Nursing theories

I understand the rationale for reading about different nursing theories. (Who knew there was so many???) However, I am now taking a break from reading about theory. It is so incredibly dry material to read for my Theory and Research class!

I read about Nightingale's Environmental Model and it's 13 canons. Ok, they make sense, and I can see how all of them apply for client health and wellness. Then I started reading Orem's Theory (self-care deficit nursing theory). I got through two pages and had to take a break. Gee, I only have this theory, plus five more to read about this week.

Then the real fun begins: we will be assigned (in groups) to write a paper on one of the theories. Oh boy. Can you sense my excitement?

I know this info applies to how to practice as an advanced practice nurse, but it is very, very, v.e.r.y. dry!!!

On the community health course, I need to hurry up and find a local preceptor for my observation clinical that starts at the end of September. ACK! I need to find a preceptor pronto, and the paperwork, plus a written assignment, is due in 2 weeks for that. Nothing like a time crunch right from the beginning of the school term, huh?

Natural childbirth

I'm excited to say, I had two natural childbirth families/births, two days in a row! YEAH!!! Both were beautiful births. Both moms were totally in control of their bodies, and very peaceful.

One of the moms had a "dysfunctional" type of contraction pattern, and the provider wanted to start pitocin. However, mom didn't want it. Not a problem! She did some nipple stimulation now and again, and that got her contractions to pick up the pace a little bit - on her own time schedule. Mom was worried that she was "stuck" at a certain dilation, after requesting and receiving several cervical checks that showed the same dilation. I told her that she's not "stuck", but rather, she's at a plateau. Her body will eventually break through that plateau and increase dilation.

I offered several position changes to help rotate her posterior baby, and it worked very nicely! I encouraged her to listen to her body, and move the way her body was telling her (aka: do what feels good). She had her hips swaying and rocking from side to side (doing the "labor dance") while leaning forward into her husband.

She was getting a little discouraged with the slow progress of labor, so I suggested moving to the bathroom. Well, that sure jump started the rest of her labor! She birthed her baby into my waiting hands in a very rapid fashion. (That would be catch #16 for me, if anyone is counting.......) I totally did not expect her to progress so quickly in such a short period of time.

What amazed me is how calm I was during this birth. I called out for assistance when she was precipitously delivering, and when another nurse came in, I calmly stated "we're having a baby". She didn't realize that I meant - mom is having her baby right NOW and that the head is already out!! The nurse did a double take, and realized what I meant :::big smiles:: Kind of humorous, looking back on it now!

Since mom wasn't in a traditional position on a bed, it made for a slightly awkward "catch". My concern was shoulders getting stuck, so I asked mom to squat down a bit more to birth the rest of her baby. Baby slid out very easily, and I lifted the little boy into his momma's waiting arms.

Baby stayed attached via the cord, on mom's chest, for quite some time. I'm not a cord cutter, unless baby needs resuscitated. (The midwife came in shortly after the birth, and I deferred to her for the remainder of the birth.)

Blogging and privacy

Here is an article about medical/physician blogs, which also pertains to nursing blogs. Well-written article! The focus of the article is on ER physicians. (Scan down below the article on paramedics to read the article on blogging.)

The article does raise some good points. Namely, if you read a journal article, you will read patient case synopses, with identifying information taken out of it. This is very similar to how we (bloggers) write about patient situations. However, because a blog is open to the public, anyone can be reading it. Not just health care professionals, as in the case of reading case studies in medical/nursing journal articles.

So, I believe that we, as bloggers, need to privatize our blog posts even more than we would if we were to be writing for a medical/nursing journal. Some of my readers know who I am, or where I work, so I certainly wouldn't want them (or anyone else) to figure out exactly who I am blogging about. That would violate patient privacy. So, I change details. I change ages, gestations, certain details of situations, genders, apgar scores, etc. I combine several situations/patients and turn it into one patient composite.

Sometimes though, I do chronical my day as it happened. However, I leave out the itty bitty details that could identify my patients. For instance, I might just say "I had a rule out labor who was only 1cm with no cervical change, so I discharged her home." That could be literally ANYONE. No personal identifying info there.

