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…

It's A Shoulder! 1

It's A Shoulder! 2

It's A Shoulder! 3

It's A Shoulder! 4

It's A Shoulder! 5

It's A Shoulder! 6

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

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

 

Tips From an L&D Triage Nurse: How To Get Admitted…and How Not To!

Before I became an L&D nurse, I wouldn’t have known what qualified one patient for admission over another.  Since I began working L&D, I’ve come to realize that most of our patients don’t, either, but we also have a very different population–those patients who think they do.

I’ll bet you’ve heard all kinds of things from your friends, your mom, your neighbor, your coworkers, your cousins, the cashier at the grocery store, the talkative old lady in aisle 12 (let’s face it: pregnant ladies are prime targets for unwarranted advice!).  But what are we L&D triage nurses really looking for when you come into the hospital?  What’s the difference between a patient who will stick around until delivery and one who won’t?  And why did we send your great-aunt’s cousin’s neighbor’s best friend home when she was dilated to 3 and dying of contractions?

Sometimes it’s more of an art than a science, but I’ll try to break it down for you nice and neat, show you a few tricks that people have tried to beat the system, and divulge how we L&D nurses tease out the truth from the tall tale.

1.  Dilation Does Not Equal Admission.

While cervical dilation provides nurses and physicians with an idea of where a woman is in the labor process, dilating before labor actually starts isn’t uncommon, even in first-time moms.  Now, it’s more likely that your multipara (a woman who has had 2 or more babies) is going to dilate earlier and more than your first-time mom, but that isn’t always the case, nor is it unsafe to head home when dilated to 4 or 5 or even 6 centimeters, though the higher you go, the less likely it is that you’re not in active labor.  Trust me (and anyone who’s ever given birth before), babies don’t usually just fall out, especially if it’s your first.

I’ve discharged patients who were dilated to 4 or 5–a few of them even being first-timers!–who were definitely not in labor.  Often, I’m met with shock and disgust.  “How dare you discharge me!  Do you realize how far dilated I am?  I could go at any time!”

Yes, that’s entirely true.  At the same time, however, so could the other lady I’m preparing to send home who’s only dilated to a 1 and 30% effaced, and there’s no guarantee that she won’t deliver before you do!

So think about it: when you do come in huffing and puffing and ready to push a baby out, do you want to be admitted to a room, or would you rather deliver in a cramped triage room because we’ve admitted every lady who was dilated to 3cm or more?

Point being, if we kept every woman who was dilated to a certain degree but not in labor, our L&D unit would be full to bursting all the time.

2. Contractions Do Not Equal Admission.

I know, I know.  Those contractions are painful, and you really do look uncomfortable. I don’t think you’re faking that.  But your contractions are 4 to 8 minutes apart, incredibly irregular, and they’re just not that strong.

Both of the qualifiers above–regularity and strength–are two things that L&D nurses look for in assessing patients for admission.  With regards to regularity, we can determine that by placing the patient on the toco–a monitor that indicates the length and pacing of contractions.  As far as strength, that is assessed by placing a hand on your belly and feeling it during a contraction.  (Just in case you didn’t know, the external monitor that times your contraction doesn’t actually tell me how strong they are.  Only properly placed internal monitors can do that!).

But contractions on their own don’t necessarily indicate the need for admission.  Instead, in conjunction with cervical dilation, L&D nurses often check to see if those contractions, irregular and mild or not, are changing mom’s cervix.  So when the L&D nurse tells you to get up and walk for an hour and come back for another cervical check, what she’s really trying to see is if a) your contractions will go away with walking (meaning they’re likely Braxton-Hicks, or false labor) and b) if your contractions are causing cervical change over decent stretch of time.

If at some point you get the brilliant idea to try to fake a contraction by manually depressing the toco–don’t.  We L&D nurses spend our entire shifts reading those strips.  We’re pretty good judges of what’s real and what’s not.  Also, when we enter the room to talk to/assess you and your contractions suddenly stop for 10 minutes, we’ll know.

