Maternal Newborn Clinical

It's so weird that I didn't blog about the Maternal Newborn clinical rotation...maybe because it went by so very fast. I had 4 weeks on a postpartum unit, and then 4 weeks on a labor and birth unit.

Postpartum: I liked the postpartum unit the best because it provided the most opportunity for education about breastfeeding, well woman care, and baby care. I took a lactation class, which was great and helped the lactation consultant on the floor with a mom who was having a really, really hard time (this was a two hour session with this mom and baby) and I learned more in those two hours than in all the lectures, classes and textbook material I've read about breastfeeding to date. The mom 1) could not recognize the baby's feeding cues early enough (by the time she noticed the baby was pretty much crying) which makes for a difficult latch (proper attachment/alignment of the baby's mouth onto the breast) 2)mom wasn't getting enough breast into the mouth, so baby was latching onto the nipple only = painful! and 3)because of the aforementioned, mom was exhausted from trying and baby was screaming. Eventually they got it together though, and I learned so much about positions and latching and how a frustrated mom can stop breastfeeding dead in its tracks. The basic organization of the rotation was that we took care of moms who had vaginal deliveries on Thursday and then moms who had cesareans on Friday, and we did head to toe assessments on their newborns everyday. It was the est rotation ever. My preceptor was phenomenal and very hands off (which I like...I don't like preceptors that hover) and she was very organized as far as what we could do alone and what we could not.

Labor and birth: of course I enjoyed it...but it's frustrating to be a nursing student when you want to be a midwife because there's so much you want to do and say but can't because it's not your role yet. You have to take a lot of orders that you may not believe in, and that's hard. It's also hard to watch women be shackled to monitors all day, unable to move and without an ounce of food. But I did see healthy babies born vaginally and by C-section and it was great. It was so amazing to be standing in the OR and watching what I've watched on TV for so many years. I mean really amazing. My last patient made my experience on L&B very memorable:


N.K. Podo (not her real name) showed up to the hospital on Wednesday for a nonstress test. They admitted her because she had lost her mucous plug and was spotting, and because she had SO MUCH going on that they didn't want her to go back home. They started to induce her instead (don't ask). What did she have going on? She was high risk because
a)she had gestational diabetes
b)pre-ecclampsia
c)isoimmunization with sensitization (I made the term a link, but it's complicated...in the most basic terms I can think of, the mom's immune system attacks the baby's blood while she's pregnant)
d)she had tested positive for the Cystic Fibrosis gene, and the father had not been tested
e)polyhydraminos (too much amniotic fluid)
f)measuring macrosomic (baby estimated to be 10lbs)
g)she was obese at 5'7" and 365 pounds, which makes monitoring the baby on a heart monitor much harder, and posed some increased risk in the the operating room
h)she had no support system present but myself

They (the attendings, residents, anesthesiologists, etc) "allowed" her to labor for three days...mostly because no one want to be the one to have to perform her C-section (they said as much) because of the excess adipose tissue and the risk factors with anesthesia (she was demanding general anesthesia because of her fear of epidurals). She labored until Friday afternoon without any food or drink or pain medicine because they would not give her narcotics by IV and she was afraid of the epidural. The reason they would not give her narcotics is because the baby's heart rate was not looking very good.

So what does this mean to a nursing student/future midwifery student? It means that instead of getting a new patient on Friday, after spending all day Thursday with her, my preceptor sent me back to her, which I was so grateful for because she was all alone. It means that a lot of labor support was needed because she was so tired and in pain and hungry and all alone and very, very scared. It means that I had to fight for the patent's right to refuse the epidural even in the face of serious bullying from the docs and her obvious pain. It means that I had to deal with the consequences of "talking back" to a doctor (because I said that maybe it would be better if only *one* of them spoke to her at a time and maybe, just maybe, we could wait until the peak of this contraction had passed?!?) This moment made me realize that I would never, ever, have a baby at a teaching hospital...to many people coming in to "consult" and "check" and "advise" and "teach" Just imagine two or three of every role, all in the room at once, trying to convince her that she wants an epidural (never mind that she's had 3 children, up to 9lbs 14oz without ever having had an epidural), trying to explain the risks and outcomes of all of these complications she has going on and an overall fat bias present from most of them on top of everything. It was a circus and I was trying to help create some calm because she was in tears and almost irate at the situation (as I would be).
There were no consequence from asserting my patients rights, other than the silent treatment form the docs, which I can live with until they get over it, besides...it will be a long time before I am on that unit again. I rarely left the patients side, but when I did it was because the nurse made me. She said the patient was "too attached" to me, and that it wasn't healthy. This really p'd me off. I mean, she had no support system...why wouldn't we want someone to help her through each contraction if it was feasible? And, she was my only patient...let me get this right, I am supposed to sit in the break room for two hours doing absolutely nothing instead of helping her? It goes against everything I believe in, and I told her so. The patient eventually went to the OR for C-section because the baby's heart rate was flattening, she wasn't making any progress at all as far as cervical dilation or station, and her water had been broken for a long time (it didn't help that everybody had there fingers up there all the time). I went to the OR with her but wasn't part of the care team (as we usually are by helping out when they need something or charting or whatever else the nurse is doing), instead I only had to sit at her head and keep her company and calm. Again, the nurse tried to make me leave because I was "off" (meaning, I was off work for the day) and again I said I was just fine where I was and would leave after we wheeled her into the recovery room, just as I had promised the patient (she had an epidural, not general anesthesia). Her baby was born, wailing! It was a beautiful sound. And she felt like 10 pounds to me. It was so great to see the baby, and to have the mom awake for it, after all she had been through. She said "I will never forget you and all you have done for me." I said "And I will never forget you and all you have allowed me to learn. I will never forget how strong you were, how strong you are." And I meant it. I will never forget this patient.

From my preceptors (1 for L&B and 1 for PP) final evaluation comments:
"If I were having a baby, I would come find you, even at the level you are right now. You're going to be a wonderful midwife...you're so intelligent...you know when to stand back at let be, and you know when to jump in and you don't hesitate when that time comes...seriously, you're great, and I can't wait to see you back on the floor as a midwifery student."

I almost cried. I struggle in class so much that I really wonder about all of this...it seems like it shouldn't be this hard. But I do not generally struggle in clinical when it comes to relating to people, especially women which really keeps me going. You never really know how your preceptor thinks you're doing in clinical until the evaluation comes... It wasn't a validation per se, but rather it was I know I am supposed to be a midwife...now other people know it too...and they know it not because I told them, but because they witnessed it.