I enjoy blogging. It's almost like a diary for me. I like looking back on my posts, and recalling situations. Sometimes I've changed details so much that even I don't remember the situation or the patient! How's that for good HIPAA??

I like to keep this blog real. There are several nursing students who read this blog, and I want them to know the reality of nursing, especially being an L&D nurse. Keeping this blog real means having to keep specific details true to form, as it happened. It's a challenge sometimes to make sure that it's still private enough that someone doesn't recognize the person that I am referring to in a post.

What a fine line we nursing and medical bloggers must follow!

Heads up to ER Stories for the link.

The dog days of summer

It's been steady business on the L&D floor the past few weeks. With the exception of a few days in June where several of us were left home on call due to low census (who would have thought???!!!), it's been almost non-stop babies.

Every shift, I have at least one woman who gives birth, and I am a second RN for at least 1-2 births per shift as well. Plus other random assignments (preterm labor, r/o labor, r/o preeclampsia, etc). It all adds up to a very busy time for everyone on L&D/maternity/newborn nursery/NICU.

Speaking of NICU, they have been full to overflowing with admissions! The docs have been begging us to slow down with the number of babies we send to them. Like we can prevent inevitable preterm births! Sometimes, the babies just fly on out, despite our attempts at tocolysis to delay birth a little bit longer.

And twins - we've had lots of twin moms in with preterm labor! What's up with all of these multiple births?? Knock on wood, at least we haven't seen any triplets or quads recently........now that I've said that, we'll get some high order multiples.

It's also STUDENT TIME AGAIN!!! I've had two days in a row this week where I have had a paramedic student assigned to me. Most of the paramedic students just are observing births, but they can also get their hands in there and do some physical assessments. I let them do an assessment on the newborn after I've done my initial newborn assessment. Then I quiz them on the normal vital sign parameters for newborns. How quick some of these guys get flustered! Dudes! I'm not testing you here, just helping your education! I let them know that I'm here to just help educate them - I don't actually critique their clinical time, or grade them. The paramedic students usually tell me a bit about their own children's births, and it's really cool to hear about birth from their perspective.

Once August begins, we'll get nursing students again on L&D. They are totally hands off, observation only. (I remember those days in nursing school - the fear of God put into you by your instructors!!!!) However, I encourage the nursing students to also get their gloves on and start assessing the newborns after (or at the same time) I do the newborn assessment. The nursing students also have this assignment sheet, which has NOT changed one bit since I was in school (!!!), where they need to write up EFM strips. So, I do a lot of education with the nursing students on how to "read" an EFM strip. That can be very time consuming, and repetitive, when you have students almost every time you work. However, I can tell which students REALLY care to learn, and those that only do what they need to do to get by.

Ok, that does irk me. If you're paying good money to get a good nursing education, wouldn't you at least show SOME enthusiasm for the clinical site? Even if you know you don't want to do L&D after graduation, or you flat out hate L&D (yep, some people do hate it, believe it or not!), at least show some enthusiasm for learning while you're with me. If you don't, I'm not going out of my way to teach you anything, and I may just "forget" to find you when it's time for the baby to be born. It's an honor and a privilege to attend a birth, so show respect for the mother, her baby, and the nurse teaching you. SHOW some enthusiasm and spirit for the birth process. Ask questions. LISTEN when I tell you the answers. Show initiative and inquire about what you can do to help the birthing mother --- or the nurse who is running around like crazy from patient to patient. Don't sit on your ass in the break room and chitchat on your cell phone.

Ok, rant done.

Where was I? Oh, let's see.....students...summertime...where WAS my train of thought?

My youngest daughter and I did a mommy and me day at the pool yesterday, so I'm a tad sunburned. Back to working 3, off 1, working 3, then finally off for FIVE!! YEAH!!!! I plan on getting a LOT of studying done on those five days off.

School? Yes, it started this week. Lots of readings to do. Plenty of papers to write. Have to work on finding a preceptor for next term (Community Health Practicum), which also links in to the didactic work I'm doing this term.

She certainly looked pregnant

But, she was not pregnant. Not one bit.

The woman presented to L&D with c/o contractions. She looked to be about 34-38 weeks pregnant, with a gravid abdomen. She had the waddle going on.

