Another way

I’ve been feeling pretty burned out lately. Just mentally and physically exhausted, and feeling very disenchanted with midwifery at the moment. My first year of midwifery school is over, and two things have happened. First, I can’t shake the terrible, in-my-gut feeling that I really don’t know much of anything yet, that everything I learned this past semester I need to re-learn again. And fine, I can do that. I can spend the summer playing catch up, because I really want to know this stuff, inside and out. My grades were good, but now, two weeks after the end of school, I am already forgetting whether megaloblastic anemia means hyperchromic and macrocytic, or hypochromic and microcytic. At one point this semester I knew the treatments for every STI under the sun, and in some cases the alternative CBC regimens as well, but these days I can only recall a fraction of it.

But even more than just the details, I have been growing more disenchanted with what I have discovered midwifery to be—at least, the midwifery I have experienced so far as a student. When you’re an idealistic, starry-eyed student who loves birth and has been longing to go to midwifery school for years, your expectations are naturally sky-high, and I guess it’s understandable that few programs or experiences will be able to live up to that. Which is not to say that my program is bad in any way, or is not giving me the information and training I need to become a good midwife someday, but it’s not exactly all I dreamed it to be. And the midwifery care I have experienced so far in my clinicals is not exactly all I dreamed it to be, either. The clinic I was working at was amazing in so many ways, and yet so inadequate in other ways. Time was the biggest barrier for me: I never seemed to have enough of it, even as a student when I was already taking too long on all of my visits. There always seemed to be too many patients to see, and a cookie-cutter approach to their care. And here I keep running into a conflict that I can’t quite resolve: I long to be able to give women competent, individualized care, care that has time to ask them about how their week has been, and work on diet and nutritional counselling, and go over their birth plans and thoughts and expectations for the birth, pain management, checklists for the new baby, etc. etc. …and there are certainly many midwives who practice like this, usually in private practice. But then, there are other midwives who will tell you that having too little time to give is just the nature of the game: that’s reality, kiddo, better suck up and learn how to deal. And the clinic I was working at was giving care to disadvantaged women who would otherwise have far inferior care through other methods, and even though aspects of their care were lacking, on the whole they were getting an amazing package, and midwives were really making a difference in their lives. So who am I to harp on cookie-cutter approaches and lack of time when these women were getting perfectly adequate care—nay, better than adequate care? And yet, that still isn’t the kind of care I want to give, and not how I thought midwifery would be.

I wonder, too, how much of this comes from my current job as a nurse in a hospital where women are just churned through the system, in and out—epidural, SROM, pitocin, push, okay, next—with no thought or attention paid to the miracle of birth. Most days, at work, I feel like a zombie. I do things I don’t believe in, uphold protocols I don’t agree with, help run women through the system like cattle, and all the while there’s a wall in place that’s keeping me from feeling any of it. I was reading a post by Navelgazing Midiwife where she discusses many of the cruel and horrific things which are done to women by their care providers during labor and birth, and I have seen so many of the things on that list done by health care providers in hospitals to women, and as a nurse, I have personally done some of those things on the list myself, such as holding womens’ legs while they’re pushing, or holding womens’ chins to their chests while they’re pushing, or encouraging them to push using a valsalva manuever. Often this is needed because these women have epidurals, and are unable to feel the contractions in the first place, but also it’s happening because that’s the only way doctors and nurses know how to push and deliver in the hospital, having never been exposed to any positions other than lithotomy.

