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whitewriterI write this sitting in the atrium of SSH waiting to hang out with another grad midwife from my year as I've realised I'm spending quite a lot of time writing in this thing at home and if I don't do it when I can, it'll eat into my sleep or run time(more likely run cause I'm lazy like that).
IOL for abnormal doppler's at 37+0.
When I got to postnatal ward the midwives questioned why on earth they would try an IOL at 37+0 knowing perfectly well that it had a high chance of failing. P1 so second baby, but still.
The story starts yesterday at 1130am when they put in a foley's because she's unfavorable (clue number one the IOL may not work). She SROMs shortly afterwards- making this technically a PPROM. Which isn't great. So she gets admitted.
Someone decided she didn't need IVABs. I guess it's because the reason for the PROM is likely to be the foley's and not an infective cause.
Still now that the waters are broken, she is at increased risk. And it's preterm too.
So she's upstairs. She was meant to get an early breakfast (meaning 0500) and then sent to BU and have the IOL start asap.
Antenatal risk factors is a prepregnancy BMI of 16. Apparently she weighed 30 kg.
No, I wouldn't classify her as short.
Currently now weighs a normal weight of 65 kg meaning she doubled in size during this pregnancy.
0730 I pull out the balloon and it takes some force (second clue the IOL wasn't gonna work)
Anyhow. She's here it's 0745. We check for forewaters (there's none) and she's 2cm. soft but thick. We start.
Shes so quiet I almost miss that she's started contracting.
830. She's shivering. I check her temp. It's up a whole deg but not technically febrile. I give her a blanket. She looks uncomfortable and crappy.
The ctg baseline is ok but there's absence of cycling for 60 mins. I was thinking absence of accelerations. But technically absence of cycling is more correct. AM senior is trying really hard to have all the stickers done in a timely manner so she classifies my trace correctly as yellow zone and asks for 250 ml bolus.
The trace looks better. Increased variability.
0830 am senior has talked to o and g. This lady needs ivabs, so I get them ready. A second IVC also since stopping the oxytocin for 1 hr to run gentamicin is not a good reason to stop the IOL. New IVC goes I .
0930.
I look at the trace and the baseline looks like it's going up.
AM senior is like nah. It's a little up but not more than 10% u can sit on it. Like the first trace was baseline 140 ( I thought 138 but ok 140) and now it looked more like 145 . Ok. So 10% is about 15. If it goes up by 14/15 beats then it's up.
She suggests I turn up the synto. Contracting 4:10.
So I'm like fine.
10:10 I have bad feelings about the trace. The baseline is definatly raised and there's a few decelerations. I hop outside the room and no one's there. I find AM senior and the CNE in the tea room chatting. I drink out of my bottle wondering how to say, my trace isn't great...
AM senior says to me trace is good? And I'm like no. It isn't please come see it. And she's like huh? I'm coming.
She's contracting 6:10 and I've turned down the oxytocin to 30
1020 is when it all goes loose.
Definate rising baseline, shallow decelerations mostly earliest some latest.
Is she fully?
We turn off the oxytocin.
Give another 250 ml bolus.
I need a new bag of hartman's only one is charted.
She's such a little thing I'm not keen to overload what is essentially a 30kg adult.
VE. Ok I'm not proud of this VE. I don't think I found the cervix at all. I wasn't confident. I was gonna say 4 maybe. And could only feel it on top left. I couldn't feel any markings on the head at all so I was like am I actually far up enough ??? I think I was just all on the outside and nowhere near the hole. Like. If I was there would be markings and I would distinctly feel the skull. I could feel the head but it wasn't the skull. AM senior has to redo it.
3cm. Thick.
We call O&G .
They come and VE also. Decision made for section.
I've called the paed and handed over details.
We get to OT. And it's my first. I'm slightly terrified but figure it out.
The consultant knows my name so clearly. He just directs me to do this and that and so forth. I'm so new looking I just follow his instructions. The cord gasses must be done promptly like less than 30 mins and the placenta must be sent for histopathology. I take ages sorting out the placenta. In hindsight this could have been done faster but getting the paperwork from scratch takes a while.
