Sunday, June 15, 2008

If you give a Woman an Epidural...

You all know the book "When You Give a Mouse a Cookie"? Well, here we go....

If you give a woman an epidural, she'll need a big bag of lactated ringers to go with it, the lactated ringers will keep her blood pressure from plummeting when she gets her epidural, but it will also swell her tissue with excess fluid so her legs and breasts will swell and she'll be shedding water weight for days if not weeks. The fluid in her breasts will make it hard for the baby to latch on at first, so the nurses will think the baby's not able to nurse and they'll recommend some formula, just until the nursing goes better, this will probably make mom feel insecure and crappy about her mothering skills and it could interfere with bonding.

After the epidural's in, she'll probably need a catheter because she won't be moving around much anymore, and hey! she can't feel anything below her belly button anyway! If she gets the catheter, she might get a urinary tract infection to go with it.

Once she gets the epidural and the catheter, even with the extra fluid, her blood pressure might drop anyway in response to the medication she's getting, she might get some epinephrine which has the following common side effects:

Anxiety; difficulty sleeping; dizziness; fearfulness; headache; nausea; nervousness; paleness; sweating; tremors; vomiting; weakness.

If she's unlucky she might even experience these side effects:

Severe allergic reactions (rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue); fast heartbeat; irregular heartbeat; wheezing.

If she gets the fluid, the epidural, the catheter, and the epinephrine, the baby might not respond very well, so the doctor will want to know what the baby's heart rate looks like all the time, and the doctor will also want to see whether mom's contractions are strong enough to dilate her cervix, so an electronic fetal scalp electrode will be screwed into the baby's head, and another special catheter, one that measures the strength of the contractions, will be pushed up inside mom's uterus. Of course, to do this, the bag of waters would have to be broken, so that the catheter can go in. Once the bag of waters is broken, the doctor will be paying close attention to the time, because doctors don't like women to walk around with a ruptured amniotic sack for much longer than a day, even if the mom and baby need longer to birth.

When she gets her fetal scalp electrode and the intrauterine pressure catheter is in place, the contractions might not look very strong on paper, so the nurse or doctor will do some cervical exams, to see how things are going. Lots of people, from the nurse, to the doctor, to the resident, to the medical student might put their fingers up inside of mom's vagina, so they can get a better idea of what's going on. But it's no big deal how many people put their hands up there, because remember, mom can't feel it! If they put their fingers up there over and over again, mom might get sick. She might get a fever, she might even get a fever in response to the epidural! But the doctors won't know exactly what's causing it, so they'll just give her a full spectrum anti-biotic to cover everything.

And if they give her a bunch of anti-biotics over the course of labor, she might get a yeast infection to go with it! If she gets a yeast infection she might give the infection to her baby too, then the baby would have thrush, which could cause more breastfeeding problems.

Once she's got the fluid, epidural, iupc, fse, the catheter, the cervical exams, and the anti-biotics, her contractions might poop out altogether, so she'll get some pitocin. The pitocin will blast her body into labor, making her contract harder and harder, faster and faster, but it won't cross the blood-brain barrier like natural oxytocin does, which is what triggers our bodies to create nature's pain killers: endorphins, so the contractions will be excruciating and very difficult to work with.

And if the contractions are very difficult to work with....

chances are.....

She'll want an epidural!

Friday, June 13, 2008

High Dose Pitocin Inductions

Apparently high dose pitocin inductions are becoming all the rage. Hospital in the big city number 2 at which I work is doing a study on them.

Color me unimpressed.

"The Literature" says women deliver more rapidly with HDPIs and that HDPIs decrease the number of C-sections. I'm skeptical, I can't wait to read the studies.

This was my first, and only I should add, experience with an HDPI.

Mom was a first timer, barely "past dates" (she was due on a Friday, we started the induction on Wednesday after her due date), she was given cervidil, a cervical ripening agent, overnight, which caused mild cramping but not much else. I placed the cervidil and BOY was her cervix posterior! I could barely reach the posterior fornix, the little pocket just behind the cervix, and I had a very difficult time trying to get to the opening of her cervix, the os, to check her dilation. In otherwords, her body had very few indicators of being ready for labor. In fact, her Bishops score, which we use to measure a woman's "inductability" was 2, not impressive.