Once she was taken into a triage room, the nurse tried to find fetal heart tones. Nothing. Not even placental swooshing sounds. The nurse called the MD to do an ultrasound. The nurse figured that it was a fetal demise, with the absence of fetal heart tones.

It was, in fact, a case of pseudocyesis - "false pregnancy".

Upon ultrasound, it was determined that not only was she not pregnant with an approximate 8 month gestation, there was nothing - nada - zilch - in her uterus.

The woman calmly said, "ok, thank you". She got dressed and left the unit. No surprise. No shock. No "where's my baby???" She simply left the unit.

She wasn't my patient, but I was left with a big "WTF??" Why didn't the doc order a psych consult, or even just try and talk to the woman? (Unit was probably too busy to deal with something that wasn't of any great concern at that moment.)

Having worked on L&D, I can tell you that this is not uncommon. It happens more often that I could imagine. Women who insist they are pregnant, or in advanced stages of pregnancy, when they are not pregnant at all. Young women, middle aged women, peri-menopausal women. Women with mental illness. Women without mental illness. It crosses all races and religions.

Pseudocyesis has multiple potential causations. The woman could have an intense emotional desire to be pregnant or have a baby. This intense desire causes changes in her endocrine system that produce symptoms of pregnancy. She could have a history of having children, or a history of miscarriage/stillbirth, or infertility. She could have a mental illness where she has an extreme focus on pregnancy or being pregnant. There is also a theory that depression can cause such changes in the body (especially in the nervous system) that it mimics the physical symptoms of pregnancy. Or, she could have a history of childhood sexual abuse.

The incidence of pseudocyesis, from what I can gather, is about 1 to 6 in 22,000 women. I actually believe that there are more cases than that. How are the individual cases reported? How is the data gathered and calculated? I see gaping holes in the statistics of pseudocyesis and the reporting of incidences.

Here is an obvious case of mental illness as the cause of a false pregnancy.


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From Psychology Today Mar/Apr2007, Vol. 40 Issue 2, p28-28:

A 30-YEAR-OLD woman waddles into a family clinic with a large belly and tender breasts. She says she can feel her baby moving inside of her. A doctor performs a pelvic exam and discovers that not only is there no baby, there's no uterus. Her medical records show she'd had a hysterectomy two years earlier.

This case presented itself to Paul Paulman, a professor and family practitioner at the University of Nebraska. It was his first encounter with a rare condition called pseudocyesis, or false pregnancy. "I showed the woman a scan of her abdomen and explained the facts," Paulman says, "and then I never saw her again. I don't know if she ever accepted the truth."

In pseudocyesis, the mind tricks the body, and vice versa. Doctors think it develops when a woman obsesses over pregnancy out of desire or fear. (Queen "Bloody" Mary I of England famously suffered false pregnancy under pressure to continue the royal line.) A woman may stop menstruating, or her stomach may become distended due to stress or constipation. But her brain interprets the signs as pregnancy, which triggers the pituitary gland to secrete hormones like prolactin to prepare the body to carry a child. She gains more weight around the midsection, and her breasts swell and might even lactate. Many false pregnancies end when the woman goes into labor and delivers nothing.

Pseudocyesis occurs in only 1 to 6 of every 22,000 pregnancies, and it can also happen to children, the elderly, and men. "I think the men are a little more emotionally ill," Paulman says. Doctors confront the patient with medical evidence and offer counseling. If that doesn't work, the patient could have an underlying psychotic illness.

Pseudocyesis has a sibling syndrome: "couvade," or sympathetic pregnancy, where men experience many of the symptoms of their wives' or daughters' pregnancies--weight gain, nausea, headache, irritability, backaches, abdominal pain. A study of 81 expectant fathers found that almost half of them gained weight in the third trimester. Sympathy abdominal pains during birth are even more common, Paulman says. "I guess we all want to be in touch with our feminine side."

********************************************************

Here is another case from Journal of Obstetrics & Gynaecology, 01443615, Nov96, Vol. 15, Issue 6:

A 20 year old single woman presented to the casualty department claiming that she was 8 months pregnant, had fallen that day and was experiencing regular contractions and vaginal bleeding. A distended abdomen, marked fetal movements and a fetal heart rate of 120 beats per minute--maternal heart rate being 100--were noted on examination. Ultrasonography showed a small non-pregnant uterus. The consultant obstetrician was of the opinion that she had never been pregnant and she was referred to the psychiatric service.

