Saturday, March 26, 2011

Losing My Hat

First, I want to apologize for taking such a long time to make this post.  I forgot my log in information and it took me awhile to recover it! 

Before I started my clinical experience as a student last year, I traveled to Frontier School of Midwifery in Hyden, Kentucky for an orientation.  At the end of the orientation each midwifery student is given a baby hat to give to the first baby they catch-or to a memorable patient.  As it turns out my first was also very memorable.  This is the story of how I lost my hat!

I have changed the names and many details to protect privacy.  Enjoy!

I had the great pleasure of meeting Emma on February 10th when she came to the office for her routine prenatal visit. Emma is the type of person that is always smiling and always has a positive attitude.  I was able to meet her husband at her next prenatal visit on February 17th. He was equally pleasant and very funny.  They were a perfect couple!  Emma and Matt were expecting their first baby, a boy to be named Jacob; he was due on February 25th, 2010. They had a strong desire to have a natural and unmedicated birth. My preceptor, Susan,  and I encouraged Emma and Matt at their prenatal visits, we gave suggestions for comfort measures at home while in early labor and told her when she should come to the hospital.  We assisted her in writing her birth plan and discussed it at length at her visits. She was very excited and very motivated to have this baby naturally.
On  February 12th,  I met Ashley and Brett.  Ashley was 36 weeks and 1 day pregnant with their first child, a girl whose name was yet to be decided. Ashley’s blood pressure was 144/90, she had 3+ pitting edema and mild headaches. We ordered a CBC and a hepatic panel as well as a 24 hour urine. We also did a non-stress test and an ultrasound to check AFI. All labs were normal that day, but she did have a significant amount of proteinuria  in the 24 hour urine test the next day. We discussed the diagnosis of PIH with Ashley and Brett and sent Ashley home to bed rest, discussed PIH precautions and gave her the cell phone number to call to reach us. We also began to let her know that if the disease progressed we would probably have to induce labor early. Ashley began to cry but her husband was at her side comforting her. She also had a strong desire for a natural birth with minimal intervention. We reassured her that we would do everything we could to make that happen but we all agreed that a healthy baby and a healthy mom was everyone’s goal.  I was able to see them again about 4 days later and Ashley’s blood pressures were about the same and she was feeling much better.  She was able to get her company to allow her to work from home thus easing some stress on her from being on bed rest. They had also chosen a name for their baby girl but wanted to keep it a surprise.  Ashley and Brett went home that day to come back in three days for another NST and blood pressure check.  On Friday February 19th she returned to the office for her appointment.  Ashley’s blood pressure had increased to 158/108 and she was beginning to have more headaches. She was now 37 weeks pregnant and her cervix was a fingertip, 50% effaced and baby was at a -2 station.  After discussing her situation with our consulting physician we all decided that it would be best to induce her labor after cervical ripening with cervidil. Ashley and Brett were comfortable with that and also felt it was best. We had them go home to get their bags and come back to Labor and Delivery.
Shortly after Ashley and Brett arrived at the hospital, Susan and I visited them and I placed a cervidil then we returned to the office to see patients. That afternoon Wendy came in for a labor check. She was 38 weeks pregnant with her third baby-the first girl for her and her husband, John.  She had been contracting every 5 minutes off and on all day. Her cervix was 4cm/50/-2. We told her she would probably continue to contract and we’d probably see her in the hospital this weekend.
After office hours, Susan and I decided to go check on Ashley before going home so we went upstairs to labor and delivery. We found a picture perfect Ashley and Brett sitting in the bed together eating dinner.  We saw their camera sitting on the table so of course we took pictures of them-it was a very precious picture! We again discussed the plan and assured them that the nurses would call us if she started to get uncomfortable and we would be right in. After spending a few minutes with the happy couple we went to the nurses station to write a progress note.  Susan co-signed my note, I closed the chart and replaced it and we stood up to go home…..just as Emma came around the corner-her smiling face was red, she was bent over and holding her abdomen with one hand and her husband’s hand with the other. The unit secretary asked “can I help you” Emma smiled and excitedly replied (mid contraction!) “yes, I think we are having a baby!” Susan and I walked up to her and began to help get her to a room.  