3.  Pain Does Not Equal Admission.

I hear this one a lot, too.  Ladies in various stages of pregnancy come in complaining of pain, and while some women feel their labor entirely in their backs or butts, chances are, if you’re feeling only constant pelvic pressure and/or back pain, you’re not in labor (at least, I really hope you’re not!).

Many of our OB docs won’t give more than a Tylenol or ibuprofen for pain in the pregnant population due to the risk to the fetus.  We have some patients who come to triage in an attempt to refill narcotics and/or get narcotics prescribed to them.  If you have issues in your pregnancy that do require narcotic drug management, do not expect your triage OB to provide/modify/manage these for you as this should be addressed by your primary OB and/or pain management team.

If you’re tired of being pregnant and you think that exaggerating/creating nonexistent pain will get you admitted and induced, think again, especially if you’re preterm.  Most hospitals these days won’t even consider an elective induction unless you’re 39 weeks along or more, and it is rare that the triage OB will opt to schedule an elective induction for a patient that isn’t his or her own, especially on the spot.  Hospitals are busy places, and trying to get your triage staff to finagle you into an impromptu induction is a really, really poor bet.

If we were to keep every pregnant woman who came in complaining of pain, we wouldn’t have any room for actual laboring patients.

4.  Water and Waders: Real or Fake

One thing that will get you admitted quicker than you can say, “Let’s have a baby!” is ruptured membranes (ie, your water is broken).

If you’re really preterm (see: earlier than 34 weeks), you will have just signed yourself up for an extended stay at the L&D Inn.  Because of the infection risk and risk of other emergencies like cord prolapse with preterm premature rupture of membranes (PPROM), you will be admitted and remain in the hospital until you deliver, which is usually around 34 weeks.

If you’re 34 weeks or later, chances are we will give you some antibiotics and either let you labor or induce labor if you’re not already in it.

Now, if you’re itching for an admission/induction and you’re thinking you can fake rupture of membranes (ROM), think again.

Let’s go over a few things that do not comprise ROM:

  1. Cervical discharge (normal in pregnancy, but can also indicate a vaginal infection)
  2. Urine
  3. Apple juice/water/Mountain Dew

I’ve had patients who have honestly mistaken both of the first two items above for their water breaking, and sometimes, it really can be hard to tell what exactly is coming out of there, especially if you’re late in pregnancy and you haven’t really seen it in a few months!

However, I’ve also had patients who have intentionally urinated on themselves to make it look like their water has broken.  I’ve had patients who have told me that it had to be their water breaking because “urine just isn’t that clear!”  I’ve had patients who have used other substances (see item #3) to make it look like their water is broken.

Let me be the first to warn you: if you’re silly enough to try to fool us with pee or any other liquid in an effort to get induced/admitted/delivered, we will figure out the truth.  Don’t be the talk of the break room.  Quit while you’re ahead.

The first thing we do when you come in through triage is test your vaginal canal with a little strip of paper called nitrazine.  This tells us the pH (acidity) of your vagina.  Normally, vaginal canals are acidic.  However, amniotic fluid is basic.  Our test strip will turn blue if your water is broken.  Of note, urine will also change nitrazine paper blue..

So after we do the nitrazine test, we’ll do another test called AmniSure.  This test checks to see if there are actual proteins from amniotic fluid present in your vagina, and this test is considered diagnostic.  If it is negative, your water isn’t broken.  If it is positive, welcome to the Inn.

If you really do believe your water is broken, it is important that you come in.  If your water is broken and you neglect it, you could end up losing your baby and in serious jeopardy yourself if you should get an infection.

5.  Looking for a Lost Mucous Plug…

While losing your mucous plug typically means you’re beginning to dilate, this by no means indicates that you’re in labor and certainly isn’t a reason to visit your L&D triage unit.

If you do come in telling us that you lost your mucous plug and you aren’t having contractions and/or some other medical issue, we will put you on the monitor for the obligatory 20 minutes, make sure your baby is OK, possibly check your cervix, and (barring some other medical issue) send you home.

