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!

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

 

Punting the Pain Scale

If you’re even remotely trained in anything related to medicine and/or if you have ever received any medical care of any kind, chances are, you’ve encountered the 0-10 pain scale that medical professionals use to assess the presence and intensity of pain in adults and older children.

Up until I worked in L&D, this scale worked pretty well to guide my practice in terms of treating and controlling pain.  In oncology, I had plenty of experience not only in using this scale, but understanding the nature of oncologic pain and keeping my patients comfortable despite their cancer, chemotherapy, radiation, surgery, and often rather dismal states of mind.

But when I moved to L&D, the way the pain scale–and indeed, pain itself–was approached was completely redefined.

On the medical units, pain was the enemy.  It was something to be kept at bay.  It was to be treated immediately, reassessed constantly, and warded off with some of our strongest drugs.

But on L&D, pain is an entirely different entity.  While some pain in L&D can be pathophysiological in nature, the vast majority of pain in L&D is not only normal, but it’s a good sign.  It’s a sign of a healthy and steadily progressing labor that will eventually lead to the birth of a baby.

Long gone were the days of running down the halls for pain medication.  If a woman wanted an epidural, she faced a 1-hour wait, assuming the anesthesiologist wasn’t in surgery.  If she wanted IV or oral pain medication, that was at the discretion of the OB and myself as the nurse in charge of her care.  Indeed, pain is part of the program on my new unit, and while it is arguably some of the most intense pain a woman will experience in her life, it is also universally accepted by the professionals on my unit as all in a shift’s work.

Along with understanding this new place pain had in my practice, I also began to understand the varying levels of pain tolerance in women and what these different levels and tolerances can mean when attempting to reconcile the subjective information the patient is giving you with the objective data you can gather on physical assessment.

A true story from my orientation experience: my preceptor, Melody, and I were finishing up a recovery on a patient who had recently delivered.  We had stepped out of the room and were hanging around the desk getting the chart ready to transfer and we kept hearing a lot of shouting from triage, and both of us, anticipating a fast delivery, got a little antsy.

About ten minutes later, my coworker, Karen, comes marching down the hall with her patient, a first-time mom whose water has broken and who appears to be in some rather intense labor.

A lesson I had learned early-on in L&D was this: especially in women experiencing childbirth for the first time, a pain rating can be a real wild card.  For some women, early childbirth is the most painful thing they have experienced in their lives, so when you get a first time mom who is having mild contractions but is nauseated and breathing through them as if she’s about to imminently deliver a baby elephant, you have to ask yourself two questions: is she just naïve to pain, or is something else going on here?  In the case of these patients (Karen’s included), one of three things was happening.

Option #1: Your patient has a low pain tolerance.

Often times, this is exactly what’s happening when you get a first-time mom who is presenting with pain that seems disproportionate to her labor stage.  In fact, that is so often the case that L&D nurses can get into the nasty habit of assuming that it’s true all the time.

Pain Scale 1

Pain Scale 2

Pain Scale 3

Pain Scale 4

Pain Scale 5

Karen was very fast to assume that her patient was simply not tolerating early labor all that well.  And in her defense, I was guilty of doing the same thing as were many of my coworkers, especially when it comes to a first-timer who was dilated to 1, wanted to go natural and was already rating her pain a 10/10.  That can be the makings of a very long, painful shift–for everyone.

However, the events of the next 30 minutes would teach me a lesson I’ll remember the rest of my life.

Complete 1

Complete 2

Complete 3

Complete 4

Option #2: Your patient is progressing faster than your objective assessment is telling you.

Yep, ol’ Karen had made a newbie’s mistake.  You see, the alternative to Karen’s patient having a low pain tolerance is this: Karen’s patient is presenting with a disproportionate amount of pain to her contraction strength/dilation/labor stage because her labor is moving faster than what we can physically assess.

Especially in a primip (first-time mom), you can see how this scenario could take a nurse by surprise.  I’d wager that 99% of the time, Karen would probably have been right in assuming her patient was, for lack of a better term, just a little bit of a wimp.  Dilated to 1, having mild contractions and presenting with that kind of pain?  Chances are, she’s probably not going to deliver imminently, despite what it may look like.

However, some women–even with their first babies–move so fast through labor and deliver so quickly that there is little to no opportunity for the nurse to reassess her patient’s pain before the baby is very nearly looking her in the eye.  I had no doubt that the contractions Karen initially palpated were mild.  But what about the one two minutes after that?  Five minutes?  Ten?  Chances are, if Karen had reassessed her patient just a tad bit earlier, she would have noticed a change in the quality of her contractions.  Especially in unmedicated first-time moms, reporting high levels of pain even in early labor isn’t necessarily unusual, and Karen likely had no reason to reassess her patient until the patient was presenting with a more urgent symptoms: the urge to poop, the urge to push, or a panic-inducing level of pain.

However, though that is the likely scenario, that may not have been the case at all.  Some women’s cervixes seem to dilate with contractions that, by all accounts, shouldn’t cause cervical change, and it isn’t until she’s complete and screaming for her nurse that you realize she’s delivering off contractions that are every 5-6 minutes apart and moderate in strength at best.  It’s mind-boggling and rare, but it does happen.

Option #3: Your patient is not mentally prepared for labor.

To pause and backtrack for a moment, please note that psychological distress, whether that be fear, feeling out of control, a pre-diagnosed condition like anxiety, a history of sexual abuse, and other emotional factors can also affect the physical level of pain reported by the patient.  I’ve found that not only can these factors present like pain on their own, but they can also intensify and aggravate pre-existing pain.

A triage patient who sticks with me to this day is a young first-time mom who was 39 weeks and came in for contractions.  When I went to the front desk to bring her back to triage, I found her sitting with legs spread in the assessment chair, sobbing and vomiting into a trashcan with several family members hovering nearby.