She noticed it was us helping her and her eyes lit up. “I am so glad you are here, that is just crazy that you were right here when I came in!”  The labor and delivery unit was buzzing with activity and unfortunately, there were no rooms open at the time. We took Emma to the c-section recovery room and helped her get onto the gurney. I checked her cervix and she was 5cm/100%/0 station. The baby’s heart rate pattern was perfect. Susan, Matt and I stayed at her side and did counter-pressures during contractions. Before long the nursing staff had a room ready so we moved her to the room, filled up the tub and helped her into the water. Emma labored in the tub for quite some time. She changed positions frequently-we got creative about keeping her comfortable and as a result we ended up with Emma and five bath towels in the tub. Between contractions we talked, she ate and drank and Matt encouraged her. Soon Emma began to feel intense back pressure, almost unbearable. We offered her sterile water papules which she accepted-Susan and I and two other nurses injected the papules-which instantly took away the pressure. She tolerated her labor very well.  She compared labor to her experience as a cross country runner-her husband also being a runner was able to understand what she was saying and used that to encourage her. As the contractions became more intense Emma would remind herself of her chosen mantra which was “pain with purpose.”
As we supported Emma in the tub a nurse came in and requested that we come review Ashley’s fetal tracing. Susan asked me to go look at the strip (she told me she trusts my judgement since I am a fetal heart monitor instructor)I saw minimal variability, some late and some variable decelerations. I discussed my plan with Susan and I ordered an IV fluid bolus and oxygen as well as a position change . I also rechecked Ashley’s cervix and removed the cervidil; unfortunately she had not changed. Her blood pressures were beginning to rise to the 165/110 range. We decided to re-evaluate after the bolus.
By this time, Emma was feeling more pressure and was having a hard time getting comfortable in the tub, she decided to get out and try the birth ball. She sat on the ball, Matt sat on a chair in front of her with pillows on his lap and she leaned on them. After a few contractions she decided that was not comfortable and requested to lie down. Shortly after lying down she began to feel an urge to push. She pushed a few times and soon the membranes were bulging out of the vagina, after a joke or two about being in “the splash zone” we decided to rupture her membranes (since Matt didn’t want to be “splashed"). Emma pushed spontaneously with only encouragement to listen to her body. Thirty –five minutes after the urge to push began, she was now crowning. Two pushes later, she pushed “Little Man Jacob” gently into my hands-I instantly placed him on her tummy so she could enjoy the sound of the healthy cry. She greeted her 5 pound 13 ounce son with a smile and tears-as did his daddy.  A family was born.
We tucked Emma, Matt and Jacob in for a rest and we went to check on Ashley again. I reviewed Ashley’s fetal monitor strip and I was concerned. The baby now had persistent late decelerations and minimal variability and no accelerations. Her cervix had still not changed and she was only having mild contractions and they were irregular. I discussed my concerns with Ashley and Brett and told them I would consult with the physician but there was a fairly strong chance that we would need to do a c-section, they were disappointed but understanding. Our consulting physician was on the L&D unit so I asked him to consult-he agreed that a c-section was the safest way to deliver the baby. The decision was made and the staff began preparations.
Just as we were about to take Ashley to the OR, Wendy came in reporting ruptured membranes two hours ago with irregular contractions. My preceptor went to the OR with Ashley and I stayed out on L&D to care for Wendy. I checked her cervix and it had not changed from my earlier exam in the office. We discussed options-Wendy also had a birth plan that included little or no intervention. We decided to watch and wait through the night.
Shortly before midnight, Ashley and Brett’s baby was born. They finally revealed her name after her birth. Sarah weighed in at 4 pounds, 11 ounces. Sarah had a bit of difficulty transitioning to extrauterine life but after a few minutes of oxygen therapy and time, she came around and did well. She was able to join her parents in the surgical recovery room within an hour for a midnight snack.
