Wednesday's woman (14/4/21)
Apr. 18th, 2021 09:36 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
whitewriterI use a lot of acronyms The list is here
Let me wax lyrical about my inability to say no -
The three weeks whereby I didn't book anything at SSH flew right on by and before you know it I was back again.
Last week (which technically ends tomorrow) has 2 days off, but one I went to MISH and did a workshop about birth, and Sunday is a sleep day.
Monday- PM shift @ SSH
Tuesday - active birth workshop
Wednesday PM shift @ SSH
Thursday - 12 hr night @ MSH
Friday -12 hr night @ MSH
Saturday - 23 hr night @ MSH
Sunday - (sleep day) off.
Right after which I then jump into 2 days straight of AM shifts at SSH.
This whole working 12 hour shifts gives me more time to work a casual job because 12 means 4 days off a week is slightly b.s. when your actually doing it. Because everyone knows sleep days aren't real days off and that education itself is time consuming.
Wednesday's woman was:
p0
21 yrs old
Gestational Diabetes melitus (GDM) diet controlled (Known as GDM Diet)
?LGA -- large for gestational age -- 95% centile on scans (remember scans are 30% inaccurate either side)
IOL for GDM
at 39 weeks.
She was colombian and her husband was Mexican
Her past Hx was: (quite interestingly) mild autism (clearly mild as she was studying to be an RN -- but to be frank, anyone can be an RN)
Pretty damn bad anemia. I was appalled that no one had offered her an iron infusion in clinic. Her stores were <3 and her Hb was 90 today.
Mec liquor.
They started her at 11:00
It took the oxytocin a long time to start working. (When I say, start working I mean: she didn't seem to feel the contractions or the pain, until quite far in). '
So I wouldn't have said she was established until at least 17:00 or 18:00
Anyhow.
So my VE at 14:00 I thought 4-5
and my VE at 18:00 I thought 5-6 -- but much thinner than the 14:00 one
My cute Colombian lady and her mexican were singing in Spanish in their room and I was trying not to disturb their mojo too much. They went for walks. It was literally, too cute.
And then the CTG sorta soured with some late decels, I repositioned, it recovered, I phoned the reg anyways because I thought they should know that it had red zoned (although it had recovered-- it hit the limit) --
in nursing, say if a blood pressure dips for like 10 mins, but then recovers you don't typically report that as long as it's good again.
Sure if in like, say 30 mins, the MAP (mean arterial pressure) goes down to say 55 and stays down, and doesn't recover g for 10 mins you'd call for a review. (provided you were sure your ART line was level and etc.). There isn't really anything you can initiate in ICU at this stage. You'd be asking the pt if they were symptomatic but even if they weren't if the art(arterial) line says the MAP is low, the MAP is low...
You might do a NIBP to double check (and if that's low too you really can't question the art line as inaccurate).
The Doc did a VE at 19:00 and decided she was 3cm.
We started at 11:00 at 2cm
And I thought we'd at least moved somewhere --- or at least thinned out --- by 18:00
but here we were again.
My VE had somehow gone backwards
And once again : she hit established around about 18:00 and asked for an epidural - and now had one insitu - and the Doc was there trying to explain that the baby hadn't moved down far enough, perhaps it was too large (well, GDM IOLs is done primarily for LGA) that it wasn't well applied to the cervix -- I couldn't feel it on VE : I thought the head was alright in terms of application. Definitely not the best applied head I felt.
And here the husband turns to the wife and says to the doc - Can she walk around to help the head come lower and the wife says - oh no - I've got an epidural in I can't walk (once again. : hospital policy at SSH. Some other hospitals do allow women to walk even with an epidural in).
The Doc goes on about how the baby is showing signs of being tired (and it was MEC liquor all the way: and The previous midwife on handover said how anemia was a strong risk factor for MEC liquor. whaddaya know. People should take anemia in pregnancy seriously).
The mec wasn't super thin to be honest. It was medium. Sorta like. Imagine different levels of beef soup. Thin is like- broth. Has a bit of poop in it, not much.
Thick would be say: massaman curry sauce.
So we weren't at curry stage. But it wasn't exactly thin thin.
Anyhow. The doc started talking about cesarean. And it's here that the woman now believes it is
dangerous to continue the labour.
Doc didn't even offer her a lactate (to check the baby's reserves. Remember - CTG is great at saying a baby is well but not great at saying if it's got poor reserves). But does mention to the woman if she really wants to have a NVB we can continue trying (what a weird statement. : It's like asking, well if you wanna risk your baby's life --which was a factor but not an immediate one because, the trace had recovered)- but we might end up with a real emergency.