As you might imagine, remembering my experience on orientation, I hustled this patient back to the triage room and immediately began to gather data.

To my surprise, as I began to interact with the patient and explained what I was doing and looking for as I assessed her, her pain dissipated before my eyes.  In the end, I concluded she was having extremely mild Braxton-Hicks (false labor) contractions and she was sent home.

As she was discharged, I reviewed what had happened.  The strength of those Braxton-Hicks contractions between the time she arrived and the time I sent her home hadn’t changed.  Her dilation hadn’t changed.  Her baby hadn’t changed position.  And she was still 39 weeks pregnant.  But when she came into triage, she had been crying and puking into a trashcan, and now she was disappearing out the double-doors, waving to me with a smile on her face.  What was the difference?

I had taken the time to build trust with her, teach her about the things that worried her, provided her with reassurance and education so she felt better prepared for the labor that was to come, and eased the worry from her mind.  And that rapport and confidence in one’s nurse can be some of the most potent pain relief of all.

Option #4: Your patient is being induced.

I know, I know. I added an option.  Now, this clearly doesn’t apply to Karen’s patient in the scenario above, but it does apply to many, many patients who will have babies in the US.  I hate to be the first to tell you this, but especially if you’re a first-time mom, induction can be painful.

First, before we even induce you, we have to check your cervix.  That involves a vaginal exam that can be rather unpleasant, especially if your cervix isn’t really ready for labor and is high in the vaginal vault and posterior (off to the back of baby’s presenting part–hopefully, the head!).  Cervical exams in this stage can feel like we’re reaching for your tonsils, and this is just the first of many.

If your cervix isn’t soft and dilated to a certain degree, we will likely choose to give you medication that will make your cervix thin and dilate before we start an IV medication like Pitocin to start, strengthen and stimulate contractions.  The reason being, if your cervix isn’t soft and thinned to a certain degree, it probably won’t open, even if we do get your contractions nice and strong and regular.

These medications are usually given vaginally, so that means another vaginal exam AND the added bonus of receiving a medication that can make you raw and sensitive in the area from which that you’re soon to push a baby.  Note that you can get multiple doses all of these drugs, and you will get more and more sensitive with each dose.  You will also get rechecked with each dose, so chalk up another vaginal exam with every drug.

If your cervix is stubborn and doesn’t want to change with medication, there is a method that is commonly used to manually (physically) dilate a cervix.  Some physicians will attempt to manually dilate digitally (with their fingers), but many will attempt to place a little balloon in the cervix, inflate the balloon, and therefore manually dilate the cervix.  If you thought the drugs were painful, I’d suggest before they use the foley balloon on you that you request to be discharge, pack your bags, and go home assuming you and baby are medically cleared.  (**Little known fact: as long as your water isn’t broken and you and baby are deemed safe after 1-2 hours of observation, this is perfectly acceptable!**)

When your cervix is favorable, unless you are already contracting steadily on your own, Pitocin is next on the list.  This is an IV drug that will make your contractions stronger, closer together, and more regular.  Those super-charged contractions are going to push baby down on what is likely a very sore private area, and most women who undergo inductions typically elect to receive epidurals so that they don’t end up experiencing the full scope of pain involved in induction.

So, with all that said, if your patient is presenting with higher levels of pain than what you’d expect, ask yourself the question: was she induced/is she being induced?  And if so, what with?

To Conclude…

Pain is a vital part of assessing patients in labor, but there is an added component of assessing a laboring patient for pain that the current pain scale model does not adequately encompass.  As a result, the nurse must compensate for this lack when talking with a laboring patient about pain.

To get an accurate pain assessment, make sure your patient feels as supported and informed in her care as possible.  Do your best to encourage and educate her if you sense her tolerance for pain is limited.  Be aware of treatments and medications that may cause the patient’s pain rating to be higher (or lower!) than expected.And of course, don’t dismiss a patient’s reports of increasing amounts of pain as blowing smoke unless you’re ready to catch!

An Unimpressed RN

Dear sir,

I know you probably don’t remember me due to the combination of what was likely alcohol, drugs and God-only-knows-what-else in your system, but I was the L&D nurse with your girlfriend last night when she delivered her 9th child.  If you do have anything resembling a fleeting memory of me, it probably looks something like this:

Unimpressed

On second thought, I think the above image would be giving your brain function at the time a bit too much credit.  Perhaps the image below would ring a bell.

Unimpressed Under the Influence

But I’m getting ahead of myself.

It had been a pretty decent shift to that point. We were pushing, the doctor was on the way, and baby was tolerating the chaos very nicely.

Dear Sir 1

 

It was all a piece of L&D cake.  That is, it was until you walked in.

Dear Sir 2

 

Verbose as you’d ever be, you made your entrance into the delivery room just ahead of the doctor.  Your girlfriend, apparently used to this, was about as impressed as I was.

Dear Sir 3

 

However, it seemed that even her sharp remarks and desperate attempts to prevent you from making a fool of yourself were doomed to fail.

Dear Sir 4

 

Indeed.  Where would we be without you.

At any rate, the baby delivered easily as one would expect for baby #9 and was happy and snug with mom for a good 30 minutes while we got her cleaned up.  You wandered around the room, raving like the lunatic you are about how blissfully (sloppily) happy you were, bumping into the surgical techs, babbling about your “gangsta” status, and making a general fool of yourself.

When your girlfriend eventually asked me to get baby’s weight, measurements and footprints, I happily obliged.

Dear Sir 5

 

Happily, that is, until I realized that with baby away from mom, you felt compelled to join us.

Dear Sir 6

Dear Sir 7

 

You spent about five minutes taking countless selfies with your newborn daughter that included suggestive facial expressions, gang signs, sexually explicit hand gestures and more babble about how “fly”, “gangsta” and “fo’ real” you are.

