Labor

They call it going into labor, because it’s work and it’s the hardest work you will ever do. I never realized how much work it is to give birth. Climbing mountains, biking across the US twice, nothing I have ever done compares to the brief glimpse of childbirth I experienced today. Hats off to all the moms out there. I never knew.

I spent several hours with a laboring mom and it made me feel for her. I felt for her pain and could only do very small things to help. Birth – such an interesting event in life that so many people experience.

2 snow days

Up north, we call this a regular winter day.  I didn’t even put on my waterproof snow pants.  The snow was pretty great and fluffy.  I estimate 5-8″.  But, I get it.  No one owns shovels,  winter coats, or winter boots.  The city does not have equipment to plow the roads.

Classes are cancelled today and tomorrow.  The temperature will drop tonight so all the unplowed roads will be frozen tomorrow morning and I’m pretty sure the majority of people here do not know how to navigate in these conditions.  Some professors recorded lectures or gave us homework to do from home but our maternity class will double up next week to catch up.  We are expected to have a regular schedule on Friday as temperatures warm again and nature will melt the roads.

Pictures: big tree outside my front door/yard, backyard, view from my front door, me making snow people and me after walking to the library and back to print my hw.

Semester 2, week 1 – fast and furious

When my clinical instructor said “stork nurse”, this is the image that came to mind.

stork

I now think, the stork nurse is a specially trained nurse who attends vaginal and surgical deliveries and is responsible for the care of the infant.  This team gives the apgar score, measures height, weight, and temperature of a newborn, gives “eyes and thighs”, (Vitamin K injection to the thigh to help newborns with blood clotting and preventive routine antibiotic eye ointment.) 

Most Labor and Delivery (L&D) nurses when they are new to L&D receive 3 months of training and a mentor to help get them accustomed to the unit.  In a typical unit, like medi-surg, a new nurse gets 12 weeks of orientation. ICU and the Emergency Room typically have 6 months of training.  Can you imagine 6 months into a job and you are still in orientation?  Or rather that’s how long it takes before you aren’t considered lost?

L&D nurses are usually staffed 1 nurse – 2 patients.  Last semester, I observed on the med surg unit it was more like 4-5 patients per nurse.  A pregnant patient obviously needs more care and things can go wrong very quickly.  After a mom gives birth, the nurse visits her room every 15 minutes to ensure she is not hemorrhaging, so another reason why she can’t have a lot of patients.

In class, my professor described giving birth sometimes as a ring of fire, so I was surprised to learn and observe, an ice pack is placed on the perineal area after birth.  I also learned more about emergency c-sections and hemorrhaging after reading the Serena Williams’ article about her recent birth in Vogue and the New York Times.   It was a good article, I highly recommend reading it.

The L&D hospital rooms are well thought out and on par with really nice hotel rooms.  There is a giant bath tub with a window.  You can look out the window but from the outside you cannot look in.  There is a walk in shower in case the mom needs to move around while giving birth.  The bed is a special bed that comes apart for different positioning while laboring.  I was so impressed by this room, the tiling was grand, the painting/decorations were serene, so much thought went into the design.  I also appreciated other small but noticeable touches.  There was a “coach” room and the name tags for people supporting the mom are labeled “coach”.  I really liked that – over dad, partner, or anything else.

I learned so many things in my first week in class and first day at clinical.  My professor described the maternity course as beyond accelerated.  By the end of next week, we are 1/3 complete with the course.  One of my classmates said she felt like she was being hit by a thousand tennis balls at the same time.  Another classmate said she had learned more in 48 hours than she had in the entire last semester.  The tutor coordinator said she received 14 requests for tutors after the first day of class.  And, after 3 really long days, I was surprised that of all things, my eyes hurt.  My body didn’t feel very tired but my eyes were heavy from having to focus for so long.

My first day on the unit was a day of firsts for me, but the only thing I want to share that was more notable that the rest of my experiences on this day, was the placenta was not what I expected.  It was heavy and the texture was harder than I thought it would be.  One side was covered with very colorful vessels (some describe as the tree of life), and the other side that is pressed against the mom is not pretty, it is a dark burgundy or crimson red.  One of my professors described this side as looking like biscuits on a pan.  It definitely did not look like the fluffy biscuits I know.  Its color and texture looked like a liver but it did have separations that might be considered like small circles.  The umbilical cord was also very long and hard.  I thought it would be softer.

Spring semester

This photo illustrates how I was ready to start my first day back… then after 8 hours at school, several hours of homework… this is how things started to look….

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It’s going to be a rough semester.  Classes consist of: Pharmacology/Pathology, Community Health, Maternity/Peds, and Professional Nursing.  It sounds great, until you really learn that Maternity is like 4 regular classes in 6 weeks.  At non-accelerated programs, you can have Labor & Birth, Postpartum, Mother & Baby, Newborn all be individual classes instead of 6 weeks.  After today’s 3 hour lecture, I left feeling like… how is this even possible?  We have our first exam, next Wed, which is class #2.  I have the weekend and Mon/Tues to memorize 88 maternity terms and 24 medications (side effects, usual dosage, actions, etc.) and refresh on female anatomy.

