Shoulders. Oh fuck.

So I had my first days back in the hospital post-H1N1 on Friday & Saturday. But let me briefly recap the last couple weeks in bullets. Forgive me.

• Caught 4 babies with my Manwife preceptor. One natural mama in hands-knees. Very difficult to do your appropriate perineal support & hand maneuvers upside down. But a definite learning experience. One pre-termer who didn't breathe & had to get intubated at BS. We were so busy this day. Literally ran nonstop all day long. Had 15 mins of down time to inhale some food.
• Caught 2 babies with awesome Midwife H. One first thing in the morning. I love that.
• Went home for the weekend. My flight got delayed for 5+ hrs. I rented a car for super cheap. Saw B. Saw my family. Caught the crud (later identified as H1N1.)

Alright, you are thusly brought back up to speed. Friday I was with Midwife A. We weren't super busy which seems to always happen with her. Most significantly, I had my first shoulder dystocia. Super scary. It wasn't a bad one...resolved in 60 seconds, but still something I haven't seen enough of to feel comfortable managing. Midwife A stepped in as soon as the baby's head started turtling; we did McRoberts, suprapubic pressure, and Midwife A delivered the posterior arm which gave enough room for the rest of the baby to be delivered. And she was a tiny thing (7ish...) to be causing so much commotion. It turned out well but scared the shit out of me. Lesson to be learned: a shoulder dystocia can happen to anyone at anytime with any size baby. Duly noted universe, I got the message. So we only had that one delivery.

Yesterday I was with Midwife Ratched. I think that I'm growing on her because she actually seemed okay with me rather than exceptionally annoyed at my mere presence. So I'm taking that as a good thing. We were rather busy yesterday. We had a lot of people coming through triage, including people actually in labor. Woo. I will admit I got super excited when vertex/vertex twins came in contracting. Sigh. Not in labor though. Better luck next time. I gave up one of my deliveries to the dad. He wanted to catch the baby. So he did. It was cute. We did two other deliveries and neither were particularly easy or straight-forward. One had FHTs down in the 80s-90s...making me super uncomfortable. Mom was just not moving baby as quickly as needed. Midwife Ratched had to step in w/the modified (aka not-in-your-butt) Ritgen. It worked...baby was OP and had a double nuchal. Ahhhh it's all so clear now. Second delivery was also not super easy...it all turned out okay in the end; but I was still terrified there would be shoulders. There wasn't...phew.

So lets do the math 11+2+1+2= 16

I am starting to feel comfortable in my clinical setting. Less awkward and more take-charge. I feel like the midwives collectively have been giving me more and more responsibility. Charting, writing H&Ps, progress notes, delivery notes, orders, etc. is a lot easier than it had been. I don't have to write drafts of my notes or stare at prenatal records blankly cos I don't know where any of the information is. I also feel like I'm starting to be on the same page as my preceptors. And actually knowing the answers to their question of: What do you think we should do with this pt? And having my answer match theirs. Using my clinical acumen to work through a vague CC of abdominal pain.

As far as my personal life goes, a lot has been happening. As my life is more and more midwifery, I feel less like my personal life belongs here in this blog. Maybe I'll feel comfortable sharing soon.

We interrupt your regularly scheduled blog...

I have H1N1 despite getting vaccinated. Gr. I'm still trying to get better. I will be back in tip-top form in no time.

Making up for lost time

I am hurting today. Caught 4 babies, thusly bringing my total to 11 births so far. Caught a baby who didn't breathe...scary. I'll write more later but I'm super tired. In the office tomorrow.

Day 2 of the baby drought

I just got home from the hospital. Again...absolutely nothing going on. My only laboring pt was sectioned around noon (sigh.) No one else in labor. A couple of triage pts. Otherwise I spent my day practicing more hand ties, charting all of my pts, catching up with my clinical journal and watching Da V*nci Code in the on-call room. Midwife A wasn't feeling well, so she just curled up under a blanket and hung out. Better luck next time...

