Midwives, Modern Medicine, and the Search for a Happy Medium

After the week I’ve had, I need to say something that should be obvious at first blush, but still comes as a surprise to many of  my patients: OBGYNs are surgeons.

There.  There it is.  Now, why is this awkward?  Lately, I’ve had a rash of patients who had bad experiences on their first go-round with physicians.   To their credit, these ladies are the few astute ones who seem to come out of their initial L&D experience with a better grasp on the status quo in obstetrics.  However, my statement above, while no secret, often comes as a revelation.  I’ll say it again: OBGYNs are surgeons.  And to be more specific, many of them prefer surgery.

Now, I’m not saying that every OBGYN heads into the on-call room at night, hops into bed and would provide you with an aerial view resembling this:

Surgeons

But think about it: if you were trained primarily in surgery and minimally in how to perform a vaginal delivery (case in point: most OBs no longer know how to safely deliver breech infants, unlike their predecessors), you would probably prefer what you’ve been most thoroughly trained to do.  It’s only natural.

Now certainly, this is a broad generalization.  I have met and currently work with many incredible OBs whose preferences are stayed by what’s best for their patient, and 9 times out of 10, this means a vaginal birth.  Often, these docs have picked up a few tricks along the way and they are rock stars when it comes to assisting women to birth vaginally.  However, unless you have some inside scoop on your doc (see: you know an L&D nurse!), choosing to go with a physician as your main OB provider may carry with it some inherent risk.

That’s where midwives come in.  Midwives, you say?  What are midwives?  What is this, the renaissance?

Thankfully for all of us, no.  We have not stumbled across some Medieval worm hole.  But midwives, who have been around since ancient times, are still around even today, serving as critical a role in L&D as they ever have, though now with far less recognition.  In the US, we have two types of midwives.

First, let me tell you about my favorite kind of midwife.  They are called CNMs, or certified nurse midwives.  CNMs are impressive for several reasons.  First, they are registered nurses.  That means they are trained professionals to start with, even before they are midwives.  Many CNMs start out their careers as L&D nurses and eventually choose to further their education to become CNMs.  Indeed, there’s no need to hop the nursing model if you want to further your education beyond a bachelor’s degree–CNMs are minimally master’s degree-prepared and trained to handle many of the same types of patients as their physician counterparts, including those requiring/desiring induction of labor, artificial rupture of membranes, emergency episiotomies, and a plethora of drug administration, including epidurals.  Yes, folks–you can have a midwife as your provider and get an epidural (assuming you’re in a hospital setting)!  In the US, CNMs work with physicians who oversee their practice and are available to step in if surgical intervention is needed.  The major difference between OBs and CNMs? I’ll bet you can guess it, but I’ll tell you anyway–CNMs aren’t surgeons!

The second kind of midwife is a CPM, or a certified professional midwife.  This particular type of midwife is somewhat controversial in my profession these days, and for good reason.  CPMs are apprentice-trained lay persons who do not have (or at least, do not require) anything close to the kind of formal training undergone by CNMs and OBGYNs.  While most are required to be certified in adult CPR, many states do not require that CPMs be required in NRP–which means that a CPM attending a home birth may or may not know how to save your baby if she has difficulty after birth.   The types of drugs they are able to administer are limited, though many of them remain high-risk drugs due to the nature of the field (methergine, oxytocin, etc.).  Conversely, some CPMs, such as those practicing in Minnesota, are unable to administer anything beyond vitamin K–so if you’re birthing at home and you begin to hemorrhage, good luck to you.  Again, it is not my intent to rail against all CPMs in this post as the requirements for education vary widely by state.  However, due to the unpredictability of labor and birth, it is not unreasonable to point out the vast differences in qualifications between CNMs and CPMs, both from the theoretical and the practical standpoint. As a result, I strongly encourage any woman looking for a midwife to go with the master’s-prepared nursing professional, no matter how comfortable you may feel with a given CPM’s personality or acquired skills.
To give you an idea of the range of skills contained in the CPM title, take a look at the link below:
https://www.ama-assn.org/sites/default/files/media-browser/specialty%20group/arc/direct-entry-midwife-state-chart-practice-information-2016.pdf

Why choose a midwife, you ask?  Specifically, why a CNM?  If you can get an epidural and a CNM can induce your labor, what makes a CNM so different from an OB?  Oh, where to begin…

