Last shift at SSH
Jan. 20th, 2024 04:48 pm![[personal profile]](https://www.dreamwidth.org/img/silk/identity/user.png){kind=small}
whitewriterFor now anyway.
They may be drama queens but their cervix just opens.
38+3
IOL for .... lolz. persistent decreased FM.
no other risk factors. - no diabetes, no high BMI, some hyperemesis gravidium in 1st and 2nd trimester with weight loss > 10% body weight. But that's not a risk factor... as far as I know -
and she regained the weight back in the 3rd trimester when it settled.
The anxiety however - was what I believed to be the most high risk factor for decreased fetal movement.
So here we were - ending a womans pregnancy because she was too anxious to continue.
20 yr old -- she was young -- so extra low risk in a sense. But also p0 meaning that if this induction didn't go well and we ended up with a c-section instead, as a lebanese woman, likely to want more than 1 or 2 children, that she'd have high risk for further c-sections and the increased risks associated with those.
The first VE was unfavourable so 2 VEs later they decided to give her prostin. Which is not commonly done - (I guess they really wanted to give her the best chance of a vaginal birth) and which is what I had in labour (except I had a different type, tampon not gel)
with the view to breaking her waters if the head came down and she was more favourable.
This is where I entered the picture.
if she was unfavourable they were planning a 2nd dose of prostin (2nd chance) and then 3rd assessment.
The doc did the VE and subsequent ARM - the head came down and I commenced the induction.
She'd been feeling some tightenings prior to the ARM but nothing substantial - certainly no to warrent an epidural.
However once I started the syntocinon the first thing said to me 3rd contraction later was "when am I allowed to have an epidural" and I was thinking - I am not the gatekeeper of your medical decisions.. but I said, well you can have one now if you like -
so I got the anaesthetist for her.
The first thing the aesthetics asked me was "big girl?" i'm like no (BMI is 20 ish)
2nd question "any risk factors?"
- and no since anxiety wouldn't be included as one (they're thinking things like.... low platelet count, GDM maybe, clotting disorders, small baby maybe IUGR, weird spine hx like spine surgery... )
She was withering around so much before I said she could have an epidural - but right after I said they were coming, she settled down plenty. Which confirmed my belief that she really wasn't in labour yet to be honest. Tightenings regular yes. But early labor.
When anesthetics came in and did the epidural in ~10 mins or so, he said "well that was easy because you stayed quite still" and commented that most others get the epidural late in labour.
Well anyhow.
I'm not a masochist. Woman wants an epidural - she'd like it now, then ok.
I had a hell of a time monitoring her contractions. At first it was really easy. I titrated up to a synto of 90mls/hr but didn't go further because honestly, I could barely monitor them -
I could feel them and they felt very short.
The incharge was questioning hyperstimulation.
The O&G reg was saying that perhaps she's having an abruption because of the decreased fetal movement (which seemed to me at the time extreeme - if she had said she was at high risk of abruption due to the prostin I would have seen the possibility- but this lady has had decreased FM since she first ever felt decreased FM... this is her first pregnancy, she doesn't even have anything to compare it to... how does that work? please explain...- have you read her history? I read every note going back to pre pregnancy including to how she frequently presented to ED with fainting anxiety spells.)
Post epidural she had one of these panic attacks, HR up to 150, BP also shot up too - surprisingly not low.
Occured for approx 30 mins - I did an ECG as requested by anesthetics but no one reviewed it.
Meanwhile I talked to her and asked her what she did when these episodes occured: she would go on her phone to distract herself. So I suggested she did that.
30 mins later everything was back to normal except the contraction obs.
It's very hard to monitor contractions with an eCTG if the toco isn't picking them up.
At 21:00 the CTG started looking rather bad. Very difficult to monitor, I thought the baby had changed position.
The epidural around 20:00 also stopped working which I had attributed to the woman laying on her left side.
We trouble shooted that for about 45 mins before I gave up and phoned anesthetics.
At 21:00 the incharge was getting worried due to my shitty CTG and difficulty to monitor contractions with a synto of 90.
So she did a VE to put on an FSE -
fully!
From 3cm at 3pm to fully at 9pm. Well.
Lebanese cervix.
She decided to stop the synto as she palped minimal resting tone and I tidied up the paperwork, now waiting for night staff to come on at 21:45 post ward handover.
She got Trish, who is quite experienced- and pretty much seems to be on permanent nights for her kids.
I assume she had a vaginal birth thereafter.
Before I left I did inform her that she did very well, and that being lebanese heritage it's no wonder.
That being said, - during our discussions over the course of the day her mother, who was also present the whole time, and didn't speak english (or if she did, she didn't speak any to me)- had had 3x csections. One for placenta in the wrong place, the 2nd for GDM big baby, 3rd unknown.
