Elizabeth Archibald

02/06/2018

The role of the certified nurse midwife nurse practitioner (CNM, NP) is to be a supportive
advocate for patients regarding reproduction, and throughout prenatal, intrapartum, and
postpartum care. The CNM see patients that need birth control prescriptions, prenatal care, and
postnatal care.

Some of the tasks that Shilo takes, include:

 Examining patients
 Prescribing medications
 Instillation of IUD’s
 Coordination of care (annual pap smears, routine lab work, growth ultrasounds)
 Teaching
 Referrals (ECG, stress test)
 Home birthing
 Birthing support when mother goes north to Coos Bay
 Postpartum care, including: well baby checks, and breast feeding counseling.

The medical assistant is responsible for getting the patient checked in, vitals/weight taken, and
urine dip performed. The medical assistant relays any questions or concerns that the patient
may have as to prepare the practitioner.

For a pregnant woman, all the vitals are very important, but the most important are a weight
check, and blood pressure. Additionally, at each visit the mother will perform a “urine dip,” to
check for protein and glucose.

The weight check is to ensure that the mother is gaining adequate weight to support the baby.
The blood pressure, and proteinuria is to screen patient for pre-eclampsia, and the glycosuria is
to screen for gestational diabetes.

Preeclampsia: This is high blood pressure in the mother. Signs of severe preeclampsia include:
Headaches, blurred vision, inability to tolerate bright light, fatigue, nausea/vomiting,
urinating small amounts, pain in the upper right abdomen, shortness of breath, and
tendency to bruise easily.

It is important to monitor for preeclampsia because it will reduce blood and oxygen flow to the
placenta/baby, and could lead to eclampsia (seizures). The only cure for preeclampsia is delivery.
(1)

Gestational diabetes: The kidneys can only filter a certain amount of glucose. When CBG levels
reach above 160 mg/dL, the glucose will be evident in the urine and indicative of probable
gestational diabetes. This is important to correct, because it can lead to a large baby that could
result in dystocia. Because the baby is used to having excessive blood glucose from the mother,
when it is born it will be hypoglycemic.

The first patient that we saw was scheduled for a depo injection. Upon talking to the patient, it
was discovered that the patient was unhappy with the weight gain that she had experienced (10
pounds in 11 weeks) and wanted to discuss different options. The patient did not want to take
an oral contraceptive (for fear of forgetting), and did not want anything artificial in her body (I.E.
Nexplanon). The practitioner discussed different options, including: the patch versus, NuvaRing.
It was discussed that the birth control patch is placed on the skin on the front or back of your
body closest to your reproductive organs. One patch is worn for 7 days. Every 7 days the patient
is to change to a new patch, and after three weeks, the patient is to go patch free for 7 days.
After 7 days of being patch free, the patient is to put on another patch. This patient has very
painful periods. For her, the practitioner stated that she could go 9 weeks without going patch
free, but that is the maximum amount of time allowed. The main side effect to watch for with
the patch is skin irritation. Next the practitioner discussed NuvaRing. It is inserted vaginally, and
can remain in the vagina for 4 weeks. At the end of the 4 weeks, the patient must remove it for
7 days, and then use a new one for 4 weeks. It is stated that during intercourse the NuvaRing can
fall out. In this case, the patient would just wash it off and then re insert it. With the options
presented, the patient decided to try the patch, and Shilo sent the order for this to Corner Drug
in Gold Beach.

The next patient was present for a prenatal visit. During this time, we performed the Leopold
maneuver to assess how the baby was positioned in the uterus, took a heart rate with the fetal
Doppler (140 BPM), took a fetal height in CM, and discussed the glucose tolerance
test/heartburn/vaccinations. The patient has a poor experience when getting her glucose
tolerance test done, because 45 minutes after drinking the sugary fluid, she vomited. The
receptionists in the office made the call to send her home and reschedule the appointment, but
per Shilo, it only takes 30 minutes for the drink to produce the effects that are needed. They
could have finished the test even with emesis. Zofran was prescribed for the patient for the
follow up. Additionally, Shilo discussed the previous prescription of Omeprazole, and the patient
stated that it was helping with her heart burn. Lastly, the patient was offered a TDAP vaccination.
It is recommended by the CDC that a pregnant woman receive the TDAP vaccination so that when
the baby is born, it already has immunity to pertussis. Discussed risks versus benefits, and
stressed that it is ultimately the choice of the mother. The patient is going to think about it and
decide later.

The third patient was also present for a prenatal visit. During this time, we performed the
Leopold maneuver to assess how the baby was positioned in the uterus, took a heart rate with
the fetal Doppler (140 BPM), took a fetal height in CM, and discussed patient’s history of asthma.
She is on Albuterol BID because the benefits of adequate breathing out way the risks of the baby
being growth restricted. The practitioner and patient decide that due to Albuterol use, it is
important to have a fetal growth ultrasound performed. Patient states that she experiences
tachycardia and palpitations more with this baby than with her second baby. She also states that
she has a history of a heart murmur. Shilo discussed getting an ECG performed or a possible 24-
hour heart monitor. Patient is also experiencing increasing fatigue, but she has not had her
hemagram performed yet. Concluding this visit, Shilo made the appointments for the growth
U/S and lab work, and sent referrals for the cardiac workup.

The fourth patient was present for a postpartum problem recheck. Patient has hepatitis C and
had gestational diabetes. The hepatitis C created an increase in bile acids that were harmful to
the baby, so the baby was delivered early via cesarean section. Patient currently is pre-diabetic.
The excess blood glucose has caused patient to create nipple yeast. She also has a foot fungus.
The patient has been treated with nystatin, and oral fluconazole. Today is a recheck since patient
has been taking medications. The nipples look good, and yeast infection is clearing up as it
should. Shilo looked in the babies mouth too, to ensure that the baby was not getting oral yeast-
she is not. No further recheck needed unless a new problem presents itself.

After clinical appointment, there were two learning sessions with two different groups of women.

The first session talked about round ligament pain, what causes it, and how to prevent it; and
domestic violence with options for help

The round ligament is located on either side of the uterus and extends down through the inguinal
ring, down to the labia. This ligament is stretched with uterine growth and causes pain that one
of the expectant mothers described as “electric crotch.” Ways to prevent round ligament pain,
include: warm baths, curling into a ball, massage, rest, and learning different ways to move.

Oasis Shelter is a Gold Beach based domestic abuse shelter that takes in women, children, and
pets.

The second session discussed postpartum baby blues, depression, and psychosis.

Postpartum baby blues are a normal reaction to exhaustion, and hormonal changes that come
with having a baby. Postpartum baby blues are temporary.

Postpartum depression lasts for an unusual amount of time, and is characterized by:
 Increased fatigue
 Feeling sad, hopeless, and/or overwhelmed
 Trouble sleeping and eating
 Feelings of guilt and worthlessness
 Losing interest in things that you used to enjoy
 Withdrawing from family and friends
 No interest in your baby
 Thoughts of hurting yourself or your baby
(2)
Symptoms of postpartum psychosis are characterized by a loss of touch with reality and
can include:
 Bizarre behavior
 Suicidal thoughts
 Hallucinations and/or delusions
 Thoughts of hurting the baby
 Rapid mood swings
 Hyperactivity
(2)

References:

(1) http://americanpregnancy.org/pregnancy-complications/preeclampsia/

(2) http://americanpregnancy.org/first-year-of-life/forms-of-postpartum-depression/