  1.  A CNM is a nurse and trained in the nursing model, not a medical model.  CNMs traditionally take a broader, more holistic view of the patient and as such, often allow mom more freedom, especially in labor (providing it is safe to do so).  Because of their holistic focus, many CNMs are more attentive and responsive to other pregnancy concerns–you know, those nagging little things like not having had a bowel movement in two weeks or morning sickness that isn’t bad enough to get you hospitalized but also has you pinned on your living room couch drinking ginger ale and utterly unable to do anything else, including watch your toddler…that kind of stuff.
  2. Having a CNM as your provider doesn’t preclude you from getting medication in labor.  Epidurals, nubain, fentanyl–CNMs are able to tend to your pain relief needs in the same way as their OB counterparts.
  3. Given that a CNM is expressly not a surgeon, most CNMs are extra dedicated to helping their patients experience good, safe vaginal births.  In short, CNMs are renowned for their patience with their patients.  That isn’t to say they won’t defer to the physician if need be, but a CNM cannot perform a C-section him- or herself, and as a result, CNMs are in it for the long haul, whereas your impatient OB may opt to CPD (cut prior to dinnertime!) for no great reason other than their convenience.
  4. Traditionally, midwives are less invasive than physicians.  And that isn’t just because they don’t do C-sections.  (Warning: generalization ahead!)  Many CNMs are both known and preferred for their gentler, hands-off approach to L&D.  For example, instead of invasive, painful perineal stretching practiced by many a physician to open the vaginal canal and speed delivery, many CNMs opt to monitor baby and allow mom to bring baby down at her own pace.  Often times, this means less tears and repairs, better control over pushing, and a slower delivery but with faster recovery time.
  5. Many CNMs are more involved in the labor process than their physician counterparts.  Now, this certainly ranges both on the OB and the midwife side, but generally speaking, CNMs tend to carry lower patient loads for the expressed purpose of being more involved in the labor and delivery process overall.  Some CNMs pick up their patients at some point in active labor and don’t leave their sides until hours after the baby is born.  Other check in at intervals and stick around when it’s time to push.  Barring unforeseen circumstances (for example, your CNM has two patients in labor at once!), the bottom line is this: you will probably see your CNM while you’re in labor much, much more often than you’d see your OB (especially considering many OBs prefer to wait until the baby is basically delivering itself, run in, catch, and run right back out as fast as possible!).
  6. Most CNMs make for great labor support partners.  Especially if yours is an uncomplicated labor and your CNM is planning to be present for the long haul, their experience with birth combined with their expertise in keeping you and baby safe is top-notch at relieving anxiety, which in turn, can often relieve pain in childbirth!  For a non-medicated woman, sometimes a CNM is the only drug they’ll need.
  7. CNMs usually let mom lead the way.  Again, this is assuming that your labor is low-risk, unmedicated (see: no epidural) and uncomplicated, most CNMs will allow mom to birth in her position of choice/comfort whereas most physicians prefer–nay, insist–that women deliver in a supine position (an archaic, outdated practice that is still in place solely for provider convenience!).  What’s the big deal, you ask, especially if you have an epidural?  The big deal is the long-term consequences for your bottom as you’re more likely to experience trauma in the supine position versus other positions (such as squatting or even side-lying) as well as the potential for a C-section as a result of lying supine and pushing, especially if this occurs over an extended period of time.
    (Think about it–we tell women to stop laying flat on their backs in the 2nd trimester of pregnancy due to the weight of the uterus on the abdominal aorta, the huge vessel that supplies blood to baby and mom’s lower extremities, but often, laboring women lay on their back for hours while pushing at the very end of pregnancy when the uterus is at its biggest and heaviest!)
  8. The big caveat to all the above: As always, CNMs and OBs range in their skill sets, preferences, personalities and personal beliefs, so be sure to do your research.  Look up what other patients have to say about the providers in your area.  Schedule meet and greets with OBs or CNMs that you’re considering and ask them questions about their practice and what they should expect.  Pay attention to their reactions to your questions as much as you listen for their answers.  And of course, if you don’t feel comfortable with something that your provider says or does at any time, always be prepared to stop the flow of events and respectfully seek answers before you allow any further treatment to occur or plans to be made.  If it’s a true emergency, you’ll know. If it isn’t, you can at least get an explanation in the wait-and-see meantime, that way you’re able to make an informed decision should something happen.

That just about covers the highlights I can think of offhand, so if any of that appeals to you and you’re looking for a different–perhaps less traumatic–L&D experience, check out your local CNMs.  You may very well be glad you did!

Angst and Anesthesia

Ah, anesthesiologists.  They are either one of the great blessings of an L&D experience or a gigantic pain in the…well, you know.

Like most folks in a hospital setting, anesthesiologists are busy people.  They are responsible for the pain relief of an entire floor of laboring women, anesthesia for C-sections both scheduled and emergent, and sometimes on-call for other large-scale emergencies that come through the ED.  And in a culture where most women feel nothing less than entitled to a quick, easy epidural and yet circumstances may require an anesthesiologist’s presence in the OR for 2+ hours simultaneously…well, you can see the dilemma.

However, I digress.  Anesthesiologists, while undoubtedly busy, are no less strapped for time than everyone else in the hospital, and when the decide to pitch hissy fits over the small stuff…it can get interesting.

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The Great L&D/PP Divide: AKA, Bikers vs. Puritans

Wow, what a very long time it’s been since I last managed to post!

Let’s just say business has been good and I’ve been preoccupied with delivering babies over the past few months.  Unfortunately, that has precluded me from writing as much as I’d like to.  It has, on the other hand, given me a lot to write about!

So let’s talk about a phenomenon that is pretty much universal in inpatient OB nursing…the difference between L&D and postpartum (PP) nurses.

If you work on a unit like mine where L&D and PP are split, it is easy to spot the personality differences between L&D and PP staff, and sometimes, this difference can cause a bit of a rift between the units as a whole.

Puritans and Bikers 1 PNG

Generally speaking, the beef that each side has with the other is due to the basic functions of L&D nurses vs PP nurses and the differences in personality that often coincide with each sub-specialty.

The Postpartum Nurse through the eyes of the L&D Nurse

Puritans and Bikers 2 PNG

A PP nurse tends to stick to a schedule and a well-laid plan, sometimes to the point of seeming inflexible.  One might say they’re sticklers for tradition (cue the Fiddler on the Roof music!).  Nevertheless, this down-to-the-minute timing is important.  They often have 3-4 couplets (moms and babies) to care for, scheduled and PRN medications to keep up with, and round-the-clock teaching, especially for new moms and dads, to contend with at all hours of the day and night.  So on that note, it’s no wonder you’d think someone spit in their cheerios when you ask them to take a fresh C-section patient in the middle of their midday assessments.

PP nurses also have the added responsibility of helping parents establish a pattern for feeding, sleeping and caring for baby, which ideally begins to take root before baby goes home.  PP nurses try to maintain some semblance of a routine so that when mom and dad are cut loose with baby in a few days, they aren’t left floundering at home, wondering how the heck they’ll ever survive without Nurse Annie rounding on them every hour.

Now, keep in mind this isn’t every PP nurse, but some carry the “it must be done my way at precisely this time” attitude beyond the point of reason.  Thankfully, the vast majority can ignore the subtle, insignificant differences in practice amongst their colleagues and adapt to the changes as they come. It’s the ones who can’t move past the fact that the L&D nurse told them the baby’s weight before their APGAR scores in report with whom you’ll most often see trouble.

The L&D Nurse through the eyes of the Postpartum Nurse

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L&D nurses typically enjoy being busy.  They are adrenaline junkies in hiding.  Unlike the ER nurse, who wears her love for the rush of a trauma on her sleeve, L&D nurses quietly thrive on the occasional thrill of the unexpected–a prolapsed cord, a crash C-section, a laboring woman who comes through triage dilated to 10cm at 1am screaming for Jesus and stopping 2 feet short of her delivery room to push out a baby in the middle of the hall–y’know, that kind of thing.

As such, L&D nurses can be perceived as disorganized, harried, rowdy, rude/outspoken, and at times, even a little bit crazy.  While I’ll give you a bit of room on that last descriptor, disorganized and harried aren’t common traits of L&D nurses…at least, not good ones (and trust me, it’s usually very obvious very quickly if an orientee can’t roll with the punches in the heat of a delivery).  Because there can be so much chaos inherent in our jobs, a good L&D nurse keeps a level head no matter what is going on.  She is likely very organized, but not off-put if she doesn’t have time to dot her i’s and cross her t’s.

