heightened when any folds of her skin were separated.

Her husband was in his twenties, short and squat but only slightly overweight. He was quiet, but maintained an attention stance at her side without faltering. He was cute in appearance but somehow awkward in every word and gesture. Obviously, he was not the one in charge in this relationship.

About mid-shift, the woman’s labor began to progress alarmingly fast. Her moans turned to screams. Her birth plan indicated that I was not under any circumstances to offer her any pain medication. The plan also stated, “I will not use ‘pushing’ or bearing down as I would prefer my baby to be brought forth by my body’s natural forces.” I couldn’t help but chuckle and wonder how the woman was going to pull that off. There is no fighting the urge to push…you will lose. But I remained supportive and kind.

Then things got violent…no kidding…violent. The woman exclaimed between contractions, “Help me to squat! I got to squat!” So, I reached behind her arm and helped her get her naked large body into a squatting position. As I was lifting, another contraction came, and to my alarm, I found myself in a headlock with my face buried next to a very sweaty, pendulous breast. The woman was screaming, “I got to push! I don’t want to push!” The contraction eased and I wriggled my face free, but she still was gripping a handful of my hair.

“Ma’am! You have to let go of me!”

By this time my nursing friends were sneaking peeks at what was happening in the room and giggling at my misfortune.

I examined the woman and she was completely dilated. She could push if she wanted to and have a baby. My nurse friend was in the room helping me by this time and we set up for a delivery…but without pushing I didn’t know when that would be…maybe hours.

I came back to the woman’s side, her husband across from me, and I started again giving her quiet encouragement. Then another one came and I ducked her arm from grasping my head again but wasn’t able to dodge her fist in my hair.

“I got to push! What do I do!” she screamed at me, her eyes wild.
“You can do this without pushing!” her husband snapped, “Remember what we talked about? You have the power!”
“WHAT DO I DOOOOOOO!” she screamed again at me.

With my neck cocked from the death grip on my hair, I looked her in the eye and said, “Honey, you do whatever your body tells you to do.”

Then, a deep, throaty, prolonged ugly grunt erupted from her lungs. Pushing had begun.

…..TO BE CONTINUED….

See Part 2 here.

A Mistake

2009-03-12T20:53:00.001-06:00

One night we got a call from an ambulance that was pulling in with a “27 week eminent delivery.” Alarmed, we raced into action to prepare for a severely preterm infant. (A full term pregnancy is considered around 40 weeks long.) I called in a neonatal team and prepared a room for delivery.
The ambulance crashed through the elevator doors with a Hispanic woman strapped to their gurney, crying. The paramedic started to ramble off his report of what was happening with the woman in labor. The neonatal team rushed to set up their equipment, preparing for resuscitation. Everything was rushed and frantic.
But then what the paramedic said made us all stop short.
“The due date is actually seven weeks later than we thought. We couldn’t understand because of the language barrier.” This made the baby only 20 weeks along in the pregnancy, about 5 months. It had no chance of survival outside of the womb. There was nothing we could do to help it. It would die if we didn’t stop her. We would have to work fast as she was actively laboring.
The paramedic went on, “We were en route and I was able to visualize membrane so I manually ruptured her bag.”
“You ruptured her bag?” I asked, outraged. He could see my alarm. I and the other nurses in the room looked at each other, not sure what else we should say to this in front of the patient. We could have tried to stop the labor and saved the baby but now that her water was broken, there was little chance. Even if we did stop her labor, without the water bag intact, the baby would most likely have severe physical deformities and major problems with the development of the lungs. Not to mention the high risk of life-threatening infection to the mom and baby. If he didn’t rupture her bag, at least she would have a little chance of getting through this.
We began to work quickly as the neonatal team left the room realizing they weren’t going to be needed. The doctor began to examine the woman while we hooked up the monitor. Her cervix was only 3 cm. Her delivery was not as “eminent” as the paramedic thought. Her membranes must have been “hour-glassing” or squeezing through the cervix—a condition that can be treated.
As time went on, we were unable to stop her labor. The time came for her to deliver and we prepared a delivery table.
“I don’t want to see it!” the woman cried between sobs, “Please just take it out of the room.”
A baby girl was delivered. She gave one tiny gasp and moved her head back and forth as I wrapped her in a warmed blanket and took her into another room. She was just long enough to cover my hand from fingertip to just over my wrist. She was just short of a pound. Her heart still beating, she repeated the movements she did at birth, her chest retracted while she tried to take a breath into her undeveloped lungs. I took her into my arm and held her. She would not die alone.
Her heart beat for 51 minutes.
I’ve been involved with many stillbirths before that day and since. It never gets any easier.

