chriscoles96-blog

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A quick delivery

6/4/19

In the morning I looked after another preterm pregnancy who was threatening to go into labour. She’d come in with abdominal pain with some discussion, checks of the cervix, steriods and some analgesics she calmed down and the pain settled. Once she was we transferred her to the Antenatal ward.

As I was passing the induction bay I was asked to look in on a women’s daughter who was in a fair bit of pain with her contractions. On palpation she appeared to be hyper stimulating, I started a CTG to be sure and discussed her with theinduction midwife and lead midwife and said I’d be happy to take her if she needed to come to the labour ward.

On the CTG she was hyper stimulating and baby’s heart rate was dropping with each contraction. I put in a cannula, and requested the doctor to review. A VE wasn’t done as she’d been induced for GDM and LFA and the prostin has only been put in a few hours before. The doctor reviewed and terbutaline was given to reduce her contractions. She was using entonox and shouting to get the baby out. I reassured her the pain would reduce once the terbutaline kicked in. However the contractions were still 4-5 and sometimes 6 in 10. Hartmanns was started and the trace began to improve.

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A large preterm

5/4/19

I took a preterm lady of 35+5 who’d come in in spontaneous labour and had been 7cms. On examinations following had been 8cms and the 8cms again. The plan was to break her waters once she’d been reviewed by a doctor. The doctor broke her waters at 9:30. She was 10cms at 11:45. She began pushing at 12:00, descent and progress was slow as she had an epidural on board. But an hour and 50 minutes of pushing babies head finally shifted and began to crown. A female infant was delivered at 13:52. Placenta following behind a minute behind making a bit of a mess - it was slightly unexpected.

The baby was checked by a peadatrician once the cord had been clamped and then cut by the dad. Once happy baby was given to mum for photos before being put back on resuscitaire to keep warm until a incubator could be brought in.

Her perineum was checked and a slight 2nd degree tear. I sutured under supervision and once done assisted to get baby on the breast. Observations were stable. Baby was weighed 3200g (7lb 1oz) - which made me think the dates may potentially have been wrong.

Baby had been hiccuping instead and me and the medical student had seen babies whole head jumping - it was a little freaky as I couldn’t tell if baby was gasping for breath or had the hiccups. Luckily there was a good fetal heart.

There was a baby delivered two rooms down who’d requested a peadatrician once asked why, I could see a flat baby so put out a 2222 (emergency call) plenty of people were with the baby so I stood by mum and dad and kept the updated and reassured. She even pushed out her placenta with me. Which I removed and checked for the midwife who was with the baby.

[chriscoles96-blog]

Bereavement SD and clinic

4/4/19

A bit of an odd day, I’ve gotten so used to my short clinic days on a Thursday that doing a long day felt strange. I started my day at a bereavement study day, but of a sad start to a day but it was good to learn about the care offered at the trust.

I then travelled up to my clinic and saw my caseloading ladies, I’m starting to see women I booked 2 months ago more regularly which is nice as I’m beginning to see some new faces, remembering them all slowly but surely.

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My clinic

28/3/19

Had another few bookings today, a few new faces added to my caseload - won’t be long before we have regular visits.

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Overtime

27/3/19

I did a clinic in my own time, it was chilled and lovely. It felt slightly strange doing Antenatal checks on women I didn’t know but I had a good flow and it made a change.

I even did a sweep for a lady in hope of getting her into labour.

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Catch up and an induction

25/3/19 -26/3/19

The night started off fairly quietly so I got to see the lady from the night before. She’d ended up having a c-section shortly after 12 midday. Baby weighed 9lb 12oz - he seriously looked like a month old baby.

Around 11 I was asked to take a lady from induction bay who was for an ARM - artificial rupture of membranes. I broke her waters at 3cms and she began to contract 2:10. Gave her two hours to mobilise, the contractions started to regulate and be 3-4:10. So a further two hours were given. She was 4cms but her contractions were dying down. An epidural was requested and syntocinon drip was started. She’d begun contracting 3/4:10 before I handed over.