No babies today

So today was decidedly quiet. Not a whole lot going on. No one in labor...only a few triage patients. And let me say that I love it when what a pt says is going on is nowhere near what's actually going on. For example, we had a near-term pt who was breech who said she felt a bulge in her vagina. We all were on high alert (is it a BBOW? SROM? Toes?) when we found out she was coming in. There was absolutely nothing in her vagina/labia/perineum so we sent her on her way. Imaginary perineal bulges? Restless perineal syndrome? After absolutely nothing going on, Midwife H lets me go home. No sooner than I'm 10 minutes from my house, MH calls me back and tells me a multip has just come in 5cms. I make the decision to head back but she calls back in 10 more minutes saying she's complete & pushing. So no babies for me! But...I did scrub a CS where our doc pulled out an ovary the size of a tangerine -- covered in cysts, including a dermoid cyst with (what felt like) a tooth inside of it. Pretty interesting.

B came in last night for the evening. She's flying out West for the weekend and just flew thru. I loved seeing her but was sad it was only for less than 8 hours. We didn't get much sleep -- late night and an early morning. This long distance business is no joke. But I really love being with her -- so it doesn't bother me. She'll be back again for a layover on Monday, then I'm flying down -- err up...to her for the weekend on Friday. Next week is Spring Break and I'm not "breaking" too much. I'll be in the hospital Tues & Thursday; office on Wednesday. I'm flying to her, then we're driving to VA so I'll get to see my family. Yay!

Pictured above --- sutures & hand ties!! (They're expired of course.) I've also been practicing my hand ties because no one does instrument ties when suturing. I'm finally starting to get it. Thank goodness. It really seemed like a weak spot for me. So hopefully I'll get to try it out tomorrow.

4+3=7

I was trying to be a good nurse-midwifery student and put my pt encounters in this god-awful tracking program that they mandate we use. I hate the program. It's not user-friendly, has weird quirks, and is really annoying. Equally aggravating are the brand new sets of ICD9/CPT codes I've got to commit to memory because they're almost completely different for intrapartum than antepartum. The search function sucks so basically I have to keep a cheat-sheet of ICD9/CPT codes that I use. Using these codes helps also keep track of your pt encounters by type (ie. prenatal visit vs. intrapartum delivery.) So I had been trekking through all of my recent pt encounters and I notice that the program has set my default information incorrectly and there is no way to go back and mass-correct. So I have to go back case by case and update the correct information. Gr. *sigh* I digress.

I had a very productive two days in the hospital. Friday I worked with Midwife Ratched who happens to hate my guts. When we came on there was a pt about to deliver and she took my easy multip vaginal delivery first thing in the morning. The nerve! So I was slightly miffed about that. We did end up admitting another pt in pretty good labor later on. Midwife R was a little less possessive and let me manage this woman's labor, push with her, and catch the baby (baby #4 for me!) Unfortunately, both MR and the doc on call were there for the delivery, ordering me to cut an epis. Little autonomy and two-against-one, I did as told. But I don't feel really awesome and midwife-y about it. MR & I did the repair together and all was well. I do have to have at least one to graduate so I got that out of the way.

I ended up coming in on Saturday as well. Talked to MR in the morning (before she went home) to see if it was busy and we had two multips in active labor. Rock on. Midwife H came on who I really like. She's super chill, very friendly and very much hands on with me. She challenges me and really facilitates learning. I've worked with her in the office several times, so I knew she'd be fun on the weekend. Plus I was interested to see the different dynamic when a) the office is closed b) there are no inductions c) docs aren't in-house hovering over your shoulder. I got to postpartum round on the pts who delivered the day before which was pretty cool as well. In addition to our pts, we admitted a drop-in with no prenatal care, contracting @ 4-5cm with a questionable EGA. Then babies came from all directions -- I caught baby #5 at 11a, baby #6 at noon, and baby #7 at 245p. No episiotomies but a second-degree laceration that I repaired pretty darn well. Turns out questionable EGA baby Dubowitzed to post-dates IUGR. The other fun thing that happened was when I was doing a vaginal exam on a pt in labor...felt the cervix, then the baby's head, then ran my finger along the head trying to determine position/sutures when I felt fingernails. Baby had its hand by its head. After feeling the fingernails for a couple seconds, baby got annoyed and balled its hand into a fist and moved it away from me.

And then yesterday I was back in the office with none other than my fav Midwife R. Boo. It's not as exciting when I've had a pretty awesome time in the hospital. But...it has to be done. I still haven't seen any pt from the office in the hospital, but I might. Who knows. Anyway...I've got some case studies to work on for tomorrow's class.