Tuesday, January 17, 2012

OMG! Obesity in Labor and Delivery

"I know", I said to the charge nurse at ten o'clock last night, as she looked at me and tried to explain what was up in Labor Room 4.

"How did you know??!!", she exclaimed.

"I looked it up on the computer system before I came upstairs. There was something in your voice that made me look." I replied. "What did you tell her?"

"That we are going to put in the epidural." she said.

I matter-of-factly said, "How can you promise that? It might not go in."

"What are you going to do?" she asked.

"I am going to stick her until it goes in or she tells me to stop trying."

The charge nurse left to see the patient, while I got my cart and bag of local anesthetic from the pyxis. she came back and said, "I told her we are going to give it the good old college try."

"Thank you."

I get in the room and there is an enormous woman, with full make-up. Why they try to make the face look so nice when the body is, well, enormous with rolls of fat, is a mystery. Fake eyelashes, everything applied like a cosmetologist, hair perfect. What I see is the red thigh-size cuff barely fitting on her arm, because the arm in obesity is shaped like a cone, and the cylinder of the blood pressure cuff poorly fits. I take a large cuff on the forearm over a thigh cuff on the arm in the O.R. any day. It reads more accurate.

As I take this in, I take the energy read of the room. It is survival. Is there dark entities in her? They are going to make it tough. Is she stable, mentally and emotionally? The critical thing is, where are the folds in her fat? Back pannuses are thinnest at the fold. She could barely spin in the bed to expose her back. She had concern because her internalized monitor 'was coming out'. The external monitors can't read fetal heart tones or uterine pressure due to the insulating nature of fat.

Open mind, open heart, and prayer to St. Michael to protect and aid me, I got ready.

Twenty cc's of saline, not ten. And the local with the 22 gauge needle, not the 25, to the hub, and no contact with bone. (I had prepped wide with the betadine and draped first).

One hundred percent of my attention was on that back, with the family member in the chair I could see out the corner of my eye. Tuohy needle, to the hub, contacting bone, the spinous process. The epidural space was going to be about three centimeters in past the hub. I took care to stay in the midline. The needle, as I pressed, swerved and popped, as if guided by unseen hand. The interspinous ligament. Almost there. I leaned with all my weight with the Tuohy needle hubbed to get the three centimeters and loss of resistance that indicates the epidural space. The husband put his head in his hands as I did this. It was gory. No blood, but a needle going more than all the way in is a trip. With firm grip, I held tension on the Tuohy, took out the stylet, and grabbed the extra long spinal needle. A pop through the dura and CSF would mean I was totally in the right spot. Sometimes extra fat people have a loss of resistance outside the ligament, and the catheter will thread. No pop. No CSF. I threaded the catheter to fifteen centimeters at the skin, a first, the deepest placement ever. And when I went to remove the Tuohy needle, with all my force, I couldn't. It was stuck.

I never had been in that predicament. I pulled, and I asked gently, "can you please bend forward?' She did. The bones loosened their grip on my needle, and it came out. Test dose felt good. And it was negative. Her blood pressure dropped and she had relief of her pain.

It is better to be lucky than good.

What I have learned through the years is not to judge.

To stay in the moment with a challenge.

And to know that in that moment, once handled, lies the opportunity to show your skill set.

In this woman, as a Reiki Master, I asked for Divine Intervention in my work. I got it.

"How did you ever get that epidural in?" Lorna, a seasoned RN, asked in amazement.

"It's easy," I answered. "I prayed."

Lorna laughed a big belly laugh at that one. She knows. Poor charge nurse needed me to hold the other leg so she could put in the foley. That was a sight I would like to forget having ever seen--it was not pretty.

I did not have time for a cho ku rei. But I did have a partnership with spirit, that worked. And I did have humbleness about being there sincerely to take away pain. I also took away my judgement of how she would have terrible insurance. I was wrong. Blue Cross PPO, one of the best.

'You take care of me, and I will take care of you." said the father-to-be, on talking about his job as a server at a swanky restaurant, and what celebrities tip better than others. For a while I had thought about my role in medicine, "I will take care of you and maybe you will pay me and maybe your insurance will and maybe they will not." But I plucked it out of my mind. It was not healthy. And look! Good insurance after all!

Do not see like everybody else sees. A challenge is a gift to let us manage it. We discover how much better we are at what we do. Others show us pieces of ourselves. Embrace differences. For what we do to them we also are doing to our own hearts. Love is the only thing that will protect us and save us from any challenge.

Choose love. Hold tight to it, no matter what the challenges. And love will find the way through the challenges that await you.


Reiki Doc

P.S. Labor epidurals are put in by sight and by feel. When you can see the interspaces between the spinous processes, you go there. When you can't see them, you go by feel. The times you can't feel the bony prominences with pressure, you have to guess. Sometimes you go in by bouncing off the bone. You have a mental picture in your head of the space, and recreate it by bumping into the edges around it.
The reason I have a gift for the morbidly obese moms on labor and delivery, is that I have 'the sight', intuition. I go by feel. And also by guidance. I get direction like, 'that won't work there' or a feeling of forboding at different sites. I go for the one that seems 'right'. And that is how I get it. I did a four foot nine inch four-hundred pounder that way. It is never easy. But take away what you see and feel and know, and go in blind...that's where I come ahead of the rest. : D