![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
whitewriterThe worst family in midwifery, is when the woman or their partner doesn't trust you.
It's a horrible sinking feeling in your gut where you know you can't meet their expectations, and you feel powerless to improve anything.
When this happens to me (which I admit, actually I don't remember it happening a lot in ICU) I go very quiet. This can be a good thing or a bad thing.
In midwifery, 40% of your job is skill but the other 50% is pure positioning. 10% is trust.
Today I felt I had 10% skill, 10% positioning and 0% trust.
ICU nurses are weird. They're even weirder when they're your husband's patients. Should I have known better, as an ICU nurse myself?
It all starts with a P0 who thought she broke her waters on Sunday night (really, Monday morning) and phoned the MAC to be told on the phone it was likely a bloody show and to wear a pad and call back in the morning. The next phone call, a different midwife advised the same.
Anyhow she was ?LGA (who gains 20 kg in a pregnancy from 75 kg at a BMI of 30 to 95kg?! -- and no, she wasn't GDM!) so they had planed to foleys on 38+6 then IOL on 39+0.
She arrives for her foleys and there's forewaters. Amnisure positive, no foleys is done and she is sent for an induction. The Spec states "long and closed" VE not attempted, its too difficult, somehow she tolerated the spec.
I decided this was a VE I didn't want to do.
so I hunted down the access.
Meanwhile, the husband seems more and more anxious. Is an IOL safe? The baby is big. Are you sure we can't just have a c-section? I want to speak to a doctor. Luckily the kind registrar is at the desk. I explain his questions, and she promptly obliges. The resident and I are also in the room.
Before she even starts his first question is, are you a resident or registrar or consultant.
And shes like I'm a doctor.... what does it matter?
He pushes again. She says Im the registrar. We run what happens here.
She goes through the benefits of natural birth as opposed to just going straight for a c-section and states that there isn't room for negotiation at present to not give the woman a chance to birth naturally.
Meanhile, I'm waiting for incharge to start the VE. Perhaps this was my first error. I should have asked the registrar if she would kindly do the VE and break the waters for me.
I couldn't start an IOL with no VE -- could I?
On palp, the head wasn't floaty, LOA. large fundus perhaps. Rather tender.
The woman didn't have contractions - tightenings, but they weren't painful she said. But she would say OUCH! and I'm like, oh whats the pain? And she'd say - water coming through my vagina.
I didn't bother doing the VE, I got the access. She gloved up. Tried to separate the labia on her way in and the woman screamed like we were ripping a stake into her heart. Her legs clamped down and she was crying (I did feel sorry for her in this moment).
My first warning should have been when I set up the IV for the IOL and I had the access with me. There was a bit of air in the line. so I quickly ran it through, probably dripped about 10 mls onto the floor and then reconnected it to the pump - air gone - accepted.
Instead of confronting me, the partner turns to the access and says, there is air in the line. And she said, there was but now its clear. And he says, If the air is past the pump, it won't register in the alarm, the nurse, she ran it through.
Yeah buddy. I ran it through so there's no air now.
Then the partner says that no one has explained the IOL to him.
I sit there and listen. I think hard. Did I not explain the drip.... the titration .... The incharge is exceedingly patient and gives a very detailed explanation.
I questioned myself for the first time tonight. Maybe I didn't do a good job of explaining the IOL. He wanted to know how much oxytocin was in the bag and what rates we would be running it at (honestly, I don't understand how that relates entirely to the whole picture but I suppose he wanted all the details and I didn't provide enough for his satisfaction).
The incharge told me, Be really careful what you say in there. This somehow went over my head.... (as you'll soon find out). It was connected. O&G were aware no VE was done, happy to commence.
So we start. The trace is beautiful.
She has a lot of tightenings.
But she's chatty. she's walking. She's hanging out.
She's eating. He asks me many times if it's okay if she eats. The CTG looks fabulous.
I wonder when the next VE would be. I didn't realise it would be 2 hours from starting the IOL but at 1830 the incharge is again telling me, we have to do it ASAP because we need to know if there are forewaters. I start talking about why we need to do it. I explain we can use the gas this time, I get her onto the gas early. I get her on low dose (no effect), then higher dose (mod effect) then higher dose (too high she hallucinates?) so I end up back in mod dose -- which apparently isn't enough.
The incharge is back.
The VE is reattempted and abandoned, the woman screams louder than you'd think.