The Boy in the Hallway

2009-02-23T06:33:00.001-07:00

A while back, a woman was brought up from the Emergency Room having presented to them with “abdominal pain.” She had her 12-year-old son with her. When I received report from the ER nurse, she said that the woman had whispered to her that she was pregnant and she didn’t want her son to know. She wanted to give up the baby for adoption. Furthermore, she believed she was in labor and drove herself to the hospital. She had no idea when her baby was due.
I looked at the woman being transferred from a cart to the bed. She was very stoic, gripping the bed with all of her might. There were tears in her eyes. Then I looked at the handsome young boy with her. He looked fearful and confused. I can’t imagine what he thought when he saw his mother wheeled into the “Labor and Delivery” department.
We asked the boy to step out into the hallway, at his mother’s request, while we examined her. As soon as the boy left the room, the mother surrendered all of her composure and began crying out in pain…loudly. When I removed the blankets to evaluate her, there was bloody show on the sheets. The woman was completely dilated and ready to give birth…now.
I called out for another nurse to assist me in preparing. I also called a nurse in from the neonatal intensive care unit since the woman had no prenatal care. I didn’t know if I would be dealing with a severely preterm baby, or if there were any congenital issues that would cause complications. As many nurses and doctors hurried in and out of the room, the woman continued to cry out loudly in pain. And there was her son, cowering in the hallway outside the room…watching and wondering. Some of the other nurses came and talked to him…but couldn’t explain what was going on because of his mother’s request…only that everything was going to be alright. They brought him a popsicle.
Moments later, the baby was born. She requested us to take it out of the room immediately. She didn’t even want to know if it was a boy or girl.
After we got her washed and settled, I asked if we could let her son back into the room. She asked if he knew what had happened. I explained that we had honored her request of confidentiality; but that her son, no doubt, figured it out…I told her that he was a smart boy. Perhaps she and he needed to have a talk. Quietly, the boy entered the room and looked at his mother with a look of such innocent and unconditional love. It touched me in such a way I will never forget.Eventually, the woman asked to see her baby. She and her son got to know their perfect little baby girl. I don’t know if she ended up keeping the baby, but I will never forget that boy.

Birthing Alone...By Choice?

2009-02-14T22:45:00.005-07:00

I just did a random Google search on childbirth and found, as one of the highest listed results, a site that promotes unassisted childbirth. This means no doctors, no midwives, no nurses; just you, birthing in your home (or perhaps outside in a tent as one person boasts on the site), doing what your body tells you to do. Also called “Freebirthing,” this is a practice that is surprisingly gaining popularity around the U.S.

First, I agree with some of the things that Ms. Shanley, the author of the site, suggests. I believe that a woman’s body is miraculously capable of transforming itself into the perfect mechanism for bringing forth the child it has cared for through nine months. I also agree that medical intervention can sometimes hinder the natural processes by which the body uses to birth effectively.

However, I would be remiss as an RN in labor and delivery if I didn’t point out a couple of things that are misrepresented in Ms. Shanley’s site. Anyone who is considering freebirthing needs to understand that this concept, although conceivable, is to the extreme. If a mountain-climber wanted to climb a mountain alone without any safety ropes, he could. Maybe he would even be successful and we would all be amazed at his accomplishment. But if he fell, there would be no hope for him to come through it unharmed. The same is true for giving birth. The hospital is there for you to bring you through if something goes wrong…and things go wrong often.