Doc just said she hadn't opened much since 11:00 (by her estimates 1cm and it was now, 8 hours).
The woman decides to go with a cesarean. She doesn't wanna take risks. She also doesn't want to wait for something bad to happen (once again, who would?).
So then here we were once again. A first timer, whose risk factors were not properly managed (she did not receive an iron infusion) was being forced into thinking that her baby was too big to be pushed out (maybe yes and maybe no) -- forced into asking for an epidural (to be fair, she sorta set herself up for it because when I discussed pain relief options with her: that was all she wanted although i gently offered her to utilise heat packs and moving around and other options - and the gas whilst she waited for the anesthetist) and said she just needed to tell me when she wanted the epi- and I'll get it- but to have confidence to see how far she could get without one first -
forced to have induction for GDM diet because policy. And LGA (but was it?... 30%).
I was double thinking how far I had pushed the oxytocin. We turned it down when the trace went red with late shallow decels- I remember the incharge saying "Poops (that's what she call's everyone) the synto's too high turn it down".
Did I run it too high? Her contractions were just so short...
I took her to OT and handed her over in OT.
I swear when I come to work at SSH I just put aside all my emotions. I am just dead inside (unless I'm in MAC where the cogs have to turn constantly)Because here we are again.
I failed the VEs.
I feel like I failed my woman. But was it me or the system?
Perfect example of where now, this woman has a 50% chance that her EM CS might affect her bonding with her baby.
Risk factors present:
GDM (but it was diet controlled, it wasn't uncontrolled)
IOL at an early gestation (post dates is at 41+3 or even 41+5 in some places so we were 2 weeks earlier than if she hadn't had GDM)
High BMI
Here's the kicker.
Did you know that if you are over 100kg at term - and labouring your not allowed to have a water birth because that's an OH&S risk for the staff caring for you.
I learn that on Wednesday too.
Anyhow I left my shift feeling the "Dead inside" feeling very keenly. It's a horrible job.
Either stick me in MAC or give me a normal birth.
Otherwise I'm just going to be hating midwifery forever.
People ask me if I like it and I'm honest. I don't. It's horrid.
Gimmie ICU any day.
1 in 3 women experience birth trauma (similar to PTSD from birth) in Australia.
Similarly:
1 to 3 or 4 ICU pt also experience PTSD if they make it out of ICU.
I smell irony somewhere.
Let me wax lyrical about my inability to say no -
The three weeks whereby I didn't book anything at SSH flew right on by and before you know it I was back again.
Last week (which technically ends tomorrow) has 2 days off, but one I went to MISH and did a workshop about birth, and Sunday is a sleep day.
Monday- PM shift @ SSH
Tuesday - active birth workshop
Wednesday PM shift @ SSH
Thursday - 12 hr night @ MSH
Friday -12 hr night @ MSH
Saturday - 23 hr night @ MSH
Sunday - (sleep day) off.
Right after which I then jump into 2 days straight of AM shifts at SSH.
This whole working 12 hour shifts gives me more time to work a casual job because 12 means 4 days off a week is slightly b.s. when your actually doing it. Because everyone knows sleep days aren't real days off and that education itself is time consuming.
Wednesday's woman was:
p0
21 yrs old
Gestational Diabetes melitus (GDM) diet controlled (Known as GDM Diet)
?LGA -- large for gestational age -- 95% centile on scans (remember scans are 30% inaccurate either side)
IOL for GDM
at 39 weeks.
She was colombian and her husband was Mexican
Her past Hx was: (quite interestingly) mild autism (clearly mild as she was studying to be an RN -- but to be frank, anyone can be an RN)
Pretty damn bad anemia. I was appalled that no one had offered her an iron infusion in clinic. Her stores were <3 and her Hb was 90 today.
Mec liquor.
They started her at 11:00
It took the oxytocin a long time to start working. (When I say, start working I mean: she didn't seem to feel the contractions or the pain, until quite far in). '
So I wouldn't have said she was established until at least 17:00 or 18:00
Anyhow.
So my VE at 14:00 I thought 4-5
and my VE at 18:00 I thought 5-6 -- but much thinner than the 14:00 one
My cute Colombian lady and her mexican were singing in Spanish in their room and I was trying not to disturb their mojo too much. They went for walks. It was literally, too cute.
And then the CTG sorta soured with some late decels, I repositioned, it recovered, I phoned the reg anyways because I thought they should know that it had red zoned (although it had recovered-- it hit the limit) --
in nursing, say if a blood pressure dips for like 10 mins, but then recovers you don't typically report that as long as it's good again.