We recommend an epidural. This simply cannot be. It's dangerous that we start an IOL and we have no starting point. We have no understanding of what's happening to the cervix.
I call the anaesthetist.
He uses ultrasound to put in the line (his own personal ultrasound machine).
He offers the husband to view the ultrasound.
The husband and the anesthetist bond over the ultrasound being cool and costing $3 g.
The husband is like how can I page you if I need.
I jump in, I can page the anesthetist as required, when needed (inside i'm thinking.... well your not a work today buddy. I am. And right now I'm questioning this extra shift.)
The husband asks the anesthetist if she can eat (again, same question) I say yes-- the husband interjects to the anesthetist, no not you -- and looks at the anesthetist. The anesthetist looks at me. Can she eat in an IOL? And im like yes she can, small things no big meals. The anesthetist sort of mentions a c-section and therefore if thats where its headed she probably shouldn't eat. I leave it at that. I feel powerless. Like my words clearly, don't matter. Honestly at this point, if this birth does not turn into a c-section I would be entirely surprised (obviously unlikely to happen on my shift). I will be reading the notes tomorrow, let me tell you.
I set up to do an IDC. I try to warn and prepare my lady that I'll be touching her labia but just externally. I won't be going in to do any exam but she will feel touching.
I should have positioned her flatter-- mistake number 2 of the night.
So when I tried to do the IDC, she clamped and clenched and I couldn't see a thing. what I did see was what I thought was a cut (turned out to be a stray strand of mucus loss -- bloody show that appeared like a cut.
Her labia had white thrush on it. and looked a little red and swollen.
Third mistake, i jabbed in the IDC hoping it would just "go in" blindly. It didn't instead, it made a bloody mess.
The husband freaks out, shes bleeding.
In charge says, get the epidural ready prior to putting the IDC in, she's not having adequate pain relief.
Another staff member in the hall just coming into night shift is so kind. She's 15 minutes early and is like "do you need help"-- and she helps me to set up the epidural pump.
Meanwhile husband is at the front desk saying "my wife is bleeding and no one cares and i'm not happy with the care in my room" (not that I heard it but the incharge told me later).
She comes, she gloves up, takes gauze and flattens the bed (the correct position) and then wipes the labia down. It's just bloody show. In fact, she can see the urethra. She whips in an IDC like a pro.
There's actually a surprising amount of urine in the bag considering she was walking to the toilet almost hourly.
The incharge tells the woman that she must have a VE and that the shift is coming to an end and no VE >4 hours since starting IOL is not good.
The woman and her husband beg that we wait to do the VE.
I can't wait to handover and leave.
21:55 slowly comes. My saviour arrives. I handover as nicely as possible.
I bid my goodbye to the woman. The husband who doesn't even look at me, is too busy talking to some staff member who has come down from ICU to ?visit? (who visits a random woman in labour? -- when I have had friends from ICU in MICH having babies, we don't go visiting intrapartum. Postpartum perhaps if their ok and via text they've invited us to visit. But otherwise no. I didn't have the guts to say no the first time the first visitor came in the room without my knowledge (I literally turned around and there was an ICU ?? intern or resident just standing there and I had no words I just said hi and then proceeded to ignore them... to my detriment) and now I've gone way past having the confidence to set the tone to disallow the 2nd person (and I swear at one point there was a 3rd in the hallway).
The woman, thanked me anyhow. With her I felt I at least felt like she didn't entirely distrust me.
I was at the desk tying up the FBC and tidying up the notes.
The incharge told me to ensure a few things that needed to be included so I ensured they were.
I could hear an almighty scream from that side of the ward and I knew that someone was doing the VE. They did it through the scream.
The result? 2cm. Forewaters broken.
I'm not sure how I made it through the shift. Most of the time I felt edgy and uncomfortable. I almost cried in the drug room but I pulled it together because literally, that wouldn't achieve a thing. I just had to keep going and hold my head high. I felt confused because the things that they wanted explained were irrelevant in my opinion to the larger picture and they kept saying that no one was telling them anything when, actually I thought people did a lot of explaining --- it just wasn't going anywhere.
i don't know who the hell wrote in the 38+2 week note that they performed a VE and she was 1cm dilated and 30% effaced and what not. I questioned the husband, did that VE occur? How did they do it? He said they didn't. They tried, they couldn't so they booked her for a foleys and said the first VE would be done then (HA. today). so whoever wrote that in EMAT is a liar and I don't see how anyone could have gotten that VE done antenatally and without epidural.