[chriscoles96-blog]

A large baby

24/3/19 - 25/3/19

Tonight I looked after a young woman who was expecting her first baby, she was classed as high risk due to her BMI 45.4. When I took over she was 4cms, she’d been induced due to baby being post dates.

During the night she’d requested an epidural - one was sited but didn’t work very effectively, she kept saying her catheter was uncomfortable so it was taken out. I got the anaesthetist to review the epidural which wasn’t working. They reviewed and it was decided a new one would be needed, a second was sited and once effective another catheter inserted by the doctor, after a vaginal examination was done. She wasn’t progressing so a syntocinon infusion was started to get her contractions going and her cervix dilating.

An hour passed and it became apparent that the epidural wasn’t working, she began to report discomfort in her catheter and shortly after began to feel her contractions, I gave her the gas and air while I got the anaesthetist to review. The epidural catheter had migrated out which was why the epidural had become ineffective- she didn’t want another sited which I didn’t blame her - it’s unusual that an epidural didn’t work a second time but there are a few people whom an epidural doesn’t work for.

It had been a long night but now with the syntocinon infusion at 36mls/hr she was contracting well. She was doing amazing coping with just gas and air, she was growing tired and had slipped down her bed - not wanting to be repositioned higher up the bed. I advised her that being upright would make it easier for her body to dilate. At 07:30 she allowed us to reposition her. At 08:00 the day staff took over and examined - unfortunately she was still 4cms - her baby felt big so it could be that was why he wasn’t moving down as his head wasn’t well applied or it could be because she was tense due to inadequate pain relief.

Either way she’d had enough and knew that a c-section would be likely because even with her contractions she wasn’t dilating. I left her with the day midwife and left, wishing her all the best.

[chriscoles96-blog]

It’s sad losing caseloading women whether due to miscarriage, GDM or multiple fetuses but sometimes we have to let what’s to be, be as it’s meant to be.

21/3/19 - clinic - lost 3 of my caseloading women today 😔

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SD and offsite birth

19/3/19

I started the day attending an IV therapy study day which means I can now touch IVs under supervision and once observed will be able to look after women on syntocinon infusions without having to get another midwife to increase every half and hour. I will also be able to put up fluids and take them down as well as antibiotics. I have to say I will feel way more autonomous once I start doing this.

In the afternoon I was on a late shift that started at 14:15, I discharged a lady with her new baby boy home and was about to take over another postnatal lady when I got the call to go out to one of our offsite birthcentre to facilitate a birth. They were a bit unsure of sending me as I’m still a band 5, but the birthcentre was my clinic base and I felt fairly comfortable there so I was happy to go. I don’t have onsite parking yet, so I did warn them that I would have to get my car and that might take a while as park and ride can be unpredictable. I left at 16:05, didn’t get to my car until 16:25 and then it was a further 20 minute drive to the birthcentre so I arrived at 16:45.

All the midwives were shocked that for someone who was down for 2/3 labour calls a week I didn’t have onsite parking yet. It should only have taken me 20 minutes to get there not 40. I introduced myself to the lady who had been take to the birth room by the 2nd midwife on due to me not having arrived before the woman.

The woman was contracting really well and this was her 3rd baby. I examined and she was 9cms but I felt with the contractions that baby would be here very soon as was really pushing down. The pool had been run as she wanted a pool birth, she went to the toilet but I did advise her to get in the pool ASAP as I thought baby would arrive until he next few contractions. She got in the pool and began to feel pressure, on the second contraction baby’s head was crowning, we pressed the buzzer for a second although a support work was also in the room. Her baby decided to be superman and come in a compound presentation (hand by face) but by 17:16 a baby boy was born in the pool. It was amazing, she picked up her son and brought him to her chest with some encouragement. They got lots of nice photos and they decided to face time there family to let there sons see there baby brother. It was beautiful, I asked her about delivery of the placenta she was on the fence about the injection but she wasn’t bleeding so we decided against it unless she did begin to bled. I asked about whether she’d like to stay in the pool or get out for delivery of the placenta, she wanted to stay in. Later she decided she would get up but as she did she felt pressure to push, so we delivered the placenta in the pool which was a first for me. I don’t know what I expected, I kind of hoped it would float to the surface but of course it didn’t it stayed planted to the bottom of the pool. We clamped the cord and got dad to cut, I took the placenta away, we gave baby to dad as the placenta made the woman a little queasy. Once she felt settled we assisted her out of the pool, and onto the bed, gave her towels to get warm and dry.