As I found myself actively resisting the growing urge to reach across the bassinet and give you the sucker punch you deserve, you realized what I was up to as I finished up the footprinting process.  And that’s when you asked the crowning question of the night:

Dear Sir 8

 

To your negligible credit, you did have the presence of mind to inform me as I finished up footprinting the baby that you probably shouldn’t hold her….at least, not yet.  Bravo for your introspection.

As I see it, the score goes about like this: you, sir, have a girlfriend, a new baby, and about 10 other children (and that is no exaggeration) that don’t need you drunk, high and acting a fool.  They need a father and they will only ever have one.

Good luck to you, sir, and moreover, to your girlfriend and children.  They’re going to need it.

Signed,

An Unimpressed RN

PS: Proper storage of your first photos with your daughter is important.  I suggest:
1. A blazing campfire
2. An industrial-strength shredder
3. The bottom of a very deep ocean/lake

Trust me.  One day when she’s old enough to understand, she’ll thank you for destroying the evidence.

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

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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.

The Cord

**While the story below is true, please note that all names, dates, and some details of the below story have been changed to protect the identities of coworkers, patients, and family members.**

A few weeks ago, I had an experience at work that changed the way I saw my profession, my work, my coworkers, and myself.

Now, I’m not a new nurse by any means.  So when I tell you that my experience was so fulfilling that I could hardly fall asleep after my shift was over, I’m not telling you this as a wet-behind-the-ears-noob with a freshly engraved stethoscope and rose-colored glasses glued to her brow.  I tell you this story as a nurse experienced in several different specialties of nursing; as a professional that was so burnt out a few years back that she questioned why she became a nurse in the first place.  I tell you this story as a nurse who has endured those demanding, arrogant, immature, or just plain aggravating family members; those obnoxious, loud, unreasonable, argumentative or just plain vindictive patients; and the painful introspection that those sometimes raw, utterly unpleasant interactions evoke.

I was just coming off lunch.  When I say lunch, I mean a night shifter’s lunch–it was just after midnight.  Everyone was taking turns heading in to eat and coming back out, leaving a few of us on the floor to keep an eye on things.

It was a night full of death, to be quite honest.  We had a record number of demises or pending demises in our facility–babies who had died or were expected to die either before or just shortly after birth.  I was caring for one of these patients, and the night had been a fairly quiet one.  In addition to our demise patients, we also had a good number of early patients–patients whose water had broken preterm, who had symptoms of preeclampsia, or patients who simply needed to be watched over until baby arrived for one reason or another.  At any rate, we had all of one actual labor patient, and being that she was a first-time mom who was being induced, the process was slower than a snail race on a hot July day.  The only thing potentially threatening to increase the activity level of our floor was a transfer who might be coming to our hospital from nearby–also a pending demise.

So as I exited the break room and returned to the main nurse’s station, I was a little surprised to hear a call bell alarm just as I arrived at my computer.  A tech on our floor answered the light, looked back at our assignment board, and promised a nurse would be there shortly.

“What is it?” I asked our tech, a short, quiet woman by the name of Carly.

“It’s the patient in room 20.  She wants her nurse to come see her.  She said she got up to the bathroom and felt pressure and something weird.”  Carly said, her facial expression betraying confusion, as if she wasn’t quite sure how to describe what the patient had told her.  “Tessa just went to lunch, though.  Can you go see her?”

“Yeah, of course.” I said, glancing at my computer, which displayed the unit census.  The patient in room 20 was an early patient, here because her water had broken at 29 weeks.  On her last exam, her cervix was high, thick, and barely dilated to one centimeter.

As I headed down the hall, I pondered what I might find.  Perhaps the patient’s water had broken more and she was feeling amniotic fluid leaking.  Still, that didn’t explain her saying she felt something “weird”.  My mind raced.  Could it be…?  The very idea of a prolapsed cord or fetal part made me walk a little faster.

When the umbilical cord prolapses, that is to say, falls out of the vagina before the baby is born, it is an emergency.  The patient must be transported back to the OR for an immediate C-section.  This is because the weight of the baby against the cord can pinch the cord off, meaning baby is no longer getting oxygenated blood from the placenta.  Brain injury and fetal death are two very real potential risks of cord prolapse, and it is one of the bigger emergencies that we see on L&D.

As I walked into Room 20, I saw the patient, Claire, and her husband, Ron, awaiting my arrival.  Claire sat on the bed, fully clothed. Ron sat on the couch.

“Hi, Claire.  I’m Sophina, one of the nurses working with Tessa tonight.  I hear you have something kinda weird going on tonight?” I said, approaching the bed and opening the drawer below my computer station, pulling out a sterile glove and gel.

Claire nodded. “Yeah, I just got up to the bathroom to pee, and I felt like there was something between my legs.  I don’t know if it’s maybe the baby’s leg or what, but I figured I should call you guys.”

The knot in my stomach was growing.  “OK, Claire.  Let’s take a look at that.  If you could slip off your pants for me, I want to check and make sure everything’s all right.”

As I pulled on my glove and swirled my fingers through the gel, Claire lay back in bed, slipped off her pants and underwear, and opened her legs just as I moved to the edge of the bed.  As her legs parted, I immediately glimpsed one of the scariest sights I’ve seen in all my years of nursing: a distinctly purplish-red umbilical cord lay coiled just outside Claire’s labia.

“Claire, this is going to be a bit cold.” I said as I grabbed the cord with my fingers and slid it back into Claire’s vagina, sitting down on the bed and quickly finding two little feet greeting me as I reached her cervix.  The cord, which had no pulse, was wedged between baby’s feet and mom’s cervix.  I pushed the feet apart, freeing the cord and manually holding the cervix and surrounding tissues open, ensuring blood flow could freely travel the full length from placenta to baby and back again.