Mucus Plug 1Mucus Plug 2Mucus Plug 3Mucus Plug 4Mucus Plug 5Mucus Plug 6Mucus Plug 7

**********************************************

Long story short, admitting in L&D is much more complicated than “Oh, you’re contracting? Let me get you a bed!”  So when you go in, expect a thorough assessment.  Be patient and honest with us.  But most of all, be patient and honest with yourself.  Doing so will likely ensure a healthy baby and a better outcome for both of you.  That’s our goal when we’re evaluating patients for admission.  Hopefully, that’s your goal, too.

Triage Tales: Inducing Irritation

Oy ve, I had another one.

What a scene. You would’ve thought she was about to deliver right then and there.  But let me back up a bit.

There I was at the nurse’s station, enjoying an evening that could easily be described as…er, well, we don’t say that word in my profession (it starts with a “q” and if you do say it, you run the risk of being assaulted by an angry horde of RNs!).

Quiet night

But nevertheless, there we were, standing around and chatting amongst ourselves, sipping our first cups of coffee and having a splendid time.

Then, the call came in from the front desk.  I was up for triage, so the yellow sticky came directly to me.

“Ashley Smith, G1P0, ctx/pain, 18 y.o., 36.4, Dr. Adams.”

In English: my patient is Ashley Smith. She’s an 18-year-old patient of Dr. Adams expecting her first baby.  She’s here for painful contractions and she’s at 36 weeks, 4 days gestation.

I glanced up at my charge nurse, who had taken the call. “Is this one for real?”

She shrugged. “I dunno.  The receptionist sounded pretty serious when she sent me the info.  It sounds like it might be.”

“Okey dokey.  I’ll put her in 2.”  I said, heading down the hallway and out through the double doors to our reception desk.

Ashley Smith was clearly uncomfortable, breathing heavily in the chair at the receptionist’s desk.  An older woman, presumably her mother, stood behind her.

“Ashley?” I approached, taking the consent forms from the receptionist.

“Yeah.” The girl replied, standing up painfully.  Her mother took one of her arms and together, we slowly made our way back through the double doors and into the triage room.  Ashley, panting and holding her belly, was obviously holding back tears as we went.

“I’m Sophina.  I’m going to be your nurse today.  When did your contractions start?”

“They started about 4 hours ago.  I’ve been up walking, moving around, all kinds of stuff.  They aren’t stopping.”  Ashley replied.

“OK.  Where’s most of your pain?” I asked.

“Down there.” She motions toward her privates.  “And sometimes in my back.”

“Gotcha.  How far apart are your contractions and how long do they last?” I ask, starting to wonder what exactly I was dealing with.  Ashley’s “contraction”, which should’ve been letting up by now, seemed more like continuous pain, and the pressure she was describing could be indicative of advanced dilation, which was causing baby’s head to push down on her perineum.  However, most women by that point are beside themselves with the urge to push and in much more distress, both symptoms that Ashley was not exhibiting.

“They don’t really stop.” Ashley said.

“I’ve tried to time them, and they seem to let up every three to four minutes for a few seconds, and then she’s right back into them.”  Ashley’s mom piped up as we arrived in the room.

Now my mind was really going.  Was I looking at a case of uterine tetany (contractions that last much longer than they should)?  Was Ashley really having contractions?  Or was this patient, a young primigravida, after something else entirely?

In the room, I started the process of gathering the data I’d need to make a full assessment.  I put Ashley on the monitor, revealing  a very happily gestating fetus.  When I placed the toco (the monitor used to measure the length of contractions), I checked Ashley’s abdomen, noting that her uterine tone felt relaxed and normal.  The toco wasn’t picking anything up, but Ashley continued to complain of contractions.  So in the midst of getting Ashley’s vitals and asking her questions, I adjusted the toco several times, taking the opportunity to touch her abdomen to assess for contraction strength.  There was absolutely no uterine tone to be felt.