I encouraged skin to skin but she didn’t feel ready and dad didn’t feel like it so we wrapped baby well. Once mum felt more herself, we put baby skin to skin and almost immediately he latched himself to the breast and began to suckle beautifully. Later I checked her perineum, she’d had a tiny second because of baby’s hand coming besides his face but it wasn’t bleeding and looked as though it would come together on its own so we left it.

I handed over to the night staff, having the paperwork written but not computed on the system, she would have gone home a few hours later to sleep in her own bed and be home with all her boys.

I went home feeling great, it was nice to deliver offsite, I wasn’t alone and I felt well supported. And the woman and baby were fit and well and she got to have the birth she wanted - she was a little shocked at how quick it had been but was happy he was okay. I had worried that i wouldn’t make it because of the offsite issues but I did and it was my 3rd waterbirth of a male infant in the last 2 weeks which was lovely.

[chriscoles96-blog]

Clinic cover

18/3/19

I covered my buddy’s Antenatal clinic today, it was nice to be offsite and I felt okay, I went with another midwife who also held her clinic at the children’s centre. My buddy had made sure the clinic was fairly comfortable, I only saw 6 women which was weird considering her appointments were usually 20 minute slots.

Everyone had bloods taken, I did two bookings and a birthplan but it was nice. It all ran fairly smoothly. And if I was behind I was only 5 minutes behind for one lady. It would have been interesting to have a full clinic to test myself but it was nice to be able to get used to the room and the equipment available.

[chriscoles96-blog]

Looking after someone with the same name

15/3/19

I did a late shift starting at 11:45, at first I wasn’t needed on the labour ward so was advised to go and do some online training. Within 30 minutes I was called to relieve the Antenatal ward midwife for break.

Once she came back from break I was told to take a woman from the induction bay to start on the syntocinon infusion. I said hi, which was a little comical as we had the same name. I discussed the plan with her which she’d known nothing about. I transferred her to the ward with me, got her set up in her room and gave her time to call in her husband whilst I got the doctor to prescribe the infusion.

She came in and saw her, got her to pass urine, commence a CTG before cannulating. I got a second midwife to witness me cannulating as we have to be observed for the first 5. I looked at her veins and they looked beautiful, I set up, got the needle in her vein - got flash back twice which is a good indicator that you’ve basically done it and your definitely in the vein but when I tried to further the cannula it was having none of it. I apologised and asked if she was happy for me to retry, the same thing happened and when I asked the midwife supervising me she said sometimes it’s like that and she reassured me I’d done everything correctly. She tired and failed herself - we thigh her veins were full of valves which can make cannulating harder. I got a doctor in who managed to get a cannula in. I apologised profusely as there is nothing worse than missing or not getting a cannula in when you use the largest sized cannulas that leave entry marks.

With the cannula in we could get on with the syntocinon infusing. Once her partner arrived, we discussed the plan, I reassessed and she was 2cms dilated and was contracting 1 in 10. The CTG was perfect so we started the syntocinon drip. Within an hour and a half she was contracting 4 in 10 regularly, we discussed her birth preferences and pain relief choices. Currently she was coping well without anything, she used the birthing ball and mobilised by the bed with her partner massaging her back during the contractions. We made it as normal as possible even though she was on continuous monitoring, music was playing and the lights were dimmed.

The time passed quickly, with very little of the hormone drip she was contracting well and baby was happy. I handed over to the night staff, she’d started to use the entonox but again not very often. She didn’t really feel her contractions until the very peek of them which was amazing - her pain threshold was incredible.