She reported that she had tried to conceive for 6 months, followed by 8 months amenorrhoea and two positive home pregnancy tests. She described morning sickness, breast enlargement and tenderness, abdominal distension and stomach cramps and claimed that she had fetal movements from 6 months at which time she had also experienced minor vaginal bleeding. Her reported attendance for regular antenatal care could not be substantiated.

She described her partner as becoming particularly caring of her during the 'pregnancy'. She found fulfilment in her pregnancy role, partly compensating for her recent unemployment.

She did not express any psychotic symptoms or major mood disorder and neuroleptics were not prescribed. Although distressed at discovering that she was not pregnant, with supportive psychotherapy she became less convinced, surmising that she had 'miscarried' and that her antenatal file was 'missing'. Her boyfriend ended his relationship with her soon afterwards and she returned to live with her parents.

*****************************************************************

Another one from Journal of Obstetrics and Gynaecology, April 2007; 27(3): 322 – 335:

We present a case report of a 16-year-old female with pseudocyesis.
Her pseudo pregnancy occurred after using Depo-Provera and then
Microgynon for contraception. We consider whether the sideeffects
of long-acting, progestin-only contraceptive contributed to
her belief of pregnancy.

Case report
A 16-year-old female self-referred, with vaginal bleeding and mild
abdominal pain, having been amenorrehoeic for 4 months, and in
supposed second trimester of pregnancy. She had been using
Depo-Provera for contraception until her last injection in March
2005. In June 2005, she started using the combined oral contraceptive
pill –Microgynon. Her last menstrual period was early July.

She was confident that there was no break in contraception cover
while changing methods. She reported having done two home
pregnancy tests – one positive and one negative, and had attended a
Family Planning Clinic on several occasions prior to her admission.
She stated that a midwife had confirmed a pregnancy of 20 – 24
weeks’ gestation, having identified fetal heart using a Doppler and
fetal movement on examination. In addition, the patient had
experienced breast tenderness, fullness and milk discharge.
Uterine fundus was not palpable abdominally and bimanual
examination confirmed a normal size uterus. On speculum
examination, the cervix appeared normal. Urinary pregnancy test
was negative, this was confirmed by serum Beta-HCG. Follicular
stimulating hormone and luteinising hormone levels were checked
to rule out other causes of amenorrhoea, e.g. polycystic ovary
syndrome. Prolactin levels did not substantiate the patient’s claim
of milk discharge.

These findings were presented to the patient, who remained
convinced that she was pregnant. She was, therefore, referred for
ultrasound scan, which showed no evidence of pregnancy. Uterus
outline was normal with an endometrial thickness of 7.8 mm and
no adnexal masses or free fluid were seen. The patient and her
family initially showed disbelief at these findings but with
discussion, eventually appeared to accept them.

This woman was followed up at the gynaecology clinic, by which
time she had fully accepted that she was not pregnant and had
started menstruating.

Happy 4th of July

What are your plans today? We're going to a free music concert in the park, followed by fireworks.

I am so grateful to have a nice, four day weekend off!! (starting yesterday)

The new term and classes start on Monday. I am going to be VERY busy this term. I'm taking Theory and Research, and Community Health Nursing. Both are very book and paper intense courses. The amount of reading to do is phenomenal! I guess it's preparation of the increasingly intense amount of work to come in this Masters program. What have I gotten myself into??

Oh yeah, that's right -- catching babies is the goal!!!

"Eyes on the prize, Violet. Eyes on the prize."

Oh no, it's July 1st!

All of you hospital people know what that means.

A new crop of residents and med students. Yep, July 1st is when the "changeover" happens in the medical hierarchy.

Reality Rounds wrote an excellent post about the annual changeover, relating it to "the big house". Ironically, that is how I refer to our main hospital, where I work. We have several smaller hospitals in the system. But we're "The Big House", or "The Mother Ship".

Time to start educating the newbies, again.

What I hate the most though, is saying good-bye to the experienced residents who are moving on in the world. Just when we get comfortable with them, they move on to bigger and better places. It's so sweet to see how much they grow from those nervous newbies to experienced chief residents!