Tomorrow we have class from 8-1 pm, then special lab, which my professor is calling maternity bootcamp from 1-8 pm.  Friday, I have my first maternity clinical from 7-7, and Sat. training at the hospital from 1-5.

Extracurricular activities… the Duke Navigator’s Program, the end of life workshop series that I was involved with in the fall, continues this spring.  I have been paired with a GI cancer patient.  Starting in two weeks, I will meet them during their chemo treatments and begin having end of life discussions with them.  My goal is to normalize these conversations with patients in serious conditions.  The goal for the patient is to discuss their thoughts and ideas, and hopefully, I can be part of their support team.

Other activities, I took it upon myself to create more opportunities for nursing students of color to support one another.  I am hoping to start an informal peer mentorship group and create opportunities for social mixers to meet one another.  By doing so, I accidentally elected myself President of a student club.  Hopefully it won’t be too much work, but help support other students’ needs by providing avenues to share experiences.

Winter break

First semester has ended, grades are in and I am on winter break.  In retrospect, I shook up life once again, and turned it upside down.  Giving my all or nothing in everything I do – uprooting life from the West Coast to the South, beginning an accelerated program as a full time student and embracing a new career – it was a lot to handle all at once.  Perhaps, if I only did one of those things, it would have been more manageable.  Looking back, I would not have done anything differently.  I am a firm believer in everything happens because they were fated.

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As I look forward to the spring, I have some thoughts on how to make the semester more manageable – only focusing 6 weeks at a time, instead of being overwhelmed with the bigger picture.  I will visualize more, breath more and spend more time outdoors.

I am returning to school with a Subaru Forester.  Surprising, I know.  I have struggled with the contradictions of wanting to travel the world without any possessions and the flip side, wanting a giant house in the mountains of Whistler with bedrooms for all my friends and enough gear to take me to all the places I want to go.  I still hold out for that dream.

The car is a educational necessity.  You can make it through the program without a car, however it is severely limiting if you do.  You reduce your own educational possibilities.  If you do not have a car, all your clinical placements are at Duke Hospital.  You only learn what one hospital can offer, you do not see how other systems do things and you potentially cannot have preference in your 4th semester preceptorship.  Then finally, as we get closer to the 4th semester, you have fewer options to carpool with classmates because you follow the schedule of your assigned nurse.  Then after graduation, when I have my first job as a nurse, if I work a night shift, or if I live somewhere rural it’s highly unlikely I will be taking public transit or biking to work.

Renting a car each time for clinicals is not cost or time effective.  Buying an inexpensive car is not reliable either because if it breaks down, you don’t have time for it to be repaired in a shop.  Now, I am a owner of a very reliable and safe car.  I hope it brings me adventures too.

I plan to return to archery, my new member orientation already planned for the first week of January.  The range is 20 miles away from school but I plan to go at least once a week and will figure out the finances.  I plan to go to hiking trails more often, less than 10 miles away from school.  I can go to the $5 movie theater (less than 7 miles away) more often and finally, I can drive to the daily state farmer’s market in Raleigh (30 miles away) for produce since my CSA won’t start until March.  I am excited by the possibilities and the freedom a car offers.  Maybe, I can even find some time to go camping.

The first 6 weeks of my spring semester is Wednesday and Thursday full day classes (Maternity/Community Health/Pharmacology/Professional Nursing) 8 am – 5pm. Friday maternity clinical at Wake Med Cary Birth Place.  I have Sat/Sun off and Mon/Tues we have occasional labs/simulations/exams, but not every week.  Then it’s spring break to Guatemala to learn about midwifery.  When we return, we switch to Pediatrics, where I will be at a different hospital site and a different day for that rotation.  Then at the end of 6 weeks, off to Tanzania for my community health clinical placement.  It’s all going to be fast and furious 12 weeks but I’m ready and excited.

Finals

We are into finals and the library is open 24 hours every day for the week.  Why does the library need to be open 24 hours?  I vaguely remember this being important in undergrad/college because a billion years ago, I did not own a personal computer until my last year at school. I sat at the library writing endless amounts of papers.  Now in this school life, I can’t see why the library needs to be open all the time?  In this new life of studying – there is no cramming for finals, there are no papers to write.  You either know the material or you don’t.  It’s weeks of knowledge built upon a semester of knowledge.

Our Pharm final is on Tuesday and I’m reviewing acid/bases.  As I was rereading my notes for this lecture, here is my personal application on acid/base, fluid balance.