The scrub nurse calls out "midwife ready for receive blanket" and I'm like shit that's me. I'm a midwife now. Lucky I have my sterile gloves ready.
And the moment they pop that kid on my hands I know that it's not 2.5kg.
It cries. Good apgars.
Paed right next to me. I put the baby on the panda. He starts rubbing. I stand there. Impotent. Glad the kid looks alright. He's like rub.
And I'm like huh.
He's like your side!
And I'm like oh. So I start rubbing this thing. Im itching to weigh it.
We change the blanket and keep rubbing a few times. He listens to the HR. I weigh the baby with the panda and it's 2360g. Underweight.
Considering her first is 3.4kg i don't think it's related to the woman's underweight status (although it could have been). She's had multiple extra scans due to her BMI and actually that's how they picked up the abnormal doppler's. On a normal BMI woman we wouldn't do extra scans beyond the morphology. So perhaps it is related (I need to keep all these things to look up in one place rather than just writing them in posts).
Paed is like admit to SCN (which I already knew) then I ask a dumb question (I know they say no q is a dumb one except the one u don't ask) which was:
When do I need to go to the SCN? And he's like where else do u need to be? And I'm like .. um. I dunno. And he's like ur not going back to birth unit and so I figure oh. Asap then. I call birth unit and get the ward clark to admit the baby. I call SCN and handover that I'm coming.
So I do the fastest check on baby and wrap it up. Grab my notes. Grab dad. The OT staff are like where r u going so I can tell the mum? And I'm like oh. SCN. And then I'm off. Cause I don't know what to do with a small baby...
In hindsight as I sit here things I missed today:
I should have done a proper set of baby observations prior to transfer, and documented those.
Documenting the baby check properly on that stupid baby chart.
Honestly though I didn't check the reflexes. I was worried I'd make the child too cold doing it. And I know the paed will do the check prior to discharge. Which is a horrid way to look at things. We need to do our work properly, so if there are abnormalities they can be picked up early and re-checked.
Other than those things, I survived!
IOL for abnormal doppler's at 37+0.
When I got to postnatal ward the midwives questioned why on earth they would try an IOL at 37+0 knowing perfectly well that it had a high chance of failing. P1 so second baby, but still.
The story starts yesterday at 1130am when they put in a foley's because she's unfavorable (clue number one the IOL may not work). She SROMs shortly afterwards- making this technically a PPROM. Which isn't great. So she gets admitted.
Someone decided she didn't need IVABs. I guess it's because the reason for the PROM is likely to be the foley's and not an infective cause.
Still now that the waters are broken, she is at increased risk. And it's preterm too.
So she's upstairs. She was meant to get an early breakfast (meaning 0500) and then sent to BU and have the IOL start asap.
Antenatal risk factors is a prepregnancy BMI of 16. Apparently she weighed 30 kg.
No, I wouldn't classify her as short.
Currently now weighs a normal weight of 65 kg meaning she doubled in size during this pregnancy.
0730 I pull out the balloon and it takes some force (second clue the IOL wasn't gonna work)
Anyhow. She's here it's 0745. We check for forewaters (there's none) and she's 2cm. soft but thick. We start.
Shes so quiet I almost miss that she's started contracting.
830. She's shivering. I check her temp. It's up a whole deg but not technically febrile. I give her a blanket. She looks uncomfortable and crappy.
The ctg baseline is ok but there's absence of cycling for 60 mins. I was thinking absence of accelerations. But technically absence of cycling is more correct. AM senior is trying really hard to have all the stickers done in a timely manner so she classifies my trace correctly as yellow zone and asks for 250 ml bolus.
The trace looks better. Increased variability.
0830 am senior has talked to o and g. This lady needs ivabs, so I get them ready. A second IVC also since stopping the oxytocin for 1 hr to run gentamicin is not a good reason to stop the IOL. New IVC goes I .
0930.
