Belly Tales

I just finished 12 pages of module notes on the common discomforts of pregnancy and non-pharmacological ways to alleviate them, and I noticed a common theme: almost everything seems to be caused by the pressure/weight/size of the enlarging uterus. Varicose veins during the 2nd and 3rd trimester? The enlarging uterus increases the pressure on pelvic veins when standing, which thereby impairs venous circulation and increases venous pressure in the lower extremities. This compression then leads to dereased blood return to the heart, which then leads to congestion of blood in the peripheral veins, and voila, you’ve got varicosities. Hemorrhoids? Same thing. Pedal edema? Same thing, with the added caveat that the increased peripheral congestion leads to increased fluid building up in the cells of your lower extremities. Low back pain? The weight of the enlarging uterus strains the lumbar vertebrae and supporting back muscles, especially if the abdominal muscles are weak. Round ligament pain? The poor ligaments are stretched to their utmost to accompany the enlarging uterus. Heartburn? The enlarging uterus has compressed the functional capacity of the stomach, and deplaced it upward (of course, high amounts of progesterone also contribute to relaxation of the cardiac sphincter, and decrease gastic motility, which then leadsto increased reflux). Leg cramps? Enlarged uterus imparing circulation on blood vessels and pelvic nerves as they travel to the lower extremities (that’s one theory, anyway). Hyperventilation and shortness of breath? The enlarged uterus has compressed the diaphragm and elevated it 4 cm by the end of the 3rd trimester, and although your thoracic diameter widens slightly during pregnancy, it can’t quite compensate. Supine hypotension? Avoid lying flat on your back, because the weight of your enlarging uterus will compress the inferior vena cava and abdominal venous tree, and many women pass out from the resulting arterial hypotension. Increased urinary frequency? You guessed it. Me large uterus, me crush puny bladder beneath me. Mwuahahahaha!

Yes, it’s true: our organs, bones, ligaments, muscles etc. etc. are all carefully designed to support a pregnancy, but you know what? Just barely. I didn’t realize how “just barely” all of it was. By the third trimester, it seems that a woman’s body has pretty much been stretched to its absolute maximum. It’s hard, hard work to carry an extra 30 pounds of concentrated weight right out in front of you for the three interminable, uncomfortable months at the end of your pregnancy. And I’m sure your response to this post will be: well of course, duh. And yes, of course, duh. But wow. Thank goodness babies are born at the end of the 3rd trimester! If there was a 4th trimester, I’m not sure women’s bodies would make it (which is of course why they’re born at the end of the 3rd trimester). But seriously, wow. Can you think of a more perfectly designed system? Really, it just absolutely blows me away, the more I learn about it.

If my mother were still alive, I’d go find her and give her a hug right now, just for getting through that third trimester with me.

It seems too perfectly poignant that Coretta Scott King should die the same day that Judge Samuel A. Alito is confirmed to the Supreme Court by a vote of 58-42. In Coretta Scott King’s death, we see the end of an era of moving towards increased freedom and civil liberties, and now, with Alito on the bench, I’m sure we’ll be seeing the start of a new era determined to limit personal freedoms and civil liberties, especially in the realm of women’s reproductive choices. I’m not sure if the Court will actually overturn Roe v. Wade, but I wouldn’t be surprised if they made rulings that give individual states a lot more freedom in terms of restricting abortion, or put other restrictions in place that substantially hamper and hog-tie Roe.

I’m sure there’s a bright side to all of this somewhere, but today, it’s pouring rain (literally and figuratively), and I don’t have the heart or the energy to find it right now. Things are going to change—they’re already changing, and have been changing for quite some time. I guess all we can do is vow to continue to fight for what we believe in, and then DO EXACTLY THAT. To quote Senator Barack Obama of Illinois: “There’s one way to guarantee that the judges who are appointed to the Supreme Court are judges that reflect our values. And that’s to win elections.” November, 2006.

