A typical day at work

I work as a newborn nurse at a busy, urban, level III NICU hospital.

Curious as to what I actually do? Read on:

(warning, long and detailed post!)

I really love my job. I am so lucky to have the privilege of meeting fresh new babies every day.

When I am the newborn nurse assigned to cover deliveries, this is what a typical day looks like: My job is to check equipment for function, stock supplies, and review prenatal records. I'll update neonatology as necessary (a neonatologist or neonatal nurse practitioner will attend any "high risk" delivery- breech, meconium stained amniotic fluid, prolonged decels on the monitor, any delivery less than 37 weeks gestation, insulin dependent diabetic mother, potential shoulder dystocia, compound presentation, vacuum or forceps, etc... ) and, of course, attend births!

When I first get to work, I will receive report for the previous shift RN about who is laboring-- any important medical history, how far dilated she is, how far along her pregnancy is, who her doctor is, etc. She will hand me the pager so that L&D can page me to an eminent delivery if I'm not on the floor.

If there aren't any women close to delivering, I will first go and check my equipment:

1.) make sure the neonatal code cart is locked and the transport isolette is stocked with an MIE bag and mask, full O2 and air tanks, has a full battery, and is pre-warmed to an acceptable temperature.

2.) check the two operating rooms and then all ten labor rooms for functioning wall oxygen/air and blender as well as functioning wall suction. I also check equipment in the warmer base drawers:

MIE bags and a full term and a premie O2 mask, suction catheters (two of each size- 14f, 10f, 8f, 6f), a stethoscope, 2 endotracheal tubes in all the following sizes: 2.0, 2.5, 3.0, 3.5, 4.0, laryngoscope blades (3 sizes) and handles, extra batteries for the handles, a MSAF kit (meconium aspirator, ET tube, stylet, and 14f suction catheter), CO2 detectors, OG tubes for lavage during codes, and of course diapers, hats, extra paperwork, tape measures, etc...

3.) check to make sure there are enough baby cribs in the closet

4.) check to make sure there are enough security sensors for our security system

In between all of this running around, I continually double check the labor board to see how far dilated our laboring moms are so I can try to manage my time efficiently. I will try to flag down the L&D charge nurse to get an updated report on any new admissions.

I will then flip through charts to review prenatal records for any pertinent data: full term?, Gravida/parity, age, relevant medical history, HBSAG and HIV status, rubella titer, blood type, urine toxicology results, etc. I will check to see if the mom will breast or bottle feed and who her pediatrician will be.

I will then try to make up identification bands for the baby... one less step to complete at the actual birth!

Usually all of this leg work gets "interrupted" by a birth or two. In this job, you've got to stay organized and be flexible!

If there are no births (rare!), then I go back up to the nursery to assist with assessments, teaching, admissions, blood work, charts, or anything else they might need.

Once I do get paged to a birth, I go into the room and set up my supplies. I like to have everything as ready as possible so that I can get all of my baby stuff done as fast as possible after the birth so I can hand the baby back over to the mom pronto. I will first turn on the radiant warmer to heat up, turn on my O2 and my suction, set up my baby blankets on the warmer, plug in the scale, set up my erythromycin with gauze and sterile water for cleaning the baby's eyes, draw up my vitamin k for the IM injection, get out an ink pad and a soapy gauze to clean the ink off, and get my transponder attached to a cord clamp. I get all my paperwork out and ready. As I'm doing this, I'm constantly assessing the situation in the birth room: is the fetal monitor on? How is the baby tolerating pushing contractions? Is the baby crowning yet? Will there be a vacuum or forceps? Do I need to page neonatology? Is there a nuchal cord? Is a tight cord clamped and cut before the birth of the body?

Once the baby is born, I hit the timer button on the warmer (for resuscitation purposes if necessary) and double check the time of birth. Most of the time, the baby is born with a lusty cry. If the baby is crying, I know that it has a good heart rate and good respirations. And I can relax a little and just let the mom enjoy her baby for a few minutes while the L&D nurse is stimulating and drying the baby on the mom's chest. After a bit, I'll ask the mom if its ok to borrow the baby for a few minutes... I'll take the baby over to the warmer and do a very quick assessment - pink? crying? good tone? Head to toe look-over. Then I'll ask the dad to get out his camera as I put the baby on the scale to get a quick weight and length. Back to the warmer. Vitamin K IM injection in the thigh, Erythromycin eye gel in the eyes. Complete the identification bands with the time of birth and sex of baby. Footprints. Have L&D nurse double check my ID bands before putting them on baby. Put security tag on baby. Finish measurements (head, chest, abdomen circumference). More thorough head to toe assessment with gestational age exam. Quickly write down anything out of the ordinary so I don't forget! Quick set of vital signs. Triple wrapped with hat (or SKIN TO SKIN with mom with warm blankets over both if she seems up for it). Hand baby to mother for breastfeeding!!!