Sure if in like, say 30 mins, the MAP (mean arterial pressure) goes down to say 55 and stays down, and doesn't recover g for 10 mins you'd call for a review. (provided you were sure your ART line was level and etc.). There isn't really anything you can initiate in ICU at this stage. You'd be asking the pt if they were symptomatic but even if they weren't if the art(arterial) line says the MAP is low, the MAP is low...
You might do a NIBP to double check (and if that's low too you really can't question the art line as inaccurate).
The Doc did a VE at 19:00 and decided she was 3cm.
We started at 11:00 at 2cm
And I thought we'd at least moved somewhere --- or at least thinned out --- by 18:00
but here we were again.
My VE had somehow gone backwards
And once again : she hit established around about 18:00 and asked for an epidural - and now had one insitu - and the Doc was there trying to explain that the baby hadn't moved down far enough, perhaps it was too large (well, GDM IOLs is done primarily for LGA) that it wasn't well applied to the cervix -- I couldn't feel it on VE : I thought the head was alright in terms of application. Definitely not the best applied head I felt.
And here the husband turns to the wife and says to the doc - Can she walk around to help the head come lower and the wife says - oh no - I've got an epidural in I can't walk (once again. : hospital policy at SSH. Some other hospitals do allow women to walk even with an epidural in).
The Doc goes on about how the baby is showing signs of being tired (and it was MEC liquor all the way: and The previous midwife on handover said how anemia was a strong risk factor for MEC liquor. whaddaya know. People should take anemia in pregnancy seriously).
The mec wasn't super thin to be honest. It was medium. Sorta like. Imagine different levels of beef soup. Thin is like- broth. Has a bit of poop in it, not much.
Thick would be say: massaman curry sauce.
So we weren't at curry stage. But it wasn't exactly thin thin.
Anyhow. The doc started talking about cesarean. And it's here that the woman now believes it is
dangerous to continue the labour.
Doc didn't even offer her a lactate (to check the baby's reserves. Remember - CTG is great at saying a baby is well but not great at saying if it's got poor reserves). But does mention to the woman if she really wants to have a NVB we can continue trying (what a weird statement. : It's like asking, well if you wanna risk your baby's life --which was a factor but not an immediate one because, the trace had recovered)- but we might end up with a real emergency.
Doc just said she hadn't opened much since 11:00 (by her estimates 1cm and it was now, 8 hours).
The woman decides to go with a cesarean. She doesn't wanna take risks. She also doesn't want to wait for something bad to happen (once again, who would?).
So then here we were once again. A first timer, whose risk factors were not properly managed (she did not receive an iron infusion) was being forced into thinking that her baby was too big to be pushed out (maybe yes and maybe no) -- forced into asking for an epidural (to be fair, she sorta set herself up for it because when I discussed pain relief options with her: that was all she wanted although i gently offered her to utilise heat packs and moving around and other options - and the gas whilst she waited for the anesthetist) and said she just needed to tell me when she wanted the epi- and I'll get it- but to have confidence to see how far she could get without one first -
forced to have induction for GDM diet because policy. And LGA (but was it?... 30%).
I was double thinking how far I had pushed the oxytocin. We turned it down when the trace went red with late shallow decels- I remember the incharge saying "Poops (that's what she call's everyone) the synto's too high turn it down".
Did I run it too high? Her contractions were just so short...
I took her to OT and handed her over in OT.
I swear when I come to work at SSH I just put aside all my emotions. I am just dead inside (unless I'm in MAC where the cogs have to turn constantly)Because here we are again.
I failed the VEs.
I feel like I failed my woman. But was it me or the system?
Perfect example of where now, this woman has a 50% chance that her EM CS might affect her bonding with her baby.
Risk factors present:
GDM (but it was diet controlled, it wasn't uncontrolled)
IOL at an early gestation (post dates is at 41+3 or even 41+5 in some places so we were 2 weeks earlier than if she hadn't had GDM)
High BMI
Here's the kicker.
Did you know that if you are over 100kg at term - and labouring your not allowed to have a water birth because that's an OH&S risk for the staff caring for you.
I learn that on Wednesday too.
Anyhow I left my shift feeling the "Dead inside" feeling very keenly. It's a horrible job.
Either stick me in MAC or give me a normal birth.
Otherwise I'm just going to be hating midwifery forever.
People ask me if I like it and I'm honest. I don't. It's horrid.
Gimmie ICU any day.
1 in 3 women experience birth trauma (similar to PTSD from birth) in Australia.
Similarly:
1 to 3 or 4 ICU pt also experience PTSD if they make it out of ICU.
I smell irony somewhere.