I left wishing I could call sick tomorrow.
It's a horrible sinking feeling in your gut where you know you can't meet their expectations, and you feel powerless to improve anything.
When this happens to me (which I admit, actually I don't remember it happening a lot in ICU) I go very quiet. This can be a good thing or a bad thing.
In midwifery, 40% of your job is skill but the other 50% is pure positioning. 10% is trust.
Today I felt I had 10% skill, 10% positioning and 0% trust.
ICU nurses are weird. They're even weirder when they're your husband's patients. Should I have known better, as an ICU nurse myself?
It all starts with a P0 who thought she broke her waters on Sunday night (really, Monday morning) and phoned the MAC to be told on the phone it was likely a bloody show and to wear a pad and call back in the morning. The next phone call, a different midwife advised the same.
Anyhow she was ?LGA (who gains 20 kg in a pregnancy from 75 kg at a BMI of 30 to 95kg?! -- and no, she wasn't GDM!) so they had planed to foleys on 38+6 then IOL on 39+0.
She arrives for her foleys and there's forewaters. Amnisure positive, no foleys is done and she is sent for an induction. The Spec states "long and closed" VE not attempted, its too difficult, somehow she tolerated the spec.
I decided this was a VE I didn't want to do.
so I hunted down the access.
Meanwhile, the husband seems more and more anxious. Is an IOL safe? The baby is big. Are you sure we can't just have a c-section? I want to speak to a doctor. Luckily the kind registrar is at the desk. I explain his questions, and she promptly obliges. The resident and I are also in the room.
Before she even starts his first question is, are you a resident or registrar or consultant.
And shes like I'm a doctor.... what does it matter?
He pushes again. She says Im the registrar. We run what happens here.
She goes through the benefits of natural birth as opposed to just going straight for a c-section and states that there isn't room for negotiation at present to not give the woman a chance to birth naturally.
Meanhile, I'm waiting for incharge to start the VE. Perhaps this was my first error. I should have asked the registrar if she would kindly do the VE and break the waters for me.
I couldn't start an IOL with no VE -- could I?
On palp, the head wasn't floaty, LOA. large fundus perhaps. Rather tender.
The woman didn't have contractions - tightenings, but they weren't painful she said. But she would say OUCH! and I'm like, oh whats the pain? And she'd say - water coming through my vagina.
I didn't bother doing the VE, I got the access. She gloved up. Tried to separate the labia on her way in and the woman screamed like we were ripping a stake into her heart. Her legs clamped down and she was crying (I did feel sorry for her in this moment).
My first warning should have been when I set up the IV for the IOL and I had the access with me. There was a bit of air in the line. so I quickly ran it through, probably dripped about 10 mls onto the floor and then reconnected it to the pump - air gone - accepted.
Instead of confronting me, the partner turns to the access and says, there is air in the line. And she said, there was but now its clear. And he says, If the air is past the pump, it won't register in the alarm, the nurse, she ran it through.
Yeah buddy. I ran it through so there's no air now.
Then the partner says that no one has explained the IOL to him.
I sit there and listen. I think hard. Did I not explain the drip.... the titration .... The incharge is exceedingly patient and gives a very detailed explanation.
I questioned myself for the first time tonight. Maybe I didn't do a good job of explaining the IOL. He wanted to know how much oxytocin was in the bag and what rates we would be running it at (honestly, I don't understand how that relates entirely to the whole picture but I suppose he wanted all the details and I didn't provide enough for his satisfaction).
The incharge told me, Be really careful what you say in there. This somehow went over my head.... (as you'll soon find out). It was connected. O&G were aware no VE was done, happy to commence.
So we start. The trace is beautiful.
She has a lot of tightenings.
But she's chatty. she's walking. She's hanging out.
She's eating. He asks me many times if it's okay if she eats. The CTG looks fabulous.
I wonder when the next VE would be. I didn't realise it would be 2 hours from starting the IOL but at 1830 the incharge is again telling me, we have to do it ASAP because we need to know if there are forewaters. I start talking about why we need to do it. I explain we can use the gas this time, I get her onto the gas early. I get her on low dose (no effect), then higher dose (mod effect) then higher dose (too high she hallucinates?) so I end up back in mod dose -- which apparently isn't enough.
The incharge is back.
The VE is reattempted and abandoned, the woman screams louder than you'd think.
We recommend an epidural. This simply cannot be. It's dangerous that we start an IOL and we have no starting point. We have no understanding of what's happening to the cervix.