As for rowdy, rude, and outspoken…again, the very nature of L&D nursing is likely to attract a more lively crowd, so don’t be too surprised if you hear your L&D nurse swear under her breath at the **** IV pole as she’s trying to prime her pitocin line as her patient is swearing at the doctor, the doctor is yelling at the surg tech, the surg tech is yelling at the nurse, and the nurse is venting her frustration on the technological advances of modern medicine.

As long as the charting is done, her report sheet is (relatively) complete, and her patients are alive and well, your L&D nurse is a happy nurse.

The Bottom Line

It’s a pretty straightforward one…L&D nurses are different from PP nurses, and for a very good reason.  If you work on an LDRP unit where L&D and PP aren’t separate, see if you can pick out the differences between those coworkers who prefer to care for the laboring and those who tend to prefer postpartum patients.

At any rate, those with strong skills in either department are indispensable assets to mothers and babies.  Because if you ask any given L&D nurse and any given PP nurse if they want to trade places for the day, your answer will invariably be…

Puritans and Bikers 4 PNG

Or, in the vernacular…”NO!”

 

A Rude Awakening

If you happen to be friends with, live with or spend enough time around nurses, you’ll likely be privy to a discussion about our work.  A common need amongst nurses is to vent after a long or stressful shift, and often times, that vent falls on the ears of the family and friends who are nearby.

However, while airing the mishaps of our most recent disaster may do us a world of good, most of us don’t realize how much information–be it technical medical terminology or slang–our family members and friends pick up in passing conversation–that is, until it’s used against us…

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Reference for the noobs/non-medical:
http://www.aafp.org/afp/2004/0401/p1707.html

No One Likes A Purple Baby

You can’t always tell a “bad” baby by the fetal heart strip.

That is to say, some babies look fantastic during labor and all the way through pushing, but when kiddo is born and the big moment comes, they just can’t seem to get the hang of “life on the outside”.

The majority of babies transition well.  When L&D nurses talk about babies “transitioning”, we mean the process that takes place immediately after birth where baby goes from being in-utero and fully dependent on mom’s body to breathe, feed, and remove waste to suddenly having to do all of that for himself.

Like I said, most babies figure it out on their own within moments of being born.  They take a surprised breath, and with a bit of drying and physical stimulation, they start to cry, their skin turns pink, and wa la!  Life doesn’t really begin as much as it just continues.

Still, my hospital requires that at all births, there is a nurse present for mom and a second nurse present for baby.  This ensures that if there is an emergency with either, both have their own dedicated staff member present and fully in-tune with their history and their treatment. The last night I worked, I got a great reminder of just why we require two RNs to be present at all births.

The Scenario

The nurse who had the patient in room 2, Barb, was an experienced L&D nurse who had an orientee, Marcy, working with her.  When one of my other coworkers mentioned that Barb and Marcy’s patient was about to deliver, I took a look at the strip and started heading down the hall.  As I was “up”–patient-less and waiting for an assignment–I was ideally free to help in the meantime.

“Well, I dunno, Sophie.  She should be good.  She has Marcy in there with her, and she’s almost off orientation.”  Breanna called from the desk.

“Oh, it’s no problem.” I replied, keeping in mind the happy FHR strip I had just seen on the monitor.  “You never know, after all.”

“True.”  Breanna agreed plainly.

As I arrived in the room with the doctor and the surgical tech, I prepared the bassinet, laying out the blankets, placing a blanket on mom’s chest, and making sure that suction, oxygen and my emergency equipment was functioning and turned on.

Barb and Marcy were helping their patient push, which was taking longer than they had expected for the first-time mom, but baby was clearly at about a +2 station and making progress with each push.  About five minutes later, baby’s head emerged, followed by the rest of his body with one last push.

As the doctor cut the cord, I stepped up at the bedside, drying and stimulating the baby as he was placed on mom’s chest.  APGARs are a little low on this one, I noted as I realized the baby wasn’t crying, had central cyanosis, and he wasn’t moving much.  Moments later, I heard the distinct sound of grunting on the end of each breath and retractions appeared around baby’s sternum.

Seconds into meeting this new little boy, it became obvious that he would require a little extra attention.  I kicked my assessment skills into high gear as I reached for my stethoscope to take a closer look.

Drying, Stimulating and Crying

Drying a baby is important as babies have difficulty maintaining their own temperatures, so the longer baby stays wet, the more likely it is for him to get cold and potentially experience some of the consequences thereof: dropping blood sugar, lethargy, and low blood oxygen to name a few.  While some of the “goop” (AKA: vernix) that baby is born in has been shown to protect baby against infection and help regulate baby’s temperature, making sure baby is dry is of paramount importance immediately after birth.  It is important to note that while some of the vernix will come off with drying, enough will stay on the newborn to provide the benefits associated with delayed bathing (which is a topic for another post!).

A natural result of drying baby is the stimulation that occurs when the blanket makes contact with his skin, and this stimulation usually causes babies to cry.  Crying will naturally help to clear any fluids that baby might have gulped on his way out, therefore opening his lungs and getting him used to the idea of breathing on his own.

Skin Color

Cyanosis is a general term that refers to a bluish coloring of the skin due to a lack of blood flow or poor oxygenation.  A little cyanosis of the hands and feet actually isn’t uncommon in newborns and is called acrocyanosis.  Acrocyanosis occurs normally as baby transitions from being in-utero to having to breathe on his own after birth: slower or decreased blood circulation to the extremities is normal as baby’s body learns to support itself through breathing.

Central cyanosis means that a baby looks purple or blue in his or her trunk.  When the infant’s chest, abdomen or face appear purple, it can be a sign that baby isn’t getting enough oxygen all around.  Though central cyanosis isn’t in and of itself indicative of decreased oxygenation, it is an indication to place an SPO2 monitor on baby’s right hand and make sure that the discoloration you’re seeing isn’t from low O2 levels.

Muscle Tone and Startle

Decreased movement is another potential sign of trouble.  When babies cry, they naturally tense their legs and arms.  In general, crying is a whole-body experience for a newborn.  Also, in addition to the stimulation of having been born, the noise and light associated with birth often triggers baby’s startle reflexes, and if baby doesn’t have good muscle tone and good reflexes pretty quickly after birth, this can point to trouble.