This is shamelessly snatched from Birthing Bliss, but once again, it was too good to ignore. Massachusets has taken a bold step towards getting rid of the dispicable formula habit by actually banning hospitals from handing out free diaper bags full of advertisements for formula to new parents, and thereby sending the subtle message that formula is hospital endorsed and oh-so-good for your baby. The full article is here, at the Massachusets Breastfeeding Coalition. All I can say is: Go Mass! May 49 other states follow your example, ASAP!

Our midwifery department arranged a special treat for us today: a demonstration of the brand new speculum that’s out on the market, FemSpec.

Looks pretty strange, doesn’t it? Has anyone ever used one of these things? Supposedly it works much better than a regular speculum because it doesn’t allow the vaginal walls to collapse inward and obstruct the view, it’s always warm, always sanitary, and a lot softer, more comfortable and less threatening-looking. It’s inserted like a tampon, and then inflated once it’s inside the vagina like a blood pressure cuff. Nifty, ultra-luxe, and definitely designed for private practices that can shell out for the more expensive, new product.

We all got samples, and I gave mine a whirl. My overall impression was that on your average nulliparous woman with an anteverted uterus, this probably works like a charm…but what about women with deeply posterior cervices and retroverted uteri? And the FemSpec is opaque, so how are you supposed to get a good look at the vaginal walls, while you’re in there? The sales rep insisted that “the doctor” will have no problem visualizing the vaginal walls during removal of the FemSpec, but I’m not quite convinced. She also assured us that the extra lever that comes with every FemSpec means that “the physician” will have no problem visualizing those posterior, hard-to-reach cervices. She kept using the pronoun “he” as well.

I’m sure on some level she must have realized that she was talking to a room full of midwives and future midwives, but maybe she was nervous, and unable to deviate from her script, and it just didn’t quite click in her brain. Maybe she had no idea that saying doctor all the time might not fly so well in a room full of midwives who do paps just as often as docs. Maybe she’s just a new, young saleswoman who hasn’t yet learned that you court whatever audience you’re giving your pitch to. In any case, it kind of rubbed me the wrong way.

I’m still hardly competant at using the conventional speculum, let alone the new one. It will be really interesting to see if these actually start to infiltrate the market, and which clinics (if any) will begin to use them. As for me, I’m reserving judgement until I have an opportunity to actually use one in a clinical setting, but a note to FemSpec: teach your sales reps that midwives and physician assistants and nurse-practitioners and sometimes even nurses ALL use speculums, not just doctors. A more all-inclusive sales pitch might actually improve your sales.

The IUD, I’m beginning to learn, is a much maligned form of contraception. It got a terrible reputation in the US because of all of the furor surrounding the Dalkon Shield in the 1970s, however, the two modern versions of the IUD (ParaGaurd, aka The Copper-T, and Mirena, aka The Hormonal One) are actually safe, effective, more or less painless, and for many women, an ideal form of birth control. In fact, IUDs are one of the most popular forms of birth control in other countries—in most of Europe, actually.

Which is all well and good. In fact, great! Go IUDs. I will happily recommend them to all of my clients who want a no-fuss, highly effective, low cost (expensive at the outset, but cheap given that they last 5-10 years), low side-effect contracetive choice—especially my clients who have already been pregnant once. Nevertheless, tenaculums give me the heebies. The teeth of these gruesome little things are actually inserted into the tender flesh of the unsuspecting cervix, and then the instrument is gradually secured, one click at a time, followed by gentle traction in order to straighten out the axis of the uterus so that the IUD can be properly placed (and we spent most of the afternoon practicing this skill on models). And while I am well aware of the fact that supposedly the cervix has very few nerve endings, and antiseptic washes followed by anesthetic gels are applied before the tenaculum, and the entire procedure is done slowly and gently, one step at a time…even so: my initial reaction was a full-body grimace, and the mental thought of OUCH. Ouch ouch ouch. Poor cervix!

However, don’t let this bias you against IUDs! Insertion is not without its discomforts (usually cramping for the first few hours, which can be managed by a trusty dose of advil or motrin), but luckily, as a consumer of IUDs, you never have to watch the actual insertion process. As a student midwife, watching will probably be the least of it—actually using a tenaculum?? It makes my hair cringe just thinking about it (and the professors had the cheek to say, with eager, chipper voices “Hopefully you’ll get several opportunities to insert IUDs during your upcoming clinicals!”.) Yeah.

