Belly Tales

The first birth was fast, over before I knew it, before I could even shake. And very special—of course it would be special.

The second two babies I caught happened in quick succession in the same morning. One was born at 9:55 am and the other was born at 11:09 am. The first a boy, the second a girl, both beautiful and vigorous and screaming their heads off, Apgars 9/9. Both mothers were unmedicated, which is something I see so infrequently in the hospital these days, and it was so beautiful to watch labor unfold without drugs, without the mothers numb from the waist up and watching TV or filing their nails, oblivious while their bodies heaved through contraction after contraction. No, these two mothers were certainly not oblivious, and it was gorgeous to watch them handle their pain—inspiring, and beautiful in how different it was, and an honor to help them through it.

The first mother was loud. She moaned, she groaned, she flapped her hand up and down quickly in a sharp, flicking motion, almost like she was trying to flick away the pain.  She was a multip, and her labor was like sledding downhill on a snowy day, no way to stop it or slow it down. Her partner was downstairs parking the car, and by the time he came upstairs, the baby had already been born. Vigorous, like I said, but so small for a full term baby—only 4 lbs. 11 ounces. And then she bled, more than I was expecting (although not actually a hemorrhage), but certainly enough to scare me. My preceptor was out of the room as the placenta was delivered and I was mildly panicking; when she came back in, she set me straight (no, that’s not a hemorrhage, but yes, that’s heavy bleeding), and she supported my decision to administer methergine, which I’d already asked the nurse to fetch.

The other new mother that day was very young, a teenager, but very mature for her age, and nearly silent throughout her labor. She had her partner on one side of her, and her mother on the other, and both of them were incredibly attentive. The mother especially, stroking her hair and saying “mi amor, mi amor” over and over. This woman made noise at the peak of her contractions, soft moaning, but in between her eyes were shut and it looked like she was asleep. Very restful. She was a primip, but everything moved right along for her. She progressed quickly, without complications, and delivered her baby girl after only 49 minutes of pushing. She was gorgeous, 7 lbs exactly, but her arm was flexed in utero, and as her anterior shoulder emerged, she extended her arm and made a nice sized gash in her mother’s labia (otherwise, the perineum was intact!), so there was a bit of a repair to do (and labial, ack!). I was very nervous about the repair, because I do feel like the perineum is one thing, but the labia are something else entirely—more personal and more intimate. If I had a choice in the matter, I’d say lacerate my perineum all you like, but stay away from my labia and clitoris, thank you very much! I was very conscious of the fact that we were repairing a vital, sensitive, sensual part of her body, and I really wanted to make sure we got it right, and I think it went okay. My preceptor did the first stitch, then I did the second, and we switched back and forth like that, putting the pieces of the laceration together like a puzzle.

The fourth baby I caught was the mother’s third child, and you could tell that she knew how tiring the first few months (years?) are. She had an epidural, and was determined to get as much sleep as possible before the birth, almost right up to the moment of the birth. We kept trying to wake her up and encourage her to push, knowing that the baby’s head was right on the perineum, and that as soon as she pushed once or twice, the baby would come out immediately. But she wasn’t interested in pushing, she was interested in sleeping, and the epidural was a very good one, so she slept. And we waited, since the tracing was beautiful and there was absolutely no reason to rush. Finally, when she was ready, she opened her eyes, pushed three times, and gave birth to her baby girl. As the head came out, I checked for a cord as I’ve been taught to do every time, and this time I actually felt one, warm and pulsing. There’s a cord, I said, and my preceptor and I tried to stretch it over the baby’s head, but it wouldn’t quite stretch far enough. It wasn’t tight, though, and there was no reason to cut it, so we just pushed it up over the baby’s shoulder, and delivered the baby through the loop of her own cord, and that was that. Nuchal cord management, without the management, just the joy of not having to cut the cord, and letting the baby get the full advantage of the extra blood flow, which studies have shown is so important in easing the transition between intrauterine and extrauterine life. Once the baby was in the mother’s arms, she was wide awake and so alert, examining all the fingers and toes, looking in the baby’s eyes, cooing at her. This is what she’d been saving her energy for, you could tell. I’m glad she was able to get all that sleep.

Four beautiful births, four beautiful babies. I’m a very lucky student midwife, indeed. And this is so much fun! Can I do this more often?? Can I keep doing this for the rest of my life? Pretty please??