Of note: this can be a sticking point for babies born by C-section.  Vaginal birth and the process of emerging from the birth canal–and all the squeezing that entails–can naturally stimulate a baby as he’s being born and also force fluid out of baby’s lungs.  C-section babies aren’t privy to this particular set of benefits, however, and as a result, sometimes babies born by C-section require a little extra attention to get them to perk up after birth.

Retractions and Grunting

Retractions are a fancy term for when the skin pulls in around baby’s ribs and sternum as he tries to breathe.  The direct result of a baby working extra hard to pull in air, retractions are a sign of respiratory distress in newborns.

The same goes for grunting, which initially sounds like baby is humming a song.  As baby exhales, he closes his glottis (which normally covers the airway when you’re swallowing food or fluids), which causes a distinctive “ah-ah-ah-ah-ah” sound.  In doing so, he causes a change in pressure in his chest that helps improve his oxygenation.  If a baby is resorting to grunting, chances are, he will need some assistance in the breathing department, whether that be suctioning, oxygen administration, chest percussion, or a combination of all three.  Grunting can be a last-ditch effort to open baby’s lungs before things go south, and I’ve seen grunting babies decline from grunting to assisted ventilations (bagging) to intubation (ventilator) depending on the source of their respiratory compromise.

*Of note: breathing is a big deal.  I know that sounds like a given, but in most babies who require resuscitation, breathing is the culprit of their distress.  Say you have a baby who’s born at term with central cyanosis and a no heart rate.  Even before you consider starting chest compressions–even if baby didn’t have a heartbeat at all–per Neonatal Resuscitation Guidelines (NRP), you must give adequate assisted ventilations (bagging) before starting chest compressions.  Most of the time, correcting problems with baby’s breathing will correct everything else.

APGAR Scores

At one minute, five minutes and ten minutes after birth, nurses assess something called an APGAR score.  This quick, objective assessment looks at five categories: skin color, heart rate, breathing effort, muscle tone, and reflex irritability.  At most, baby can get a “2” in each category.  At the least, he can get a “0”.  So on a scale from 0 to 10, an APGAR score tells a provider quickly how a baby is transitioning.

At one minute, my baby scored as follows:
Breathing: 1 -irregular, discoordinated breathing efforts
Heart rate: 2 -pulse is 150bpm, normal range
Muscle tone: 1 -baby has some muscle tone present, but less than normal
Reflex irritability: 2 -baby’s reflexes are normal
Skin color: 0 -baby has central cyanosis

Total APGAR: 6
(As a reference, most babies are born with APGAR scores of 8-9.  A score of less than 7 indicates a need for medical attention).

Back to the Scenario

With baby’s physical assessment looking borderline, I took the baby to the warmer with his mother’s enthusiastic permission.  I placed an SPO2 (blood oxygen) monitor on baby’s right hand and looked for a baseline.  Heart rate was in the 170’s–up from when I had listened to him on mom–and his blood oxygen was lower than normal.

With audible gurgling and coarse lung sounds, suction was in order.  I suctioned baby’s nose and mouth quickly, immediately pulling out some thick, clear secretions.  Suctioning can be an irritating process to a baby which can have the added benefit of making baby cry.  My baby did just that.  He cried immediately after I suctioned him, producing more fluid from his mouth and nose.  A few suctions later, baby’s heart rate came down, his O2 went up, his retractions stopped and grunting significantly decreased, and we were looking at a much happier boy.

In the end, this baby did well.  He was brought back to his mother and monitored for the rest of his time in L&D, but he transferred to postpartum without issues and was discharged normally with his mom a few days after he was born.

However, this scenario just goes to show: a happy strip doesn’t mean a happy baby, and it pays to stay on your toes at all times!

The Mystery That Is The Cervix

L&D nurses are weird.  And with that broad generalization, I’ll happily be the first to lay claim to it.  As if the very existence of this blog isn’t proof that at the very least, I’m a bit touched, I don’t know what would suffice as evidence.

Happily, in my current job as well as in all previous, I’m far from alone.  Unlike in my previous jobs, however, L&D nursing involves a skill that is routinely required and arguably somewhat difficult to master: the art of the cervical exam.

I know I’ve alluded to the complexities of cervical exams in previous posts, but in this one, I’m going to dive into why they’re just so darn difficult at times.  I realized as I took place in an admittedly strange but surprisingly commonplace ritual on my unit the other day that cervical exams are something of a low-key hazing for orienting RNs who have little to no OB experience, and that included myself at one time.  Abby, one of my new coworkers, was on her way to check her patient who we were trying to determine whether or not to admit for labor, and she was a bit apprehensive as she hadn’t had a whole lot of experience checking women whose cervixes were dilated to less than 5cm.

So as she walked past the desk, the four of us who were there to witness her brave march to triage looked up from our charting, waggled our fingers her way, and gave her our best parting wishes.

Mystery Cervix

So, now that you’ve gotten a look into the oddities of my workplace, let me explain from the very beginning.

The cervix is a round, muscular ring of tissue that connects the vaginal canal to the uterus.  It is essentially the gatekeeper to the womb.  In non-pregnant women, the cervix is typically 2-3 cm long.  When women become pregnant, the cervix is what allows the sperm to enter the uterus, travel up the fallopian tubes and fertilize the released egg(s).

In a pregnant woman who is not yet in labor or nearing her due date, the cervix should be closed, thick and high in the vaginal canal.  As the baby grows, the baby’s presenting part (hopefully the head!) will push the cervix down, and by the 3rd trimester (sometimes even by the 2nd), the cervix should be descended into the vaginal canal far enough that it can be felt by a healthcare provider during a vaginal exam.

Because I need visual representations to really understand things, I found you this picture, courtesy of the CDC:

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The Basics of a Cervical Exam

When performing a cervical exam (also called a vaginal exam; these terms are used interchangeably, although the cervix is what you’re looking to assess in both instances), the provider uses the index and middle finger of the dominant hand, inserts those fingers into the vagina, and feels for the cervix.

Especially when you’re starting out, making sure your patient is in a good position before you perform the exam is everything.  NOTE: make sure that you make it clear to the patient that you’re going to perform a cervical check and ask her if she wants people to leave the room before you do so!  Some women will kick out everyone except you.  Others have no problem with having their father, uncles, grandfathers, brothers, and about 20 male cousins all watching as you check.  Either way, be sure to ask!

