Guest post from a midwife friend

Just to give you an idea of how crazy things can get in the hospital based CNM line of work - a 12 hour shift from a friend of mine, a great guy, father of 6, who is also a CNM. Oh, he's also an IBCLC. Here it is, just as it appeared in my inbox.

*******************
Alicia,

Here’s a post for your blog.

I had a crazy morning today. Yesterday I was on a 24, 8 in the clinic, four hours of admin time and a 12 hour shift on L&D. When I came on there were three women on midwifery service being induced, one was oligo, one was PROM 12 hours previously, and the third, now get this, was a 42 year old G3P2 with GDM a2 (who refused insulin but accepted glyburide in pregnancy) with chronic HTN who weighed 350 lbs. Obviously that last one was way out of my scope, but the kicker is she refused OB care because she refused to have a male care provider. That night the OB was male, and then there was me. It was not a big problem however, as I went in to talk to her for a bit and explained what was going on then said that while both of the staff were male, we did have two family practice interns who were female, but they both need to be directly supervised. It could have been quite a pickle, but the situation was completely defused by the way I presented myself, so it turned out not to be a problem. The big problem was that I was out of my scope, so I spent a lot of time working directly with the OB to make sure I wasn't missing anything.

So I began with the inductions and things went fairly smooth throughout the night until about 0500. I was pushing with my PROM patient who, after almost 18 hours of active labor was trying to avoid a c/s for arrest of decent. The kiddo would simply not move, after two hours of pushing I called in the OB to assess and he agreed to let me have another 30 minutes before we called a c/s. Slowly things began to move a little but the kiddo was still not coming. I decided the baby may come if I give him a little more room, so I cut an episiotomy (only my second) and that did the trick, he quickly moved down and three contractions later he came out, direct OP with no head flexion ( I don't know if you can call it a military presentation, but it was close). As a result she had a partial third degree. I called the OB to close the capsule when the CRNA poked his head in and told me my diabetic was delivering and the OB was in another delivery.

I quickly covered that patient and ran to the other room where I came upon a baby out to the ears and white as a ghost. He had a tight double nucal cord with a true knot in the cord that began to tighten as I tried to deliver through, so I did a somersault maneuver and when he came out he was white and floppy and apneic. I clamped and cut, and took him to the warmer to start NRP while I waited for the NICU team. He took a few breaths of PPV but was still not breathing when the team arrived and I could step back and take care of my other patient.

In the end he was okay but things were very tense for about ten minutes. She had a first degree, so I went to find my OB to figure out a plan for getting both of these repairs done in a timely manner and found him finishing a delivery in another room and just starting to do his repair. Now it was about 0630 and while we were planning what to do next I was called to another room where mom said her baby was in her bed. I ran in there to find the little guy squirming and mom lying back semi-responsive. I clamped and cut and passed him to the nurse and checked on mom. It turns out she had just had Nubain and phenergan and was still out of it, but at least she was stable. I took care of the placenta there was a bit more bleeding than I would like, but still okay. Luckily for the other three women, this patient did not need a repair and was okay for me to move on.

No Kidding, as I left the room I heard screaming coming from the hallway and found a cluster of nurses frantically trying to move a woman from triage to a labor room, with them was a terrified family practice intern. I followed into the room where I was quickly joined by anesthesia. In the confusion I heard three things, G2P1, scheduled C/S today, and "lets get her to the OR for a stat section" But there was no way she was going there, I grabbed gloves and went to check her when I saw her membranes bulging out of her introitus. Mom was screaming, anesthesia was yelling, the nurses were buzzing, and dad was white in the corner. From her perineum I called out for everyone to be calm, I explained to mom that there was no way she would make it to the operating room and that this baby was going to be born in next contraction. I used my tissue forceps to pop her bag and with the next contraction she crowned and screamed and scooted up in the bed. In the next lull between contractions I explained to mom that the burning was normal and that she needed to try not to be afraid, listen to my voice and push through the burn. She seemed to calm down a bit and pushed well with the next contraction. She delivered a healthy baby with a compound posterior hand, over a first degree with a 2 cm sub-urethral laceration. I set up the intern to do the repair and told her not to start until staff came to help her with the repair. As it turned out this mom was a scheduled section because she had a fourth degree with a recto-vaginal fistula after her first baby and was afraid of a repeat nightmare. I'm glad I could help her avoid both the nightmare and the extra hole in her uterus. What a waste, to do a section for a prior fourth degree, there are just too many variables in play for me to consider a section to avoid a fourth. But no matter, it worked out well.

I left that room to tend to my repairs that were beginning to pile up. The OB went to close the capsule on my partial third, and I went back to my diabetic to finish her repair. By now it was 0730 and the day crew were coming in for report, so I asked the day staff to help the intern with the almost c/s patient. After finishing my first repair I went in to finish closing the third degree, by now she was beginning to get some serious swelling so I asked a nursing student to help by retracting while I closed. Just as I finished there the day shift midwife came and told me that my oligo family that I had worked with all night was complete and +2 and asked, if I was still around would I please come join them for the delivery. I was honored, so of course I did. She pushed well and things moved fast. The baby had light mec, so NICU was there, but then the baby's heart rate dropped to the sixties and wouldn't come back up. I encouraged mom to give a big hard push while I used the Ritgen maneuver to milk the head through the last turn. He came out well after about four minutes in the sixties. I delee'd and passed him to the NICU team who took care of him well and he did great. That was at about 0810.

What a morning! Five deliveries in three hours! Three of them precips and the other two tricky. As it turns out, the reason I rarely saw the OB during this time was that he took three or four deliveries himself in that same time. All told I think our total in that baby boom was nine births in four hours. It took almost three more hours to clean up all the paperwork and make sure I had all my notes in order. I got home just in time for lunch and two hour nap before Elizabeth had to go to sleep for her night shift tonight. Well, such is life.

So that is the story of the craziest day I have ever had, and I didn't even tell you about the "unplanned" home birth that came in and almost had the pediatric resident call the cops on her for wanting to leave AMA three hours later. Things are not normally like that of course, I average about 10 births each month in four 24 hours shifts. After last night I now KNOW I can handle anything.