Busy times, clinic #9

Births on Monday, Tuesday and Wednesday.
I had two moms, both second timers that I was expecting to go rather quickly.
Monday's homebirth dallied around until we took her in. We gave her an epidural, and then finally to section (she did end up progressing to 10 cm, but with the very slow progress and no descent as well as an increase in the baseline uterine pressure [the OB put an intrauterine pressure catheter in] causing pretty much tetanic contractions, the decision was made to go to caesarean section). The baby apgared at 9 and 10, but 30 minutes later he stopped breathing and turned a very dusky grey. I thought he was choking, so stimulated him and suctioned him. I also noticed that he was shaking his arm kind of funny, and I called the Head Midwife over to see if she thought it was a seizure, which she didn't, but he was pretty much stopped by then. She said we would observe and do a paed consult if he did it again. After 2 hours of observation, he didn't do it again, so we discharged him to the nursery. After I got home the nursery nurse paged saying that he was having grunting, flaring, and retractions, so I did a paed consult. While they were examining him, he started a full blown seizure, and shortly after that had another one. So off to NICU... and rounds and rounds of tests. Turns out that it was caused by high intracranial pressure, and as that wore off, so did the seizures, and he will not likely have any lasting effects. The thing was that he had moulding, but not a lot - I have seen plenty worse with no issues. Anyway, I'm glad that it is resolved. It was quite the learning experience - I now know what a neonatal seizure looks like: much milder than adult seizures.

Tuesday's birth was a 'butter' birth - at home, quick, and beautiful.

Wednesday's birth I assisted at. A lovely birth, the mom was so calm and peaceful through it all, and there were lots of tears throughout the room as she delivered, especially from the 10(?) year old son, happy tears... I had tears come to my eyes too, as there was a lot of love present, and it was palpable. There was also something at this birth that I've never seen - trouble delivering the posterior (or bottom) shoulder. Her perineum was very tight, and finally it tore pretty badly when the posterior shoulder delivered. The midwife at first thought that it tore into the anal sphincter and that we'd have to get an OB to repair it, but after a thorough inspection, we could see the sphincter intact. It did take some time to repair it.

And of course, the rest of the week was taken up with doing home visits for these moms and clinic, which was relatively uneventful.

I did get a page from a mom who works with animals, and she had been exposed to leptospirosis. My internal response was: lepto-what?! But of course I maintained a professional demeanor (I hope!), and said that I'd investigate what to do for that. So I consulted with Maternal-Foetal-Medicine and they consulted with Infectious Diseases. Turns out that the incubation period for this infection is up to three weeks, so if she feels anything, even a vague sense of not feeling perfectly well, she will be treated with antibiotics. There is not an extended amount reported in the literature, but apparantly it can cause abortions. So there was a bit of back and forth for that too.

Ever learning, and ever serving. I love weeks like this!

Clinic day #8

Clinic day went well yesterday.

I am seeing extra clients because my neighbour midwife is on her month of holidays, so there were lots of new people to meet yesterday. I also encountered a few new situations yesterday - sending someone to the general hospital for RhoGAM (this is a shot that you get at 28 weeks and often postpartum if you have Rh negative blood type), and having someone ask how many babies I'd delivered and not being impressed with my answer. (!)

I made a boo-boo too. I was looking over a woman's chart before seeing her and noticed that her primary had made a note to not use the doppler (this woman didn't want any ultrasound exposure in the pregnancy). I discussed it with her, and agreed not to use it, but then in the course of the routine that I've done a thousand times I picked up the doppler and listened to the heartbeat. She didn't say anything, and I proceeded to finish my clinic day. It was only after clinic when I was reviewing my charts that I saw the note again and mortification set in. I'd gone against a woman's wishes - trampled on her informed choice... So I think I'll call to apologize.

Bummer

I attended a labour at home for a primip on Tuesday morning - I checked her at 0020 5cm, bulgy bag, 75% effaced ???LOP??? Suture lines hard to feel through bulgy bag. At 0140 after SROM (clear) she was 7cm, ROA/asynclitic and wanting to push. At 0220, 8cm and definitely a breech. Bummer. College guidelines say that we have to consult with an OB, so off to the hospital, where they did a c/sec under GA at 0320 or somthing like that. We went to the hospital where I don't have privileges (since she was dilating quickly and wanting to push: it was the closest), so I didn't get to go. I'm bummed that she had to have a section, but also bummed that I didn't diagnose the breech until she was 8 cm.

Clinic day #7

Clinic this week was very full. I had gotten 4 hours sleep the night before, so was already running on low reserves. My day started at 9am and went to 6:30pm with three first visits (which take longer and significantly more energy). I usually have to stay afterwards for 1/2 hr to finish up charting etc. but yesterday after 1/2 hr I wasn't even half done, so I just left and returned today to finish it up. My goal is to get to a place where I finish charting by the end of the day - to keep up with the extra charting as I go along instead of letting it all pile up.

I am excited about my new clients - some young, some older, but all happy to be pregnant. I am going to have a crazy April - 3 primips!!!