In general, you want your patient to be lying on her back in bed with the head of the bed flat.  Have her bring her heels to her butt and let her knees fall out in a butterfly position.  Use plenty of gel.  No one likes a dry check, and if she’s uncomfortable, she will instinctively scoot back and up the bed, fighting you all the way (this is also known as “climbing the bed” in the vernacular of this particular specialty).

Another trick I’ve learned along the way is to sit on the bed as you perform the exam.  This gives you a stable base from which to perform your check, and if you really need to reach for that cervix, it’ll be a lot harder to do it if you’re standing up.  You can also keep a hand on her leg that’s nearest you, not only reminding her to stay relaxed, but also as a means of protecting yourself should she kick, either intentionally or reflexively (for the record, I’ve never had this happen, but I fully expect it will and there is nothing wrong with being prepared!).

Especially if she’s young/nervous/sensitive, be sure to talk her through it.  Tell her what you’re doing, what she’ll feel and remind her to breathe through any pain she experiences. Be honest with her.  If you can’t feel her cervix low in the vaginal canal and you’re going to have to push posterior (toward her back), tell her it will be painful.  Encourage her to tell you if she has a history of sexual abuse as this can severely impact how you approach a cervical exam.  Don’t be afraid to stop your exam and give her a break if she’s really not tolerating the process well and resume the exam after you’ve both had a chance to take some deep breaths.  Some multips have been through so many cervical exams, they don’t really care anymore, but err on the side of caution.  Cervical exams are by their very nature uncomfortable and extremely intimate.  Be the kind of examiner that you’d want if you had to have your cervix (or your wife/girlfriend’s cervix) checked.

Something to keep in mind (and something that may new L&D nurses struggle with) is that sometimes, no matter how hard you try, cervical exams will hurt your patient.  That can be hard to come to terms with as a nurse as we are accustomed to relieving pain, not causing it.  This particular exam is incredibly intimate and involves extremely sensitive areas of the female anatomy, which can make it difficult for you as a nurse to carry on when you know your patient is in pain as a direct result of your actions.  I promise, you’ll get quicker and more accurate as time goes on, but no matter how good you get, sometimes you won’t be able to avoid causing a bit of pain with cervical checks.  Stick to the guidelines in the paragraph above, however, and most patients will still trust you, even after a tough check.

A final piece of advice for this section: when you know the exam is hurting your patient, you can’t talk her through it/apologize afterward too much.  And usually both are required to keep her trust after an uncomfortable check.

The First Time You Check A Cervix

The cervix can be tough to find, especially for new L&D nurses because as at first, pretty much everything in there just feels warm and mushy.  Most new L&D nurses won’t feel the cervix the first time they perform a vaginal exam.  It often takes a few vaginal exams to not only feel comfortable enough to feel around for something that isn’t just vaginal wall, but also to get an idea of what isn’t cervix so that when you do feel one, you know it’s something different.  Usually, it takes a few awkward moments of feeling around in there and a near-accidental encounter with a cervix to realize, “oh, that‘s a cervix!”.  If you’re new to L&D and struggling with vaginal exams, welcome to the club.  There are times where I still can’t find cervixes (especially closed or only slightly dilated ones!) and need to call for a backup checker (typically, the charge nurse).

Standard Deviation: The Art of Cervical Exams

Please note that cervical exams are something of an art.  No two cervixes are the same–just like all nurses and doctors are different.  So two different people may check the same cervix seconds apart and get different readings.  Why?  Because there is no way to objectively assess cervical dilation.  In all cervical exams, you’re stuck with a subjective manual exam.  Sorry, no magical cervical measuring tape here.  A cervical exam is based on personal interpretation of one’s own assessment.

So when I check a lady and say she’s a 2 and the next nurse checks and says she’s a 1.5, that may only mean the second nurse has bigger fingers than I do.  Really.  It can be that arbitrary.  Or maybe I checked during a contraction and the next nurse checked between contractions (which is generally the polite thing to do, though early on in labor, your patient may not experience much pain with contractions or feel them at all!).  So while cervical exams are certainly an important skill to develop, it is important to keep in mind that they’re not always going to align perfectly from nurse to nurse (or doc to doc or doc to nurse etc.,), though they should at least be in the ballpark of each other.  Usually, I’m within 1cm or less of other nurses’/physician’s assessments if there’s any deviation at all.  That’s a good goal to strive for.

Cervical Consistency

Depending on dilation and labor stage, cervixes can be hard, medium, or soft in consistency.  As cervixes dilate and thin, they also become softer.  A hard or moderate cervix can sometimes feel “crinkly” on the edges.  A cervix of this consistency typically indicates very, very early labor or a woman who isn’t in labor at all.  A soft cervix feels a lot like an earlobe. Usually, you’ll feel a soft cervix in women who are either near their due dates, overdue, or in labor.

What Am I Looking For?

When performing a cervical exam, the nurse is trying to determine if the cervix: 1) has dilated, or opened; 2) has effaced, or thinned out; 3) has a soft vs hard consistency; and 4) is anterior, posterior or centrally located on top of baby’s head.

Mystery Cervix 2 - Copy

Dilation

In the diagram above, the light purple section represents the dilation of the cervix.  You can see the cervix is somewhat descended into the vaginal vault below, though keep in mind that even in a non-pregnant state, part of the cervix normally protrudes into the vaginal canal.  The inner os and outer os are key in determining dilation.

Mystery Cervix 3

In order to truly determine dilation, you need to be able to reach through the cervix with your finger(s) and touch the baby’s head. The degree of dilation at the inner os is the true dilation of the cervix.  Keep that in mind as that has tricked many a newbie before (including me!).

Tip for determining dilation early in your career: take a paper tape measure (the kind used to measure babies) and tape it with the centimeter side up on the back of your name badge.  After you check a cervix and discard your glove, use your fingers to check what you felt against the tape measure.  This can be a good double-check to see if your assessments are relatively accurate.

Early Stages: Thick, High and Barely Dilated

In a patient who isn’t too far dilated or effaced, a cervix can be not only hard to find, but hard to check.  This may be because it is so long that it’s hard to get through to the inner os, or it could be posterior (around the back of the baby’s head) and a long ways away from your curious fingers.  A closed cervix usually feels like a dimple and can be really, really difficult to even find.