I have been involved with literally thousands of deliveries and I would challenge Ms. Shanley to share with us the number that she has actually been involved with. I am very happy for her and the people who have contributed their birth stories to her that they had wonderful birth experiences alone…I would say they are the exception. Nearly all of them tell of their babies coming fast or “shooting” out, but we don’t hear from those who didn’t. Usually, it takes hard work and finesse to prevent adverse events including tearing, shoulder dystocia, hemorrhage, and many other mishaps, some of which can be fatal…for baby and mom. Ms. Shanley states,

No one, however, regardless of their "expertise," can guarantee that a baby will be born safely. Some babies die. It's simply nature's way.
--Laura Shanley, author of Unassisted Childbirth, quote taken from her website regarding safety of unassisted childbirth.

Why, if you care about your baby, would you take the chance that it would die in childbirth? Why would that be OK with you? Wouldn’t you do everything you could to keep your child safe? You would take every precaution for your child’s safety after it’s born, why not before? Why is it any different? Why are you putting your own ideal birth “experience” before the safety of your child? Some people would call this selfish. Ms. Shanley herself tells about her delivery at home of a known preterm baby and simply watching it die. She didn't even call for help until after it was dead. I'm sorry but I can't call that "nature's way" when you had the resources there available to you to help your child. If your child fell out of a boat would you stand there and watch him drown and say, "Well, that's just nature's way?"

Furthermore, to respond to Ms. Shanley’s remarks about health professionals: she forgets that it is our job to care. Let me say it again—WE CARE! We care about you, about your baby, about your comfort, about your wishes. And what we care about most is a healthy mom holding a healthy baby when it’s all said and done. If you want a natural childbirth, we won’t stand in the way. We do it all the time!

As I have said before, what will ultimately determine your value as a parent is the way you raise your child. Nobody cares how you gave birth…it simply doesn’t matter in the big picture of parenting.

Form your own opinion. Laura Shanley's site: http://www.unassistedchildbirth.com/

For a lively debate to Ms. Shanley's views, I recommend http://www.homebirthdebate.blogspot.com/.

Breathing?...Oh, Right.

2009-02-08T00:00:00.003-07:00

A baby was born to a couple who had hired a doula to support them through labor. This particular doula was very pointed about what should and shouldn’t be done, particularly in regard to what would happen after the birth. She wanted to help the mother breastfeed right away and she discussed this with me at length. I was supportive of this as I, too, am an advocate of immediate skin to skin contact and initiation of breastfeeding within the first few minutes of life. I was to place the baby on the mother’s abdomen right from the birth canal and do my care of the baby there. I agreed and she was satisfied. (Little did she know, or at least she wouldn’t hear, that this is my normal practice anyway.)

When the baby was born, it didn’t make any breathing efforts at all. It was blue and wasn’t moving. I took the baby to the warmer with an explanation to the parents, and begun resuscitating the baby as I have been trained. The baby made weak efforts to breath. As I continued to work emergently with the baby, I found the doula at my side saying firmly, “We need to get it to breast right now!”

I just want to gently point out that, usually, it’s good for a baby to be able to BREATH before we worry about sticking a nipple in its mouth.

Home Delivery Gone Wrong

2009-02-06T01:55:00.002-07:00

We had a patient arrive by ambulance the other day. She was laboring at home in the care of a lay midwife (one who doesn't have formal medical training and/or certification.) We had gotten a call from this patient's midwife stating, "Well, the head has been out for about an hour now and its just not coming out so I think we're going to head in to the hospital now...I just wanted to give you all a heads up."

Well, to say the least, after telling them to call for an ambulance immediately, our department went into a complete uproar. When a baby's shoulders get stuck and won't come out for more than about 30 seconds here in the hospital, we immediately go into emergency mode. This can be fatal for the baby and ultimately for the mom if not dealt with.

Well, they arrived by ambulance and the doctor was able to deliver the baby through different maneuvers. But, of course, the baby was dead...and the mom started to hemorrhage. How unfortunate...and sensless. We were able to stablize the mother, but as a staff we were so angry that this couple let this happen...all in the name of having a natural childbirth with no intervention. All the mother said was, "I guess it wasn't meant to be." How foolish and sad.

