We've had a run of high risk pregnancies lately (what else is new?), specifically women with cervical incompetence.
Cervical incompetence is when the cervix starts to prematurely efface (thin out) and dilate, usually resulting in premature delivery if measures are not taken to prevent the birth. We don't always know what causes cervical incompetence in women.
The first thing we look at is her history: has this happened before? Has she had losses or preterm births? Is this her first pregnancy? Has she had surgery on her cervix in the past? Could she have an infection that is causing premature labor/dilation/effacement?
One of the first things we, as nurses, need to do is keep this mom in bed. Any pressure from the presenting fetal part (or bulging membrane as is often the case) can cause further dilation and effacement of her cervix. Sometimes, her physician might be ok with her getting up to use the bathroom. As the nurse, however, we must constantly remain diligent to the possibility of worsening of her cervical status (and possible impending preterm birth). If you get mom up to use the bathroom, and she feels an increase in rectal/vaginal pressure, or gets very crampy, perhaps a bedpan will be more appropriate.
This mom is going to need baseline labs drawn. We'll check a CBC specifically for her white blood cell count. Elevated WBC could indicate an infection. Her physician will more than likely want to perform an amnioscentesis. The amniotic fluid will be assessed for the presence of WBCs, low glucose levels, and the presence of any bacteria or other organisms. Any of these three items can be indicative of an intrauterine infection, which would more than likely mean she needs to have her baby sooner, rather than later.
If all three items are negative/normal, then physicians will usually proceed with tocolytic therapy and/or a rescue cerclage. A rescue cerclage, also known as a McDonald cerclage, is a series of stitches that are placed around the cervix to help keep it closed for the duration of the pregnancy. A woman would need to be placed under general anesthesia or receive a regional block for placement of a cerclage.
The suture used for a cerclage is not like normal suture, which usually dissolves in 2-4 weeks. This is a much thicker, permanent suture, and has an appearance and width of a shoestring. This stitch will stay in place until such time that the woman and her physician have determined is a good time to remove it. Usually this would be when she is about 35 weeks, starting to labor, or is showing signs of an infection or a worsening maternal/fetal condition. It wouldn't be a good idea to labor with a stitch in place, as it could lacerate the cervix as her body tries to dilate and efface her cervix through contractions.
Removing the suture is very easy - a speculum is inserted, and long scissors are used to clip the suture in several places. Long forceps are then used to remove the suture. No anesthesia is needed. Most women might feel a little crampy, but otherwise, it's rather painless and easy.
As I said early, tocolytic therapy is usually indicated and utilized as well. Tocolytics are medications that are used to stop or slow down preterm labor. There are medications that can be given via an IV line, through subcutaneous injections, or in an oral form. Depending on individual circumstances, the woman and her physician will decide which medication(s) are best for her.
Once a woman is diagnosed with cervical incompetence, she can expect to be on some form of bedrest. Sometimes this necessitates a prolonged admission to the hospital. Other times she can maintain her bedrest while at home. It all truly depends on the specific situation/gestational age/membrane status.
Wow! I can't believe how fast the time has gone! I turned in the last of my assignments today for my fourth term. First year of midwifery school - DONE!
I am officially finished with the Bridge portion of school. Time to move on to the "meat and potatoes" of grad school. Hip Hip Hooray (!!!) for meat and potatoes!!
The next term starts January 4th, so I will be doing some relaxing between now and then. Oh yes, and working my shifts on L&D. My Christmas week/weekend schedule is horrendous. I'll barely have time to see my family this year :-(
The OB/women's health annual Christmas party was last evening. For a change of scenery, it was held at a local horse race track/casino. Strange place for a Christmas party, I think. But, it was fun. Got to chit chat with some of the girls from the antepartum unit, as well as some of my coworkers from L&D. I also won over $500 from betting on the horse races! Pretty awesome little sum of money to go towards Christmas shopping.
I was a good girl, and didn't drink too much at the party this year. Yes, I do tend to be the drinker (as do many of my coworkers) when it's an open bar. But, it just wasn't in me to drink much this time. Which is a good thing, because I end up getting pretty gassy and bloated the next day from drinking. A wonderful side effect of how my body processes alcohol sugars since I had my gastric bypass surgery. Yeah, really pleasant. Pass the Gas-X please!
