You can teach an old nurse new tricks

So, I'm on my third new nurse to precept now. My first night with her was last night... She comes from a state many states away from us... she used to work in a large hospital where they moved people through in an assembly line type fashion.. In the door, epidural in, pit going, baby out.. moved to post partum... next patient... She also typically cared for 2 laboring patients at a time. Well, we have the luxury most nights of having one-on-one nursing care for our laboring mothers.

When we came on our shift we were assigned to a woman who was 8cms. She had no pitocin and no epidural. So, I told my preceptee that we would be getting the woman out of bed and in some type of water... it could be the jacuzzi tub or the shower.. whatever.. no woman should have to do transition without an epidural OUT of the water... In my opinion... The new nurse was astounded... First of all when I suggested we get her out of bed to urinate she couldn't believe it... She said they never would have done that... Let alone get her out of bed to take a long hot shower... Well, we did it... we got mom in the shower and she was LOVING it....

This nurse who had been a L&D nurse for several years (in the teens) said she felt like a new nurse on the job last night... She said she never stayed with her patients in labor... we stayed in the bathroom with her spraying her back with hot water and massaging her .... She couldn't believe the way we practiced nursing.... And, when I went to get the patient in hands and knees she said to me she has NEVER had a patient in that position. Ever. In that many years of nursing. Wow...

Well, I guess she learned a few new tricks from this younger nurse last night... Nice healthy 9 pound baby born direct OP!

MANA conference

So, I'm going to the Midwives Alliance of North America (MANA) conference in Canada in November. I'm excited!

In charge

Initially when my nurse supervisor asked me to take the role of charge nurse, I hesitated and said I didn't feel comfortable. Which is the truth. But, then I looked at my reasoning. Why? I like having my own patients and being involved in their care.... keeping busy and not worrying about everybody else. I didn't want to be in charge of all of the nurses. I didn't want to have "the buck stopping with me." If we have to transfer a patient to a higher level hospital.. it is me who would have to arrange for helicopter transfer, etc... If we have an emergency c-section, guess who has to call all of the appropriate people, make all the arrangements? If we don't have enough staff in the morning for the 2 section, induction and 2 leftover labor patients, guess who has to make it work?

But, then I realized it is my nurse manager who will be making referrals for me when I leave. And, if I balk at the chance to take on more responsibility, how will that look? So, I caved in. I told her I would be the charge nurse - ON occasion when no else is scheduled who usually does it. I've done it once so far... and we did have to transfer a patient in from another hospital and we did have an emergency cesarean section... both on my first night of being in charge... And, it wasn't so bad... I'm in charge again tonight... We'll see how it goes... But, if nothing else, it looks good on the resume, no? :)

What is a Midwife?

What does it mean to be a Midwife?

To me, a midwife is a woman who nurtures and protects a woman during one of the most vulnerable and impressionable times of her life: while she is pregnant and during her childbirth experience. Practically, the occupation of a midwife has expanded to include well woman care, fertility counseling and postpartum care as well (Rooks, 1997, p. 1). The midwife fills the role of educator, supporter, counselor and gate-keeper of safety. As the famous quote from Aristotle states, “A midwife should have a lady’s hands a hawk’s eyes and a lion’s heart.” To me this quote verbalizes the understanding that the role of a midwife is multi-faceted. The “lady’s hands” represent a midwife’s gentle guidance, support and understanding along with her caring nature. The “hawk’s eyes” represent a midwife’s ability to protect the safety of the mother and baby by recognizing early warning signs of complications while preserving the innate normalcy of birth by not disturbing the process unnecessarily. And, finally, the “lion’s heart” represents the willingness of the midwife to intervene bravely and swiftly when necessary.

What does it mean to be a Nurse Midwife?

The certified nurse midwife (CNM) is a registered nurse who has obtained an advanced practice master of science in nursing (MSN) degree and has passed an accreditation examination in order to become licensed by her state to practice midwifery. The CNM practices in collaboration with nurses and physicians in a team-like fashion in order to provide patient-centered, evidenced-based care to women. The CNM can do well women care, pre-conception and birth control counseling, prenatal care, labor and delivery, and postpartum care. She is an expert in normal woman’s healthcare. It is her job to spot complications early and consult and collaborate with other providers as needed. She also refers high-risk patients to physicians when the patient’s care is no longer in her scope of practice.

What does it mean to be a Nurse Midwife in the United States?

Because of the opportunities available to women in the United States due to its economic and social status, American women have a wide variety in healthcare and career choices. The same variety is evident within the field of midwifery in the United States. Therefore, if someone says they are a “midwife,” it is seldom sufficient as a definition of what they do.

