RNfromMS

I believe the March of Dimes does seminars. This wouldn't necessarily help with becoming certified, but it may be a start. Our hospital has them coming to do a seminar in October (4 hours) that I plan to attend. I don't necessarily want to become a counselor as much as to learn how to care for these patients.

I originally clicked on this thread b/c I thought it sounded so preposterous. Now I think it's really interesting. I am definately going to ask docs and long-time RNs at work about this. In the population I work with, we don't see many red-heads so I had no idea. I have a cousin who is definately red-headed and has 3 children under the age of 9. I plan to ask her about this too. My only first-hand experience with anything like this: I am a "dirty-blonde" with red tendencies (my maternal grandmother was a strawberry blonde). I definately spent many years with heavier than normal periods (at least in comparison to friends and family). At several times in my menstrual years I was found to be anemic, although not at every blood check (the last one was so severe, they checked a ferritin level; it was 7.) I never had children though so I don't know about PPH. Definately something to wonder about. As another poster said, whether it can be backed up or not, I will definately have hemabate and methergine at bedside if I have a red-headed patient. Hmmmmm.

When I first started reading this thread, I thought the same thing about that I see it more often than that. However, in further processing, I would think it may be 1% of our patient population; however, we are a high risk unit, deliver lots of babies and have a whole lot of PPROM patients. Maybe that's why I (and maybe the other poster, too) thought it was more common. Also, if the PPROMer has an elevated temp (>101F) and tender to touch abdomen, the docs are going to call her "suspected chorio" and start the regimen. If things do not improve drastically in a predetermined amount of time, they are going to call her chorio and deliver the baby. Of course, all our placentas on these patients go to pathology and I haven't heard the actual statistics from that. (But they haven't stopped handling them this way, so it can't be too off.) Just my 2 cents.

I have to say that I hate it when my patients ask me how many children I have. I feel like they are trying to determine if I am qualified to care for them. I do not have children; it was not a decision but it is my life. I regret not having children, but cannot change it. Do I think I could be a better L&D nurse if I had experienced labor...maybe, no probably. However, as we tell everyone, every pregnancy is different. If I had been pregnant and gone through labor, that does not mean I would know necessarily what my patient is going through. It is cultural, religious, individual. It can also be different depending on which delivery it is, on the patient's emotional & physical well-being. Whether she has support. Whether she wants the baby. Whether she feels she can care for the baby. You get the idea. So even though I haven't personally experienced the process, I have participated in the care of many births and feel I can bring empathy and understanding to the situation. I hope I never get to where I feel like I know it all and view every birth the same way.

At our hospital, we only treat moms with positive GBS cultures; 4 hour minimum treatment of PCN prior to delivery. That means PCN every 4 hours until delivery (unless allergic, then Clindamycin); if mom delivers at 4 hours after first dose, but does not get second dose started, it is ok. If mom delivers 3 hours 59 minutes after first dose, baby must be worked up and started on antibiotics. If mom is unknown, but with a history of GBS with prior pregnancy, peds does a work up and starts antibiotics; however, I don't know if they treat babies with unknown GBS and no prior history. If mom ever had a baby who was positive for GBS, her present status does not matter; she is treated in labor and baby is treated in tx is inadequate. Two problems we have at our hospital. 1) If mom is GBS positive and has a ERCS without ROM, we do not treat but our peds treats baby. Apparently, the OB staff has found documentation supporting this, but Peds will not accept. 2) If mom is allergic to PCN, we treat with clindamycin, but Peds does not accept this as adequate treatment. Peds says clindamycin does not treat GBS; OB says it does. AAARRRGGG!