By then, my heart was pounding.  I looked up at the wall where the call bell sat, just out of arm’s reach.  I glanced at the fetal heart machine–also out of reach.  It was then that I noticed Ron, who had darted to the door, obviously sensing that something wasn’t right.

“Ron, go out to the nurse’s station.  I need everyone in here now.” I told him firmly but calmly.

Ron nodded. “Oh–Ok!” He stuttered, jolting out the door and down the hall.

I looked down at Claire.  Fear had overtaken her features. “Claire, baby’s umbilical cord has fallen out of your vagina.  I’m holding it in with my fingers, and until we get baby delivered, I have to keep my fingers in there so that baby can still get oxygenated blood.  We’re going to take you back for a C-section.  Hang on–we’ve got help coming.”

Claire nodded. “Is the baby–is she–?”

And just as soon as Claire began to ask the question, I felt one of those little feet kick against my fingers.

I smiled, heaving a breath of relief. “She just kicked me, Claire.  She’s still with us.” I said, noting more movement of those feet on my hand.

Claire nodded. “OK. OK.”  Tears welled in her eyes.

“What’s her name?” I asked.

“Gemma.”  Claire said as her eyes overflowed and her nose began to run.

“Take some deep breaths, Claire.  Keep that oxygen coming to baby.  Good job.  You’re doing just great.”  I said calmly as Claire began to follow my instruction, her eyes locked into mine.

I had no sooner finished speaking than my charge nurse, a thin, tall, self-assured woman named Amanda, zipped into the room, with yet another of my fellow nurses, Shelly, on her heels.  Carly was on Amanda’s other side and Ron was running steadily behind them.

“It’s a prolapse?” Amanda turned on the fetal heart machine and looked to me.

“It is.  I’ve got baby off the cord.  We need Dr. Daniels and Dr. Patel.” I said, referencing the OBGYN and anesthesiologist on call.

Amanda, while calling the front desk with one hand, was squeezing gel onto the fetal heart monitor with the other.  Shelly and Carly were rapidly preparing the bed for transport to the OR.  I picked my feet up off the floor, shifting to a kneeling position on the bed while keeping constant pressure on baby’s feet and Claire’s cervix.

Gemma’s tiny feet kept moving, and it took my constant attention to ensure that those little feet didn’t move into a new position and become wedged against the cord.  It occurred to me that in a constantly changing environment like the one inside Claire, any change–especially a subtle one that might perhaps go unnoticed by me in an environment I could only feel and couldn’t see–could be fatal.  Until Gemma was delivered, she needed my rapt attention.  With every move of baby’s feet and every minute change in position that Claire made, I had to make sure that cord remained untrapped.

“Do you have a pulse?” Amanda asked.

“No, but baby is moving.” I relayed.

Seconds later, Amanda scanned Claire’s abdomen, and the faint but steady pound of a fetal heart greeted our ears.  Baby was chugging away in the 90-100 beats per minute range, a full 30 beats per minute where she should have been at very least, but it was objective confirmation that she was still with us.

“OK, we’re good.”  Shelly said as she finished unplugging the bed and monitors.

“Let’s move!” Amanda said, turning off the machine, dropping the monitor and pulling a blanket over Claire and myself as the bed began to move for the hallway.

We dashed out of the room and into the hall, the crowd of four that pushed the bed steadily growing as we went.  We picked up Dr. Daniels and Dr. Patel somewhere along the way, and then a cluster of NICU nurses who were coming downstairs for our section.  Amanda was updating the physicians on the status of both patients and the course of events that led to the urgent stampede for the OR at all of one in the morning.

But as for me, my attention never fully left Claire and Gemma.  Claire was crying and I was giving her moment by moment updates–every kick, every nudge–while carefully monitoring what I was feeling on the inside and moving my fingers accordingly.  The two of us communicated quietly and sometimes silently, but as we rolled, I suddenly felt pulsation in that thick cord that lay between my fingers.

“I’ve got a pulse in the cord!” I exclaimed for all to hear as we rounded the corner to the OR.

“Get me a heart rate when you can!” Dr. Daniels, a tall, somewhat scruffy, but genuinely kind and highly competent OBGYN called as we crashed through the double doors into the OR.

Together, Claire and I moved in a closely coordinated effort from her bed to the OR table, my fingers steadfastly guarding that cord.  “Fetal heart rate is 90-110.” I called as Claire settled in on the OR table and I slid off the other side, standing to Claire’s right.  All had been well in the move; the cord was still free.

Everything was happening at once.  Amanda and Shelly positioned Claire on the table.  Dr. Patel started a second IV.  Jerry, our surgical tech, had the instruments set up within a minute.  Dr. Daniels inserted a urinary catheter just above my fingers, and Amanda prepped Claire’s abdomen.  In the meantime, Gemma’s heart rate was anywhere from 90 to 140.  With all the movement associated with preparing for surgery and the gymnastic effort of inserting a catheter above my fingers while still allowing me to maintain pressure on the vaginal canal and fetal feet, I focused all of my attention solely on the situation just inside Claire’s uterus, chasing Gemma’s feet and keeping Claire’s cervix off the cord.

I knelt next to the OR table on the floor as the sterile drapes came down over Claire’s lower body and my head.  Dr. Daniels stood in front of me; Jerry stood behind me.  From my new position, I realized I had lost my leverage for holding Claire’s cervix and vaginal canal open as well as for keeping Gemma’s feet pushed off the cord.  I was working against gravity and from a clear disadvantage.

“OK, she’s under! Go!” Dr. Patel sounded the shot that began the race.