I look at the trace and the baseline looks like it's going up.
AM senior is like nah. It's a little up but not more than 10% u can sit on it. Like the first trace was baseline 140 ( I thought 138 but ok 140) and now it looked more like 145 . Ok. So 10% is about 15. If it goes up by 14/15 beats then it's up.
She suggests I turn up the synto. Contracting 4:10.
So I'm like fine.
10:10 I have bad feelings about the trace. The baseline is definatly raised and there's a few decelerations. I hop outside the room and no one's there. I find AM senior and the CNE in the tea room chatting. I drink out of my bottle wondering how to say, my trace isn't great...
AM senior says to me trace is good? And I'm like no. It isn't please come see it. And she's like huh? I'm coming.
She's contracting 6:10 and I've turned down the oxytocin to 30
1020 is when it all goes loose.
Definate rising baseline, shallow decelerations mostly earliest some latest.
Is she fully?
We turn off the oxytocin.
Give another 250 ml bolus.
I need a new bag of hartman's only one is charted.
She's such a little thing I'm not keen to overload what is essentially a 30kg adult.
VE. Ok I'm not proud of this VE. I don't think I found the cervix at all. I wasn't confident. I was gonna say 4 maybe. And could only feel it on top left. I couldn't feel any markings on the head at all so I was like am I actually far up enough ??? I think I was just all on the outside and nowhere near the hole. Like. If I was there would be markings and I would distinctly feel the skull. I could feel the head but it wasn't the skull. AM senior has to redo it.
3cm. Thick.
We call O&G .
They come and VE also. Decision made for section.
I've called the paed and handed over details.
We get to OT. And it's my first. I'm slightly terrified but figure it out.
The consultant knows my name so clearly. He just directs me to do this and that and so forth. I'm so new looking I just follow his instructions. The cord gasses must be done promptly like less than 30 mins and the placenta must be sent for histopathology. I take ages sorting out the placenta. In hindsight this could have been done faster but getting the paperwork from scratch takes a while.
The scrub nurse calls out "midwife ready for receive blanket" and I'm like shit that's me. I'm a midwife now. Lucky I have my sterile gloves ready.
And the moment they pop that kid on my hands I know that it's not 2.5kg.
It cries. Good apgars.
Paed right next to me. I put the baby on the panda. He starts rubbing. I stand there. Impotent. Glad the kid looks alright. He's like rub.
And I'm like huh.
He's like your side!
And I'm like oh. So I start rubbing this thing. Im itching to weigh it.
We change the blanket and keep rubbing a few times. He listens to the HR. I weigh the baby with the panda and it's 2360g. Underweight.
Considering her first is 3.4kg i don't think it's related to the woman's underweight status (although it could have been). She's had multiple extra scans due to her BMI and actually that's how they picked up the abnormal doppler's. On a normal BMI woman we wouldn't do extra scans beyond the morphology. So perhaps it is related (I need to keep all these things to look up in one place rather than just writing them in posts).
Paed is like admit to SCN (which I already knew) then I ask a dumb question (I know they say no q is a dumb one except the one u don't ask) which was:
When do I need to go to the SCN? And he's like where else do u need to be? And I'm like .. um. I dunno. And he's like ur not going back to birth unit and so I figure oh. Asap then. I call birth unit and get the ward clark to admit the baby. I call SCN and handover that I'm coming.
So I do the fastest check on baby and wrap it up. Grab my notes. Grab dad. The OT staff are like where r u going so I can tell the mum? And I'm like oh. SCN. And then I'm off. Cause I don't know what to do with a small baby...
In hindsight as I sit here things I missed today:
I should have done a proper set of baby observations prior to transfer, and documented those.
Documenting the baby check properly on that stupid baby chart.
Honestly though I didn't check the reflexes. I was worried I'd make the child too cold doing it. And I know the paed will do the check prior to discharge. Which is a horrid way to look at things. We need to do our work properly, so if there are abnormalities they can be picked up early and re-checked.
Other than those things, I survived!