First off and most importantly, I want to extend my condolences to each and everyone of you who have suffered these losses, even those of you reading, but unable to share for whatever reason. I am a L&D nurse in a very high risk hospital where unfortunately we see more than our fair share of IUFDs, ectopics, and losses of all types. I want to thank each and everyone of you who have shared your stories, both personally and through L&D experience. Especially thanks to NHmommy for starting the thread. I cannot tell you how invaluable this has been to me. I unfortunately have never had the opportunity to experience pregnancy and have had a total hysterectomy with bilateral oopherectomy three years ago. I am in this line of work because I truly love nursing and the wonder of birth. I am totally enthralled each and every time I am involved with the birth process (I am starting my third year in this specialty). Even with my most difficult patients, I enjoy being involved with the birth. I hate to admit it, but I am one of those nurses who never knows what to say. I appreciate everyones candor on this issue. It might help in the future. In one of the posts, someone said she feels she is protruding on a private moment. I guess that is one of my problems. I never know what to say. (This has been a problem recently because one of my moms asked another nurse why I wouldn't talk to her when I came in to chart; thankfully she told her that I was a big crybaby who would start crying at the drop of a hat..I think that helped her understand me, but more importantly it helped me see that I have to learn to handle these situations better.) Our hospital use the memory boxes; we have the regular ones with room for a gown and blanket for the full term babies and smaller ones for the early losses. We have a group of smockers locally who make smocked gowns for us to take pics with and to put in our memory boxes (FT losses). We also put in the ID bands we make, tape measures, anything we would normally use with a birth that we think the moms might like later. We take pictures of all the babies, no matter how early. We take one for our charts, of course, but we try to take a few tasteful ones for our moms; we place a gown on the baby (or over if too small). I try to make sure you can see the feet and hands in the picture. We were using poloroids when I first started, but now we use digital and print the pics in the charge nurse office. We also supply a folder with literature that is handpicked for the particular situation (early loss, teen mothers, families with other children, dads dealing with grief, grandparents). We have illustrated books for the children. We also have all this information provided in Spanish. My personal choice for the pictures is to place them in the box underneath the other items. I let my moms know the pictures are there for them to see when they are ready to see them, not the first thing they see when they open the box. That way, the moms that aren't ready to deal don't have to be scared to open the box. (The pictures are a personal pet peeve of mine; I want them to be something that can be looked at without horror and can be shown to family and friends who might want to share in the experience with them. I tell the other nurses, especially my orientees, to please think about what the mother will see when she wants to look at the pictures...don't be clinical.) Another thing is the paperwork. They want us to have consents signed as soon as we can (autopsy, burial, etc), because the patient cannot sign these until 4 hours after the administration of pain medication and pathology/morgue cannot pick up until it is complete. However, most people do not want to deal with making decisions as soon as we admit them; they are dealing with a shock and have not had time to process, let alone make these kinds of decisions. They also usually want to talk to their family members. Of course, after they deliver, we transfer them to our antepartum floor for their postpartum care and our AP nurse claim not to know how to deal with the papers. This is very frustrating and leads to making the L&D nurses look like insensitive clods for trying to get it done. I am glad that you addressed the early miscarriages and ectopic losses. I admit that we don't deal with these well. I am printing off several of the posts so that I can share them at work. I think we also have a problem with how some of our residents deal with the moms, like some of the others have noted. Another thing that I would like to address is placing pregnant moms on the fetal monitors. In the triage area, I like to get the blood pressure first on the monitor so that I know what mom's heart rate is. In L&D, I know some (well, most) of the moms don't like having the BP cuffs and EKG leads on all the time, but I will tell you why I think it is so important. We have had more than one instance of documented FHR that was actually maternal (yes, mom's was running in the 110s or 120s); then the families don't understand how the baby can be gone when it was on the monitor. Then I know when I get the FHR it is actual if I know what mom's is running. If mom is running a high HR and the FHR I find is close to the same, I keep looking and/or I call for a resident with an ultrasound. Also, I like the idea of printing an US pics for the moms with losses. I am going to make that suggestion. I know this has been long and I appreciate the opportunity to be able to share. I think maybe I have rambled and it is not in any kind of order. I just wanted to make sure that I addressed everything. Thanks again for the insight. I hope this will help make me (and my coworkers) better able to deal with the families with fetal losses.

Do you remember which culture this was? It would be really good to know this for future reference. Thanks.

Actually the only reason for the c-section that would play a role is CPD.

Our unit uses the 20u of pitocin in 1000cc of D5LR and can titrate up to 32mu per protocol; can go up to 36mu with a doctor order.

"Then he began the exam without the standard "You'll feel me touch" which is a little disconcerting." We have a resident at our hospital that is a 2nd year as of the first of July. I don't know how he made it through his internship (they spend that first year in triage) because he was so rought with the patients during exam and would even check them without KY. I know that most of the nurses who chaperoned him during that year called him on it several times. I was with him today when he examined a laboring patient and he was completely different. I think it is very important for the nurses to express their opinion for inappropriate treatment like that. We have also had words with the few residents who, when a patient being checked screamed or pulled away, would make comments to them like "I don't know how you got pregnant acting like that." I have not had one act like that in a while.

Just curious...why did you have to have the first two sections? That could be a good indication of whether you will be successful in your attempt. Also, where I work (in Memphis) we have a few successful VBACs and we always use pitocin with them. (We never use Cytotec because you can't stop it's effect once it's been inserted.) But, with pitocin, if you become overstimulated (which is the big scare with VBACS), it can be turned off and given Terbutaline to stop the contractions or, at least, slow them down. We also like to have an IUPC (intrauterine pressure catheter) placed as soon as RBOW happens so that we have a good indication of contraction pattern and strength. Anyway, good luck and my prayers are with you.