Personally, I call dilation based on the following:
Fingertip: I can get 1 finger through the cervix, but I can’t quite put it flat on baby’s head at the inner os.
1cm: 1 finger through to the inner os, flat on baby’s head.
2cm: 2 fingers on top of each other through to the inner os on baby’s head.
3cm: 2 fingers side by side through to the inner os on baby’s head.
4cm: 2 fingers through to the inner os, slightly preadable between the edges of the cervix to a degree I can show you on my fingers, but can’t really describe. (This is where your tape measure comes in handy!  Figure out what 4cm looks/feels like with your fingers!)
5cm: 2 fingers through to the inner os, spreadable more so than a patient dilated to 4, but less than 6.  Again, hard to describe without showing you.  Make sure to use your tape measure!

*Your method of determining dilation may be different than mine based on your finger size!

Later Stages: Wide and Thin!

 Mystery Cervix 7

As dilation continues, the cervix will begin to feel less and less like a tube and more and more like a rim around the baby’s head.  At a certain point, you will no longer be able to spread your fingers wide enough to determine how dilated your patient is.  When this happens, the best method of checking dilation is to find the cervix and to try to put as much of your fingers on it as possible between the edge of the cervix and wall of the vaginal canal.  Again, your assessment may vary from mine based on finger size, but my general guidelines are as follows:

6cm: At this dilation, I can usually still spread my fingers enough to perform an adequate exam.  However, if I try to put my two fingers on the cervix, there is more cervix than I have finger width.
7cm: I can get 2 fingers side by side on the cervix. *(Remember, 2 fingers side by side is my measurement for 3cm, so if there is this much cervix left, I simply subtract from 10cm to get my dilation.  Same goes for the following dilations!).
8cm: I can get 1.5 fingers size by side on the cervix.
9cm: I can get 1 full finger on the cervix.  Usually, the cervix feels pretty thin by this point.
9.5cm/lip/rim: a little tiny strip of cervix is still present on your exam.  So…close!
10cm: NO CERVIX LEFT!  LET’S HAVE A BABY!!!

Effacement

Generally speaking, as a woman’s cervix dilates, it is also going to thin out.  So the more dilated a woman is, the thinner her cervix should be.  As a woman’s cervix effaces, it lets down the baby’s head into the vaginal vault, so as this progresses, you may notice baby’s head getting lower and lower and that with each check, you have to go in less and less distance to find the head.  We measure effacement in percentages in increments of 10 from 0 to 100.

Mystery Cervix 4

Starting at the thick end, 0% effaced means a woman’s cervix hasn’t thinned out at all.  Now, typically, when a cervix is this thick, it’s closed.  Unless confirmed by ultrasound, it is fairly unlikely that you will ever be able to insert a finger into a cervix that is 0% effaced, though I’ve felt some that are pretty darn close.

As you might have guessed, 50% effaced is halfway thinned out.  On my own assessment, I say that a woman’s cervix is 50% effaced when it comes up to my first knuckle.

From 50% effaced, each increment of 10 brings you a little bit closer to fully effaced, or 100% effaced.  Eventually, the cervix may feel so thin and may be so firmly pressed down by baby’s head that it is thin as paper, at which point we’d say the patient is 100% effaced.  She just needs to finish dilating and we can think about having a baby!

As you gain experiencing with checking cervixes, you’ll also notice that some cervixes will feel stretchy and you’ll be able to stretch them with your fingers.  A stretchy cervix is a happy cervix.  This usually means your patient is going to dilate nicely.

It is important to note that in general, first-time moms (primiparas) will undergo more effacement first, then dilation.  Mothers who have already had a baby or babies (multiparas) tend to dilate more, then efface.  So if you check a primipara who is in labor and you note her cervix is extremely thin, and then on your second check, you can’t find it, slow down, retrace your steps, and check again.  I’ve had patients who have been fully effaced at a dilation of 3.  Those cervixes are darn near impossible to find, but typically, you can if you’re thorough!

Cervical Position

As I’ve referenced above, cervixes aren’t always straight back.  Sometimes, especially in a mom who isn’t too far dilated and isn’t really ready for labor, her cervix will be posterior, or to the back of the vaginal vault.  Some cervixes are very anterior, or toward the front of baby’s head, and they sit “up”, just past the pubic bone.  Some cervixes are off to the sides.

The truly wonderful ones, however, are in mid-position (straight back), soft, and consistently dilating/effacing in an effort to bring us a baby.

Mystery Cervix 5

Mystery Cervix 6

Station

Although station isn’t related to the position of the cervix, this is also something you’ll be paying attention to when you check your patient.

As you check mom’s dilation and effacement, take note of where the top of baby’s head (again, presenting part, so hopefully the head!) is in relation to the ischial spines (bony prominences of the pelvis that are in the narrowest area of the vaginal vault) .  Even if you have to go way back to find mom’s cervix, the baby’s head may be low in the vaginal vault, and where the front-most part of baby’s head is in relation to the pubic bone determines station.

Station1

In terms of station, the baby’s head is said to be fully engaged when he reaches 0 station.  By the time baby is at 3+ station, the head is crowning.  Typically, by the time baby reaches 1+ station, the head may be just visible when mom pushes with contractions.

Tricks for Cervical Exams

A good trick to check a minimally dilated cervix or any woman who you are checking for the first time is to use your middle finger (or longest finger) to sweep along the baby’s head, starting anteriorly (toward the front) and going back.  Don’t forget to check the sides!

For minimally dilated cervixes that are too far back to reach: when you find the edge of the cervix, hook it with your middle finger and pull it gently down toward you.  Usually, you can insert your second finger at this time and get a good feel for dilation and effacement.

Another tip is to have your patient make a fist and put it underneath the small of her back.  This can help to tip the cervix forward in the vaginal vault so it’s easier to reach.

If baby’s head is not engaged in the pelvis, sometimes pushing down gently on mom’s belly can bring a floating baby down, therefore pushing the cervix toward you.

Most of all, be patient and don’t be afraid to have someone check after you, just to make sure!

Happy cervical exams, fellow L&D nurses!  May the cervix be with you!

That Awkward Moment When…

I know.  There are a lot of awkward moments in my job.  So I’ll be quick to clarify.

That awkward moment when…you save someone’s life and no one else* knows it.
(This does not include the responding nurses/physician!)