Enjoy the 1st of July everyone!

Neonatal deaths

I had cared for a woman on her first post op day, after having an emergency c/s. She was still fairly critical, and on magnesium, so she stayed with us on L&D. Sadly, her baby did not make it. I cannot go into details. People made some serious mistakes and errors in judgment, and a beautiful baby died because of it.

Our unit is reeling from this death. It was a totally preventable, unnecessary death. The nurses who cared for this mom before and immediately after the birth needed debriefed. Her primary nurse was encouraged to take some time off, but amazingly came back to work again the next evening. She's stronger than I would have been.

For those who believe that all births can be beautiful, natural things if left unhindered, please realize this: there are times when being in the hospital is truly the best for a mother and her unborn baby. This would have been an even worse outcome if she had not come to the hospital.

Just in a complete state of shock. Absolute, utter shock at the loss of life.

Anger at the people who are responsible.

Sadness for the grieving family.

What you may (or may not) know about labor and birth

I thought I'd do a mini-childbirth class here --- online! Specifically: what you may or may not know about labor and birth. Things that you may not read about in books like "What to Expect When You're Expecting". (Note: this will not be all encompassing -- every woman is different, and every birth is different!)

Labor:

Contractions can feel different for each woman. Sometimes they can be felt in the lower front part of your pelvis, your back, hips, or even down your thighs. It can feel like menstrual cramps, tightenings with little pain, stabbing, throbbing, aching, or any of the above.

Contractions usually will get stronger and closer together in labor. They might start out where they only last 30 seconds, and will usually increase in duration as labor progresses. Contractions might be anywhere from 1-2 minutes apart, to 5-10 minutes apart. Usually, the further apart they are, the earlier you are in labor. The closer you get to giving birth, the closer your contractions should come. Ironically, right before giving birth, your contractions might space out again. I consider this to be the time where your body is conserving energy for those last couple of "big" contractions that help bring your baby down and out.

Let's talk vaginal discharge in labor. It can look like mucous, like a big ball of snot. It can be pink, clear (like water), white (leukorrhea), green/yellow (meconium or a vaginal infection). Or you might have no discharge or leaking.

Speaking of leaking. When your water breaks, it will continue to leak during labor. Especially when you have a contraction, more fluid will come out. It seems like the water spout never ends for some women! This is because, in a normal pregnancy, the fetus will continue to produce amniotic fluid. Some women are surprised to learn that amniotic fluid is produced in the baby's kidneys - yes, that's right! Amniotic fluid is baby pee!

Ok, so you're leaking fluid continuously in labor (or intermittantly). What to do? Heavy menstrual pads can help. Or, if it's a lot of liquid, I say just create a big bulky "diaper" - a towel wadded up with those lovely mesh panties works great.

More vaginal discharge......bleeding in labor. It's normal to have some "bloody show" or even some light to moderate bleeding in labor. Depending on what stage/dilation, you might notice some bleeding at one point or another. As long as you do not have a huge amount of bright red blood dripping down your legs, or saturating one pad (or more) per hour, it's considered normal IN A NORMAL PREGNANCY. If you have any problems, or suspect that your bleeding is not normal - CALL YOUR PROVIDER. They know your medical/OB history and can help determine if your bleeding is normal or abnormal for you.

That being said, normal pregnancy, normal placental location, normal labor -- some bleeding is normal. You might have some spotting early in labor, and again when you hit transition or are close to having your baby. I've noticed that the last few centimeters of dilation tend to produce a good "bloody show" as the cervix dilates those last 2-3 cms. I see this quite a bit when a woman is about 7-8 cms. It's a good sign! Don't be alarmed by the bleeding. If your provider (doctor, midwife, or nurse) hasn't noticed the bleeding, just let them know. They can assess whether it's a normal amount, or if it's "too much" and cause for concern. More often than not, they will be happy to see some bleeding - this means birth isn't that far away!