I call the anaesthetist.
He uses ultrasound to put in the line (his own personal ultrasound machine).
He offers the husband to view the ultrasound.
The husband and the anesthetist bond over the ultrasound being cool and costing $3 g.
The husband is like how can I page you if I need.
I jump in, I can page the anesthetist as required, when needed (inside i'm thinking.... well your not a work today buddy. I am. And right now I'm questioning this extra shift.)
The husband asks the anesthetist if she can eat (again, same question) I say yes-- the husband interjects to the anesthetist, no not you -- and looks at the anesthetist. The anesthetist looks at me. Can she eat in an IOL? And im like yes she can, small things no big meals. The anesthetist sort of mentions a c-section and therefore if thats where its headed she probably shouldn't eat. I leave it at that. I feel powerless. Like my words clearly, don't matter. Honestly at this point, if this birth does not turn into a c-section I would be entirely surprised (obviously unlikely to happen on my shift). I will be reading the notes tomorrow, let me tell you.
I set up to do an IDC. I try to warn and prepare my lady that I'll be touching her labia but just externally. I won't be going in to do any exam but she will feel touching.
I should have positioned her flatter-- mistake number 2 of the night.
So when I tried to do the IDC, she clamped and clenched and I couldn't see a thing. what I did see was what I thought was a cut (turned out to be a stray strand of mucus loss -- bloody show that appeared like a cut.
Her labia had white thrush on it. and looked a little red and swollen.
Third mistake, i jabbed in the IDC hoping it would just "go in" blindly. It didn't instead, it made a bloody mess.
The husband freaks out, shes bleeding.
In charge says, get the epidural ready prior to putting the IDC in, she's not having adequate pain relief.
Another staff member in the hall just coming into night shift is so kind. She's 15 minutes early and is like "do you need help"-- and she helps me to set up the epidural pump.
Meanwhile husband is at the front desk saying "my wife is bleeding and no one cares and i'm not happy with the care in my room" (not that I heard it but the incharge told me later).
She comes, she gloves up, takes gauze and flattens the bed (the correct position) and then wipes the labia down. It's just bloody show. In fact, she can see the urethra. She whips in an IDC like a pro.
There's actually a surprising amount of urine in the bag considering she was walking to the toilet almost hourly.
The incharge tells the woman that she must have a VE and that the shift is coming to an end and no VE >4 hours since starting IOL is not good.
The woman and her husband beg that we wait to do the VE.
I can't wait to handover and leave.
21:55 slowly comes. My saviour arrives. I handover as nicely as possible.
I bid my goodbye to the woman. The husband who doesn't even look at me, is too busy talking to some staff member who has come down from ICU to ?visit? (who visits a random woman in labour? -- when I have had friends from ICU in MICH having babies, we don't go visiting intrapartum. Postpartum perhaps if their ok and via text they've invited us to visit. But otherwise no. I didn't have the guts to say no the first time the first visitor came in the room without my knowledge (I literally turned around and there was an ICU ?? intern or resident just standing there and I had no words I just said hi and then proceeded to ignore them... to my detriment) and now I've gone way past having the confidence to set the tone to disallow the 2nd person (and I swear at one point there was a 3rd in the hallway).
The woman, thanked me anyhow. With her I felt I at least felt like she didn't entirely distrust me.
I was at the desk tying up the FBC and tidying up the notes.
The incharge told me to ensure a few things that needed to be included so I ensured they were.
I could hear an almighty scream from that side of the ward and I knew that someone was doing the VE. They did it through the scream.
The result? 2cm. Forewaters broken.
I'm not sure how I made it through the shift. Most of the time I felt edgy and uncomfortable. I almost cried in the drug room but I pulled it together because literally, that wouldn't achieve a thing. I just had to keep going and hold my head high. I felt confused because the things that they wanted explained were irrelevant in my opinion to the larger picture and they kept saying that no one was telling them anything when, actually I thought people did a lot of explaining --- it just wasn't going anywhere.
i don't know who the hell wrote in the 38+2 week note that they performed a VE and she was 1cm dilated and 30% effaced and what not. I questioned the husband, did that VE occur? How did they do it? He said they didn't. They tried, they couldn't so they booked her for a foleys and said the first VE would be done then (HA. today). so whoever wrote that in EMAT is a liar and I don't see how anyone could have gotten that VE done antenatally and without epidural.
I left wishing I could call sick tomorrow.