Susan and I said goodbye to Ashley, Emma and Wendy and told them we would see them in the morning unless they needed us sooner. We asked the nurses to please call if Wendy became more uncomfortable with contractions.
I came home to find my two little girls had taken over my bed but I was able to slide in next to them. I slept lightly and restlessly for a few hours. At 6:30 am Susan called to say that Wendy had not started to contract yet and her cervix had not changed so she ordered pitocin augmentation. We both decided we would shower and then meet at the hospital. When we arrived, Wendy was still not having many contractions but was very comfortable with the idea of pitocin augmentation. The plan was to use a low dose and turn it off when she began to have regular contractions and cervical change. We visited our other patients then Susan went to the office to take care of some paperwork and I met my husband and children at McDonald’s for a quick breakfast, then we both returned.
Several hours later, Wendy became more uncomfortable so we turned off the pitocin and encouraged her to change positions.  Wendy began to become more vocal and the contractions were more intense. Just as we could tell transition was near, a nurse came into the room and frantically said “I need you in room one, you have a patient here that is 35 weeks and she is 9 cm!” The new patient only spoke Spanish so Susan (who speaks fluent Spanish) left to go check on the new patient. I rechecked Wendy and she was 7 cm. Susan sent a nurse to get me so I could catch Maria’s baby.  John took over the counter-pressures and a nurse stayed with Wendy. 
Maria’s baby was in a right, occiput posterior position and despite pushing well, the baby was not moving down. Maria was in total control and smiled and laughed with her family between contractions. I told them I would do my best to speak only in Spanish and they were more than welcome to laugh at me if I said something wrong.  I kept my promise and spoke almost exclusively in Spanish. We rolled Maria to her left side and within two pushes she was crowning. She asked if the baby had hair-I reassured her that he did have a lot and with a wink, I told her it was blonde.  She laughed and said “oops!”  her husband also laughed and they joked about the “blonde” hair. The next contraction she eased her baby boy out over an intact perineum. I placed baby right where he should be-on mom’s belly. Because he was a little early, the pediatrician was being conservative and prior to birth ordered direct admit to the NICU for at least 24 hours.  We let mom keep baby for several minutes-he was very vigorous and appeared to be very healthy. The nursery nurses then took the baby for evaluation. Gabriel weighed 4 pounds 15 ounces. Just after the placenta delivered, a nurse came in to tell us that Wendy said “the baby is coming.”
Susan and I rushed to Wendy’s room and checked her-she was still 7cm but feeling the urge to push so she pushed. After a few pushes she wanted to change position so she moved to her hands and knees and the urge to push went away. After several contractions it returned. She soon became uncomfortable on her hands and knees and said she was more comfortable on her back. She pushed a few more times before we discovered her baby was also in a posterior position so we turned her onto her left side, she pushed twice and delivered “Miss Mariah” very controlled and gently, over an intact perineum. I handed baby right to her and she was thrilled, mom and dad touched the baby, noticed her features and compared them to the other children. After the cord stopped pulsating I clamped the cord and dad cut it. Mariah stayed with mom and all newborn procedures were performed while Wendy held Mariah. Wendy began to bleed a little heavier than I would like so we gave her some pitocin and she asked that the nurses weigh Mariah while we got her bleeding under control. Miss Mariah weighed in at 6 pounds 9 ounces. After some pitocin and Mariah nursing, the bleeding slowed.
By this time it was Saturday afternoon.  Susan and I finished our documentation, made one last visit to each of our patients and went home for the day.  Sunday morning we returned for rounds, we visited each of the patients-all were doing well, all babies were nursing well and all mommies were feeling good.  After visiting everyone, I returned to Emma and Matt’s room and presented them with their hat for Jacob and told them the story of Frontier. They loved the story and asked me many questions about midwifery.  They had no idea how much care midwives provide but were thrilled to learn that most of Emma’s healthcare could be provided by a midwife. I thanked them profusely for allowing me to be a part of their birth experience.  I truly could not have asked for a better two days to start out my clinical experience!!!