I. Can’t. Wait.

Yesterday was Everything You Ever Wanted to Know About Hormonal Contraception Day, EVAR. Yes, truly. Everything. We staggered out of class at the end of the day with pressure ulcers (read, bedsores) on our ischial tuberosities (read, butt bones), and heads that felt rather like over-full waterballoons ready to burst, or maybe gigantic blisters ready to pop, or huge, overstuffed armchairs that are slowly leaking fluffy white stuffing out of a tiny tear in the upholstery. And yeah, don’t get me wrong: hormonal contraception is way cool, but maybe not 6 straight hours of it in a row.

Today was a bit more varied. We began the day with antepartum vaginal exams and ended the day with our microscopy check-outs, with a 2 hour lecture on abnormal pap smears thrown into the middle for good measure. Management of abnormal pap smears: wow, there’s a lot to know about that (note to self: CONSULT!!). Microscopy: will be a lot more fun when we actually get to examine real yeast and BV and trich, instead of perfectly healthy vaginal secretions which just aren’t that interesting to look at (healthy vaginal epithelium, for example, just sort of sits there, whereas real live trichomonads actually swim around and wiggle! …). Vaginal exams: uh…well…good in theory, but I really have no idea.

It’s amazing how much of midwifery is in the dark. So little of your knowledge is gathered and assessed with your eyes; you “look” with your fingertips. Thing is, my fingertips are absolutely blind right now. They know nothing. I’ve done maybe three vaginal exams in my entire life. We talked for a good long while about effacement (the thinning out of the cervix) and dilation, and how to assess both, and how difficult it can be to even tell where the cervix is when it’s 100% effaced and paper-thin. Our instructor kept describing scenarios to us where we’d need to know to look for this, or know to check for that…where the outer os of the cervix might be open, but the inner os closed, how we’ll know that what we’re feeling is ruptured membranes versus intact membranes with the water displaced behind the head—she talked so confidently, and with such assurance, and she spoke as if it were all so simple.

Yet how can she lecture to us about the subtle differences between rim and fully dilated when we’re probably not even going to be able to tell the difference between 2 cm and 7 cm, or 50% and 100% effaced? It’s all a Mystery to me. Staring at my professor today was like staring at someone across a great gulf: I could see her there on the other side, brimming with her hard-won knowledge, talking matter-of-factly about things that seemed so straightforward to her, but to me, the uninitiated, it seemed like I’d never get to the other side. When I examine a woman’s cervix, let me assure you: I have no idea WHAT in the blazes I’m feeling! I have no idea when vaginal exams are going to start to make sense: 6 months from now? Two years from now? When will I be standing on the other side of the canyon, explaining the subtle differences between 0 station and +1 station? I have a feeling it will be a bit like learning a new language: you struggle, and struggle, and struggle, and then, one day, you overhear two people talking on the subway in that language and realize you just understood every word they said.

But first, the struggle. Clinicals are going to be a blast, aren’t they? You gotta love it when the learning curve is an 85% incline, straight up.

If I could wish for anything for this site this year, it would be a brand new, shiny banner that actually features a belly, or something pretty and birth-related like that. I think I’ll make that a goal for this year: get thyself a new banner! Enough with the daisies already.

Today was devoted to the flora of the vagina: what’s normal, what’s not, what happens when yeast decides to take up residence, or when the lactobacilli flee in droves, or when all sorts of unfriendly sexually transmitted diseases invade. Our professor referred to the vagina as the secret garden, and that’s such a beautiful name for it that I think I’m going to have to steal it and start using it myself. It really IS a secret garden, full of amazing quantities of healthy bacteria that keep the pH nice and low, self-clean and prevent unfriendly bacteria from taking over: such a delicate, yet tenacious, balance. Honestly, the more I learn about the female body, the more amazed I become. We’re so friggin’ cool! I already thought we were cool before school even started, but now the coolness quotient is somewhere up near the “awe” level. I can’t wait to become a midwife and teach other women about just how cool their bodies are. What a dream job.