Transition --- hard, hard work at this point. You might feel discouraged, want to give up, go home, get drugs if you haven't already gotten some at this point. All normal to feel this way. The end is near! Hang on momma! You can do this! You might find that you don't want to be touched, or maybe you want to have your back rubbed, or hips squeezed, or you need to move and do a "labor dance" to bring baby down. You might yell at your partner(s) to be quiet, because this is a very intense time, and you might need to put all your focus on riding it out through each contraction. No one will be upset if you say things you might not normally say at this point. No need for apologies. No need to be "lady-like". Curse, moan, groan, pace, pant, walk, breathe, whatever you need to do. Listen to what your body is telling you and go with it. Sometimes you might not know what your body is telling you. Perhaps your partner/labor support/nurse will make suggestions. If you don't like the suggestions, guess what? Your body is talking to you! Listen to it. If you need to get up and be upright, do it. If you need to pace, do it. If you need to get on all fours, do it. There is no right or wrong at this point.

As labor progresses, and you get to be completed dilated (10 cms), you will feel some rectal/vaginal pressure. It may feel just like you need to have a big bowel movement, or like you just "have to go". Let your provider know that you're feeling this. If you do not have an epidural, this pressure can get very, very intense, and you might even start involuntary bearing down. This can be scary if you've never felt this before, or even if you have felt this before. Talk to your provider or partner about your fears. (Side note: with my 3rd baby, I started to get very scared when I felt the pressure and urge to bear down a little bit. It helped me just to tell my midwife that I was scared. I realized, even though this was my 3rd birth -- no epidurals with any of them - that I was scared to push! Don't know why, but I was scared. It actually helped me to verbalize my fear, and know that my midwife was right there by my side to be emotionally supportive. My fear dissipated quickly, and poof......out came my baby girl!)

What if you have an epidural? Will you feel rectal/vaginal pressure? Hopefully yes. It's a good thing to feel pressure. This helps you know where and how to push your baby out. If you don't feel the pressure, that's ok too. Perhaps your baby is still high in your pelvis, and needs some time to "labor down" until you can feel some pressure. If you still don't feel pressure, maybe your epidural rate needs turned down, or even off, to help get some sensation to push. I have found that women with heavy epidurals tend to have a difficult time with pushing, because they cannot feel any pressure "down there" to help them in their pushing efforts. This can greatly increase pushing time, and make mom (and sometimes baby) very tired. Which can lead to the need for medical intervention (vacuum or forceps) or even a c/section birth. Ask to have your epidural reduced so you can feel pressure. And prepare yourself mentally: feeling pressure is GOOD! It's ok to be scared that the pain will come back. But know this, the epidural provides excellent pain coverage for contraction pain, even after it's shut off or decreased. It can take several hours for all sensation to come back.

Pushing: it can take a first time mom up to 3 hours to push her baby out. This is normal! Like I said above, an epidural can prolong pushing times if the epidural is very heavy and you can't feel to push. I have also seen first time moms with epidurals who push for only 10-15 minutes before birthing their babies. It's a wide range of times for pushing. Don't feel discouraged if your pushing takes longer than someone elses. It's ok! Everyone is different!

Pushing also brings a great relief to the mom. Without an epidural (or even with one), you may feel an utter sense of relief and wonder that you are DONE when the baby is born. What an amazing thing you've just done - bringing your baby into the world! The pain is almost instantly gone once the baby is born. (Isn't that a great thing to look forward to?)

Books books books!

The Midwife, by Jennifer Worth.
-- This one is next on my agenda of books to read. The story of a nurse turned midwife in the UK. Historical, taking place in the mid 20th century.




The Birth House, by Ami McKay.
-- Just finished reading this one last night! I could not put it down!!! The story centers around a young woman who apprenticed under Miss B, a local midwife. Takes place in the early 20th century. Complete with newspaper clippings in the text to supplement the storyline. Very, very interesting! Sad to say, we still have the same midwife vs physician fighting going on. I would love it if Miss McKay would write a second book, going more into Dora's life as a midwife, mother and lover, as well as women and family advocate into the latter years of her life.



Midwife of the Blue Ridge, by Christine Blevins.
-- I found this gem in the clearance section of a "large name" bookstore. This one is about a Scottish born midwife, Maggie, who travels to the Colonies in the 1700's as an indentured servant. Lots and lots of early American history here, with battles between the settlers, indentured servants/slaves, and Native Americans. Romance too! Not a whole lot of birthing, but enough to keep me interested. Hard to put down this book when reading it!