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!

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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!

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

 

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.

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

Six Minutes

Even though we just met, I know that look on your face.  I know it all too well.

I know what lies behind that expression: a desperate struggle between a wild, unsubstantiated hope and raw, unhindered fear.  Let  me tell you, a hundred years could pass, and you still couldn’t be ready for what’s going to happen.  I know, it’s not something you want to hear yet–but it’s something for which I must prepare you, because it’s going to happen soon.

I know how hard it is for you to even consider the likely outcome of this situation, so I’ll give you a bit of padding from this unpleasant reality for now.  After all, it’s the baby that wasn’t even supposed to be possible–and not to mention, it’s the holidays.  And I know that in order to keep yourself together, to some extent, you need that mental distance between your head and the facts, at least for now.

I know what your boyfriend is trying to do.  I know he’s trying his best to prevent this.  Most men like to fix things, not talk about them, and that’s his mode at present.  But this is one problem that neither of you made, nor can you fix.  He talks about telling your child one day about how hard you had to fight to keep him or her alive, and I struggle to keep my expression neutral, knowing that he speaks of a scenario that is never to be.

Nonviable.  It’s one of the harshest words I know.  And at this point, it’s a waiting game of the worst kind: will the contractions pick up again, in spite of the magnesium?  Will your already thin and dilated cervix dilate more?  Will baby come tonight?  I’m your nurse, and quietly, despite your talk of being here for another six weeks, I know, but I won’t say it.  Not yet.

Those contractions are looking meaner in these early hours.  I strap the toco to you and gel up the fetal heart monitor as you talk about the magnesium–when does the bag get changed?  Will the new bag work better?  I know you don’t want to hear the mag isn’t working anymore–your body is losing the battle to keep this baby inside.  A weak cervix and angry uterus are going to end this little life before it begins.  But I tell you anyway, gently, because you need to know.  You need to be somewhat prepared for what is going to happen, because as far as I can tell, it’s probably going to happen soon.

Oh, that’s a beautiful sound–the happy heartbeat of an 18-weeker.  He or she is moving, that’s for sure–that was a direct punch to the monitor!  A thumping rhythm in the 140’s–steady, strong, perfect.  It’s a good moment in the span of our time together, and I let you relish fifteen minutes of listening to that sweet sound for the joy of seeing your face light up and for fear that it’ll be the last time you hear it.

Magnesium is nasty, I know.  It makes you feel like crap, but you’re one of those wonderful women who would walk on nails to save her baby.  And you’re taking this drug like a champ.  So we’ll do the dance between morphine, Zofran and mag, hoping that the first two drugs will temper the effects of the latter and that between the mag and the morphine, you’ll somehow get some sleep tonight.

But sleep is not to come.  The contractions pick up and you notice you’re bleeding–bloody show, a sign your cervix is dilating even more.  As I draw up another dose of morphine, I know the bitter tears in your eyes as you try to accept what’s going to happen.  And believe me when I tell you that they will sting more than any tears you’ll ever cry again, but they’re tears that must be cried if you ever want to stop crying.

The morphine isn’t touching the pain this time.  I was afraid of that.  I stop the magnesium, pull off your IV lines and BP cuff, disconnect your SCDs and remove the monitors.  I check your cervix only to find out you’re dilated to 7 and fully effaced.  The truth is unavoidable at this point: the jig is nearly up.  I have gloves in your room, the charge nurse on standby, and the doctor in house.  We’re ready.  You look up at me and ask how much it will hurt.  We discuss your pain, what to expect in terms of baby, and what you want done with baby when he or she gets here.  They’re questions you’re not prepared to answer and never will be, but not to worry–I’ll guide you through this.

It’s time.  You’re about to come off the bed as I pull on sterile gloves and place a finger just inside your labia, feeling the strange squish of an unruptured bag of water.  Seconds later, I guide the bag out slowly, making sure the birth is controlled and atraumatic.  The charge nurse and I work quickly through the layers of the slippery bag, and in a matter of seconds that feels like years, another nurse hands us the scissors.  One, two, three, four layers later, the water breaks and the amniotic fluid parts to reveal your 18-week-old baby.

I scoop her fragile form up in a blanket and the charge nurse grabs a stethoscope, listening to that tiny chest.  The third nurse cuts and clamps the cord.  It’s a girl, we tell you, wrapping her up and placing her in your arms.

Baby is hanging on, but she won’t be for long.  The doctor arrives and the charge nurse tells him about the birth quietly.  I watch your daughter, just as awed as you are, as her tiny hand finds yours and grasps one of your fingers with five of hers.  The charge nurse steps in several times to listen for her fading heartbeat.  Finally, six minutes later, she tells us the inevitable: baby is gone.

Those bitter tears are back as we quietly go about our duties, ensuring you’re recovering as well as possible from the birth.  Your boyfriend, who has been distant, comes near for a look at baby, and together, you begin to marvel at her perfect little body, her unopened eyes, her tiny lips and nose and fingers.  Will we ever know her eye color, you ask?  No, I reply, her little eyes are still fused shut.  But chances are, she could hear your voice and she could feel your touch for the six minutes she spent with you on earth.

About an hour and a half later, I take baby and make footprints, handprints, foot impressions, and fill out keepsake a birth certificate and crib card.  A tiny knit hat and cloth diaper are hers to wear and keep.  I bundle her up and bring her back to you.  You take her as warmly and gladly as any mother accepting her child, and for the rest of the night, she, as in the first 18 weeks of her life, will have no other cradle.

It’s morning and I have to go.  I know how hard the next year will be, and when I stop in to say goodbye, we talk about it.  While it will be a long road ahead, in talking with you, I sense that you are well-equipped to navigate the process of mourning and loss.  I encourage you to let yourself grieve, be aware of the anger that will occasionally engulf you, and be ready for the mood swings that will come out of nowhere over the next 12 months.  It will get better, I promise, and though it will be difficult, you and you alone will remember the best parts of this child: her life within you, her kicks, her movement, the changes of your pregnancy.  She is uniquely yours to love and to remember, and no one can take that from you.

After we have parted, I think about the night we spent together and everything I had told you.  I know so much–more than I wish I did.  And yet, there is one very simple question that even I cannot answer.

Why?

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.

Triage Tales: Inducing Irritation

Oy ve, I had another one.

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

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

Quiet night

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Say it 1Say it 2Say it 3

Say it 4

Finally:

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

Say it 5

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

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

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

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

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

“How’s your pain, Ashley?” I asked.

“No change.” She replied shortly.

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

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

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

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

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

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