The traditional direct-entry and lay midwives are present in the U.S. along with certified nurse midwives. Direct-entry and lay midwives have not been trained at universities as nurses first and they do their deliveries at home or in birth centers (Rooks, 1997, p. 8). The legality of practicing midwifery is regulated by individual states, some of which still consider it illegal to practice midwifery as a lay or direct entry midwife (Midwives Alliance of North America, 2011). But, even within the category of certified nurse midwives there is variation in practice. Most CNMs deliver babies in the hospital, but some do births in birth centers or homes. And, the application of their training in practice can vary as well. There are some midwives who subscribe to the midwifery model of care and some to the medical model of care.

As you can see, simply because one is a midwife, does not pigeon hole them into behaving in one prescribed manner. This is a positive aspect of this profession, in my opinion. There are choices women must make when setting forth in the journey into midwifery. Knowing that you want to be a midwife is only but a beginning. What kind of midwife do you want to be? What kind of training will get you there? These are the questions you must explore in order to embrace your calling fully.

For me, my decision to become a midwife came before my decision to become a nurse. I felt my choices in childbirth were limited and the birth of my son suffered because of it. Due to this, I educated myself and realized there were indeed choices in childbirth. I then became a doula and supported many women throughout their pregnancies and births. It was during my rewarding work as a doula that I realized I wanted to become a midwife. At that point I had attended births with both CNMs and home birth lay midwives. I did have to seriously consider what type of midwife I was going to become.

The deciding factor for me was the impact that practicing lay midwifery in a state where it is illegal, like it is in my home state, would have on my family. I decided the most responsible pathway for me to follow was to become a CNM and make positive changes to birth within the current socially recognized and respected birth system.

References:

Midwives Alliance of North America. (2011). Direct-entry midwifery state-by-state legal status. Retrieved from http://mana.org/statechart.html

Rooks, J.P. (1997). Midwifery and Childbirth in America. Temple University Press. Philadelphia, PA.

Midwifery in the USA

When I think about the difference between maternity care in America and abroad, a few things come to mind: The insignificance of midwifery care in the United States, and the medicalization of maternity care in the United States.

Midwives attended only 8% of all births in the United States in 2003 (Center for Disease Control and Prevention [CDC], 2006). Most births in America are attended by surgeons: Highly trained, specialized medical professionals. Some believe this is akin to cutting butter with a chainsaw. The medical management of pregnancy, labor and delivery is routine in the United States. The focus is on pathology: detecting it and treating it. And, a pregnancy cannot be labeled as “normal” until after it is over. The medical model is not designed to treat healthy people, which is what the vast majority of pregnant women are: Healthy, normal women undergoing the normal physiological process of pregnancy. Of the developed countries, only the United States and Canada rely on specialized surgeons to treat their low risk, healthy pregnant patients routinely (Wagner, 1998) In contrast to the care physicians provide, midwives’ care of women focuses on the physiologic normalcy of pregnancy, rather than the potential pathology (Kennedy & Shannon, 2004). Midwifery care is well-suited to the healthy pregnant woman and involves less medical interventions and cesarean sections (Sakala & Corry, 2008). Despite American women having higher satisfaction from midwifery care and a reduction in interventions and cesarean sections, midwives still have no regular place in the American health care system (Rooks, 1997).

Center for Disease Control and Prevention. (2006). Quick Stats: Percentage of Births Attended by Midwives – United States, 2003.

Kennedy, H. & Shannon, M. (2004). Keeping birth normal: Research findings on midwifery care during childbirth. Journal of Obstetric, Gynecologic & Neonatal Nursing, 33 (5): 554-560.

Rooks, J. (1997). Midwifery and Childbirth in America. Temple University Press: Philadelphia, PA.

Sakala, C. & Corry, M. (2008). Evidence based maternity care: What it is and what it can achieve. Childbirth Connection: New York, NY.

Wagner, M. (1998). Midwifery in the industrialized world. Journal of the Society of Obstetricians and Gynaecologists of Canada, 20:1225–34.

World Health Organization. (2010). Trends in maternal mortality: 1990 to 2008, Estimates

developed by WHO, UNICEF, UNFPA and The World Bank, Annex 1. 2010

From Student to Teacher

It seems like it wasn't all the long ago that I began my job as a L&D RN. I was on orientation for almost a year because we have a top notch orientation program. As a new RN to begin with entering a specialty field like OB, I knew I needed intense training. This influenced my choice of where I accepted a position. In our unit we systematically go through every type of patient you could encounter and train new nurses until they feel totally comfortable taking anything that walks through the door. The categories we go through are:
Postpartum mom and baby
"Baby Catching" or the immediate care and resuscitation of the newborn
Circulating on Cesarean sections
Scrubbing for cesarean sections
Outpatients (rule out labor, preterm labor, rule out ROM, bleeding, decreased fetal movement, etc)
Labor and Delivery
High risk (mostly antepartums: PPROM, preeclampsia, Previa, etc.)

