Thursday's women
So I came back on Thursday to my second PM shift of the week to find out that Wednesday's woman didn't progress at the midnight VE and so therefore was c-sectioned at 01:00.
What did I think happened? I think the epidural slowed down her labour progress, and as she was not allowed to have an augment in labour, even though the CTG showed good contractions -- a CTG does not really indicate anything more than when uterine tone increases and decreases - so frequency, but not strength etc. -- and the CTG trace was crapola so they weren't gonna allow stressing out the baby with an augment.
Hence she didn't progress (cause contractions were shite) and hence she had a c-section because it was getting long in the tooth at 1am.
Ask a woman who has been labouring for 12 hrs, at 1am, -- with a borderline unhappy baby looking CTG - if they wanna keep going with labour and I'd say considering fetal welfare is at stake your gonna pick the c-section.
anyhow so then on Thursday after a slightly delayed start time (due to the incharge being late, and then the AM incharge being impatient and handing over to someone else, and then the actual incharge shows up, and the boss decides the actual incharge should be the actual incharge - thus meaning handover was REstarted 20 mins late, delaying also- allocation -- staff standing around --- honestly. Anyways)
So I'm allocated to take over from an old classmate of mine in midwifery school (but she trained at SSH whilst I was at MSH):
37+0 (so exactly term baby today)
IOL for IUGR
woman with past medical Hx gastric sleeve.
Hx of depression (medicated for 3 ish years) but is now overcome. I very judgingly thought it was related to the gastric sleeve (being overweight) but on persuing her file properly could see it was related to a TOP she had done. TOP is a very interesting subject-- and its effect on mental health is poorly looked at I think.
Nil other concerns however the gastric sleeve has very much affected this pregnancy.
1. she had to be in doctors clinic. the consultant obstetrician does not allow gastric sleeve women to be in midwives - and I entirely agree.
These women have a very high risk of remaining malnourished during pregnancy.
Nausea and vomiting is much more prevalent with a gastric sleeve - leaving them vulnerable to proper nutrition -- which, in turn can affect fetal growth
2. body habitus changes Palpation of the antenatal abdomen is a fine art. Total art. When you add in variables like the size and shape of different women -this makes it even more of an art form. Add in a Hx of obesity - either current or past - and the palp becomes even more difficult to feel a baby's position, to measure fundal height accurately (a crude but general yardstick utilised to determine fetal and uterine growth without an U/S)
Both of the above means that the doctors will want regular blood tests for iron levels, and other nutritional markers - as well as regular ultrasound scans to measure fetal growth.
My stance on ultrasounds remain the same. They're incredibly inaccurate with 15% swing either side of a weight as to the true weight or size of a baby. They frequently find things (or don't find things) that either should or shouldn't be there --- and essential decisions are made on the basis of the ultrasound which I think should be taken with a grain of salt. This being said, it's very hard to ignore a test result once u have it in front of you - and just say "well its 15% inaccurate either way" when it's a test result that states: your child is not growing properly and is dropping centiles.
Anytime a test is being done, one always needs to know: what is the test for, what will I do with these results and how will it impact my future decisions.
3. body image issues are amplified in pregnancy and considering you had a gastric sleeve done, you were probably someone who struggled with body image (and other health fears) in the past. So mental health implications are heightened further
So here we are at 37 weeks with a prinip, undergoing an induction of labour at the earliest possible time period due to an ultrasound scan at 34 or 36 weeks which guessed the baby's size to be approx 2.2kg (very small) and to have dropped from 80th to 5th centile between 28 and 36 weeks.
A foleys catheter was put in the day before at 36+6 and the woman spent a sleepless night at home, anxious about the events of the following day.
The foleys had been excruciating, she said. Very painful, and freaked her out for what breaking her waters would feel like - and actually it was very different and not painful at all. (Other than the pain of someone's hand in your vagina going up further than you might think to be humanly possible, ARM is essentially painless.
After the hand has broken your waters, the next sensation is one in which you peed yourself but you cannot control- and this happens continuously throughout.
They commenced the oxytocin infusion at 0930 and at approx 11:30 pain actually ramped up. By 1430 when I entered the scene, the anesthetist was putting in an epidural.
Initial VE: 3cm, posterior cervix
subsequent VE at 1:15: 3cm cervix less posterior
oxytocin at first max of 180mls/hr and first bag about to finish.
The plan was once the anesthetist had finished putting in the epidural and the woman was comfortable, for the contractions to be palpated and a decision made to go up on the oxytocin provided the CTG remained beautiful.
It was a beautiful trace. There was very little on it to suggest I should be concerned in any way (unlike Wednesday's trace). Was this little IUGR baby really that robust?