All in all, I have baby at the warmer for 6-10 minutes before giving the baby back to mom. I'm usually so quick that I am finished with the baby before the mom's perineal repair is finished. I pride myself on being quick... many other nurses take as long as 25-30 minutes! That's a loooong time to be without your baby after birth! Some of these tasks must be done in the delivery room (footprints, bands, security tag, baby meds, vital signs) and the other things (gestational age exam and measurements) only take a minute to do and its really helpful to the nursery to get them done and it helps determine whether or not the baby will need to be on hypoglycemia protocol. Sometimes, if things are really crazy on the unit, I can omit these two things, but I often just throw it in anyway... it doesn't take long.

Once the baby's handed off to the mom, I help her with breastfeeding and tell her to hit the call light of she needs anything... then I clean up my mess (I usually just throw all my soiled linens and trash on the ground since I'm working so fast) and leave the room to finish paperwork. Charting takes a good 10 minutes to complete.

Then, I have to check vital signs on the baby every half hour (and check blood sugar if applicable) before bringing the baby up to the newborn nursery at two hours of age. This can become quite a busy task when there are multiple babies born on the floor!

There are obviously variations to this routine depending on the baby (Premature? Respiratory Distress? Immediate admission to NICU) or the delivery. In a c-section, I will have all of my equipment and supplies set out/turned on and then put on a sterile gown and stand near the sterile field next to the mom's legs. After the baby is removed and the cord is clamped and cut, the obstetrician will hand me the baby and I will take the baby immediately to the radiant warmer for drying, stimulation, and a quick head to toe assessment. If the mother is awake and seems interested, I will (if baby is stable), quickly wrap baby in a blanket and take him/her over to the mom for a minute so she can see the baby right away. I believe that this simple act goes a LONG way to help with bonding in cesarean deliveries. Oh, how I wish I could have seen my baby so soon after my c-section! Then, I'll return the baby to the warmer to complete my "tasks" before wrapping the baby and handing the baby off to the father. Unfortunately, I cannot leave the OR without taking the father and the baby with me (I am the one responsible for the baby), and if the unit is busy, I cannot linger for long. After 10 minutes or so, I lead the dad and the baby to the recovery room to wait for mom.

If the baby warrants some resuscitation, I follow NRP guidelines. Thank goodness, most babies only need a little bit of free flow O2 if anything at all. Thankfully, neonatology is always only minutes away and the L&D nurse is always there if I need a hand with resuscitation.

It is so amazing to have the honor of being in attendance at so many births. Although work is extremely busy and very physically demanding, I absolutely love it. I am hoping to constantly improve my practice to allow more skin to skin and sooner to facilitate bonding and early breastfeeding. I also hope to rub off on more nurses... I think I'm the only one who does this regularly!

My job is incredibly rewarding!

Resource

My my, it has been a while. I guess that being a part time working mother to two little ones in diapers can be quite time-consuming! I haven't posted in over 4 months. As my two year old would say: "Yikes, mommy, yikes!"

Part of my lack of blogging might be more to discouragement than to time-issues, though, I must confess. Since my glorious natural VBAC almost 9 months ago, I have served as a resource person to many of my friends seeking natural birth. Unfortunately, though, as a barometer of today's high-intervention obstetrical climate, many of these friends have had not-so-happy births.

I was so incredibly thrilled with my AMAZING natural birth in June 2010, that I was pretty vocal about it on facebook. Not surprising, I made quite a name for myself as being a natural birth advocate and wannabe-midwife. In the weeks and months following my birth, I received about a dozen e-mails from friends and acquaintances who were desperately seeking advice and encouragement on their journeys toward a happy birth. A good proportion of these pregnant women had similar stories to mine: a traumatic first birth (most often an unexpected c-section) and a desire to overcome feelings of feminine inadequacy and distrust of their bodies by having a glory-birth for their second (or third) baby. Many of them, like me, were shocked and outraged by obstetricians discouraging them or even forbidding them from attempting VBACs. I received e-mail after e-mail from women in my extended circle outlying such similar predicaments.

