The worst part of my job

I wrote this post a few weeks ago, but for privacy concerns (as well as emotional reasons), I delayed posting it until now. After reading it, I think you might understand why.

“Incompetent cervix” is a term that I hate. What are you saying to a woman when you tell her that her cervix is incompetant? When the medical diagnosis has “incompetent” in its title, it is virtually impossible to avoid loading that woman down with guilt and failure, no matter how gently you say it, or how delicately you phrase it. What does it mean to be incompetent? It’s such a cruel word. You’re basically telling the woman, on some level, that she’s not good enough, that she did something wrong, that her body doesn’t work the way it’s supposed to, and that she’s incapable of carrying her baby “correctly”. How do any of these subtexts help a woman whose body is dilating against her will, and is already frightened and anxious and confused?? Does anyone stop to consider that maybe, just maybe, all you’re doing is heaping more baggage onto a woman who is already full of pain, doubt and self-excoriation? If a man was unable to father children, would you ever dream of naming his diagnosis “incompetent testicles”?

Last night I had an antepartum patient at 20 weeks gestation who was 3 cm dilated with bulging membranes. She was terrified of losing her baby (this would be her second loss), and she was convinced that it was all her fault. She was blaming herself for working too much (her job required that she spend long hours on her feet), and blaming herself for not coming in sooner (she went for two weeks with mild cramps before thinking to contact her doctor about it), not realizing she was pregnant earlier, not getting prenatal care sooner…she was running through a sad and endless list of guilt and blame and self-torture, and THEN, the icing on the cake, now that she is finally fully aware of the direness of her situation, she’s slapped with the diagnosis “incompetant cervix”—it’s like kicking someone when they’re already down.

I held her hand and brought her tissues and told her again and again that this was not her fault—that there was nothing she could have done to prevent it. I told her that pregnancy is not a fragile condition that requires constant, all-consuming vigilence to maintain, but that in fact, all of this probably would have happened anyway, even if she had had a desk job or had come in immediately when she started having cramps. If a woman is going to miscarry, being on your feet all the time might make it happen sooner, but I don’t think being on your feet will cause a miscarriage in the first place. A cerclage two weeks earlier wouldn’t have necessarily prevented her body from dilating either—in fact, a cerclage might have just made everything worse, since she would then be at risk of ripping the cerclage as she dilates and tearing her cervix on top of everything else. I told her that her cervix just had a mind of its own—it was an independent cervix—and that unfortunately, this is just how some womens’ bodies are. I told her that there was nothing she did to bring this on, and nothing she could have done to keep it from happening, and that it was not her fault. I don’t know if she believed me, or even heard me, but I do think it’s important to say this outloud to someone, even so.

We had her in a steep trendelenberg position (where the feet are elevated above the head, and the body is in a backwards slanting position—this helps take pressure off of the dilating cervix). She was on strict bedrest, using a bedpan when she needed it (quite a feat, to pee while slanting upside down). All to no avail: her membranes grossly ruptured early this morning, and upon exam, her cervix was fully dilated. For better or worse, her body was aborting her baby, and there was nothing we could do to save the baby or keep the miscarriage from happening.

This is the worst part of my job. The absolute worst. I remember once in nursing school I was shadowing a midwife who was circumcising an infant, which was one of the most horrific procedures I had yet witnessed, and I remember saying to the midwife that circumcision must be the worst part of her job. The midwife stopped dead in her tracks and looked at me like I was an idiot, and said: “telling a family that their baby has died is the worst part of my job.” I felt like a complete and total ass.

I wanted to smack the resident who did the vaginal exam right after she’d ruptured. He barely introduced himself to her, put his fingers inside her, had a good feel around, and then refused to answer her point-blank questions, because he didn’t have good news. You could see it in his face right away, but when she asked him if she had dilated more than 3 cm, he wouldn’t answer her directly. I asked him how dilated she was, and he said to me “rim”, but she didn’t know what that meant, and he was gone in a flash, so I was the one who had to sit down next to her and put my hand on her shaking body and tell her the hard truth: she was almost fully dilated, and that because her waters were ruptured, and the baby was only 20 weeks, there was very little we could do for her at this point. She was going into labor, and her baby wasn’t viable.

My shift ended before she delivered. We got her some demerol for the pain, and her husband came to comfort her. I hate nights like this. Even writing about it now I feel like somehow I am debasing it, turning it into something glib, making it seem like it’s all in a days work for your average, industrious labor and delivery nurse, portraying myself as the seasoned veteran who knows how to handle miscarriages—I’m not! It’s never right or normal or okay and I never know how to handle myself. I cry every time. Usually not for the baby itself, but for the family’s grief and pain. My patient and her husband held each other and sobbed, and I just stood there like an idiot, watching them, with tears welling up. My heart and thoughts are with them even now. I don’t know where people get the strength to bear pain like this, but it’s absolutely astounding. I think, actually, that that’s one of the things I like best about my job: we deal with life and death, with miracles, we get to witness the very best in people, see families at their brightest moment, but also see families in their darkest hour, their strongest moment, when they are bearing up under unspeakable pain, and the miracle of that strength is a testament to human nature, and always amazing to watch.

I am getting all sappy and grandiose. I need to get some sleep. It was a very long night.

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