[chriscoles96-blog]

12/3/19 - Bruise or Birthmark. Definitely a interesting and thought provoking study session.

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Clinic day

14/3/19

I was definitely a bit optimistic about getting a birthplan completed within 30 minutes espescially when I was using the new notes for the first time. Normally I would book an hour but the lady had wanted 8:30 and I already had someone booked for 9, so I’d booked it hoping it would run smoothly forgetting she’d have the new notes. At the moment we have two sets of notes, ones that have been there a while and they are trailing a new set which seem to have a lot of issues. The birthplan page made very little sense to me.

So I ran almost half hour over, luckily both my next two ladies were 18 weeks with appointments that are slightly quicker and they didn’t mind waiting as it meant they got to work a little later. I apologised and made a note that I would only do birthplan a with at least a 45 minute slot.

I did catch up by 11:00am but it meant having to write my notes later on. For the first time in weeks I felt like I was moving backwards instead of forwards. I might make a birthplan proforma to make those appointments run a little smoother. Because I found that the new notes didn’t cover everything.

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Another waterbirth

12/3/19

I love waterbirth it’s a birth with very little interference, it’s a birth completely controlled by the woman and many bring there own baby’s up out of the water as it’s an instinct.

I’d been on a study day in the morning and came back to a midwife worrying about who would take a potential labourer in one of the birthrooms as her lady hadn’t long delivered. I went in and introduced myself, she was very uncomfortable and was laying on her side as she felt unable to stand or walk due to the pressure. Her contractions were strong and about 2-3 in 10 minutes. I did the usual checks before listening in to her babies heartbeat before examining for dilatation. At 12:15 she was 3cms and I did discuss them going home after some pain relief which they didn’t feel comfortable with so I made a plan for them to go off the ward for a hot drink and some lunch and advised to come back if any changes or any worries.

During the examination I had given her a vaginal sweep and felt like if she could tolerate upright positions the babies head would come down a bit harder on the cervix as there was a gap between the two currently. I didn’t think it would take her long to get to 4cms if they walked for a bit. So I gave her drugs to numb the pain a little and advised them to go for a walk.

They went and I saw a multiparous women with a ?SROM and contractions. She was contracting 2 in 10 minutes strong on palpation, because she had laboured before and I’d seen liquor on her pads I decided to examine to see if she was in labour. On examination she was 2cms, so I did send her home with numbers to call if she felt herself go into labour, I also advised her to monitor the colour of the liquor and with the intention of her coming back tomorrow for an induction if she didn’t send herself into labour. She also wanted an epidural so I advised her to go to the assessment unit instead of us at the birthcentre when she cane in in labour.

Once she’d gone, I found my other lady walking back slowly and appearing to be way more uncomfortable, I set her up on the ball with her partner behind her as she was struggling to stand and during each contraction would sink to the floor and bounce in a crouched position. I decided with them both to examine two hours after the last examination to see if there had been any change - with the intention of them going home if there had been no change which I didn’t think would be likely.

On examination at 14:15 she was 4cms, she was so happy that she could stay and relaxed a bit more. She hadn’t slept much the night before as had been contraction since 3am. I encouraged her to try and nap on her left side for a bit, I got some water in the room and set her up with the gas and air. We discussed her birth preferences, and I found that she would like a waterbirth. I ran the pool as she rested so that it was ready if she cracked on.

Her partner went to get some snacks and hot drinks and she had something to eat - only a few bites before the contractions picked up a bit. A paramedic was on the ward and wanted to be apart of the birth of they were happy, I asked them if this would be okay, they were a bit doubtful due to him being a man but did agree for him to be present - she was worried about him seeing down there, I did reassure her that she won’t care once she begins to deliver and she agreed with this once she had.

He came in and introduced himself and was very nice and kept himself in positions that made her comfortable. She got up to go to the toilet at 15:30 prior to getting in the pool. At which time he asked me when we escalated, at first I didn’t understand what he meant but I realised soon after that he wasn’t used to sitting and waiting and watching. So I told him we don’t, as there’s nothing to worry about, I said if we don’t see baby before 18:15 then we examine again. He couldn’t quite believe how calm and peaceful the environment of the birthing room on the birthcentre was after seeing a delivery on the labour ward.