You know you’re in midwifery school when you find yourself examining your own vaginal secretions under a microscope during your class on microscopy. All of us dutifully trooped off to the bathroom with our Q-tip swabs to collect our specimens, then hurried back to the classroom to make our slides—there were a few nursing students in the hallway watching us with puzzled looks on their faces. It reminded me of the time last semester when a fellow student got told off by a nursing instructor for washing her speculum in the bathroom sink after the peer pelvics. You’d think that by now they would have gotten used to the whacky midwives they share the 7th floor with. Anyway, in theory, I can now distinguish between yeast buds, trichomonas and bacterial vaginosis under the microscope, but thankfully, the only thing I saw on my slide were normal squamous epithelial cells from the walls of my very own secret garden.

The curse, the red tide, my period, my monthly, my friend, on the rag, on the spurt, and on and on. All the jokes, all the whining, all the bitching, all the unfair media portrayal, the cultural stigma, the fear, the shame…menstruation gets such a bad rep that, at the very least, I felt it deserved to be paired with a word like “magical” for a refreshing change of pace, if for no other reason than its very complexity. Do you have any idea how many hormones are involved in your monthly menstrual cycle? Take a guess: 2 hormones? 3? 4? I can’t even tell you. Our lecture today covered the ups and downs of the 5 major hormones that are involved, but the lecturer kept slipping in little comments like: “and of course, prostaglandins, and inhibin, and [insert other hormone names that I wasn't even able to catch] also play a part, but I’m not going to get into that today.” Damn straight it’s magical. It’s absolutely amazing! If we ever tried to reproduce the entire cycle in a laboratory setting, there’s no way in hell we’d ever be able to get it right. Do you have any idea how many things are all happening at once? It’s a bit mind boggling.

Mind-boggled. Yup, that’s pretty much how I feel right now. This semester is going to be a TON of work. I have so much on my plate already that I don’t even know where to start (hence, this delightful post: why start in on your homework when you can procrastinate and post to your blog instead?). And as for the menstrual cycle…this is something we studied in nursing school, and I had a hard time grasping it then. This is something I’m going to have to go over again and again and again until I know it forward and backwards, because it’s so damn important (and so damn complex). This is the reason and the beginning, the why and the how, of pregnancy. The hypothalamic-pituitary-ovarian axis, the follicular phase, the proliferative phase, the secretory phase, the luteal phase…all these names for something that your body does automatically, naturally, without fuss and often with very few mistakes, every single month for most of your adult life.

Lecture today was great. The guest lecturer was smart and sassy and a lot of fun—material that could have been really boring was actually made fascinating, which says a lot. And lots of little fun facts tossed in for good measure. For example, did you know that bleeding is not actually necessary at all during the cycle if you’re on birth control? Because of the presence of progesterone from the very beginning of the cycle, the lining of the endometrium doesn’t ever proliferate very much at all, but just stays steady at about 2 mm of development, and can stay that way for quite some time, if you ever want to just go through a few pill packs back to back and skip the week of placebos that allow for bleeding. In fact, apparently the only reason the placebo week was structured into the pill cycle was because of a decision made by a very Catholic man in the 1950s, who felt that monthly bleeding was necessary in order to help remind women of Eve, and the fact that they’re women, I guess. There’s a new pill out now that will charge you an arm and a leg for the privilege of only bleeding four times a year (Seasonale), but you might as well save some money and just take your regular pills back to back (although talk to your midwife/health care provider about it first, of course).