I’ve been slowly growing more and more disgusted with the hospital system. For a long time now, I’ve been able to justify my work in the hospital as worthwhile and helpful because 1) women in hospitals are so disempowered in the first place that ANY act of love and kindness makes an enormous difference there and 2) the majority of women, for better or worse, labor and birth in hospitals, and it’s important to me to try to reach and help women who don’t even know they need or want help in the first place. I’ve always thought that the women who choose to birth in a birth center or have a homebirth have already taken bold steps to protect themselves, their bodies and their babies from unnecessary and maleficent (i.e. the opposite of beneficent) acts, and that in choosing such a thing, they have already educated and empowered themselves to a level that many women who choose hospital births never reach. So, I have justified my work in the hospital by reminding myself that I am able to reach the largest number of women possible, and help women who may not have had the chance (for whatever reason) to educate themselves, or are at a pre-contemplative stage, and haven’t been able to even think about other options; for quite awhile, now, I have been telling myself that just being there at births like this, as a pro-woman advocate who can try to minimize the interventions, or add a touch of humanity to an otherwise disempowering experience, is a worthwhile and meaningful endeavor.

These concepts have sustained me for almost three years now, but lately, I am really beginning to have second thoughts.

Case in point: the doctor orders pitocin because he doesn’t want to have to sit around all night waiting for the woman to give birth according to her own body clock. He’d rather be at home, sleeping in his bed; pitocin will speed up the arduous waiting process (and here I am, thinking the waiting process is a beautiful part of the mystery of birth—but clearly, I’m deranged) . The woman doesn’t need pit, and giving her pit is going to make her labor go more quickly, sure, but it’s also going to make her labor more intense, so that she’ll probably be begging for an epidural before too long (and epidurals cause an enormous cascade of interventions which irrevocably change the course of labor…and so many women come in asking for an epidural before they’ve even started active labor). Pitocin is also going to put her baby at increased risk for fetal distress as the little one is often exposed to enormous contractions that the woman’s body would otherwise have NEVER been able to generate on its own. Pitocin causes water retention and keeps the body from processing glucose as efficiently as it otherwise would…which is not so useful when a) the woman’s body is doing the equivalent of running a marathon, and needs to process glucose as efficiently as possible (forget the fact that most of the woman in the hospital aren’t allowed to eat during labor, and are trying to run a marathon on no glucose at all…we’ll go there later), and b) the near-mandatory IV in the hospital, and the fluid bolus that is necessary for an epidural, among other things, makes it almost unavoidable that the woman is overloaded with fluid, which the pitocin and its inevitable water retention, is just going to make worse . Pitocin more often causes more harm than good. I KNOW this, and yet…the doctor orders pit, and I dutifully go and get the pump, and begin the process.

I am complicit in making these womens’ labors longer and more difficult. What’s more…I have developed complex methods for accepting the rationale for the pitocin. I have caught myself agreeing with a doctor’s reasoning for why such and such woman needs pit. And this is just one small aspect of labor and birth in the hospital which I am complicit in! There are thousands of other acts as well. I am the one who hands the doctor the internal, invasive monitors. On occassion, I have even asked a doctor for an internal fetal scalp electrode, just so the woman who is on continuous monitoring but is wanting to avoid an epidural can actually move around, and dance, and squat, and not have to stay in bed the entire time in a position that allows the external FHM to pick up the fetal heart. I know that studies have shown that external fetal heart monitoring has a 60% false positive rate, or something outrageous like that, and that the monitors can show distress when in actuality the baby is fine. I know that studies that have found that intermittant monitoring with a doppler is just as effective as continuous monitoring, and that the continuous monitoring doesn’t improve outcomes at all, it just increases the cesarean rate. I KNOW this, and yet, I have had to enforce continuous monitoring on couples that didn’t want it. I have held women’s legs apart while the doctors cut episiotomies against their protests. I have tried to help these women accept such acts, and come to terms with them, and grieve and mourn for the labor they wanted but weren’t able to have…but is this really helping women at all?

I have had to explain and justify the hospital’s sick protocols to couples I should have been protecting. I’ve told starving women in the middle of 30 hour marathon labors that no, they can’t actually eat anything except ice chips, because the order says NPO (nothing per mouth), and as a nurse working in a hospital, I am legally bound to follow orders. I have tried for years to convince myself that I am trying to fight this terrible system, but in truth, I am beginning to see more and more that so long as I work FOR the hospital, I am just a cog in its soul-devouring wheel.