Anyway, I worked my way through all of these categories and began practicing on my own and have been doing so for a few years now... And, recently, I was asked to take on the role of "Preceptor." I am now teaching the new nurses who come on the department all of the things they need to know to function independently.

When I was initially asked to fulfill this role, I was currently the newest RN on the floor. I questioned my supervisors decision to put me in this position... But, she seemed convinced I would do well, so I agreed to fill the need if she needed me to. To my surprise, I thoroughly enjoy the preceptor role!

I began by having the new nurse mostly follow me and learn through observation and we moved to the point now where I am mostly following her and observing her, offering feedback and double checking charting. I ask her questions as we go to ensure her complete understanding. For example, if we have a non-reassuring fetal heart rate I will ask her what may be causing the pattern we are seeing, what we should do about it and what orders we can expect from the doctor.

Some challenges I find during precepting revolve mostly around my patience. I didn't previously think I had a problem being patient... But, it is incredibly nerve-racking when I send the new RN into the room to do something simple that would take me 2 minutes and 10 minutes later she is still not out of the room. "What is she doing in there?" "Is something wrong?" I find it hard to not DO. When there is a list of things to do to get a patient admitted and I could easily do it quickly.... I have to sit on my hands and wait for the learner to work her way though the tasks at a painstakingly slow pace.... not doing anything wrong, just taking a LONG time to do everything. It makes me wonder how much of this my preceptor felt when she was teaching me.

I do enjoy it, though. More than I thought I would. My pupil is almost ready to leave the nest and fly by herself. A few more weeks and she will be set loose. It makes me proud to see her progress. Teaching is not something I ever thought I would enjoy... I always liked to have my patient and keep busy... But, surprisingly, I will be happy to take on my next orientation assignment.

The Growing Bookshelf

My last final exam for this term is tomorrow. I already have my grade for my finance and economics class: An A. But, I do not have much hope held out for an A in my pathophysiology course. I would have to get every question right on the final to get the A. But, I'm working on accepting my non-A grade. I am too hard on myself. It was a hard course... and between working and my sleep issues... It seems I am chronically fatigued anymore... My studying could have been more than it was. Well, and not to mention today.. the day before the final.. I am here blogging... Can we say procrastination?

I then have a week off - spring break of sorts - Then I start my next term. It has eleven required textbooks. They are doosies, too.. Each one of them looks as if it could be a whole semester in and of itself. William's Obstetrics, Maternal, Fetal, and Neonatal Physiology.... Etc, etc... Really interesting ones, too like Human Labor & Birth and Anatomy & Physiology for midwives.

I am very excited to finally be having a midwifery course: Advanced reproductive dynamics... But I also have two other courses and the many, many books required is a bit daunting.

So, I have a week off to gaze at my mound of books and wonder where to even begin....
One step at a time.

2nd Term: Half Way Done

I’m at the mid-term point in my second term of midwifery school. So, what’s been going on? It is still super demanding. If I am not working, I have a full list of “to-do’s” for graduate school. This week I wrote 2 papers: one on colon cancer and one on budgeting. I also just completed a project on hemolytic anemia of the newborn. I was excited about this project because it was the first project/paper that I was able to pick my own topic. I’ve done loads of papers on topics I struggle to find relevance in for my future practice. But, for this project I got to pick the specific topic. It had to be a disease process and it had to focuse on the pathophysiology of that process. So, I began thinking of diseases that related to my field. Of course I thought about PIH and HELLP. But, those were obvious, I thought. So, I went through out text book and looked at things we covered to give me an idea for my project. I saw the section on blood types… Nothing specific… Just the basics: A blood type contains A antigens and anti-B antibodies, etc. It got me thinking about ABO incompatibilities and Rh incompatibilities between mothers and their fetuses. That’s something I don’t know the exact pathophysiology about. So, I had my topic: hemolytic anemia of the newborn. Something I need to know that I don’t.

So, that project was fun to do. And, the next time I give Rhogam to a woman I will know the exact pahophysiology and the reasoning behind it. I am beginning to enjoy classes a lot more when I can foresee them contributing towards my future practice. Although, all physiologic knowledge is useful… this felt MORE useful… You know?

Anyway, that’s what I’ve been up to lately.