Finally, it was time for the acid test: dilation check.  Ashley was dilated to about a 1 and 40% effaced–certainly not advanced or indicative of active labor by any means.  It was when I was entering her dilation into the computer, which provides a historic view of her previous checks, that I realized this was Ashley’s fifth time through triage that week.

Now with a much clearer idea of what I was dealing with, I told Ashley I’d get ahold of the doc and be back in about 15 minutes.  Shaking my head, I did a bit of charting, made sure I had a 20-minute strip of baby’s heart rate and Ashley’s non-existent contractions, and prepared to call.

Just as I was about to call, however, Ashley’s mom stuck her head out of the triage room door. “Sophina, can you come check her again? She’s having a lot of pain!”

I hopped up and zipped into the room, where Ashley was writhing on the stretcher. Once again, the toco revealed no contraction activity, and Ashley’s uterus was relaxed.  I pulled on a sterile glove and gel and performed yet another cervical exam–absolutely no change.  Reassuring Ashley and her mother that nothing was happening, I readjusted my monitors, headed to the computer and called the doc.

Generously, the physician agreed to give some Tylenol #3 (Tylenol with codeine) for my uncomfortable soon-to-be mom, and as I headed back into the room with the drug and a glass of water, I prepared myself for what I knew was likely going to happen.

“All right, Ashley.  It looks like you’re not in labor.  Your cervix hasn’t changed since last week, the majority of your pain is down low and in your back, both of which are common in normal third-trimester pregnancies, and I’m not picking up any contractions of any kind, which is consistent with how you’ve described your pain.”

It was like flipping a switch.  Suddenly, Ashley didn’t appear to be in pain anymore.  The tears and the writhing and the look of discomfort were instantly gone.  She was glaring at me with the sullen disgust of a teenager whose bluff had been called.

“I’ve got some Tylenol #3 here, which is Tylenol with codeine, so we’ll see if that will help your pain any.  Otherwise, your baby looks nice and happy and I think we’ll be getting you on your way home soon.”  I said, scanning Ashley’s bracelet and her med.

Ashley verified her name and date of birth without looking at me.  While she took her med, it was obvious she was on the verge of breaking down.  I waited, knowing it was coming, finishing my medication documentation as her patience wore thin…

Say it 1Say it 2Say it 3

Say it 4

Finally:

“This is stupid!  I’m so sick of being pregnant!  I just want an induction.  Go out there and tell the doctor I want to be induced tonight! I just don’t wanna be pregnant anymore!!!”  Ashley exploded, looking me dead in the eye.

Say it 5

I turned to face her.  “Ashley, your baby is not yet at term.  We absolutely do not induce before 39 weeks except for medical reasons due to the higher risk of C-section and poorer outcomes for both moms and babies.  Your vitals and assessment are perfect.   Your baby looks great.  What you are experiencing are the normal pains and aches of pregnancy, and unfortunately, there is very little I can recommend for that aside from Tylenol, walking, perhaps a warm shower, and a good massage.”  I explained firmly.  Ashley once more looked away and down at the sheet, angrily staring at her belly.

“I’ll give you about thirty minutes to see if that Tylenol #3 takes your pain down a notch, but in the meantime, I’m going to get your discharge instructions together.  Do you have any questions or is there anything I can get for you right now?” I asked.

Ashley shook her head “no”, still avoiding eye contact.  Ah, the silent treatment.  It was all I could do not to flash back to my own teenage years.

“All right. Call me if you need me or if you have questions.”

I left the room with both Ashley and her mother staring me down and headed to the computer.  I quickly printed discharge instructions, found a pen and finished up my charting.  Thirty minutes later on the dot, I entered the room again and noted Ashley sitting in bed casually, playing on her phone.

“How’s your pain, Ashley?” I asked.

“No change.” She replied shortly.

“I can’t believe you’re really going to discharge her when she’s in this much pain!  This is ridiculous!” Ashley’s mother exclaimed dramatically.