Another interesting fun fact: the Morning After Pill (aka EC or Emergency Contraception) really truly IS birth control, and not an abortifacient, and yes, I already knew this, but now I understand why. EC is basically just pure progesterone, and it works best during the follicular phase of the cycle, where the sudden burst of incoming progesterone is enough to prevent the release of leutenizing hormone that triggers ovulation. In other words, EC works best if it’s taken before ovulation occurs, in order to prevent ovulation. However, if ovulation has already occurred, the surge in progesterone may slow down fallopian tube motility and therefore possibly prevent implantation (in which case, I guess I could see how conservatives could potentially argue that this prevention of implantation is in fact the killing of a baby, but I do think it’s a rather thin argument). However, the little fun fact I didn’t realize is this: as soon as you’re pregnant (i.e., as soon as the trophoblast has implanted), the corpus luteum begins to make progesterone in vast quantities, and if you happen to take EC at this point in the cycle, it won’t disturb or prevent the pregnancy in any way whatsoever. In other words, if you’re already pregnant (i.e., the trophoblast has already implanted), EC does not end or harm your pregnancy in any way. In other words, it’s NOT an abortifacient. As soon as that trophoblast implants, the corpus luteum is working its ass off to produce massive amounts of progesterone anyway just to keep the pregnancy afloat until the placenta can take over hormone duty; a little extra squirt of EC progesterone at this time does NOTHING to disrupt this. FYI. (Why do I feel that if more people actually understood how EC worked, so many of the objections to it would just disappear, and the FDA might finally get around to approving it for over-the-counter use? Righto. Get the word out, ladies.)

Who are these men who love and date and marry midwives (and student midwives)? What an amazing breed! They don’t flinch or grimace when they hear words like “vagina”, “uterus” and “cervix” being bantered around the dinner table, they let you gush on and on about the beautiful birth you saw the night before, and they aren’t too miffed when you stop dead in your tracks to oggle the beautiful pregnant woman walking by. My own beloved boy is of this variety, and I am a lucky woman indeed. He knew absolutely nothing about homebirth when he first started dating me, but now he’s become a fierce advocate. He sometimes pumps me up for work on the days when I’m not in the mood by chanting “bellies, uteri, vulvas, babies” until I finally get excited again. And he buys me really cool books for the holidays, like Peggy Vincent’s Baby Catcher, which I just finished devouring during my flight back from England.

It’s a fantastic book. I mean, seriously, what a fun book! By the end of it, you feel like you’ve known Peggy Vincent for most of your life, and it really makes you want to just find her telephone number and call her up and chat with her (or, in my case, call her up and beg: let me be your apprentice for a year, I’ll cook all your meals, I’ll clean your car with a toothbrush, I’ll sleep on your floor, pleeeaaaase!!). The book begins with Peggy in nursing school, then follows her through several years as a labor and delivery nurse, a birth educator, a student midwife, and finally a homebirth midwife with a busy private practice. She has a very sharp memory, and the writing is descriptive and lovely, and it’s a really fast and easy read; you’re sucked in before you even know what hit you. The narrative is centered around the retelling of birth stories, and the myriad adventures Peggy had as a homebirth midwife, but there’s plenty of commentary tucked in as well. The book ends on a somewhat subdued note, as Peggy is sued by a woman that she wasn’t even officially delivering, and ends up losing her insurance just because she was involved in the first place, even though she didn’t do anything wrong. Sadly, this loss was echoed on the national level in 1991 when CNA Insurance, the insurance carrier for all certified nurse midwives in the US at that time, withdrew coverage from all CNMs who attended homebirths. While the ACNM now provides reasonably priced insurance for homebirth midwives, there are still so many barriers in place which prevent licensed midwives from attending homebirths, with our without insurance. Just look at the midwives in the capital region of NY, my own homestate: licensed, but still having to practice “bare” and undercover. Our society is always so quick to blame and mistrust the midwife—and homebirth midwives especially. Even if she did everything right, even if she was just standing in the room during a bad outcome while someone else was doing the delivery, I’m sure the lawyers and doctors and insurance companies would find a way to penalize her.

I’ve strayed somewhat, though. The point I was trying to make is that Baby Catcher is great! Just to give you a sample, here’s one of my favorite quotes from it:

I remembered my midwifery school classmate, Gaia’s, comment: “Just think about it. As midwives, we meet wildly interesting people and stay up all night with them. We ask them questions about their sex lives, eat their food, feel inside their bodies, snoop around their houses, drink champagne at all hours, and best of all, we get to catch delicious little naked, wet babies. What I can’t figure out is, why doesn’t everyone want to be a midwife?”

My thoughts exactly! And now, I’ve got to hit the sack. Tonight is a school night, and the new semester begins TOMORROW!!