Oh, here were my pretty nails from last night:
My 6 year old daughter loves the blue nail polish, with the sparkles painted over top. (Nail polish is NYC - the cheap stuff - we love it!)
My goal is writing that last post is multifaceted:
--- Each situation is different for each person
--- There may be several options
--- There is no true right or wrong answer
--- We are all individuals, thus, we have the right to making our own decisions
--- We, on labor and delivery, deal with sticky situations where there are no clear cut "guidelines" or set ways to do things
--- We, as humans, need to remain flexible to the subtle differences, and open to possible solutions
There is no easy answer to the scenario that I posited. However, it was a type of situation that does happen on L&D. L&D is not all pretty roses and happy endings. It is one of the most difficult areas when it comes to ethics and decision making.
I have worked with families in a variety of situations where the outcome was questionable. I have second guessed physicians on their decision making. I have thought to myself, "what if this happened to me?" What would I do?
The truth is, unless we are placed in a particular situation, we do not always know exactly what it is that we would do. As you read in the comments from the last post, there is a wide variety of opinions and thoughts as to what (you) would do in this situation. I'm very glad to see that everyone was also very respectful in their comments, and there wasn't any bashing of opinions.
I always welcome the input from parents of preemies and what they have experienced in their situations, and the outcomes of their child(ren). I also welcome the input from NICU nurses - they see the outcomes of what happens to the micropreemies throughout their initial stay in the hospital after birth. I hear and see different things in my own NICU that sadden me, but unfortunately, I don't ever really know the outcomes for most babies that are born under my care after they are transferred to the NICU. I have often wondered if there was a way to follow up, and find out how things turn out for the babies and their families. Of course, unless parents actually write to us, or come back to visit, we just don't know.
Your infertility cycle was successful. You're pregnant! Everything is moving along beautifully with your pregnancy. Your older children are excited about having a new baby brother or sister.
You made it past the 12 week gestation, where you have lost babies before.
You've made it to 16 weeks and start to feel movement. You're starting to feel hope that you will have a successful pregnancy to term, after multiple losses in a row.
When you notice one day in your 17th week of pregnancy that you're trickling fluid. You worry that maybe it's just urine trickling out. It can't be amniotic fluid, you rationalize to yourself.
You go to the hospital to be evaluated. Baby's heartbeat is beating away normally at 160 beats per minute. Baby is moving around on ultrasound. Doesn't look like there was a loss of amniotic fluid, but yet, you keep leaking *something*. The tests come back that it's not amniotic fluid.
But you keep leaking.
Finally, a test is done via amnio to see if it's amniotic fluid.
With your heart breaking, you learn that it really is amniotic fluid leaking out. Your cervix has started to dilate and contractions have also started spontaneously.
You're only 17 weeks pregnant. Viability is 24 weeks gestation.
Do you choose the aggressive therapy of tocolytics, strict bedrest, the possibility of a cerclage, the possibility of infection - no guarantees that any of it will work - of nothing being able to stop your labor, delivering your baby before you can reach viability?
Or do you decide to let nature take it's course? Watch and wait, spontaneously deliver on your own, probably develop an intrauterine infection while waiting?? ......or induce labor and delivery?
What would you do?
(Just theoretical - I do not expect you to actually say what you would do. This is just to get you thinking about one of the many dilemmas that women face every single day in this country.)
Ho ho ho! Just 2 1/2 weeks left until Christmas. Have you finished your shopping yet? I just got started with mine. ::wink wink:: I am the great procrastinator when it comes to Christmas shopping.
This year, I have decided to do the majority of my shopping online. So, just point and click, enter my credit card number, and DING! Presto, pronto! It's all delivered right to my doorstep.
I have one heck of a work schedule for Christmas though. All evening shifts - Dec 24, 25, 26, 27, 29, 30. Only one day off in there. Who wrote that crappy schedule up?? Oh, I must have. Argh. (We do self scheduling.) What was I thinking?
The tree is up. My youngest did most of the decorating of the tree herself. (Even though the tree is a little crooked.) She beamed with pride when it was all finished. Amazing how such minor things to an adult are such a big deal to a 6 year old!
Did a little decorating in the house, but didn't go all out this year. I get so winded from little bits of activity. I'm fairly sure that I have bronchitis, with a nice little side dish of an asthma exacerbation. Sounds like fun right? I would love to put some lights up outside, the with the cold air making my breathing even worse, it's just not possible yet. (Come on lungs - heal up!!)