I would encourage them, pray for them, and tell them what worked for me. I gently pointed them toward midwife care, hypnobabies, and natural birth (no epidurals!). I pulled out some research articles on fetal positioning. I sent links, videos, articles... I loaned out books. Anything to pump them up to feel excited about their upcoming births!

Of the 6 friends who have already given birth... four were repeat c-sections!!!! ARGH!

One VBAC hopeful had a planned c/s for breech. Another delivered a 9lb2oz baby by repeat c/s-- 42 weeks gestation and well over 24 hours of active labor and never progressing past 5 cm. I was so proud of her for her efforts... and sad that the birth was not how she hoped. Two more moms - one, a VBA2C hopeful, both became discouraged by their OB and talked out of even trying to VBAC. They both had their babies by c/s this week.

I am reminded by these outcomes just how amazing it is that I was able to have such a beautiful and restorative birth. We must never ever ever take experiences like that for granted.

The two non-c/s deliveries? One was a quick and comfortable hypnobabies birth for a first time mom! YEAH! She delivered at a birth center and got to come home only hours later.

The other was a quick and comfortable vaginal TWIN delivery! YES!! I had been corresponding with this friend throughout her stressful pregnancy (stressful only because she was labeled "high risk" because of the twins and subjected to lots of testing, bedrest, and hospital admissions). By the time she was "gently induced" for PIH, she was already 5 cm on admission and didn't feel her contractions until about 8cm. She was comfortable until she was told it was time to push. Everything went so fast... she almost had baby A in the toilet! She said it was incredible and she felt great! I am just so thrilled for her!!!! She stood her ground, found a supportive care-giver, armed herself with knowledge, and had a fabulous birth as a result. These were her first babies!

I have discovered a passion in myself for supporting women in this crazy season of life called childbearing. It has become a scary unknown for many women-- there are so many horror stories, much misinformation, and so many risk-inflating and intimidating OBs who bully women into inductions and cesareans.

I, for one, will not let them bully my friends.

Foremilk/Hindmilk Imbalance

Haven't been able to get much sleep lately. The littlest one (she's four months now!) had been waking every 2-4 hours again at night. She had been sleeping through the night for the longest time... and then all of a sudden, she was very unpredictable in her sleep patterns. To top if off, my 2 year old decided he preferred sleeping in "mommy-daddy bed!" and would tip-toe out of his room at various points in the night to climb in with us (and wiggle wiggle wiggle... impossible to sleep!).

While I haven't been able to fix the latter problem, I finally figured out the former! My baby girl has been having some pretty yucky poops lately-- green stools. This raised a red flag for me. I realized she was having an imbalanced foremilk to hindmilk ratio. The extra sugar in the foremilk can cause gassiness and green frothy stools in babies, and the fat in the hindmilk is what keeps them fuller longer and helps them to grow.

So... I tested my hypothesis yesterday. I only nursed on one side until she was completely satisfied, and then the next feeding I'd start on the other side. I realized that my baby is a VERY SLOW nurser and once she gets her belly full of foremilk, she takes forever to finish up with the fatty stuff. I'm just too impatient, I guess! I realized that I was popping her off and putting her on the other breast before she could receive enough hind milk. So... last night, I let her completely finish on one side... and instead of taking about 15 minutes, it took a whopping 45 minutes! (which is a LONG time for me to sit/lay and nurse!) BUT- she slept all night!!! WOOHOO!

Hopefully she won't be so cranky/gassy and will be able to sleep longer and grow faster!

So excited that we figured it out!

Patient Story: Repeat C/S gone wrong, part 2

I heard through the grapevine about a friend of a friend:

She was scheduled for her third C/S (second repeat C/S) with her third child. Perfect pregnancy. Should be pretty straight forward.

Apparently, this poor woman had a terrible reaction to the spinal anesthesia during her surgery which caused a heart attack on the OR table and subsequently her lungs filled with fluid, burning the lining. She spent two days in the ICU and has now had many respiratory issues since the birth.

Ridiculous. Thankfully, she and baby are ok, and will have no long-term damage. I shudder to think of what could have happened.

Love Fest

There is a nurse that works per diem in my unit at my hospital and she also works full time at the hospital where I delivered my 2nd baby. I didn't know many people that worked at that hospital, so I was very pleasantly surprised when my coworker walked into the delivery room as I was birthing my baby to be the newborn nurse. There were only five people in that quiet and dim room- my husband and myself, my nurse, my midwife, and the newborn nurse. Immediately after Lilee was born, I was so completely overcome with "love hormones" that I began proclaiming my love for everyone in the room! It was so crazy- it was like I had to fall in love with everyone nearby! That oxytocin is strong stuff!