I am continually amazed and saddened by the sheer number of women who come to hospitals to give birth, some of them even knowing full well what they’re in for—such a small number of women find or even want anything else. I am astounded that women allow such things to be done to them in the hospital. I am saddened that so many women are willing to subject themselves to such treatment, and so few of them know to ask for anything else. Where are we going wrong when it comes to education and informed choice? How is this status quo perpetuated? I am discouraged (though no longer surprised) that when homebirth comes up in conversation, people will tell me that such acts are dangerous and selfish and uncivilized, and yet…they’ll allow providers to ignore their desires, talk over their protests, disregard their questions, disempower them, laugh at their birth plans, walk all over them, tell them what they need/want, physically hurt them and their babies, pursue courses of action which several studies have shown are harmful or dangerous, drag babies out with forceps, insist on unnecessary cesareans, cut episiotomies, push pitocin, urge induction, refuse to allow a VBAC…the list could go on and on. I have seen so many HORRIFIC things in the hospital, and much of it being performed on women who are more than happy to submissively let it happen.

And there’s the rub, isn’t it? Because for a lot of women, a hospital birth is exactly the kind of birth they want. And if they’re happy with this, then who am I to try to intervene and impose my own sense of what makes a good birth on them? I may tell myself that I am working to help protect women who may not have received all of the information necessary to make an informed decision about the type of birth they wanted, but if they HAD received enough information, perhaps they would have chosen a different kind of birth…and sure, there are plenty of women out there who fall into this category. But then, there are plenty of women out there who DID receive all the information they needed to make an informed decision, and having done so, chose to have a hospital birth.

And that is their choice, certainly. But these women don’t need advocacy from a nurse like me. My passions and ideas, all of the energy and love and support I want to offer to laboring women—all of it is wasted in a hospital. I am beginning to think, more and more, that me, personally…who I am, given what I believe about birth…that I won’t be able to work within the hospital system for much longer. I want to go outside the system and promote a vision of labor and birth in this country that has absolutely nothing to do with hospitals and their sick protocols, or active management, or pitocin drips, or continuous monitors. Lately, whenever I go to work, I find myself thinking: how in the world could people ever really want to have their babies here? Just the rooms alone…so sterile and inhospitable, despite the hospital’s attempt to make them more palateable with wood panelling or whatever. You’re still giving birth in a fishbowl, full of icky equiptment, in lithotomy position nine times out of ten, with your feet in stirrups or held by the nurse (me) and your partner, flat on your back, in the glare of bright lights, while someone gowned head to toe in sterile blue, with a mask on, and gloves, “delivers” your baby for you then hands it off to a pediatrician to suction to kingdom come.

Yes, I know this post is taking quite a departure from my normal lines of thought, and may even be pushing me so far out on the “radical fringe” that many of you, my loyal readers, won’t even be able to understand where I’m coming from any more…and yes, I usually have a much more positive and chipper spin on birth and midwifery, and am ready to fight the good fight. But lately, I’ve been feeling too disenheartened to fight much. And I guess in my attempt to chronicle my journey towards midwifery, it’s as important to capture the downs as much as the ups. There are choices and options available to women which exist outside the hospital, and I want to be able to offer these to women as a midwife, but from where I’m standing as a student, I have no idea how to even get there. I’ll graduate and get a job wherever I can find a job (IF I can even find a job as a midwife) and this will most likely be in a hospital, since the majority of jobs for midwives in this city are in hospitals, and very few midwives fresh out of school with no experience are ready or able to move into private practice directly. So, hospital midwife, hi ho, hi ho. I know I have to start somewhere and gain experience somewhere, and I guess it’s better to know the system inside out before you move beyond the system, but my heart is sick atm, and I find myself enjoying my shifts on postpartum so much more than labor and delivery lately, because at least in postpartum the trauma is done, and all you have to focus on is healing, and the joy of the baby.

I’m really hoping that my Birthing From Within childbirth education classes at the end of the month are as rejuvenating as I think they’ll be, because I really need some rejuvenation.