Back to work today. I called off sick all last week due to this chest cold/bronchitis/asthma thing.
Yeah, we still have some leftover turkey. How long is it still good, refrigerated? Time to use the rest of the leftovers, I think.
Make it into soup!
1 can cheddar broccoli soup
2 cans milk
1 cup broccoli (fresh or frozen)
1 cup chopped up turkey
1/3 cup shredded cheddar cheese
Toss it all together in a pot. Simmer for 15-20 minutes, or until broccoli is cooked all the way. Season with salt and pepper to your taste. (Yes, I'm eating this for the 1000th time, right now!)
Make it into turkey alfredo fettucine!
Chopped turkey
Milk or heavy cream
Parmesan cheese
Garlic
Mix it all together to make a sauce. Simmer to thicken. Serve over fettuccine noodles.
Make turkey sandwiches!
Sliced turkey
Turkey gravy
Warm it up. Serve it over bread for an open faced sandwich.
Still have more turkey left? (Yep, you know you do!)
Feed it to the dog. Or pitch it out in the trash. Who really wants to eat turkey for a month after Thanksgiving anyway???
I ordered my books for next term for school. The next term - already!? Yep, it starts the first week of January.
I have the last paper for clinical (community health) done, just need to submit it, as well as some other paperwork that needs submitted and is already done.
I'm working with a partner for the "big project" for Health Promotion. It's a case study, where we pull apart the subject, objective information. Then we do an assessment and a plan for teaching. We create concrete goals for the patient in the scenario, and determine how the outcomes will be measured. It's a humongous paper to write. Huuuuuuge.
And really? Do we have this much time in the real world for a new patient encounter, where we address all of her health care needs? I understand the concepts of the assignment though. It's all about looking at the big picture and being the primary health care provider. Quite a switch from being "the nurse".
Next term: Pathophysiology and History of Midwifery.
:::smiles:::
(still fighting off a nasty chest cold)
Lately: I have been sick with the crud (Yeah! Crud!) and I've been trying to rest up. I'm also working on my last minute assignments due at the end of the term for school.
Bear with me. I do have more post ideas coming up soon!
Working day shift this weekend. Am I crazy? Yes, I must be. I signed up for days for the weekend. What was I thinking?
It's crazy busy, as usual.
I had a nice first time momma give birth to a hefty size boy yesterday. She only pushed for 30 minutes! Excellent job!!
I'm going to end it at that, so as not to drag the negativity from the day into this post. I'll save the confrontations and issues for another post, another day.
Here's to beautiful births!!!!
I survived my first time officially in "Charge"! What started out as just the first four hours of the shift, ended up being the full eight hour shift in charge. It just made more sense when the 7pm nurse came on, and things were still so insane.
Yes, our Thanksgiving was a very busy and full time on L&D this year. It usually is, for some reason!
Evening shift, which is usually staffed with 9-10 nurses, had only 7 nurses scheduled - including me, the brand new charge nurse. The unit was full. We had 3 patients that would need to be one-to-one with a nurse right from the start. That left 9 other patients to be divided up between 4 nurses (including yours truly - the charge nurse almost always takes an assignment on my unit). One nurse, unfortunately, needed to take 3 patients. The off-going charge nurse helped me determine how to make assignments...........then I was on my own.
Patients came in. We got a transfer. Very few were sent home. I called in the on-call manager and gave her the transfer. We did a c/section right at the midpoint of the shift. Through it all, I managed to juggle it. I even got several nurses to get their dinner breaks before the middle of the shift!
Another c/section was called just before 11pm, and I figured out the staffing for that as well.
All in all, it went well. I was very open to suggestions from other nurses as to how to best divide up assignments and switch things around as we had acuity level changes. Some patients that were "easier" assignments became one-to-one for nursing care, and everyone managed to help each other. I ended up taking 2 "easy" stable pre-viable preterm patients, as well as being the 2nd RN at 2 births, helping with patient checks, starting an IV, drawing some labs............
Holy crap. It was busy. Of course, now that I successfully managed to coordinate everything for a full eight hour shift, I'm going to be assigned as a charge nurse again in the future. I proved myself more than capable......with no training or orientation on how to do it.
I'm off to go finish cooking my Thanksgiving turkey dinner today. I think it's well deserved!
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