Once in the pool she zoned out a little, it calmed her so much that she was able to zone herself out. I listened in every 15 minutes, checked her temp and pool temp every hour and changed the entonox cyclinder (which had run out) with the paramedics help. The paramedic followed suit, I watched and waited quietly, I advised to interact with them but forgot to mention that at times quiet is better but he did. At 16:45 her behaviour was a bit more panicked, she kept coming out of her zone and couldn’t relax or keep still, I talked her through it. She was sounding a little pushy but I couldn’t see a thing even with a torch and mirror when she was in all fours. I got her to sit with her back against the pool and her feet towards me pressed against the other side. At 17:00 during a contraction she appeared to be pushing and I thought I saw some gaping (slight vaginal opening/movement) but I wasn’t too sure. At 17:16 she was pushy and I began to see more movement and eventually babies waters and head behind them. I got the paramedic to press the buzzer to call for a second midwife. And I talked the woman down as her zone had slipped and she was finding it hard to keep her legs open. I reassured her, she had done amazing and would soon be holding her baby boy. The paramedic was next to her partner, I called him over to see the birth. The woman was focusing on me, and by the second push she had it, so at 17:21 babies head was delivered and as it did the waters burst and thick meconium dispersed in the pool, I reassured parents and prepared them for the potential of us taking baby to be checked over. With the next push, at 17:23 baby was delivered into the water with his cord around a hand and a leg, I slowly unwrapped him and brought him out and onto his mums chest. He didn’t appear to have meconium bear his mouth and I couldn’t see any obviously in his mouth so I decided to rubbed him dry with a towel. He breathed within a few seconds, pinking up and emptying his lungs with a great roaring cry.

At 3 minutes old he looked well and was still crying loudly, he didn’t look compromised or struggling so I wanted him to stay skin-to-skin with mum. The peadatrician came in, we explained the situation and he looked at baby and didn’t see a need to take baby from mum to look at him but told us to call him back if any concerns. He brought up mucus but it was clear so that was reassuring.

At 17:33 after taking photos, we clamped the cord and dad cut the cord - got some photos of this before taking baby, wrapping and giving him to dad while we helped mum out of the pool to deliver the placenta on the bed - which was mums preference considering the pool was green. At 17:40 the placenta was delivered by maternal effort. We assessed for tears with consent and found a second degree tear that extended almost right down to the bottom so did a PR to check muscle tone and to ensure it hadn’t gone through and become a 3rd. After a pool birth we give an hour to allow the tissues to dry. We got her dry and comfortable on the bed before handing baby back for more skin to skin and to start feeding. He was a natural, I talked her through and gave her the basics and he latched well, I checked her observations which were fine. Offered tea and toast, she accepted tea but decided to finish her sandwich.

At 18:50 we prepared for suturing, I started at 19:00, doing it under supervision, although the tear was more complicated due to it including the hymenal ring it felt easier as she wasn’t jumpy. By 19:45 we were done and it had come together beautifully, her legs were down and care of stitched discussed. At 19:50 I did baby observations due to the meconium at birth, head circumference, weight and gave him vitamin k, allowing parents to take pictures of his weight 3435g. I got someone to get mum tea and toast, and dad was happy without a hot drink. I also did the initial head to toe check and found that baby had Mongolian blue spots on his bottom and back and a light one on his forehead - so I made a note of these on his body map chart.

I then handed over to the night staff and sat and completed my notes, I’d not had a break so I was being a little slower than usual. I got it done, congratulated them again before heading home 30 minutes later than usual.

[chriscoles96-blog]

A quiet one

11/3/19

I started the day with some conflict resolution training which was interesting but probably not the best thing to do at 9am on a Monday morning.

The training overrun, so instead of having 45 minutes to myself before the start of shift I had 25 minutes. We had one labourer in the birth centre, who was being cared for, another lady turned up a day early for her Antenatal appointment so I saw her. Did the routine checks, gave her a sweep and booked her a follow up appointment with her midwife the following week.