When I competed in my first half ironman, 70.3.  Everything that could go wrong went wrong that day.  First, it was an ocean swim and I had never practiced that distance (1.2 mile swim) in an ocean.  I ended up having a terrible time sighting the shore line because of the sun, and I swallowed horrible amounts of salt water, making me feel nausea when exiting the swim.  When exchanging empty water bottles for full water bottles on the 56 mile bike course, I failed to practice drinking the course provided fluid mix and was repulsed by the flavor.  It made me want to vomit and I ended up only drinking water.  By the run course, the mid day heat had started, and I sweated excessively while only drinking water.  I wanted to finish the race because if I went to a medical station while on the course I would be stamped with a DNF (did not finish).  I figured if I passed out on the course, someone would scoop me up, so I finished the 13.1 run and then went to the medical tent to get IV fluids.  What went wrong – here’s the real life application:

Normally – your cells are isotonic – same amount of intracellular fluid = extracellular fluid, solute to water concentration are the same on both sides of the cell.  In my race, I had a loss of salt from sweat, and taking in too much water without other solutes to balance my water-fluid concentration, which is called hyponatremia.  HYPOTONIC (more solutes inside the cell, water follows solutes inside the cell, and your cells SWELL). Water moves from extracellular to intracellular and your fingers/feet swell.  Serious complications, left untreated can result in coma, seizures, respiratory arrest.  Sodium levels are less than 135 mEq/L.  Admin: (I think is a hypotonic solution of D5W.)

Next application example:  When I biked the U.S., there was one very hot day in the Ozarks (Missouri).  I had 20 miles left in our day, and I had drunk all my water.  I felt dizzy and looked for a shady patch to stop.  I looked up in the tress, and instead of seeing leaves swaying in the wind, I saw people dancing.  Upon closer inspection, there were not people dancing in the trees, but there were leaves.  Clearly, I was on my way to having heat stroke, but some how compelled myself to finish, arrive at camp and replenish my fluids and take a cool shower.  If I did go to the hospital, I think I would have received a (hypertonic) solution of D5 1/2 NS D5NS for fluid replacement.  A nurse would have monitored my BP, pulse rate and quality of lung sounds, as well as NA and urine output.

The opposite of hyponatremia is HYPERnatremia.  It is inadequate water, excessive water excretion usually from dehydration, heat stroke, or too much sodium (kidney failure).  Sodium is greater than 145 mEq/L.  Cells are HYPERTONIC – more solutes are outside than inside the cell, water follows solutes outside of the cell, cell shrinks. Left untreated can result in significant neurological, endocrine, and cardiac problems.

If you have trouble remembering hypotonic vs. hypertonic.  Hypo sounds like hippo – and I think of Fiona, the hippo at the Cincinnati zoo.  She’s made recent headlines.  She’s growing and is huge, therefore SWELL.  And, hyper is just the opposite.

I don’t have any personal application for the other solutes we have to remember so here they are:

When dissolved in water, electrolytes separate into ions and then conduct either a positive (cations: magnesium, potassium, sodium, calcium) or negative (anions: phosphate, sulfate, chloride, bicarbonate) electrical current.

Na – major extracellular fluid cation, regulates osmotic forces and water balance, regulates acid-base fluid balance (buffer), facilitates nerve conduction and neuro-muscular function, active and passive transport across cellular membrane.  Sodium levels 135-145 mEq/L.

Potassium – K (3.5-5 mEq/L) – major intracellular fluid cation, maintains cell electrical neutrality, facilitates neuromuscular transmission of nerve impulses; vital role in cell metabolism; functioning of cardiac, lung, muscle tissues, acid-base balance (leg cramps).  Reciprocal action with sodium.

HYPOkalemia –potassium less than 3.5 mEq/L.  Result of increased loss of K (avocados, dried fruit, cantaloupe, bananas, potatoes, spinach).

HYPERkalemia – potassium greater than 5.0 mEq/L.  results of inadequate renal excretion (kidney function), life-threatening – risk of cardiac arrhythmia/cardiac arrest.

-potential, ECF shift – insufficient insulin/acidosis (diabetic), trauma/surgery, fever, uncontrolled diabetes

Magnesium – Mg (1.5-2.5 mEq/L) – smooth muscle contraction (whole grains, dark vegs)

HYPOmagnesemia – less than 1.5, (malnutrition, alcohol use disorder, laxative use) – increased nerve impulse

HYPERmagnesemia – higher – chronic kidney disease.

Calcium – Ca (4.5-5.5 mEq/L) – cell permeability, bone and teeth formation, cardiac action potential, muscle contraction, blood clotting.

HYPOcalcemia – less than 4.5 mEq/L – Crohn’s disease (malabsorption), Vitamin D deficiency (alcohol use disorder, chronic kidney disease)

HYPERcalcemia – too much – bone cancer…

Here are some questions for you to answer after reading:

  • What are examples of isotonic, hypertonic, and hypotonic iv fluids that a nurse would administer? What would be important to monitor when administering a hypertonic solution?
  • What are the major cations and ions located in the intracellular and extracellular fluids?
  • What is the normal range and role of the following electrolytes: sodium, potassium, calcium, and magnesium?
  • What happens to cells when they are placed in isotonic, hypertonic, hypotonic extracellular fluids?
  • What does isotonic, hypertonic, and hypotonic mean?