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

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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!

That Awkward Moment When…

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

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

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

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

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

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

Hemorrhage 1

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

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

Hemorrhage 2

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

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

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

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

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

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

Hemorrhage 3

Hemorrhage 4

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

No.

Simply put, no.

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

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

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

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

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

A Cruise to Sciatica

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

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

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

Sciatica, Greece 1

Sciatica, Greece 2

Sciatica, Greece 3

Sciatica, Greece 4

Sciatica, Greece 5

Sciatica, Greece 6

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

The L&D Perspective in a NICU Habitat

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

NICU vs LD 1

NICU vs LD 2

NICU vs LD 3

NICU vs LD 4

NICU vs LD 5

NICU vs LD 6

NICU vs LD 7

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

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

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

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

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

FHR Basics 1

FHR Basics 2

FHR Basics 3

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

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

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

FHR Basics 4

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

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

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

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

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

FHR Basics 5

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

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

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

FHR 1

FHR 2

FHR 3

FHR 4

FHR 5

FHR 6

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

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

 

Newton’s Laws of L&D Physics: A Nurse At Rest…

It isn’t that L&D nurses are lazy.  Hardly, in fact.  It’s just that we get so little down time that when we do find ourselves with a second to relax, it can be difficult to pick up momentum and start moving again.

And though we may gripe about the slow shifts where it’s hard to stay focused (much less awake!), we secretly kind of need these shifts every now and then…

Laws of Motion 1

Laws of Motion 2

Laws of Motion 3

Laws of Motion 4

Laws of Motion 5

Laws of Motion 6

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 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.