whitewriter (![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png)
whitewriter) wrote2021-01-24 10:55 am
whitewriter) wrote2021-01-24 10:55 am
Entry tags:
IVF Friday
Summer has finally landed in 2021. Prior to this it had been an extremely mild summer, closer to what felt like Spring time weather in Sydney. Today, I took down the Christmas and fireplace decorations (I was intending to take them down on Australia Day) and we've pulled out the portable air conditioner and have the hose plugged into the small living room window. It's set to 24 degrees and if it gets close to 27 its considered success.
I didn't quite feel like writing in here today; but I find that when I force myself to start up on a topic, I can't stop and before you know it, a post has been completed. I haven't been reading the comments lately- but lately, I realised there were comments, and whilst digging through them I've been re-reading my posts. They could be a lot more "readable".
Looking at my own profession(s) with both the existential eye of the green nube (midwifery) and the early-senior (nursing) gives me a unique view. I both know, and don't know a lot.
It's not a place I really enjoy being in but it certainly is an experience that deserves to be written about and reflected upon, properly.
Goal for 2021: I would like to improve on the quality of my entries. [and hopefully find time to edit past ones].
An example of the abject disorganisation of SSH is that myself (the casual now) and a permanent staffer (approx 3 yrs experience) were rostered on the swing shift.
Only one person is meant to be rostered on the swing shift per day.
This wasn't realised until 8:30 I think, as that's when the manager texted both of us to ask if one of us could start earlier.
Ordinarily I live approx 40 min drive away (with an $8 toll on a 80-110 kmph freeway)which means I leave my house with 1 hour to get to work on time, without rushing and plenty of room for traffic and coffee and getting into the head space. I was staying at mums (and was "sleeping" on the couch so I could watch the inauguration highlights) so that meant it was a 25 min drive away (without tolls).
The high lights weren't over but I hightailed it over there because finishing work slightly early sounded like a good idea.
In general, I don't think informing us at 0830 to come in "earlier" than 10:00 would have been realistic for anyone...
I rushed and managed to get there at 09:37 (I'm starting to become a stickler for time now).
Meaning, I got to go to MAC and the perm staffer (who couldn't get there any earlier than 10:00 because she slept right up until when she needed to get up and go to work) got sent to ... SCN.
SCN at SSH has a reputation for staff being mean.
(not that I've worked there) but the permanent staffer whom I asked if she was ok in there and how was her day going etc. said the staff are -- best to be described as, "non-communicative".
Sounds like fun (not).
Meanwhile we had a few IVF ladies in (so funny how randomly women seem to cluster into categories)
I always feel awkward asking women about their IVF journeys. Things I'd like to ask are:
So who did you use (which company).
How did you know that you needed to use IVF? which also correlates to - why did you need IVF?
How was your experience?
and then there's also:
How much money did you spend?
I kept my mouth buttoned. If it's not obvious (sometimes the reasons are clear) and or its not in the notes, I just keep hoping somewhere along the dealings of the day, it'll just come out without me having to ask.
Endometriosis was likely the answer for her IVF journey.
The first was a nice low risk (looking) 25 year old prinip who was very anxious about everything. She was also very unknowledgeable about everything so I took the pleasure of trying to explain everything as much as possible without going into too much detail but also probing what she'd already been told so as not to step on any one else's previous information.
She was there at 39+3 for a foleys catheter insertion for induction at 39+4 because as an IVF Baby, they did not want it to go over the due date (that's standard practice for all IVF Babies).
I wasn't sure why it's standard practice for IVF babies not to be allowed to go over 40 weeks. Especially since for normal, low risk women we are trained to explain that asking for an induction prior to 41 weeks of pregnancy is not in the best interest of their body or their baby. However after doing some reading I figured:
the reason is likely in the wording. "normal, low risk pregnancy". If you require IVF To become pregnant, your no longer considered "normal" nor "low risk".
Reasons we tell women why we shouldn't induce them earlier than 40+0 (provided all is going well)
-During weeks 37-38 the baby's lungs and brain are still developing
-The baby's body gains fat during this time and this helps the baby keep a healthy body temperature.
-Baby's born before 39 weeks are more likely to have problems with breathing and feeding, have severe jaundice, and require admission to NICU/SCN (so be separated from the mother).
-They have a high chance of having cerebral palsy which affects movement, hearing, seeing, thinking and learning.
- Infant death may be low, however the rate is higher for babies who are delivered before 39 weeks.
- Women who carry their baby until at least 39 weeks also have less postpartum depression, which may be because their infants are less likely to have problems than those born early.
In any case IVF lady was at 39+3 so all those aforementioned benefit boxes has been ticked.
The risk of adverse perinatal outcomes in the infant increases gradually after 40 weeks gestation.