At first the toco started working again - and picked up 5:10 contractions and I was like hang on. Can't ramp up the oxytocin here... but after 20 mins, and a palp later i could tell they were really more like 3:10. so up the synto went at 15:30
to max. rate 240mls/hr
The CTG stays beautiful.
17:20 rolls around faster than I know it and thats 4 hrs post the 1300 VE and we have synto at max rate here so I know I need to do the VE. The epidural is working well, and my VE is,
4cm (generous 4cm), still fairly thick cervix. Easily found - not posterior, but its a bit like feeling a thick rubber tyre inside her pelvis. It wasn't quite soft or stretchy, to be totally honest. O&G come around for a review and grills me on my VE and forces me to admit - that it really doesn't seem that much different from the 13:00 VE (admittedly done by another midwife.
They're happy for another 4 hours at max max rate provided the trace stays perfect.
So I commence on 4 hours of antenatal expressing, discussing breastfeeding, general chit chat where we compared our first trimesters (since I'm 26 weeks currently.. which makes me only 11 weeks behind her.. shit that's less than 3 months away) and agreed 2nd was the best. We talked about tooks like the Haka which I had similarly heard about and wanted to get (to collect the let down) and how she'd purchased it and was keen to try it. She was very easy to talk to and I tried to infuse some midwifery knowledge to her fears about inheriting her mother's concerns with breastfeeding her and her siblings in childhood. Her mother was concerned she could not make a supply, and so they all ended up on formula.
I wondered in some small sense if this is why this girl ended up with a gastric sleeve - and if her other siblings had similar weight issues.
In the tea room - I talked to the receptionist who showed me countless photos of people she knew who were overweight but not morbidly obese, but got gastric sleeves or bands by paying for them.
A lot of them posted on insta or fb thereafter their transformations.
When I was leaving it was 21:20 and the night doctors had just come on, and was reviewing my lady. The progress VE after 4 hours of insane amounts of oxytocin (we were on the 3rd bag and now it's at triple strength to avoid fluid overload) -- I agree the doctor should do it, as I know that this VE is going to make the big decision: To cesarian or to keep going with the induction.
I'm not expecting much - and it ends up being the same as before, a tight 4cm. This cervix is not budging. They discuss the cesarian. and she signs the consent.
Her only comment to me was "it's a bit overwhelming" and I'm sure it was. If I was her i'd be bawling my eyes out.
The incharge kept popping into my room throughout the shift checking the CTG was as good as I thought it was, and she'd always ask how it was going in there and in one of my comments I said "all is well.
I'd like to see more progress in terms of VE and CTG (the CTG can also indicate progress in labour) but I just don't see it) and the incharge just said, well, if at this extreme rate of oxytocin there is no progress then clearly, there is not much else that can be done. And I agreed.;)
At one stage I wondered if they forgot to put the oxytocin into the bag,
I made up the 2nd bag though, and I know I put it in properly - so there's no way it was just hartmanns in there.
I wonder if the baby really was 2.2kg
I was surprised throughout my meandering conversations that no one had mentioned the baby might ned to go to special care nursery post birth. At a weight of 2.2kg - I was under the impression that all babies under 2.5kg were generally admitted to SCN. If only for a short period of monitoring and BGLs.
We briefly discussed this, and how she would go over for feeds if that was the case.
No one had talked to her about antenatal expressing either, in clinic. And I wonder if that was largely because she was in doctors and not midwives clinic. Doctors don't usually talk about those hippy things.
In other topics. Dads.
This one was pretty funny. He was a roofer by trade, and you could tell his nervousness when he started talking a lot (which is what happened after she signed the cesarean section form). I curbed that by giving him something to do -- change into surgical attire.
It's a stressful day, he'd barely slept the night before as well.
He was feilding all sorts of text messages from their family - there's about 4 siblings on his side and 1 on hers - and they all wanted to know the VE results (I think the woman was on the phone to her mother whilst I was doing the 1720 one which I thought was rather funny. Imagine being on the phone whilst another woman's hand was inside your vagina rooting around and feeling your cervix?! Her husband wasn't present and I wanted her to not feel alone so I didn't mind.) or wanted to know what was happening in the room.
Honestly, when it comes to my own IOL (if I do indeed get there) I don't think I'll be telling anyone. Maybe my mum. Maybe. Probably not, she'll have a stressful day thinking about it. They can all just find out when it's all over. Rather than having 50 people in the room (hypothetically in the room) wondering what's going on.
The woman advised me regarding baby names. She said she'd picked some out but once she confided in the options to her family (mother and mother in law) they all had complaints and whines that forced her to find other names and let those ones go. She thought it would be better to just, pick. and tell no one until it was a done deal. I thought that was an interesting interpretation. I gotta get my butt moving on the name picking game. Otherwise I really will just call it Peter if its a boy and Rita if it's a girl.