Today I had a patient who was 27 weeks pregnant who presented to L&D on Sunday afternoon for suspicious tracing. She was placed on magnesium sulfate therapy and given betamethasone injections. This morning, as soon as the doctors turned over report at 8 am, they decided that they needed to do a c-section due to repetitive deep variables and late decelerations that had been occurring over the last several hours and did not appear to be getting any better. After delivery of the 1003 gm (2 lb 3 oz) baby boy who was intubated and sent to NICU, they found that the placenta had a 70% abruption. Then as they were beginning to tuck things in for the closure, they noticed a cyst on her right ovary (pt told me later that she knew she had a cyst there, but figured she would have to deal with it later...probably a few years). They decided to go ahead and remove it. It was a dermoid cyst, rather ugly one, about 4-5 cm round. (For those who don't remember this term from school and never dealt with it in practice, it is a bizarre tumor, usually benign, in the ovary that contains a diversity of tissue, teeth, bone, thyroid, etc. It develoops from a totipotential germ cell..a primary oocyte...that is retained within the egg sac which can give rise to all orders of cells necessary to form mature tissues and often recognizable structures such as sebaceous material, neural tissue and teeth.) Ours had a huge wad of hair on top of it (looked like a brillo pad on top) and you could see teeth underneath the outside layer of the cyst. It was so weird looking. Needless to say, we sent it off to pathology along with the placenta for studying.

We have an unusually high number of pre-eclamptic patients at our hospital (high risk) and very few of them have Hepatitis C.

Blows my mind...a hospital that does L&D but doesn't do epidurals? Wow! Most of our patients would never go there. They come in the door asking for their epidural. In our hospital, the rule used to be that you have to be 4 cm to get an epidural, but now it is whenever the patients wants it as long as we are committed to delivering at that time. I've also heard of hospitals that say you can't get an epidural after you reach 7 or 8 cms. Not us, you can get an epidural as long as you are able to sit on the side of the bed without sitting on the baby's head. I've seen patients get an epidural at 9cm. The other day a lady came in complete wanting an epidural; the baby was very high so we started a bolus. However, she delivered 400 cc into her 1000cc bolus. As a L&D nurse, I feel the epidural is very much the patient's choice. I can't tell you how many times I've had mothers refuse to let their teenage daughter have an epidural because she needed to learn a lesson (ha!) or the FOB say that he doesn't want her to have anything because it might hurt his baby. Of course, these are usually the same s.o.b.'s that tell them to quit yelling when they're pushing. I have been known to say something about Karma at that point. I personally enjoy my patients who have natural childbirth as their choice. They are usually very centered and not very demanding. The patients who are out of control, screaming and demanding medicine (not epidural), I do not try to force epidurals on them, but I do explain that they cannot have IV pain medicine after 7 cm and that is usually when the pain is going to be the worst. When admitting a patient, I will ask if they want an epidural. If they say no, I tell them that that is their option, but ask if they are refusing for fear or something someone told them about epidurals (I find that a lot of teenagers have "friends" telling them horror stories about epidurals even if they never had one). I tell all my patients who do not want an epidural that when they are interviewed by anesthesia staff (standard procedure) to tell them that they do not want one at this time but not to refuse one outright because even though they can change their mind at any point, if they've told the CRNA outright NO, they will have to be interviewed again to make sure the CRNA knows what they really want. It just saves time in the long run. My funniest story is the Hispanic woman who came in 9 cm and delivered about 20 minutes after admission. She was telling the translator that she had never been able to get an epidural because the nurses would never let her have one! When the translator told me this later in the hall, I told her that she might relay to the woman that if she wants an epidural with the next baby, she might want to come to the hospital a little sooner.

This is always a sad situation. We have IUFDs at my hospital way too often for my sanity, but usually as soon as it is discovered (in clinic or triage), they admit the patient and start induction. I find that a lot of people (some staffers, some family members) don't understand why the patient would be subjected to labor only to deliver a dead fetus. They think she should just be given a c-section so that she can get it over with. But the real reason for my post: My sister was pregnant in 1989 with her fourth pregnancy. She had delivered a beautiful little girl in 1986 after several years of trying to get pregnant and then miscarried two times after that. About two and a half monts into this pregnancy, she had a period of very heavy lady partsl bleeding and went to the doctor. She was told she had miscarried and they scheduled for her to have a d&c done the following week. When she went in for the d&c, they did blood tests and USG per protocol prior to starting procedure and found that she was still pregnant. At 31-2/7 weeks, she SROM'd at work and went to doctor. They sent her to the hospital where she received antibiotics for PPROM and steroids for five days. On the 5th day (32 weeks), they did another USG and found the baby to be breech so decided to c-section her then. Not only was the baby actually not breech, but while the placenta was firmly in place in the fundus, the baby was lying inside the fallopian tube (right at the opening). She was 3 lbs 3 oz and spent 4 weeks in the NICU. She is now 16 years old, 5' 8" tall and weighs about 180 pounds (due to Hashimoto's syndrome).