So she recieved her cervidil overnight and pit was started, at FOUR MILLIUNITS AN HOUR, the next morning. Apparently in some places they're starting it at six milliunits an hour!

If we use the analogy of labor being like running a marathon, think of an induction as being tied to a car with which you must keep up in order to reach the finish line. Most times, the car would start slow, walking pace, like two miles an hour, and over the course of the day, the car (pitocin) would go a little faster, and a little faster, 'til you're finally running along at a good clip, and hopefully not being dragged behind the car! With HDPIs you sort of get pushed out of the car when it's already going 25 miles and hour and you just go faster from there.

When I took her the next afternoon, her pitocin was already up to 30 milliunits, which is pretty much the maximum recommended dose for any laboring woman, she couldn't feel it though because of course she had an epidural, not that I blame her a bit, I doubt I could take a pit induction that high myself without some pharmaceutical help.

Unfortunately, such a high dose caused, surprise surprise, hyperstimulus of the uterus so baby was having deep decels, and her uterus wasn't relaxing between contractions and she was contracting every minute.

We cut her pit in half and she started having a nicer labor pattern, but every so often baby would have a very deep variable deceleration. We suspected the cord might be wrapped around something at that point.

We started easing the pit back up again, this time using a low dose protocol, and soon her water broke with clear fluids. Whew! Despite the stress, baby hadn't pooped inside of her. Good.

Her uterus seemed to be pooping out (not suprising that she wasn't maintaining contractions with all the pit pumped into her from before, this is pretty common) so we kept increasing the pit.

About an hour after her water broke, we started seeing meconium, the baby's first bowl movement. Thick, thick, pea soup mec.

Finally, she was complete, we had her start pushing. The baby was having fewer variables, but his baseline had risen, which can indicate fever, or stress in a fetus, I was afraid he was on the verge of pooping out completely and he'd be plummeting down, and we'd be headed for a section.

After an hour an forty minutes of pushing, a pretty average time for a first time mom, the baby was born, covered head to toe in thick mec, floppy, dusky as all get out, with that glazed unfocused very not-present look. Yeesh. He had his cord wrapped around his neck AND his left had, which because of the cord was tucked up along side his head when he was born. I am so so thankful the Neotal Nurse Practitioner was there, I would not have wanted to try and resucitate that baby myself. She intubated him twice, and he didn't give his first small cries until four minutes after he was born. His apgars were five(!) and eight. Yikes. Yikes. Yikes.

So, what do I think about HDPIs so far. It seems like an impossible induction to do without drugs, I think it's a good set up to stress out babies, as well as leading to hyperstimulation of the uterus, which in turn could cause the uterus to rupture. The dreaded abruption.

Ladies, do your research, advocate for yourself, and if you can't, get a doula who will advocate for you.

Wednesday, May 21, 2008

hello again

bad me, I've been neglecting my blog.

Well, I'm working out of home again, at a new hospital-in-the-city. I didn't realize how stressed I was working at the county until I left work one day smiling. I don't get to see as many of my Somalian mamas anymore but I'm enjoying working with our newest wave of immigrants, the Karen people of Burma/Myanmar (I'm still sorting out what the best name for this country is, I believe Myanmar might actually be more colonialist, I'm looking into it).

I'm dragging my heels getting back into school, I think I'm not looking forward to statistics. Sad indeed.

On other fronts I have decided to yank my kiddo out of school and unschool him next year. I am STOKED. No more will he learn that Abraham Lincoln was "the great emancipator" and other lock, stock, and crock. It's trips to the museum, IWW meetings, forays into funky scavenged architectural stores and hopefully a trip to see Wicked, when it comes to town.

I'm busy getting ready for the RNC, coming to a hometown near you, you can bet your butt that if it was the DNC I'd be just as busy. I'll be working as a street medic on day one, with other plans later in the convention.

I'm loving my CSA and encourage everyone and anyone to check out this awesome way of supporting local organic agriculture for not much dinero. Who knew that the tastiest quiche I've ever had would be one made of wild ramps, stinging nettles, and sorrel.

I'm hoping to bring BOLD (birth on labor day) to Minneapolis, I loved doing The Vagina Monologues years ago in college. Birth is like fire these days, everyone is inflamed!

Just a quick update, more musings and meanderings soon.