Claire’s unconscious body began to move as Dr. Daniels swiftly cut down through the abdominal tissue, making a beeline for the uterus.  I struggled to keep my fingers positioned around the cord, my motivation to maintain and hold my position the same as it had been in Claire’s room and in the hallway.  There was simply no time for excuses or mistakes or fatigue, despite my cramping shoulder and aching arm.  One false move from me, one instance where I allowed something to escape my notice, one episode of inattention, and the baby whose feet I had been chasing for the past 18 minutes could die.

“How ya doin’ down there, Soph?” Dr. Daniels asked.

“Oh, I’m good.  How close are you?” I asked from under the drape.

“Almost there, Soph.  Hang in there.”  He replied.

“No worries.  We’re doing all right.”

And perhaps 30 seconds later, I felt those little feet lift off of my fingers, the cord slipping up and away.

“I got her!” Dr. Daniels exclaimed.

I was about to ask how the baby was doing when I heard a loud, rather vigorous cry.

The OR erupted in laughter and relief as the NICU nurses and respiratory therapist welcomed their new patient into the world.

Slowly, I moved out from under the drape, careful not to brush the sterile instruments as I made my way for the OR door.  I held my jacket over my mouth, having not had the opportunity to get a mask on the way in.  And as I exited, I saw a small, pink, squalling little life amidst the receiving blankets, and two little feet, still kicking.

I returned to the OR and recovered Claire in the PACU when the surgery was over.  I brought Ron and Claire’s mother into the room as Claire woke up.  I explained how things had gone, that Gemma was in the capable hands of our NICU personnel, and that her transfer was only precautionary–she was doing so incredibly great, despite the circumstances.  And as Claire woke up more fully, she suddenly recognized me, took my hand, looked to her mother, and said, “Mom, this is the woman who saved Gemma’s life.”

That was the first instance of the copious thanks that came my way that night.  Before leaving Claire and Ron with their new nurse on postpartum, Claire’s mother approached me for a fiercely grateful hug.  Claire then called me over for a hug herself, both of us nearly in tears.  And despite the death that had surrounded us that night, I left work that morning knowing that one baby was alive–for 20 minutes and for the rest of her life, she was alive in no small part because of me.

So when I awoke the next evening and took note of a soreness in my shoulder and an ache in my arm, I stopped, perplexed but for a moment until I remembered Claire, Ron, Claire’s mother, and little Gemma with those kicking feet.

I don’t think a sore arm has ever felt better.

The Happiest Job On Earth

Somewhere between the shampoo and conditioning experience of my haircut a few days back, I mentioned to Anna, my hairdresser, that I am an L&D nurse.

“Ohhhh, you’re so lucky! I’ll bet you have the happiest job on earth!” She cooed.

“Well, kinda…” I trailed off, realizing that I was in a salon full of nice-looking ladies who probably didn’t want to hear about the ugly side of my work.

“Well, I’m sure it has its downsides, but you spend your whole shift holding babies, right?”

“Actually, Anna, babies are only on my floor two hours before I send them to postpartum.” I said, not even bothering to foray into the real meat and potatoes of just why L&D nursing isn’t what practically everyone who isn’t an L&D nurse seems to think it is.

I left my haircut exceedingly happy with my new look, but a bit rubbed by Anna’s faulty yet common opinion of my profession.  And then I realized–Cervix With a Smile!  What better place to write an expose on the real ins and outs of L&D nursing?

This post is admittedly geared toward nurses who are interested in L&D, but really, it applies to anyone, especially if you think my shift is entirely comprised of baby powder and cute little outfits with a Johnson & Johnson “Nurses Heal” ambiance and slow string music.  As an aside, if you know a postpartum, pediatric, PICU or NICU nurse, many of the below points also apply to their work.

So here we go, folks.  Take a walk in my plastic wipe-able clogs and see what L&D looks like from my side of the bed.

Why L&D Nursing isn’t what you think it is:

  1. I’m a professional.
    When you walk into your friend/family member’s room and see that brand new little baby, you see a new part of your life.  You see your friend or family member’s new son or daughter, a new part of your social circle, a new little person that you will come to know and love.
    I’m a nurse.  You know what I see when I look at that same baby?  A patient.  That baby, just like his or her mother, is my patient, and while I will certainly talk to the kiddo while I’m taking her temperature and making her cry with her first shot, I’m not forming emotional attachments to the baby like you and the baby’s parents are.  While some may see it as cold, I view that infant through the objective eyes of a professional.
    Case in point, when I visited a close relative in the hospital and met her baby for the first time, I had to remind myself that I was not her nurse–and it wasn’t my job to watch the monitors (although I admittedly did, purely out of habit!).
    My perspective on my tiny patients isn’t to diminish the significance of their lives; rather, it is for his or her protection.  Because if something bad starts to happen to that baby, what would you rather have me do–freak out like your best friend or react like a professional nurse?
  2. I have a lot of things to do that don’t involve holding the baby. No really, I mean a lot.
    During the course of my shift, I am charting on mom’s contractions and baby’s heart rate and ensuring that those are happy patterns every 15 minutes.  If something goes wrong with either, I am at the bedside to intervene.  That may include changing the rate of medications on the IV pump, giving more fluids, giving oxygen, or sometimes even repositioning mom to make baby happy–even if that takes five coworkers to do because mom is 300lb and has an epidural.
    Speaking of which, if mom has an epidural and all is going well, I’m checking on her level of consciousness, respiratory pattern, anesthesia level, pain rating and a host of other things every 30 minutes.  I’m getting her temperature and emptying her bladder every 2 hours.
    And all that stuff is what I have to do before baby is born.
    After baby arrives, I’ve got vitals, pain and fundal checks (those fun, fun tummy presses for those of you who have delivered in a hospital) on mom every 15 minutes for the first hour, every 30 minutes for the second hour, vitals on baby every 30 minutes for 2 hours, two meds for baby, one med for mom, and a whole ton of charting that has to be done before I can move mom and baby to postpartum.  And that doesn’t even begin to cover teaching mom to breastfeed or doing a recovery from a C-section!
  3. Once baby is here, my work is almost done.
    As an L&D nurse, I only keep mom and baby on my floor for another 2 hours after birth.  This certainly doesn’t even begin to encompass an entire shift of baby holding.  But even if you were to talk to a NICU nurse or a postpartum nurse, they’ll tell you they certainly don’t spend their shifts holding babies.
    Postpartum nurses have 4-6 couplets (moms and babies) to tend to.  That’s 8-12 patients that are fully dependent on them!  Between med passes and breastfeeding assistance and parent education and charting, you probably won’t catch any of them spending their shift baby rocking in the nursery (which is minimally used anymore at most hospitals anyway).  While there certainly are nurses who take a few minutes here and there to rock their smallest patients to sleep if mom is already out, this is a rarity, especially in the 21st century.
    NICU nurses are highly specialized, rendering care to the most fragile little humans on the planet.  Just like myself and postpartum nurses, they especially view their infant charges as patients and keep their carefully trained eyes open for the first hint of trouble.  Many of their patients are so small that they are actually being shielded from external stimuli such as touch to simulate the warm, dark environment of the womb.  And while some of those babies certainly are big enough to hold, the fact that many NICUs have volunteers who come in specifically to hold their babies should tell you that a NICU nurse’s day is filled with much, much more than baby holding.
  4. Labor is hard…on everyone!  Ladies, I’ll take your high fives in the comments.
    Even with an epidural and a great nurse and doc and a wonderful partner and supportive family, labor is tough.  And that’s under the best of circumstances.  How about we look at a more common scenario.
    Let’s say you come in at 5 centimeters with killer contractions.  The anesthesiologist is back in a C-section, your breathing techniques aren’t working anymore, I have to strap a bunch of monitors to your abdomen amidst your contractions and need you to stay seated so I can monitor the baby, but the only thing that helps your pain is walking–but then I can’t see baby’s heartbeat.  Your mother is freaking out at me because I can’t sugar-plum-fairy your pain away, your other relative is taking pictures of you as you cry on the birth ball, and the OB is trying to get ahold of me to let me know that she/he wants you delivered by 1700.  Somehow, an anesthesiologist magically appears, but it’s your unlucky day because the epidural isn’t everything you dreamed of and more, and you can still feel some amount of pain through your epidural (which is normal, but God forbid anyone suggest to a woman these days that labor will still have its painful moments!).  Meanwhile, your baby’s heartbeat is starting to dip in ways that I don’t like, I have a room full of your crazy family, and you’re so caught up in your contractions and your screaming family members that you can barely hear my coaching, which might actually make your labor tolerable until the anesthesiologist comes back to give you a nice extra epidural dose right after this next C-section, assuming you are still pregnant.
    Take any aspect of that scenario.  I see at least one of those situations on every shift, usually more.  There are some shifts that I’d kill to spend a night rocking babies.
    The last few points mostly focused on the circumstances of my job that make my work what it is.  But what about the circumstances that my patients bring in with them?
  5. Not all moms are healthy.
    In fact, a rising number come into pregnancy with serious preexisting conditions.  Obesity, diabetes, heart disease–you name it.  Women with all kinds of health problems get pregnant, and pregnancy is often no walk in the park for those who do begin the race healthy.  Add an already unhealthy mom and you’ve got a stage primed for preeclampsia, gestational diabetes, HELLP syndrome, and a myriad of other conditions and complications that go along with disease processes that not only affect mom but baby, too.
  6. Not all moms stay healthy.
    The truly unfortunate cases are those women who enter pregnancy from a healthy vantage point only to be blindsided by something unforeseen.  They had no risk factors, no predisposing issues, but they got hit with whoppers anyway.
  7. Not all moms care enough to keep themselves healthy.
    These are the cases that infuriate most healthcare workers.  They’re the moms who get pregnant and just don’t want to kick that smoking habit.  Or using crack or heroin.  Or drinking.  Or cutting or overeating or under-eating.