So that answers the 2nd part of the question (why not wait until 41 or 42 weeks).
If you've gone through the hard yards of IVF, leaving things to chance thereafter seems like an unwise decision.
As with everything in midwifery, (and unsurprisingly considering the lack of consistency even amongst districts) different countries do things differently. There is no international consensus regarding when a baby should really be born (or when an induction should be commenced). So when trying to find an "international standard" I usually look to the the World Health Organisation. WHO recommends after 42 weeks in the uncomplicated pregnancy.
It's her second baby, the first being 5 years ago. She's having pains that she states she's not sure about/ feels like labour pains. 30-ish weeks gestation, not fully sure because she hasn't had a booking in (our system automatically tells us the gestation if I put in their record number) and I couldn't find a wheel - and I was also, too lazy to do the maths based on her EDC.
Reason for IVF? stage 4 endometriosis, with Hx involving bowel surgery to remove tissue that had migrated from her uterus.
Her booking in was due for next week. She was also non-specifically negative about the baby's movements "I don't think I felt him all day but I've been really busy, oh but I can feel him now that I've sat down." type of comments.
I couldn't palpate any tightenings.
The important part of the ?in early labour algorithm was also that she had a short cervix: 1.7cm, meaning that her private dr had put in a cervical stitch or cerclage which would need to be removed if she was actually in threatened premature labour (TPL) or, at term (she wasn't).
We did a spec : long and closed, cerclage still in. Did a fetal fibronectin (fFN)(a $200 test that predicts with some varying levels of certainty how likely a woman would deliver in the next day to two week) - her fFN was 32 so that means, low likelihood of delivery in the next 2 weeks.
fFN is a really interesting test.
Fetal fibronectin is commonly found in the vaginal fluids prior to 22 weeks due to the establishment of the tissues during this time. However between 22-35 weeks, fFN levels should be undetectable. Detection is correlated to a disturbance at the junction between where the uterine lining (decidua) meets the amniotic sac. Higher amounts of fFN during this time means eminent delivery which means, holy shit book an ambulance and transfer her to MSH (although you'd think it should be obvious from how a woman is acting/and if she's experiencing contractions) - mid range readings suggest percentage chance of delivery with +/- can be calculated-- and treatments can be enacted to stop the progress from TPL to actual labour. After 36 weeks, its normal to find fFN, as the body prepares for labour.
In any case the CTG was beautiful and we determined based on the suture being closed, and the fFN basically nought that she wasn't in TPL and sent her home.
It took approximately 1.5 hours to write the above. 2 if I didn't count sorta half thinking about buying a new fridge and making the tea...
I didn't quite feel like writing in here today; but I find that when I force myself to start up on a topic, I can't stop and before you know it, a post has been completed. I haven't been reading the comments lately- but lately, I realised there were comments, and whilst digging through them I've been re-reading my posts. They could be a lot more "readable".
Looking at my own profession(s) with both the existential eye of the green nube (midwifery) and the early-senior (nursing) gives me a unique view. I both know, and don't know a lot.
It's not a place I really enjoy being in but it certainly is an experience that deserves to be written about and reflected upon, properly.
Goal for 2021: I would like to improve on the quality of my entries. [and hopefully find time to edit past ones].
An example of the abject disorganisation of SSH is that myself (the casual now) and a permanent staffer (approx 3 yrs experience) were rostered on the swing shift.
Only one person is meant to be rostered on the swing shift per day.
This wasn't realised until 8:30 I think, as that's when the manager texted both of us to ask if one of us could start earlier.
Ordinarily I live approx 40 min drive away (with an $8 toll on a 80-110 kmph freeway)which means I leave my house with 1 hour to get to work on time, without rushing and plenty of room for traffic and coffee and getting into the head space. I was staying at mums (and was "sleeping" on the couch so I could watch the inauguration highlights) so that meant it was a 25 min drive away (without tolls).
The high lights weren't over but I hightailed it over there because finishing work slightly early sounded like a good idea.
In general, I don't think informing us at 0830 to come in "earlier" than 10:00 would have been realistic for anyone...
I rushed and managed to get there at 09:37 (I'm starting to become a stickler for time now).
Meaning, I got to go to MAC and the perm staffer (who couldn't get there any earlier than 10:00 because she slept right up until when she needed to get up and go to work) got sent to ... SCN.
SCN at SSH has a reputation for staff being mean.
(not that I've worked there) but the permanent staffer whom I asked if she was ok in there and how was her day going etc. said the staff are -- best to be described as, "non-communicative".
Sounds like fun (not).
Meanwhile we had a few IVF ladies in (so funny how randomly women seem to cluster into categories)
I always feel awkward asking women about their IVF journeys. Things I'd like to ask are:
So who did you use (which company).