I had my first postpartum hemorrhage the other day.  It was terrifying.  Again, I don’t tell you that as a new nurse whose experience barely extends beyond the imaginative, scenario-based world of training.  And while the scene was unforgettable–arguably, indescribable, as after several edits, I still don’t feel I’ve captured the full chaos of the situation–one thing will always stick with me.

I was the only one who realized what was going on.

I’ll set the stage for you.  I’m about at the end of a recovery after a fairly difficult vaginal delivery.  The patient is doing fine.  Baby is doing fine.  The mom has some visitors in her room and they’re casually chatting while I’m giving her some pain medication.  However, as I’m pushing the med, the patient starts to feel sick.  I hand her a bucket and she is very clearly nauseated, retching but unable to produce anything.  I think to myself, perhaps she’s simply naïve to narcotics.  That could be the case.  Some folks are extremely sensitive to narcs and will become sick quickly after an IV push.  However, it was just as I was starting to think that this was pretty intense to be a reaction to a narcotic, it happened–

A loud splash, as if someone had thrown a bucket of water on the floor.  I look down to see the biggest puddle of red I’ve ever seen creeping rapidly toward my shoes.  And then, a family member’s reaction so misplaced, I can barely believe what I’m hearing…

Hemorrhage 1

Now, let me pause here to explain to you how delivery beds are made.  They have a bucket underneath them that is specifically designed to catch blood during a delivery.  That bucket was in the path of this gush.  Delivery beds aren’t thin, either, meaning there is a lot of distance, including mattress and metal pieces, to travel through in order to reach the floor.  That’s a lot of stuff between the patient and the floor–plenty of material to slow down a fluid spill.  For blood to have hit the floor hard enough to splash…wow.  That’s a lot of blood.

All of this crossed my mind in the span of a few milliseconds before I reached for my poor patient’s boggy uterus and hit the emergency bells.

Hemorrhage 2

If, by some strange coincidence, you realize as you read this that you were among the family members who were sitting in the room when this happened, I really didn’t mean to be rude.  Let’s just say I was stunned–flabbergast–appalled at the thought that you were sitting at bedside during a massive postpartum hemorrhage and laughing as your family member was bleeding to death.

Don’t get me wrong: I don’t expect those guests to be medical experts.  But there is something strange and unsettling about people who laugh at of a volume of blood that is rarely shown in appropriate circumstances on TV, much less seen in a real-life situation involving a loved one.  I argue not for the medical proficiency of her guests, as this was not necessary to deduce that serious trouble was amiss.  Rather, there was a sickening lack of basic concern for the crimson pool that grew by the second and the simultaneously dwindling consciousness of the woman in bed.

At any rate, after an initial moment of stunned silence, the family members left the room, and in a matter of seconds, the cavalry arrived.  The patient was barely conscious, her blood pressure so low that the machine couldn’t read it.  I had pulled back the blankets to reveal a pool of blood in the bed, soaking the mattress and sheets from foot to waist.  One nurse was starting a large bore IV while another opened up the pitocin and fluids that were already running, infusing them in at full blast.  Another nurse put an oxygen mask over my patient just as the doc came running in, slid a hand into my patient’s uterus and pulled out some of the biggest clots I’ve ever seen.

In all, we estimated somewhere around 2.5 liters of blood lost in less than a minute.  Really, 2.5 liters.  Consider that te average human adult has somewhere in the neighborhood of 5 liters of blood circulating.  Approximately half of my patient’s blood had exsanguinated and now lay in the bed or on the floor.

After stabilizing my patient and cleaning up the veritable mess that remained, we let the visitors back in at her request.  I felt bad for the poor girl.  She had been up for over 24 hours, had gone through hell in labor, and now looked like death warmed over (and that is no exaggeration).  Her blood levels, even on the CBC immediately after the bleed, were low.  I expected she’d receive a blood transfusion before my shift was up.

But when her visitors came marching back in, to my amazement, they seemed to have forgotten the events that led to their abrupt eviction and instead, peppered my patient with comments like this:

Hemorrhage 3

Hemorrhage 4

I know what you’re thinking.  They’re probably just being nice, you’ll say.  They’re probably trying to make her feel better, you reason.

No.

Simply put, no.

I only wish their reaction could be attributed to some benevolent desire to make this patient feel like less of a train wreck than she was.  In fact, I made every effort to believe they were only being nice until I was eventually confronted by the uncomfortable facts: they were nothing short of completely sincere.

To boot, even my patient didn’t seem to understand the fact that she had done the Texas two-step with death that night and come out on top, even when I explained to her the extent of her bleeding, the meaning of her CBC results, and the fact that she might get blood to prevent spontaneous bleeds that could result from extremely low blood counts.

So it was an odd night to say the least.  I headed home feeling a bit off, knowing that I had done something incredible, but with very little acknowledgement.  It’s happened before, and I know it will happen again.  It’s just strange to be the one who experiences it in full: the crash in vital signs, the blood, the near-fatality, the incredible response of the staff…

…and to go from all that adrenaline, action and real-life heroism to a patient and family whose biggest concern is…when the mom can have something to eat.

However, as one of my more thoughtful coworkers pointed out, maybe it’s better that way.

A Cruise to Sciatica

This post is admittedly a little random, but it focuses on two major features of working as a nurse on my unit and working nights: first, the randomness that defines the hours between 0300-0600 (commonly known in my workplace and many others as “the wall”, wherein everyone is so tired and so slap happy that you never know what the conversation will bring) and second, the long-running tradition of teasing the charge nurses.

Charge nurses have a tough job.  I’ve been a charge nurse before, and it’s certainly not a job I envy.  In charge of organizing the other nurses, making patient assignments, and keeping the floor afloat, charge nurses are used to rolling with the punches, especially the ones that come from their own staff.

Enjoy a sample of a typical discussion right around 0400, when most of us are actively “hitting the wall”.

Sciatica, Greece 1

Sciatica, Greece 2

Sciatica, Greece 3

Sciatica, Greece 4

Sciatica, Greece 5

Sciatica, Greece 6

To all the charge nurses everywhere…thank you for what you do!  And remember, we only tease the ones we love!

