Womens Health Clinical Reflective Journal

Nicole Rossi
Although I had the exciting opportunity to observe a Cesarean birth during my labor and delivery
clinical rotation, the assessment and admission history questioning of a 20-year-old pregnant woman
(G1P0) taught me a lot and left a lasting impression. It began with introductions, and I ensured that the
patient was comfortable with having me in the room and emphasized that I would leave whenever she
wanted. The doctor performed a vaginal exam while asking about her history with drug use, weight gain
during pregnancy, etc. The exam showed that she was 3 cm dilated and 90% effaced, but contrary to the
patients belief, the membranes had not ruptured. Her abdomen was palpated to find the fundus of the
uterus and fetal heart monitors were put in place. Periodically, the nurse examined the fetal heart rate
trends and the length, frequency, and strength of the contractions and explained the figures to me. During
questioning, the patient stoically admitted to smoking marijuana, abusing prescription pills like
Oxycodone, and using heroine during the early stages of pregnancy. However, she has kept up the daily
consumption of 90 mg of Methadone. Although the patient listed these drug use behaviors, both the
doctor and nurse remained composed and the nurse continued the typical health history questions such as
the patients health conditions and family history, last menstrual period, previous doctors visits and
prenatal regimen, etc. The doctor explained that the baby is sitting in a small amount of amniotic fluid
(oligohydramnios) and has not reached her full growth potential (intrauterine growth restriction). The
mother remained relatively emotionless and soft spoken during the interview. The topic of family support
came up and she stated that she lived with her mother and grandfather, the living situation is stable and
without abuse, she has multiple sisters who offer support, and she has a boyfriend who she is not 100%
sure is the father, but he knows and is supportive nonetheless. She was set on keeping the baby and that
adoption was not an option. Once questioning concluded, the nurse took me out of the room to examine
the urine sample. The urine was foul and immediately came up with nitrates and the patient was given
gentamicin. The GBS culture swab, which I observed in the exam room, came up positive as well.
Outside of the room, the nurses composed expression changed to one of possible upset and disapproval
with eyes wide open and eyebrows raised. She explained to me that the drugs probably caused the IUGR
and that the fetus was sized at 34 weeks when it was actually 38 weeks. This was not a rare occurrence in
the hospital and she seemed slightly surprised that the boyfriend was so supportive of the girlfriend and
the soon-to-be baby, despite the uncertainty of the paternity. It was then that I was sent to the OR to
observe and then care for the postpartum mother during the Cesarean birth.
The situation that I encountered brought about various feelings and reactions. I was thrilled to be able
to observe and connect multiple concepts learned during lecture and was very anxious as to whether I
would get a chance to see this patient deliver her baby during my shift. However, most of the time,
although my outward reaction was one of calm collectiveness, I felt anger, sadness, and worry. Even
though the patient reported a great support system, I wondered if the young age along with not knowing
who the father is would affect the upbringing of the baby. I should not make assumptions, but the patients
emotionless faade could either show lack of concern for the baby, ignorance to the reality of what
changes were about to come, or she was hiding worry herself. I like to think that she does care about the
baby, especially since she is definitely set on keeping her and went through detoxification, but she had
barely any prenatal care so she may not be completely cognizant on what the responsibilities entail. The
boyfriend was quiet in the corner with a stoic yet almost peaceful expression and the patients mother
cried upon seeing her child. These observable relationship dynamics in the room really confused me, but I
truly hope that all of the family members involved provide assistance in addition to the teachings done
within the hospital, so that the baby gets all of the necessary care and attention. I also felt a strong sense
of anger and sadness when I found out that the patient abused drugs and continues to use Methadone
daily. I have seen a NAS baby going through withdrawal before and since then have been disgusted at the
idea that mothers can actually do that to their babies. I understand that they suffer from an addiction and
sometimes are not able to just stop or taper off easily, but it hurts me to see a baby suffer at the expense of

it. That is why I felt so strongly during the admission questioning about drug use, but I realized after
researching Methadone that it is a method used for drug detoxification. I assumed that it was just another
item to the list of drugs abused by the patient, but she actually was seeking help for her drug use. After
my conversation with you about it, I was confused as to why you said that clinics hand out this
medication daily to people, but now I understand and feel bad for my judgmental misconceptions. I was
even more surprised given the 90 mg single dose per day value. However, a study has shown that the
mean dose of pregnant women on Methadone was 152 mg (McCarthy, Leamon, Willitis, & Salo, 2015).
On the other hand, the same study also concluded that multiple divided daily doses were better for the
mother with recovery and withdrawal symptoms and fetus with abstinence syndrome, so maybe the
situation could have been made better for this patient with a different dosing plan (McCarthy, Leamon,
Willitis, & Salo, 2015). The nurses appeared to have the same judgmental view of the overall situation
that I previously held. She had that look of disapproval and shook her head when she came out of the
room and explained to me about the drugs effects on the fetal assessment. I believe that this reaction had
an effect on my own thoughts about the situation, since I look to these nurses for experiential guidance.
During the other segments of the experience, I was very curious and attentive to every detail of the
assessment and tests and wanted to make those connections to lecture and simulation.
I am glad that I had this experience early on in my clinical. It incorporated many of the tests,
assessments, and concepts discussed during lecture. I was able to ask questions and make connections
related to the GBS test, why the baby was smaller than expected and sitting in less amniotic fluid, what
would happen when the mother was Rh negative with and Rh positive baby, and what the nurse was
looking for during the urinalysis. When the nurse asked if the pregnant patient had received her tDAP and
Hepatitis B vaccines, I remembered that these vaccines are safe to give to women during pregnancy.
During positioning of the patient in bed, I knew to slide the wedge underneath the patients right side and
reflected on simulation when we explained that the action would increase the oxygen and blood flow to
the baby. I was able to understand the dilation and effacement values that the doctor announced after the
vaginal exam and was disappointed when I knew that this woman was not going to start the second stage
of labor anytime soon. By knowing and understanding some of these basic concepts concerning the first
stage of labor from class and having the labor simulation, I feel like I was prepared for this experience. I
did not recognize any real differences from the lecture material and the clinical experience that I had.
Overall, I am thankful for being able to observe and learn all that I did during that clinical shift, because it
really helped solidify topics from class.
I really do think that this situation will affect how I handle similar ones in the future. I will not be
so quick to judge drug users, especially when they are actively seeking help. Instead, I will applaud their
efforts to quit and encourage continuation of detoxification so that drugs will no longer be necessary. In
addition, I understand that family situations present themselves in various forms in todays society. A
seemingly discombobulated dynamic could actually be stable. That is why it is important to conduct
assessments, questionings, and refer to social workers to help when the need is identified. The pregnant
patient, just as with any patient, should be examined and cared for with a holistic lens. In the future, I will
try my best to withhold quick judgments, attempt to see the patient for who they are as a person and care
for their individualized needs, and hopefully one day be a super nurse.

References
McCarthy, J.J., Leamon, M.H., Willitis, N.H., & Salo, R. (2015). The effect of methadone dose regimen
on neonatal abstinence syndrome. Journal of Addition Medicine, 9(2). doi:
10.1097/ADM.0000000000000099