Anyway... I saw my coworker for the first time since the birth last night and I was just so shocked at how much I wanted to talk to her and be around her. I didn't know her too well before the birth, but now, after she attended my birth, I just feel so connected to her. It's so interesting to think about how something as personal and intimate as birth can bring two people together! That (natural) oxytocin (NOT pitocin!) is so good at causing bonding to occur- not just between mother and baby, but everyone else in the room. It's kind of like how a baby duck imprints to the first thing he sees (usually his mother). I felt bonded to everyone I saw immediately after the birth. Another reason to choose your birth team wisely!

weeping

I had a sudden "attack" of weepiness yesterday regarding my c-section. It has been two years. When will this end?

It's amazing to me how completely and totally that one day has changed my life. I get so frustrated when people just brush cesareans off like they are no big deal, that they are "just another way to give birth." WRONG! I didn't birth my son. He was ripped from me. Unnecessarily. It isn't just the section that frustrates me. It's all the events that led up to it. If I hadn't gone for my biophysical profile, they wouldn't have noticed the "low fluid". AFI is a tricky thing to measure by sonogram. If the fluid is on the inside of the uterus, between the baby and the interior wall, it won't be seen and won't be measurable by sono. It just makes me so mad that there was this tiny excuse that they found to induce me. I had a perfect pregnancy and I was young and healthy. And I am so mad at myself for letting them do it. I wanted to leave, but they manipulated me by saying I would be "discharged AMA" and that "if anything happened to your baby, it would be your fault." Disgusting.

The induction led to the epidural, which led the the c/s. I know from my second birth that I had absolutely no problem at all birthing a big baby. I know I could have done it. Why did I let them mess with my body????

My son's birth broke me. I felt assaulted and victimized. Strapped down, naked, to a metal table with bright spotlights shining on my most private parts while a dozen people file into the room. A drape is set up in front of me-- was it to shield me from the surgery or was it to dehumanize the section for the surgeon? I felt so alone as I was cut open, my uterus taken out of my body.

Even before the actual surgery, when I was pushing in the labor room-- there were two nurses, a midwife, an OBGYN, and a med student all yelling at me to "PUSH," again with my naked body exposed to the world with spotlights and an open door. Strangers could have walked right in. How humiliating. I didn't at all feel like a person. I felt like a just another patient on a birth assembly line. "Let's just get her delivered!"

This DISGUSTS me! I thought that my beautiful birth with my VBAC victory baby would have helped me heal. But, now I know how AMAZING natural birth can be. And I feel even worse that I missed out on that with my son. That experience was stolen from me. And instead, I struggled with a very difficult physical and emotional recovery. And... in some ways, I will never recover.

Patient Story: denied birth

I recently found an old friend of facebook and we got to chatting about our kids and she sent me her birth story for her second daughter:
"my first baby was born at an army hospital 6 years ago, and she was a natural birth. However, the army nurses were very against anyone getting out of bed and moving so I was made to stay flat on my back in bed the entire time, and then gave birth to my posterior baby while going through the worst agony of my entire life. Not such a fun experience, but at least I didn't have a c-section with her. Then in 2007, I went into labor in the middle of the night and things were going smoothly. I had an epidural this time and actually was very relaxed, and when it came time to push, I was not nearly as exhausted as with my first. I pushed for 15 minutes and the doctor told me that he could see her head, that with the next push we would have a baby. When that time came and I was pushing, he suddenly started yelling at me to stop and telling the nurses to call the OR, and I had to have an emergency c-section. I had no idea what was going on; I felt fine and the baby's heart rate was totally normal. As it turns out, she was frank breech and he would not let me deliver her, never mind the fact that her bum was partway out at this point! I was furious and scared. It was definitely horrifying, to say the least. He kept telling me that if I continued to push, my cervix could close around her neck and she would die. I now know, after having a vbac, that that was very unlikely. Anyways, she and I both recovered, at least physically. I still hold bitter feelings about the entire situation, so when she was 6 months old and I found out I was pregnant again, I began researching vbacs. As it turns out, there is a group of midwives here that will do them, and it was an absolutely wonderful, perfect birth experience. I spoke with my midwives about my c/s, and they said that had I been their patient, they would have just delivered her as long as she was not in distress. How in the world the doctors and nurses did not know she was breech is beyond me, but I know I can't change the past. I just refuse to go back to that hospital for anything!"

The above story made me SO ANGRY. I can't even tell you! That vaginal breech births are virtually impossible in a US hospital is just such a shame!