    Or, they’re diagnosed with a serious illness either before or during pregnancy, and they won’t take their medication, follow up with their doctors, or do much of anything to ensure not only their own safety, but the well-being of their unborn child.  It’s heartbreaking and frustrating and ultimately, I as a nurse can do nothing about it other than educate and try to help mom see a better way to live her life.Between the women in any of the categories above, some will stay with us for months prior to delivery.  Some will deliver early.  Some will have emergency C-sections.  Some will become NICU moms.  Some will deliver normally and everything will be fine.  A small number will get seriously sick, and a few will even die.  Some will lose their babies either before or shortly after birth.  Either way, their ailments will not only affect their lives, but the lives of their babies, their families, and all those around them.
  8. Not all babies are wanted.  It isn’t necessarily the norm, but L&D nurses see the full range of the human spectrum.  We see the parents who are ecstatic and have read every book on the planet about parenting.  They’re ready.  They’re beaming.  It’s glorious.
    And then, there are those moms who don’t want anything to do with their baby after he or she is born.  Mom sits in bed withdrawn, numb to the little life in the bassinet beside her.
    I’m not talking about mothers who have postpartum depression or some other condition that prevents them from bonding with their infant.  I’m talking about fully healthy and entirely capable women who just don’t care.
    Neglect is often evident long before mom leaves the hospital.  And the kicker?  There’s not a darn thing any of us can do about it.
  9. Not every parent will treat their baby right.
    In a similar vein as the category above, there are those moms who scream and cuss at their unborn babies and newborns, who have begun the process of ruining them with profanity and abuse and anger.  There are the angry fathers, the disappointed parents, the ones who wanted a girl and not a boy or a boy and not a girl.  They’re the ones who you say a silent prayer as they slip down the hallway–an innocent life disappearing into violent, unloving arms.  They’re the ones you pray don’t end up in the NICU, PICU, or worse.
  10. Sometimes children have children.  I know, I said it.  In an age where Teenage Mom is all the rage, I’ll tell you that from my standpoint, often times, those are sad stories, no matter what the good ol’ TV or the teenage mom’s mom or her sweet little old auntie will tell you.  I know that not every child born to an adolescent will end up in the admittedly fatalistic picture I’m painting, but I also know there are a good many who will, and when you’ve seen your third 16-year-old who has miscarried twice in a year and is now on her third pregnancy because “I just wanna have a baby”, then perhaps you’ll understand my disdain for the culturally rampant lie that would have you believe that teenagers in the USA are ready to be parents.
    These aren’t daytime soaps.  They’re stories about innocence and opportunities lost.  They’re stories about children raising children who will never have the benefit of being raised by an adult, and as a result, will likely struggle to become adults themselves someday.  They’re stories about balancing high school and parenthood, about a child clinging to the tattered remains of a past adolescence as circumstances thrust them into a premature adulthood, often without any real role models to copy.  They’re stories about absent parents and the perpetuation of a cycle that sees children as possessions, not human beings to be treasured and disciplined and brought up.
    And it’s a sad reality that our culture has opted to sensationalize and normalize such behavior instead of exposing it for what it really is–a selfish, dangerous lie.
  11. Especially these days, many people see their children as accessories.
    On the same note as item #10, sometimes even adults are really just children having children.
    I guarantee you, you know someone like this.  They’re the mother who is being induced because she has to have her baby on this specific day so she can still make her hair appointment two days after.  Or she has to have a boy because that’s the color she painted the nursery.  These are the parents who love to talk about their kids like prize trophies, but the instant the children become real little people with needs of their own, the desires of the parents trump the needs of the kids, and suddenly mom’s throwing a tantrum because she doesn’t have time to feed the baby–she’ll be late for girls’ night out!
    Now, I’m certainly not saying that once you’re a parent, you forego any semblance of your own life.  I’m talking about parents who consistently and arrogantly put their own desires above the needs of their children, and when you see it as often as I do, it’s an ugly sight to behold.  It is a disease borne out of a very human urge to think only about me, me, me, and there are few traits more disgusting and misplaced than when found in parents.
  12. Some births don’t go as planned and some are downright traumatic.
    There are few things more heartbreaking to me than to have to tell a mom who is hell-bent on delivering her baby vaginally that it just isn’t going to happen–we must do a C-section.  Or seeing a mom, with no support from her partner, opting to get an epidural when all she wanted was to deliver without pharmacological pain intervention.  Or watching the on-call OB cut an episiotomy without warning or reason on a woman who didn’t want to be cut.  Or watching a traumatic birth take place, knowing that that woman’s sex life and bowel patterns will never be the same.
    Say what you want to about some women who come in with 12-page birth plans, but if it were your birth and your baby, you’d be just as heartbroken if things didn’t go the way you wanted.
    As a nurse, I am your advocate, and when you experience what you perceive as failure or trauma in the process of delivering, you can bet that I feel it as well.
  13. Not all babies are born alive.
    I know that’s a loaded statement, but it’s one that you should think about when you imagine me at work.  Some of my most important contributions to my profession and my patients are when I take care of those parents who have lost their children.
    L&D nurses, despite our usual role in delivering new life, are also present for when babies are born dead.  Moms still labor, contractions still hurt, and babies must be born, even when their lives are over before they begin.
    L&D nurses are present in that process from start to finish.  Often times, it’s the L&D nurse who will look for baby’s heartbeat when mom comes in, telling us she hasn’t felt baby move in a little while.  It’s an L&D nurse who calls the doc, orders the STAT ultrasound, and is there when the parents get the bad news.  L&D nurses admit those patients and are with them and their families throughout labor and all the way through delivery to recovery.  We are the ones who set the tone for the family, provide the keepsakes and photos they will treasure, and try to protect and respect the body and memory of a child that the no one will never get to know.
  14. Not all babies live.  If you thought #13 was as tough as it gets, think again.  L&D nurses are not only there with the parents who deliver stillborn or miscarried children, but also for those who deliver babies who are alive, but will almost certainly die.  Anything from birth defects to prematurity to unknown causes can be the culprit, but it’s only one more aspect of the heartbreaking and frighteningly common theme of loss in obstetrics.
    When that baby is born alive and gasping for air, who will the parents rely on to teach them, to reassure them, to make baby comfortable as he or she slips away or to try to save that life?  How will those precious moments with that little one be remembered?  It is possibly the most difficult aspects of the job.

