Friday, June 26, 2009

OB, oh boy!

It pleases newFNP that she continues to experience new challenges in clinic.  Otherwise, the work gets a little too rote.  Thankfully, newFNP's prenatal practice has been supplying her with a couple of not taught in school-style scenarios.

In the past week, newFNP has had five patients on the verge of labor.  Generally what happens is that newFNP educated patients on when they should go to labor & delivery and, with the exception of her eighth-grader in labor, that is what happens.

Not so much this week.  One patient presented for her repeat c-section, ineligible for VBAC due to her first c-section being conducted vertically, checked herself into the hospital and then checked herself out, only to drive to another hospital where she had the cesarean.  Another patient presented to her c-section appointment because her fetus is stubbornly breech, only to be turned away and instructed to return in a week.  NewFNP scheduled this c-section according to the hospital's protocol for breech position, not according to her own whimsy.  Whatever.

Finally, not once, but twice in the past week, newFNP has had patients present to the clinic in labor.  Her most recent patient (G3P2) was three days post-dates and had a urine dip that screamed UTI and dysuria to boot.  To top it off, she was contracting every three minutes in the exam room.   She was laughing through the contractions and they were only lasting about 20 seconds.  NewFNP, however, was not laughing.  

Here was newFNP's conundrum.  It was simple really: treat the UTI with some Rocephin and then send her to labor  delivery or just send her to labor & delivery.  Truly, newFNP thinks that either way would have been fine.  But she prefers to TCB in the clinic, rather than shuffling her patients off with business left to take care of.

NewFNP called her Family Practice MD colleague who advised her to do a vaginal exam to assess for cervical dilation and effacement, give the Rocephin based on what was going on all up in that and go from there.  

Here's the problem: newFNP doesn't totally trust her cervical exam.  She just hasn't done enough of them on pregnant ladies in labor.  Sure, if she could put her head in there with a miner's light, she could easily tell if that action is dilated.  But on a 232-pound lady who is 10 months and three days pregnant, the exam is not so easy for newFNP.  Nonetheless, newFNP strode back to the room, sterile gloves in hand, and proceeded to examine the hell out of that cervix.

And folks, that was a good cervix to assess.  NewFNP felt 5-6 centimeters of dilation and nothing but head.  NewFNP's patient, shocked, just kept laughing through the contractions.  NewFNP called her MA to deliver the Rocephin, called the prenatal coordinator to deliver the taxi voucher as her patient had driven herself to her clinic appointment, had her call her truck driving husband and ask him to turn that action around, and sent her on her way.

She gave birth to a healthy 9-pound girl a few hours later.

The fifth patient just went to the L&D floor as directed.  

So, all in all, 20% of these ladies had labors that went down as newFNP had anticipated.  Doesn't matter.  All that matters to newFNP are healthy moms and babies.  

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