How did you know that you needed to use IVF? which also correlates to - why did you need IVF?
How was your experience?
and then there's also:
How much money did you spend?
I kept my mouth buttoned. If it's not obvious (sometimes the reasons are clear) and or its not in the notes, I just keep hoping somewhere along the dealings of the day, it'll just come out without me having to ask.
Endometriosis was likely the answer for her IVF journey.
The first was a nice low risk (looking) 25 year old prinip who was very anxious about everything. She was also very unknowledgeable about everything so I took the pleasure of trying to explain everything as much as possible without going into too much detail but also probing what she'd already been told so as not to step on any one else's previous information.
She was there at 39+3 for a foleys catheter insertion for induction at 39+4 because as an IVF Baby, they did not want it to go over the due date (that's standard practice for all IVF Babies).
I wasn't sure why it's standard practice for IVF babies not to be allowed to go over 40 weeks. Especially since for normal, low risk women we are trained to explain that asking for an induction prior to 41 weeks of pregnancy is not in the best interest of their body or their baby. However after doing some reading I figured:
the reason is likely in the wording. "normal, low risk pregnancy". If you require IVF To become pregnant, your no longer considered "normal" nor "low risk".
Reasons we tell women why we shouldn't induce them earlier than 40+0 (provided all is going well)
-During weeks 37-38 the baby's lungs and brain are still developing
-The baby's body gains fat during this time and this helps the baby keep a healthy body temperature.
-Baby's born before 39 weeks are more likely to have problems with breathing and feeding, have severe jaundice, and require admission to NICU/SCN (so be separated from the mother).
-They have a high chance of having cerebral palsy which affects movement, hearing, seeing, thinking and learning.
- Infant death may be low, however the rate is higher for babies who are delivered before 39 weeks.
- Women who carry their baby until at least 39 weeks also have less postpartum depression, which may be because their infants are less likely to have problems than those born early.
In any case IVF lady was at 39+3 so all those aforementioned benefit boxes has been ticked.
The risk of adverse perinatal outcomes in the infant increases gradually after 40 weeks gestation.
So that answers the 2nd part of the question (why not wait until 41 or 42 weeks).
If you've gone through the hard yards of IVF, leaving things to chance thereafter seems like an unwise decision.
As with everything in midwifery, (and unsurprisingly considering the lack of consistency even amongst districts) different countries do things differently. There is no international consensus regarding when a baby should really be born (or when an induction should be commenced). So when trying to find an "international standard" I usually look to the the World Health Organisation. WHO recommends after 42 weeks in the uncomplicated pregnancy.
It's her second baby, the first being 5 years ago. She's having pains that she states she's not sure about/ feels like labour pains. 30-ish weeks gestation, not fully sure because she hasn't had a booking in (our system automatically tells us the gestation if I put in their record number) and I couldn't find a wheel - and I was also, too lazy to do the maths based on her EDC.
Reason for IVF? stage 4 endometriosis, with Hx involving bowel surgery to remove tissue that had migrated from her uterus.
Her booking in was due for next week. She was also non-specifically negative about the baby's movements "I don't think I felt him all day but I've been really busy, oh but I can feel him now that I've sat down." type of comments.
I couldn't palpate any tightenings.
The important part of the ?in early labour algorithm was also that she had a short cervix: 1.7cm, meaning that her private dr had put in a cervical stitch or cerclage which would need to be removed if she was actually in threatened premature labour (TPL) or, at term (she wasn't).
We did a spec : long and closed, cerclage still in. Did a fetal fibronectin (fFN)(a $200 test that predicts with some varying levels of certainty how likely a woman would deliver in the next day to two week) - her fFN was 32 so that means, low likelihood of delivery in the next 2 weeks.
fFN is a really interesting test.
Fetal fibronectin is commonly found in the vaginal fluids prior to 22 weeks due to the establishment of the tissues during this time. However between 22-35 weeks, fFN levels should be undetectable. Detection is correlated to a disturbance at the junction between where the uterine lining (decidua) meets the amniotic sac. Higher amounts of fFN during this time means eminent delivery which means, holy shit book an ambulance and transfer her to MSH (although you'd think it should be obvious from how a woman is acting/and if she's experiencing contractions) - mid range readings suggest percentage chance of delivery with +/- can be calculated-- and treatments can be enacted to stop the progress from TPL to actual labour. After 36 weeks, its normal to find fFN, as the body prepares for labour.
In any case the CTG was beautiful and we determined based on the suture being closed, and the fFN basically nought that she wasn't in TPL and sent her home.
It took approximately 1.5 hours to write the above. 2 if I didn't count sorta half thinking about buying a new fridge and making the tea...