I looked at Ashley, who was absorbed in a game of Solitaire and coolly ignoring me, and back at Ashley’s mother. “Ma’am, what your daughter is experiencing is clearly not labor.  We do not admit healthy moms and babies for pregnancy discomfort.  If you are truly concerned that something else is wrong, then I will call over to the main ER and let them know your daughter has been medically cleared by L&D, and she can be seen there.  Is that something you’d like?” I looked at Ashley.

Ashley shrugged, clearly out of ideas. “I’m good.”

I nodded.  “Great. Now, let’s go over your discharge instructions.”

Ten minutes later, my biggest fans were heading out the double doors back to the parking lot.

So if you’re expecting a baby and find yourself tired of being pregnant, take a walk, take a Tylenol, watch some TV, read a book, cook some dinner–but whatever you do, don’t try to trick your triage nurse!

The Catch

**Names in the following story have been changed to protect the privacy of patients and coworkers**

I’m proud to say that I recently found myself in my first precipitous birth–that is, it happened so fast that I had to catch the baby myself.

In some ways, doing a “precip”, as it is commonly called, is a rite of passage for night shift L&D nurses.  With many doctors in my hospital opting to head home and trust us to call them in time to deliver versus camping out in the call rooms just down the hall, this sets us up for precips, especially when you have a grand multip (a lady who has delivered 7 or more babies) come huffing and puffing into triage screaming, “The baby’s coming now!”  If you want to see an entire floor of L&D nurses run, be a fly on the wall when that scenario repeats itself.

My experience wasn’t quite as dramatic, but it was a surprise nonetheless.  It was Alana’s second baby–those dastardly, sneaky second babies!–and she had been admitted at 1800 for an elective induction.  The previous shift had started her Pitocin just before I arrived, and by the time I took over, she was well on her way into labor.

Things progressed nicely, and soon, Alana was getting her epidural as contractions kicked out every 2-3 minutes.  Dr. Donaldson, Alana’s OB, had stopped by after her epidural was placed and broke her water, telling me to give her a call when Alana was complete and it was time to push.  Alana had had a long labor with her first baby and on our cervical exams, this baby’s head was still high, so we figured it would probably be a little while until Alana would deliver.  As I checked Alana’s cervix through the night, it was clear that she was making steady progress, going from a 2 to a 7 from the time she was admitted to the time of my last check just before midnight.

It was right as the hour hand was edging past the 12 when I asked my charge nurse, Erin, if I could head down for some dinner. “I don’t think my patient is going to last long enough for me to eat a normal meal from the cafeteria,” I had told her.  Two AM was when the cafeteria opened its full selection of the overnight meal, and being that it was a little over halfway through a 12-hour shift, most of us night shifters held out for 0200 with surprising tenacity.

Erin nodded. “Sure, we’ll keep an eye on things while you’re gone!” She said.

As planned, I headed to the cafeteria, scarfed down some lunch and headed back to my floor.  One of my coworkers had looked in on Alana while I was eating, and Alana was starting to feel lots of pressure with contractions–a good sign that things were moving along well.

I headed straight in to see Alana after lunch and noticed during a contraction that she certainly was having increased pain.  Suspecting that she might be making a quick move for delivery, I headed to the supply room for a straight cath kit (used to catheterize moms with epidurals who cannot empty their own bladders due to the anesthesia) and returned to Alana’s side.

A common trick of the smart L&D nurse is to check a patient’s dilation immediately after straight cathing her.  She is in the right position for a check (lying down nearly flat on the bed, legs apart and knees out) and if you keep the sterile glove on your dominant hand sterile during the cath procedure, you already have the glove and gel necessary to perform a cervical exam.

That had been my plan as I gelled up the catheter, slipped it into Alana’s urethra, and glanced at the clock.  It was just before 0115.  Making a note of the time for charting purposes, I glanced down at my cath tray to make sure I had enough gel for a cervical exam and looked back to Alana.

Alana’s perineum was bulging under my fingers, the distinct and growing form of a fetal head peering out between her labia.  I was so surprised, I had to look twice.  Sure enough, that was a head crowning.

“OK, I’m feeling a lot of pressure all of a sudden.” Alana said, her breathing suddenly labored.