And she was lebanese, so.
See you in September - if you'll have me back SSH.
They may be drama queens but their cervix just opens.
38+3
IOL for .... lolz. persistent decreased FM.
no other risk factors. - no diabetes, no high BMI, some hyperemesis gravidium in 1st and 2nd trimester with weight loss > 10% body weight. But that's not a risk factor... as far as I know -
and she regained the weight back in the 3rd trimester when it settled.
The anxiety however - was what I believed to be the most high risk factor for decreased fetal movement.
So here we were - ending a womans pregnancy because she was too anxious to continue.
20 yr old -- she was young -- so extra low risk in a sense. But also p0 meaning that if this induction didn't go well and we ended up with a c-section instead, as a lebanese woman, likely to want more than 1 or 2 children, that she'd have high risk for further c-sections and the increased risks associated with those.
The first VE was unfavourable so 2 VEs later they decided to give her prostin. Which is not commonly done - (I guess they really wanted to give her the best chance of a vaginal birth) and which is what I had in labour (except I had a different type, tampon not gel)
with the view to breaking her waters if the head came down and she was more favourable.
This is where I entered the picture.
if she was unfavourable they were planning a 2nd dose of prostin (2nd chance) and then 3rd assessment.
The doc did the VE and subsequent ARM - the head came down and I commenced the induction.
She'd been feeling some tightenings prior to the ARM but nothing substantial - certainly no to warrent an epidural.
However once I started the syntocinon the first thing said to me 3rd contraction later was "when am I allowed to have an epidural" and I was thinking - I am not the gatekeeper of your medical decisions.. but I said, well you can have one now if you like -
so I got the anaesthetist for her.
The first thing the aesthetics asked me was "big girl?" i'm like no (BMI is 20 ish)
2nd question "any risk factors?"
- and no since anxiety wouldn't be included as one (they're thinking things like.... low platelet count, GDM maybe, clotting disorders, small baby maybe IUGR, weird spine hx like spine surgery... )
She was withering around so much before I said she could have an epidural - but right after I said they were coming, she settled down plenty. Which confirmed my belief that she really wasn't in labour yet to be honest. Tightenings regular yes. But early labor.
When anesthetics came in and did the epidural in ~10 mins or so, he said "well that was easy because you stayed quite still" and commented that most others get the epidural late in labour.
Well anyhow.
I'm not a masochist. Woman wants an epidural - she'd like it now, then ok.
I had a hell of a time monitoring her contractions. At first it was really easy. I titrated up to a synto of 90mls/hr but didn't go further because honestly, I could barely monitor them -
I could feel them and they felt very short.
The incharge was questioning hyperstimulation.
The O&G reg was saying that perhaps she's having an abruption because of the decreased fetal movement (which seemed to me at the time extreeme - if she had said she was at high risk of abruption due to the prostin I would have seen the possibility- but this lady has had decreased FM since she first ever felt decreased FM... this is her first pregnancy, she doesn't even have anything to compare it to... how does that work? please explain...- have you read her history? I read every note going back to pre pregnancy including to how she frequently presented to ED with fainting anxiety spells.)
Post epidural she had one of these panic attacks, HR up to 150, BP also shot up too - surprisingly not low.
Occured for approx 30 mins - I did an ECG as requested by anesthetics but no one reviewed it.
Meanwhile I talked to her and asked her what she did when these episodes occured: she would go on her phone to distract herself. So I suggested she did that.
30 mins later everything was back to normal except the contraction obs.
It's very hard to monitor contractions with an eCTG if the toco isn't picking them up.
At 21:00 the CTG started looking rather bad. Very difficult to monitor, I thought the baby had changed position.
The epidural around 20:00 also stopped working which I had attributed to the woman laying on her left side.
We trouble shooted that for about 45 mins before I gave up and phoned anesthetics.
At 21:00 the incharge was getting worried due to my shitty CTG and difficulty to monitor contractions with a synto of 90.
So she did a VE to put on an FSE -
fully!
From 3cm at 3pm to fully at 9pm. Well.
Lebanese cervix.
She decided to stop the synto as she palped minimal resting tone and I tidied up the paperwork, now waiting for night staff to come on at 21:45 post ward handover.
She got Trish, who is quite experienced- and pretty much seems to be on permanent nights for her kids.
I assume she had a vaginal birth thereafter.
Before I left I did inform her that she did very well, and that being lebanese heritage it's no wonder.
That being said, - during our discussions over the course of the day her mother, who was also present the whole time, and didn't speak english (or if she did, she didn't speak any to me)- had had 3x csections. One for placenta in the wrong place, the 2nd for GDM big baby, 3rd unknown.
And she was lebanese, so.
See you in September - if you'll have me back SSH.