What did I think happened? I think the epidural slowed down her labour progress, and as she was not allowed to have an augment in labour, even though the CTG showed good contractions -- a CTG does not really indicate anything more than when uterine tone increases and decreases - so frequency, but not strength etc. -- and the CTG trace was crapola so they weren't gonna allow stressing out the baby with an augment.
Hence she didn't progress (cause contractions were shite) and hence she had a c-section because it was getting long in the tooth at 1am.
Ask a woman who has been labouring for 12 hrs, at 1am, -- with a borderline unhappy baby looking CTG - if they wanna keep going with labour and I'd say considering fetal welfare is at stake your gonna pick the c-section.
anyhow so then on Thursday after a slightly delayed start time (due to the incharge being late, and then the AM incharge being impatient and handing over to someone else, and then the actual incharge shows up, and the boss decides the actual incharge should be the actual incharge - thus meaning handover was REstarted 20 mins late, delaying also- allocation -- staff standing around --- honestly. Anyways)
So I'm allocated to take over from an old classmate of mine in midwifery school (but she trained at SSH whilst I was at MSH):
37+0 (so exactly term baby today)
IOL for IUGR
woman with past medical Hx gastric sleeve.
Hx of depression (medicated for 3 ish years) but is now overcome. I very judgingly thought it was related to the gastric sleeve (being overweight) but on persuing her file properly could see it was related to a TOP she had done. TOP is a very interesting subject-- and its effect on mental health is poorly looked at I think.
Nil other concerns however the gastric sleeve has very much affected this pregnancy.
1. she had to be in doctors clinic. the consultant obstetrician does not allow gastric sleeve women to be in midwives - and I entirely agree.
These women have a very high risk of remaining malnourished during pregnancy.
Nausea and vomiting is much more prevalent with a gastric sleeve - leaving them vulnerable to proper nutrition -- which, in turn can affect fetal growth
2. body habitus changes Palpation of the antenatal abdomen is a fine art. Total art. When you add in variables like the size and shape of different women -this makes it even more of an art form. Add in a Hx of obesity - either current or past - and the palp becomes even more difficult to feel a baby's position, to measure fundal height accurately (a crude but general yardstick utilised to determine fetal and uterine growth without an U/S)
Both of the above means that the doctors will want regular blood tests for iron levels, and other nutritional markers - as well as regular ultrasound scans to measure fetal growth.
My stance on ultrasounds remain the same. They're incredibly inaccurate with 15% swing either side of a weight as to the true weight or size of a baby. They frequently find things (or don't find things) that either should or shouldn't be there --- and essential decisions are made on the basis of the ultrasound which I think should be taken with a grain of salt. This being said, it's very hard to ignore a test result once u have it in front of you - and just say "well its 15% inaccurate either way" when it's a test result that states: your child is not growing properly and is dropping centiles.
Anytime a test is being done, one always needs to know: what is the test for, what will I do with these results and how will it impact my future decisions.
3. body image issues are amplified in pregnancy and considering you had a gastric sleeve done, you were probably someone who struggled with body image (and other health fears) in the past. So mental health implications are heightened further
So here we are at 37 weeks with a prinip, undergoing an induction of labour at the earliest possible time period due to an ultrasound scan at 34 or 36 weeks which guessed the baby's size to be approx 2.2kg (very small) and to have dropped from 80th to 5th centile between 28 and 36 weeks.
A foleys catheter was put in the day before at 36+6 and the woman spent a sleepless night at home, anxious about the events of the following day.
The foleys had been excruciating, she said. Very painful, and freaked her out for what breaking her waters would feel like - and actually it was very different and not painful at all. (Other than the pain of someone's hand in your vagina going up further than you might think to be humanly possible, ARM is essentially painless.
After the hand has broken your waters, the next sensation is one in which you peed yourself but you cannot control- and this happens continuously throughout.
They commenced the oxytocin infusion at 0930 and at approx 11:30 pain actually ramped up. By 1430 when I entered the scene, the anesthetist was putting in an epidural.
Initial VE: 3cm, posterior cervix
subsequent VE at 1:15: 3cm cervix less posterior
oxytocin at first max of 180mls/hr and first bag about to finish.
The plan was once the anesthetist had finished putting in the epidural and the woman was comfortable, for the contractions to be palpated and a decision made to go up on the oxytocin provided the CTG remained beautiful.
It was a beautiful trace. There was very little on it to suggest I should be concerned in any way (unlike Wednesday's trace). Was this little IUGR baby really that robust?
