Challenging clinical shift..... a reflection

On first appearances the board looked OK...(and what is the board?...it has every ones name on in the ward so you know the occupancy & whats what at a glance)... it always seems OK when its not completely full. However we all know looks can be deceiving and the acuity of the patient load is not measured by just bed occupancy. Its always good to work with a great team.... because as we know this makes life much easier... and we were all run off our feet. There were three Cesarean sections that afternoon... one after the other... of which I had two... here's an ethical question for you? should women be able to choose to have an elective Cesarean Section (C/S) at 38 weeks? it was an uneventful pregnancy... and at birth the baby is diagnosed with Respiratory Distress Syndrome (RDS). Neonatal Respiratory Distress Syndrome is a common breathing problem in premature infants. Did you know that babies have 12 times higher chance of developing RDS from an elective C/S @ 38 weeks... I wonder if the woman knew this fact before making her decision?

After birth, newborns with mild respiratory distress syndrome may require only supplemental oxygen. Newborns with severe respiratory distress syndrome may require oxygen delivered by continuous positive airway pressure (CPAP)—a technique that allows newborns to breathe on their own while being given slightly pressurized oxygen or air given through prongs placed in both nostrils). In newborns with severe respiratory distress syndrome, a tube (endotracheal tube) may need to be passed into the windpipe (intubation), and the newborns breathing may need to be supported with mechanical ventilation. This would also mean the baby would need to be transferred to a teritary hospital that can provide the staff and care for the infant. This baby was intubated and transferred by the NETS team.... I then spent time reassuring the mother that all would be well, fortunately she was going to bottle feed which therefore meant she did not have to express her milk and send it to the baby hospital. Later in the evening she told me that the baby was doing well and may only be intubated for 24 hours.

My other challenge was looking after a profoundly deaf woman who was not well after the birth... she also had a multitude of complex social problems... I was walking past the room to the loud cries of a baby, walked in to find the mother fast asleep and the screaming baby...this really bought home to me some of the issues confronting both the mother and baby... I picked up the baby and settled it back to sleep.... later I watched dad (who is also profoundly deaf) change the babies nappy.... he was vigorously wiping the baby's bottom and the baby was screaming... not once did he look up to watch the baby... I realised how much education was required.... and spent considerable amount of time talking slowly and clearly so that he could lip read my advice... however you could only do short periods at a time... he appeared to get bored with it all.... they are a young couple whose parents provide a lot of support and help which this also creates a problem. There are baby monitors for deaf mothers... that alert the mother & father to the crying baby... and of course it is important to be constantly looking at the babies face for its expressions...

Family dynamics are always intriguing, we as midwives get to observe them and this can be fascinating. Mother - daughter, mother - son, and then there's the in-law relationship. When there is a disability this then also puts added strain on the relationships...... due to the autonomy of the client and the need to be autonomous... as a parent they have to learn to allow them to make their own decisions... this happens in all relationships.... this one was particularly difficult on all counts....

It was interesting for me... usually when you are in a room there is the noise from the telly or people talking... however this room was silent especially when the baby was sleeping... I was kneeling to empty the catheter bag... it was quiet in the room...the IVAC started to alarm... but my hands were full so I couldn't turn off the alarm.... it was a piecing noise nobody in the room heard it...it must have been going for a few minutes when another midwife entered the room to see what the problem was... she was surprised to see me there and said "can you not hear that alarm?" I laughed and said my hands are full.. couldn't turn it off and I was amazed that the sound was so annoying could not be heard by anyone in the room but me....this experience gave me a small insight into what there life might be like... one I would not want. Fortunately for this young woman she was breastfeeding like a dream.. she had a good milk supply and enjoyed feeding.....I was confident that the baby would not go hungry and at least its crying would be for other reasons... other than being hungry, a small consolation. As you can imagine I could spend my whole shift just with this couple providing them with care and education but alas I have four other clients to share my time with.

On entering another room, I was amazed to see the woman, baby and partner all huddled in the bed together...the partner was almost lying on top of the baby... I said good afternoon and suggested that it was not a good idea for them all to be lying in this small bed and almost covering the newborn baby.....the partner was upset and said "I'm not sure its my baby..." to which I responded... well whoever baby it is, it is not good to all be sleeping almost on top of the baby... the mother responded by saying... he's joking... it is his baby" at this point I wondered why did I come to work today..... as my shift was turning into a shambles.... a baby with RDS, two day 1 cesarean sections, a deaf couple and a man who didn't know if this was his baby... and I wondered how the rest of the shift would go as I had only met half my patients.....

A bell was ringing..... then a man shouted in pain.... I thought what the hell is that? a few people gathered in the corridor... we are used to women yelling but not a man.... I entered the room to find a man doubled over in pain.... now I really wondered what am I doing here....after making a quick assessment and asking a few questions, it turns out he had injured himself a few days ago and had not been to the doctors and the pain just got worse...his wife had just had a baby yesterday... so as we are a maternity hospital we packed him off in an ambulance.....lesson to men... if you have injured yourself and have pain go to the doctors, it will only get worse if not treated... and if you don't want to go to the doctors, don't visit your wife in hospital.....and complain of the pain you have....

My other cesarean mother had so many visitors I could not get into provide the care required with all the visitors who did not want to go and the mother did not want them to go..... this baby was not ready to breastfeed and they both needed lots of time and education........

could my shift get worse.....with breastfeeding issues...IV antibiotics, complex family issues.....pain relief requests...resiting IV cannula....just the normal run of the mill... everyone running around busy.... it must be the first time I have been late off finishing because I have to write up my client reports..... I must be slipping or I was so busy I just never got on top of things.....it was a matter of doing what was most important first.....but the bells kept on ringing.... could of done with another pair of hands.....

Its funny I always tell my students.... you must make sure you document contemporaneously...which I did at the bedside but not in the progress notes... for me this was the shift from hell...everyone was of late.... it goes to show you that if your client acuity is high you will fall behind in managing your load. It will just take one client to have breastfeeding issues or a complex social problem and you are out of whack....

What would I do differently next time.... probably keep more up to date with my client progress notes.... I could have made time to update each one as I dealt with their issues rather than at the end of the shift... ask the visitors to leave after an hour....and not engage with the complex social issues....easier said than done... profoundly deaf people need a lot of one on one time for communication purposes... I would re-organise the work loads... however there just was not enough staff... so much for the governments 3% cuts.... it comes off at ground level.... just not good enough....

Yes I had a double scotch when I got home........