I’ll bet you are! My mind exclaimed. “I’m not too surprised to hear that.  It looks like the baby is coming right now.” I said, pulling out the straight cath, throwing away the kit, ripping off my dirty gloves and grabbing a new set of sterile gloves as I pulled the emergency cord out of the wall.

“Right now?” Alana exclaimed.

I was hurriedly pulling on sterile gloves as the baby’s head pushed further and further out of Alana’s vagina.  “Yep, right now!” I replied. “It’s OK, Alana.  Baby’s almost out on her own.  Take nice, deep breaths for me and hang on while I get the cavalry in here.” I said, placing a hand on the baby’s head and supporting Alana’s perineum as I watched the baby wiggle her emerging noggin between contractions, working to help her mom push her out.

The door burst open. “You OK, Sophie?” Shelly, one of my favorite coworkers, asked as she entered the room.  As her eyes fell on the bed, they widened into saucers. “What do you need?” She blurted.

“A delivery cart, a tech and a charge nurse!” I said, keeping gentle pressure on the baby’s head as another contraction pushed the baby against Alana’s perineum.

“Oh, man, there’s so much pressure!” Alana grimaced.

“Breathe through it, Alana.  You’re almost there!” I coached.

“You got it!” Shelly said, ducking out of the room just as Erin, two other nurses and Jerry, the surgical tech, burst into the room.

“I’ve got a precip!” I called, now holding half of the baby’s face in my hand as Alana’s contractions involuntarily squeezed the head out.

“Oh, well!” Erin said, slapping on sterile gloves and zipping over to Alana’s side.  Shelly came running through the door with a delivery cart a few seconds later and I heard a sterile gown rustle just as Alana’s body kicked off another contraction.

“Here comes another one!” Alana shrieked.

Erin reached over Alana’s leg and slipped one hand around the baby’s neck, checking for a  cord.  “Push, Alana, push that baby out!  We’re here now–you can do it!”  Erin commanded, her voice full of reassurance and encouragement.

Alana needed no further invitation.  I moved my right hand to hold the baby’s head and held up Alana’s perineum with my left hand, guiding the slippery, wiggly little body gently out of her mother as Alana delivered her baby girl with minimal voluntary effort.  Even as the rest of the baby delivered, I noticed to my surprise that the newborn already had her eyes open.  A scream of indignation arose from the bloody, sticky little bundle in my hands and two dark brown eyes gazed up at me.  I don’t think I was able to hide my sigh of relief as I looked over the kicking, pink little baby and realized she had come out perfectly.

“Great job, Alana!  You did it!” Erin was congratulating the beaming new mom.

I was watching the baby, whose squinting eyes searched the room with a level of alertness I had never seen in a newborn.  Shortly after she was born, those eyes met mine and paused, her forehead creasing as if to say, “You’re not the doctor!”

Another nurse placed a delivery blanket on Alana’s belly.

Yeah, well, you’re not supposed to be here yet, you stinker! I replied mentally, placing the baby on Alana’s abdomen and drying her off with the delivery blanket as those beautiful cries filled the room.

“Nice job, Soph.”  Erin said quietly, joining me at the end of the bed. “Was that your first precip?”

“Sure was.” I replied, my heart still racing with the thrill of the moment.

“Way to keep your cool, girl!” She gave me a pat on the back and headed to the warmer for more blankets.

Jerry clamped and cut the cord, stepping into my place to check Alana for tears as Erin and I tended to mom and baby.  About fifteen minutes later, Dr. Donaldson arrived and confirmed that Alana had no tears–we were good to clean her up.  For about the tenth time, I told the story of how the baby was nearly born during a straight cath attempt.  Dr. Donaldson, a (thankfully) very laid-back physician, smiled and congratulated me, heading back home for some sleep.

L&D is by its very nature an unpredictable work environment–you never know what will happen from second to second.  And although that can often encompass a number of traumatic and terrifying experiences, I learned that night that not all surprises are bad.  Some of them are pink, kicking and crying with big brown eyes.