Not long after she’d gone the buzzer was pulled in the labourers room, there were already two midwifes in there and half babies head was delivered so was tightly applied to the perineum so I knew straight away that we were expecting a should dystocia.

She said as much and got me to linger in case I needed to pull the emergency buzzer which of course we did because with the next couple of contractions the head delivered but wouldn’t restitute. On pulling the emergency buzzer many other midwives were in the room to assist, one called the peadatrician and the others aided with mcroberts and then suprapubic pressure and mcroberts once more, after the suprapubic pressure the should slipped under the symphysis pubis with a sudden restitution and we knew that with some gentle axial traction baby would be born.

It came out fairly easily, didn’t actually look too big, and with a bit of drying with a warm towel breathed spontaneously. The peadatrician had a look at her and were happy that no palsy’s were present. I supported with feeding after and discussed what had happened as she seemed a little shocked. I got her some tea and toast. Generated her notes after weighing baby.

After she was transferred to the ward I focused on some of my online training. It had been a fairly quiet, stress free day. Seeing the management of the shoulder dystocia did catch me off guard a little as McRoberts back in London was lift legs back, here they do that but then down and up again, it looked a bit 👀. It was slightly unusual but it worked very effectively and next time I’ll feel a bit more on it as I know there general practice, it hadn’t been said at the PROMPT study day.

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A waterbirth

8/3/19 - 9/3/19

Another night shift meant to be on the birthcentre spent partly on the main unit. Today I was sent to help on the Antenatal ward, there were 8 women, mostly settled but one who was contracting and threatening to go into labour. She’d only just begun contracting but at her previous birth hadn’t realised she was in labour until her partner saw babies head and delivered in the bathroom. Due to this fact the other midwife on the Antenatal ward didn’t want to take any chances. On examination she was 2cms but a few minutes after I left her her partner called to say she felt pressure and the urge to push - so we transferred her to the labour ward - only to have her transferred back 20 minutes later as she’d settled and the contractions had eased off.

I went on my break at half 12 only to come back and be asked to take a labourer on the birthcentre. She’d wanted a homebirth but due to staffing issues had been asked to come in for her safety. She came over to the birthcentre at 03:35, she looked calm and relaxed but was said to be 4cms. She wanted a waterbirth but we agreed it best to mobilise for a bit until the contractions became stronger. I ran the pool so it was ready once she did transition. By 4:10 her contractions were stronger and more regular - I warmed the pool while she passed urine and at 4:25 she got into the pool.

At 4:40 I called for a second midwife as she felt pushy and I thought I’d seen some vaginal gapping. I was the only midwife on the unit with a support worker so it probably was a good call. When the second arrived she had calmed a little and no longer felt pushy. Her waters broke at 4:52 and 6 minutes later a beautiful chubby little boy was born. He decided to do a superman and come out in a compound position so unfortunately mum sustained a small second degree tear.

I left them to enjoy there baby for a few minutes, got some photos of them all together. It was a beautiful waterbirth I was completely irrelevant, I prompted mum to pick up her baby only gently guiding baby through her legs. We got her out of the pool, delivered the placenta and she started feeding after we had checked for a tear. Although the tear needed suturing it needed to be left for at least an hour to allow the tissues to be drier for suturing.

At 06:50 I did my first suturing since being qualified under supervision and guidance. When I’d examined I’d decided it had looked a good tear for my first attempt. It felt good to do the whole process, it had been scary and due to her having grazes where I needed to suture it was a bit sensitive and made her a little jumpy. It was nice to do everything start to finish but it’s not an easy thing causing pain even when you have numbed the area as much as possible.

We talked after and she was completely fine with it, she understood it was unfortunate that the grazes were where they were. She got up and weed and I did the paperwork, I handed over to the day staff about needing anti d and bloods and knew she’d be going home soon to take her new son to see her two daughters.

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An amazing study day! And I got a monkey 🐒 - 8/3/19