Can't Get The Baby Out? Here's Some Ideas

2009-01-30T04:34:00.003-07:00

The following are true stories -- believe it or not!

A patient has been stuck at a certain dilation for some time without change. The doctors have discussed a possible c-section with the patient and she and her husband are very disappointed due to the fact that she has tried everything to accomplish a natural labor and vaginal birth. After giving the patient and her husband time alone, the nurse enters the room to find the husband with his face between his wife's legs shouting, "Come out baby! Come out!"

A man was supporting his wife who had been laboring for many hours and was distressed at the length of time it was taking for the baby to arrive. The nurse enters the room to find the husband holding his wife shaking her up and down like a bottle of ketchup hoping to expedite the process.

A woman had hired a doula to help her through her labor whose advise and help she requested when contractions weren't strong enough to dilate her cervix. Doulas usually have many good suggestions of natural means of helping labor along. The nurse entered the room to find the doula in bed with the patient, spooning her, performing nipple stimulation from behind her while the husband read a book at the bedside. (Maybe not the most appropriate choice for a hospital setting.)

Trust or Mistrust: The Controversial Birth Plan

2009-01-30T04:21:00.003-07:00

If you are planning on coming to the hospital with a strict birth plan, or maybe even planning a home birth, here is a story that you should consider before you do:

A woman came into our unit with her husband one night in early labor. As we showed her to her room it became apparent that she intended to take control of her labor from the beginning. Declining the gown that we offered her, she opened one of her many bags and began to change into her own gown that she had selected just for the occasion. She introduced her two hired doulas (labor coaches) while her husband presented us with a typed, multi-paged birth plan that she had prepared based on her research during her pregnancy of natural childbirth. In it, like many other patients that we see, she spelled out her wishes for how her labor would be managed:

“I decline having a routine IV access placed.”
“I wish to have minimal monitoring of my baby. No continuous monitoring please.”
“I wish to have a natural birth. Please do not offer me pain medications unless I ask for them.”
“I do not want to have a C-Section unless absolutely necessary, and would like the opportunity to discuss it with my husband first.”
“No vacuum or forceps.”
“I would like minimal staff entering my room during my labor.”
“I would like to keep cervical exams to a minimum.”

The birth plan continued like this for several pages containing requests most of which we would accommodate anyway…without her requests for them. This was similar to the many birth plans that are presented to us on a regular basis by our patients and that we work hard to respect and follow. But the thing that stuck out about this birth plan was the fact that at the end-- it was notarized.

Was this supposed to make it more official? Was it supposed to threaten us in some way? Threatened is how we felt. Is that the best way to begin a therapeutic relationship?

Luckily, her labor progressed in a normal way and we were able to keep to her birth plan without any mishaps. We monitored her only as often as we were required to by hospital policy. She was able to do what she and her two doulas wished – birthing ball, tub, massage – common labor comforts. (As if labor was at all comfortable…)

Throughout her care, she confided to her nurse that she really didn’t want to birth in a hospital setting. She wanted a home birth. But she decided to come to the hospital only to have doctors more available if needed, and only if they agreed to keep from intervening in her natural labor process.

But in labor, things can go wrong so shockingly fast.

With the patient annoyed, the nurse placed the monitor on to check the baby only to find the fetal heart rate to be very low – 50 beats per minute. The nurse called for help as the heart rate continued to fall. The baby would soon be dead if we didn’t act now. We quickly took her back to the OR for an emergency C-Section and had the baby out within 7 minutes. But by the time we were able to help the baby there was no heart beat. We were unable to resuscitate in time and the baby will have permanent brain damage if it lives at all. Had we been able to monitor, we would have been able to intervene sooner, and that mother would have had a beautiful healthy bouncing baby boy in her arms.

What would have been more important: her ideal labor experience? Or a healthy baby and mother? Patients spend so much time researching in order to be able to tell us what they do and do not want in labor, but is that where their top priorities should be? Let us keep you and your baby safe. After all, you have the ultimate task of raising your child. It will be the way you raise your child that will determine what kind of parent you are…certainly not the way you gave birth.