At first the toco started working again - and picked up 5:10 contractions and I was like hang on. Can't ramp up the oxytocin here... but after 20 mins, and a palp later i could tell they were really more like 3:10. so up the synto went at 15:30
to max. rate 240mls/hr
The CTG stays beautiful.
17:20 rolls around faster than I know it and thats 4 hrs post the 1300 VE and we have synto at max rate here so I know I need to do the VE. The epidural is working well, and my VE is,
4cm (generous 4cm), still fairly thick cervix. Easily found - not posterior, but its a bit like feeling a thick rubber tyre inside her pelvis. It wasn't quite soft or stretchy, to be totally honest. O&G come around for a review and grills me on my VE and forces me to admit - that it really doesn't seem that much different from the 13:00 VE (admittedly done by another midwife.
They're happy for another 4 hours at max max rate provided the trace stays perfect.
So I commence on 4 hours of antenatal expressing, discussing breastfeeding, general chit chat where we compared our first trimesters (since I'm 26 weeks currently.. which makes me only 11 weeks behind her.. shit that's less than 3 months away) and agreed 2nd was the best. We talked about tooks like the Haka which I had similarly heard about and wanted to get (to collect the let down) and how she'd purchased it and was keen to try it. She was very easy to talk to and I tried to infuse some midwifery knowledge to her fears about inheriting her mother's concerns with breastfeeding her and her siblings in childhood. Her mother was concerned she could not make a supply, and so they all ended up on formula.
I wondered in some small sense if this is why this girl ended up with a gastric sleeve - and if her other siblings had similar weight issues.
In the tea room - I talked to the receptionist who showed me countless photos of people she knew who were overweight but not morbidly obese, but got gastric sleeves or bands by paying for them.
A lot of them posted on insta or fb thereafter their transformations.
When I was leaving it was 21:20 and the night doctors had just come on, and was reviewing my lady. The progress VE after 4 hours of insane amounts of oxytocin (we were on the 3rd bag and now it's at triple strength to avoid fluid overload) -- I agree the doctor should do it, as I know that this VE is going to make the big decision: To cesarian or to keep going with the induction.
I'm not expecting much - and it ends up being the same as before, a tight 4cm. This cervix is not budging. They discuss the cesarian. and she signs the consent.
Her only comment to me was "it's a bit overwhelming" and I'm sure it was. If I was her i'd be bawling my eyes out.
The incharge kept popping into my room throughout the shift checking the CTG was as good as I thought it was, and she'd always ask how it was going in there and in one of my comments I said "all is well.
I'd like to see more progress in terms of VE and CTG (the CTG can also indicate progress in labour) but I just don't see it) and the incharge just said, well, if at this extreme rate of oxytocin there is no progress then clearly, there is not much else that can be done. And I agreed.;)
At one stage I wondered if they forgot to put the oxytocin into the bag,
I made up the 2nd bag though, and I know I put it in properly - so there's no way it was just hartmanns in there.
I wonder if the baby really was 2.2kg
I was surprised throughout my meandering conversations that no one had mentioned the baby might ned to go to special care nursery post birth. At a weight of 2.2kg - I was under the impression that all babies under 2.5kg were generally admitted to SCN. If only for a short period of monitoring and BGLs.
We briefly discussed this, and how she would go over for feeds if that was the case.
No one had talked to her about antenatal expressing either, in clinic. And I wonder if that was largely because she was in doctors and not midwives clinic. Doctors don't usually talk about those hippy things.
In other topics. Dads.
This one was pretty funny. He was a roofer by trade, and you could tell his nervousness when he started talking a lot (which is what happened after she signed the cesarean section form). I curbed that by giving him something to do -- change into surgical attire.
It's a stressful day, he'd barely slept the night before as well.
He was feilding all sorts of text messages from their family - there's about 4 siblings on his side and 1 on hers - and they all wanted to know the VE results (I think the woman was on the phone to her mother whilst I was doing the 1720 one which I thought was rather funny. Imagine being on the phone whilst another woman's hand was inside your vagina rooting around and feeling your cervix?! Her husband wasn't present and I wanted her to not feel alone so I didn't mind.) or wanted to know what was happening in the room.
Honestly, when it comes to my own IOL (if I do indeed get there) I don't think I'll be telling anyone. Maybe my mum. Maybe. Probably not, she'll have a stressful day thinking about it. They can all just find out when it's all over. Rather than having 50 people in the room (hypothetically in the room) wondering what's going on.
The woman advised me regarding baby names. She said she'd picked some out but once she confided in the options to her family (mother and mother in law) they all had complaints and whines that forced her to find other names and let those ones go. She thought it would be better to just, pick. and tell no one until it was a done deal. I thought that was an interesting interpretation. I gotta get my butt moving on the name picking game. Otherwise I really will just call it Peter if its a boy and Rita if it's a girl.