The L&D Perspective in a NICU Habitat

L&D nurses and NICU nurses see babies differently.  It’s something I’m thankful for every time we send one of our kiddos to the unit.  However, it’s only when the NICU is overflowing and it’s my turn to float that I begin to realize exactly how big the divide is between the NICU and L&D perspective…

NICU vs LD 1

NICU vs LD 2

NICU vs LD 3

NICU vs LD 4

NICU vs LD 5

NICU vs LD 6

NICU vs LD 7

Fetal Heart Monitoring: How to Make an L&D Nurse Run

It isn’t uncommon in the course of my shift for me to be sitting at the computer, happily charting away, when a well-intentioned family member/friend/visitor of a laboring mom bellies up to the counter, locks eyes with the big-screen fetal heart monitor, and starts asking questions.

Now, fetal heart monitoring is much more complicated than what I can explain in the span of this blog.  There is introductory (basic) FHM, which, once passed, is one of the factors that allows a newly minted L&D nurse to work independently.  Then there is intermediate FHM, which is a follow-up course that goes into more detail and depth on how to read, interpret and respond to the information we gather from our laboring moms and babies.

So what’s the big deal with fetal heart monitoring?  Pretty easy: when you walk into a room and see a laboring mother, you see one patient.  I see two (at least, assuming this isn’t a multiple birth!).  However, of those two patients, there is one patient that I cannot directly assess because that patient is inside the other patient!  So why do I watch the monitor like a hawk?  Because the information on that monitor is my only direct look into how patient #2 is doing.

Let’s get into some basics.  A fetal heart strip is divided into two parts: the top part is the fetal heart rate itself.  This is represented by a line that moves vertically across the page to represent the baby’s heart rate in beats per minute (bpm).  The bottom part is tracing the mother’s contractions.

FHR Basics 1

FHR Basics 2

FHR Basics 3

Now, in a normal term pregnancy, I expect to see a certain amount of variability in the fetal heart rate, or the “bounce” present in the FHR.  Variability is determined by looking at the fetal heart rate pattern between contractions and is a result of the fetus’s immature sympathetic and parasympathetic (vying nervous systems) pulling on each other like a tug-of-war.  Sympathetic nervous system gets the upper hand and you have an increase in FHR.  Parasympathetic nervous system gets the upper hand and you have a decrease in FHR.  Pretty easy, right?

The FHR in the first example above tells me that baby is probably pretty darn happy in there.  Especially if there are accelerations present, this typically indicates a content baby with a good placenta and good oxygen exchange.

Since what goes up must come down, there also exists a phenomenon called decelerations in fetal heart monitoring.

FHR Basics 4

Early decelerations are usually a sign of head compression.  When a contraction squeezes on baby and baby is getting low in the vaginal vault (and hence, close to delivery), this can trigger the baby’s vagus nerve (not Vegas, vagus!), which in turn slows the heart rate as the contraction gets stronger and squeezes harder.  With this kind of deceleration, the heart rate should return to normal as the contraction lets up.  L&D nurses like to see early decels because it usually means there’s a baby coming soon!

Late decelerations, on the other hand, especially if paired with minimal or absent variability, can be a sign of fetal distress.  What a late deceleration tells me as an L&D nurse is that baby isn’t coping well with the stress of labor.  During a contraction, blood flow to baby is temporarily suspended as the uterus contracts and cuts off the vessels leading into and out of the uterus.  Normally, the blood that remains in the placenta and in baby during a contraction is oxygenated enough that a baby typically won’t notice the temporary lack of fresh O2 during a contraction.  However, if baby is stressed from labor and her oxygen levels are low anyway, she may really take offense at her O2 source being cut off for any amount of time, and as a result, her heart rate drops as she’s not able to compensate.  Of note: late decelerations can also be a result of an epidural, which can decrease maternal blood pressure and therefore decreases the amount of blood and O2 going to baby.

Fixes for late decelerations include: changing mom’s position to improve blood flow to the uterus, placing O2 on mom (and thus increasing the O2 going to baby), turning down/turning off Pitocin (decrease the frequency and strength of contractions so baby isn’t getting squeezed as much), turning up IV fluids (increasing the blood volume so baby is better perfused), IV ephedrine (a drug that increases maternal blood pressure if that’s the culprit) and, of course, delivery (no more contractions–yay!).  If you’ve ever seen an L&D nurse (or perhaps a crowd of them) come running into a room, throw a laboring mom all over the bed and go through some variation of the steps above, you’ve probably witnessed them reacting to late decelerations.

Variable decelerations typically indicate that the umbilical cord is getting pinched.  They usually happen with or around contractions.  Whether baby is laying on it, squeezing it (I’ve seen it happen via ultrasound!), or the cord is around baby’s neck, body, foot, etc., if you’re seeing variable decels, usually the cord is in a wonky spot.  Thankfully, variable decels aren’t usually very concerning unless they’re really deep (down into the 80-bpm or lower range) or they don’t recover fairly quickly.

Prolonged decelerations, much like late decelerations, are a sign of fetal intolerance of labor.  The fixes are typically the same as those listed for late decels, though it has been my experience that especially with prolonged decels, if mom doesn’t deliver soon, she’ll probably be heading back for a C-section.

FHR Basics 5

Fetal tachycardia, or a fetal heart rate with a baseline of 160bpm or greater lasting for at least 10 minutes, can be normal, especially in a particularly active baby.  However, it can also be a sign of distress and indicate anything from maternal infection to fetal heart problems.  I have seen tachycardic strips as a result of mom smoking a cigarette before coming into triage.  I’ve also seen tachycardic strips as a result of uterine rupture and placental abruption.  I’ve seen even more as a result of maternal infection (whether that be an infection of the amniotic fluid or something as normal as the flu).  As a result, most L&D nurses hate, hate, hate to see strips where baby is tachy as it is usually a sign of trouble brewing.

Fetal bradycardia, while not uncommon when nearing delivery, is one of those things most L&D nurses really watch for.  Unless you’re close to delivery, there is no good reason for fetal bradycardia (at least that I’ve seen!), and most fetuses that exhibit sustained bradycardia are headed for the OR if they don’t shape up!

So, now that we’ve gone through the basics, perhaps you can appreciate the following.  I call it, “An Assessment of Fetal Well-Being  Based on the Facial Expressions of Your Average L&D RN”.

FHR 1

FHR 2

FHR 3

FHR 4

FHR 5

FHR 6

PS: if you’re interested in further exploring the concepts in this post, please reference the following webpage, which I have found to be very thorough!  Real-life FHM strips included!

http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/LaborandDelivery/electronic_fetal_heart_monitoring.htm