The points listed above certainly do not comprise an exclusive or complete list of why L&D nursing is difficult; they’re just the most obvious ones to me; the ones that come immediately to mind.  I fully expect to return to this article and edit as needed, either to clarify or augment points listed.

And sure, I could write a whole different article on why I love my job and why it’s so rewarding, but honestly, those are reasons you can probably think of yourself.  They’re things you commonly associate with my work and perhaps things you’ve had the pleasure of experiencing firsthand.  What you need to take away from this is that it takes a certain kind of person to do my job and still walk away at the end of shift feeling fulfilled and happy.  And unless you can take all the wonderful, happy things that come with L&D nursing and accept that with the list above, you’re not cut out to do what I do.

So the bottom line is that L&D nursing is still nursing.  It still is an art and science that deals with human beings, and as long as that is the case, it will include pieces of all the heartache and pain contained in the span of a human lifetime.  Indeed, if pregnancy and childbirth have the potential to be some of the brightest and happiest events in a person’s life, they also have great potential to be the darkest and saddest.

In short, if you’re looking for the happiest job on earth, don’t look to L&D.  Heck, please don’t even look in nursing.

But I hear Disney’s still hiring.

The Heroes in Blue

One of the funny things about being on orientation is how you view those around you who have experience in your field.

Before I accepted a job in L&D, I cared for adults almost exclusively.  Save for a mandatory rotation in pediatrics in nursing school and a few close calls on a medical-surgical floor that saw patients from a few days old to a few days away from dead, I had never cared for anyone under the age of about 17.  Back then, on the few occasions I was asked to float to the L&D or postpartum units, despite my undeniable interest in someday working on those units, my cry was much the same as other nurses who had never worked in those fields: “But I don’t know nothin’ ’bout birthin’ no babies!”

L&D nursing is an entirely different kind of nursing altogether, so it makes sense then that those of us who are entering the field from a different specialty regard the veteran L&D nurses with a sense of awe.

First, there are technical skills in L&D nursing that you don’t find anywhere else.  In L&D, a fair amount of the nurse’s time is spent interpreting fetal heart patterns and contraction patterns that are printed off on a strip of paper–or, more modernly, collected in a computer program.  This allows the nurse to ensure the well-being of the baby and make sure that the mother’s labor pattern is adequate.  There’s also learning how to check a cervix for dilation, which is easily one of the trickiest skills I’ve ever had to master (and am still in the process of mastering, to be honest!).

A typical conversation between myself and my preceptor, LOTR style:

Preceptor: OK, what do you think the patient was dilated?
Me: …um, I’m not really sure.  I couldn’t feel anything.
Preceptor: OK, try again.
Me: ………OK.  *rechecks patient, thinking this couldn’t possibly be more awkward*
Preceptor: What do you think?
Me, giving up:  Honestly, I have no idea.
gollum

Preceptor: All right.  She was a 6.  She’s off to the right and posterior.
Me, now awkward and frustrated:
tricksy cervixes!

And, of course, what would a day in L&D be without performing a quick in and out catheterization of a laboring woman with an epidural.  Speaking of epidurals, do you know how to set up a room for a tired anesthesiologist who is preparing to place her tenth epidural of the night?  Do you know how–or when–to set up a room for delivery, and when to call the physician?  Do you know how to call the NICU for a delivery?  Or how to perform CPR on a dying newborn?

A few months ago, I didn’t either, but I was surrounded by people who did, and I was in awe.

Aside from the complete newness of L&D, the burden of my inexperience and lack of raw knowledge on the subject made the transition a bit intimidating.  Don’t get me wrong–I did a fair share of reading in advance, but no book can prepare you for the eventuality of caring for a woman in labor and finding both her safety and the well-being of her unborn child squarely in your hands.

Melody, a middle-aged woman with a brood of children at home, was my preceptor.  Now, Melody was impressive in her own right as an L&D nurse, but much more than your average women and children’s RN, she brought years of ICU experience to the table.  Decisive, quick-thinking, and with a sharp, assessing eye, she was highly intelligent, superiorly skilled, and surprisingly witty.  For the first few weeks, I followed Melody around like a lost kitten, wide-eyed at the events around me that shocked me at every turn, but that Melody breezed through like a cruise in the Bahamas.

If you’ve ever watched Scrubs and seen the episode where one of JD’s daydreams involves Dr. Cox as a superhero, cape and all, then you know a little bit of how I view Melody.

Scrubs Dr Cox Hero

Melody used to walk down the halls like that, her blue scrub coat flapping in the wake of the breeze as we headed to our next assignment.  She was untouchable, unstoppable, and utterly fearless.  She could calm the craziest patient, trace the wiggliest baby, and exerted a calm knowing in situations that were nothing but chaos.

I’ve had a few occasions since graduating from orientation status that I’ve felt that same confidence and commanded that same authority.  I’ve been able to assuage the fears of an anxious mother-to-be, teach a nervous new father how to care for his infant, and coach a flagging couple through the rigors of labor into parenthood.

So if you’re an L&D nurse who has ever oriented a newbie, please consider this post my thanks to you.  I wouldn’t be who I am today without the many, many nurses along the way who helped me learn the ropes of my profession, and I am excited to keep learning and to continue exploring this exciting, expansive new field.  Thank you for answering my questions, for encouraging me when I’ve failed, and for teaching me without fail how to be the best nurse I can be.

You are my silent heroes in blue.

That Pesky First Post

Y’know, it seems to me that when I’m running around my labor and delivery (L&D) unit so busy that I can’t remember where I’m going, that’s when I want to write so badly, I can barely contain myself.  But on nights like this–those unusual nights where I have a brief reprieve from the chaos that is my work–I barely have two words to rub together.

I’m not a new nurse–not at all, honestly.  I’ve done all kinds of nursing, but none like this before.  My last few months were spent on orientation, trying to learn the ropes in this highly specialized field.  And what an intense few months it has been.

Don’t get me wrong–I know how fortunate I am.  Many nurses would kill for my job.  But L&D nursing, as rewarding as it can be, has its ups and downs just like any other specialty in my highly diversified profession.  Contrary to popular belief, my job entails much, much more than cuddling babies and holding the hands of laboring women.

Labor is a natural process, there’s no questioning that.  Mammals of all kinds have experienced labor in the process of safely delivering offspring into the world from time immemorial.  But just because something is natural doesn’t mean it’s without its dangers, and especially in the case of labor, history–if nothing else–will testify to that.

As an L&D nurse, I exist in this strange middle ground.  I’m a mediator who makes every attempt to steer the natural course of events down that narrow road that’s flanked on either side by inaction, intervention, and all the associated the pitfalls therein.  I still have much to learn, and I follow in the footsteps of my preceptors and coworkers, the great men and women who have taught and are continuing to teach me the tricks of their trade.

So whether you’re a student nurse, a new mother, an expectant father, an OBGYN, an L&D nurse yourself, or just a curious passer-by, go ahead.  Take a read.  I’ll see you on the other end of my next post.