Here’s a very interesting article from England which questions the use of routine electronic fetal monitoring.

[Gillian] Smith [Scottish national officer of the Royal College of Midwives] is heading a campaign by the RCM Scotland to reduce the number of unnecessary interventions women in labour are subjected to. She said: “Is routine electronic foetal monitoring required in every single woman? Perhaps they do not need it. Does that then start a string of interventions because the woman is strapped down and can’t move about?”There is research to prove that a woman who is up and about will labour better.

Our campaign is about trying to encourage midwives not to give in too quickly. Research tells us that women who receive one-to-one care are less likely to need analgesia and Caesareans. There is a tendency to perhaps intervene a little earlier than is actually required.”

According to the article, the cesarean rate in England has doubled in the past 20 years, and is now close to the 25% mark (which is still lower than the cesarean rate here in the US). Many studies have demonstrated that intermittent auscultation in low-risk women with healthy pregnancies is just as effective as continous electronic fetal monitoring, with the added benefit of allowing the woman to move around and not be confined to her bed during labor.

From further down in the article (the naysayers point of view, if you will):

Dr David Farquharson, clinical director for women’s reproductive health at the Edinburgh Royal Infirmary, said the practice of electronic foetal monitoring was standard in his hospital to reassure doctors and patients.He said: “This is a very controversial area. A lot of obstetricians do not feel comfortable not having a record of foetal heart rate when the woman comes into hospital.

“The alternative is the midwife listening with a hand-held device, and that depends on her being confident on hearing it.

“The problem with that is knowing what they are listening to, then counting the beats with a watch. There is always the risk you could be taking the mother’s pulse. That’s a worry to obstetricians.”

That last sentence is the kicker there. I ask you this: would a midwife who is well trained in fetal auscultation, and who probably does it on a daily basis, really be so simple as to confuse a maternal heart rate with a fetal heart rate, or be unable to find the fetal heart rate in the first place? Is their trust in the clinical skills of their midwives so low? Is this really the worry that’s keeping Scottish obstetricians up at night?? Please. Distinguishing the maternal heart rate from the fetal heart rate is often a very simple matter of taking the woman’s pulse at the same time while listening to the baby’s heart—if what you’re feeling in the pulse is matching what you’re hearing in the heart rate, then obviously you’re listening to the mother’s pulse and not the fetal pulse.

Fetoscopes can be just as sensitive as electronic monitors, and in some situations are actually better than EFMs for the simple reason that they don’t produce artifact, and there’s actually a living, breathing, thinking clinician on the other end of the fetoscope. Electronic monitors often have built in computer logic buttons which will try to make sense of a fetal heart pattern that the machine doesn’t understand (for example, if there is extreme tachycardia, some EFMs, not being able to understand a heart rate over 200 beats per minute, will automatically halve the heart rate, and the only way to tell for sure is to actually listen to the heart rate itself, i.e. auscultation.) Fetoscopes are also supposed to be used to confirm the presence of supraventricular tachycardia, to make sure that missed and skipped beats are not artifact appearing on the EFM—we were just taught this in class during our lecture on fetal heart rate monitoring. I think the worry really stems from the fact that more and more trust is being placed in machines, while the skills and critical thinking of experienced clinicans is being devalued in the face of technology. Very few clinicians are even trained to use a fetoscope any more, just like doctors are no longer being trained to deliver breech presentations. Sensitive, important skills are being lost to newer generations of practitioners, so that now the standard has become cesarean cesearean cesarean, sometimes because doctors no longer have the skills to do anything but.

I wonder if England can begin to limit the use of EFM, will America follow it’s lead? In our litigious society, part of me seriously doubts it, but I’ll keep my fingers crossed anyway. Go RCM! We’re rooting for you.

This is the simple truth: when life is incredibly busy and overwhelming, and you’re doing all you can just to hold on by the seat of your pants, working through your clinical rotations, attending classes, studying for exams, and also putting in the odd work shift as a nurse so that you can continue to eat…and when life is so damn INTERESTING, and you’re doing amazing things, like catching babies (four so far!!!!) and learning so damn much every day, and falling asleep at night absolutely exhausted, because learning takes so much energy, and 12 hour clinical shifts when all you’re doing the entire time is running around absorbing new information, and trying to make heads and tails of it….well, the point being, BLOGGING is the absolute last thing on the list, unfortunately. Which is a very sad, hard truth, because these are the days—these early, amazing, new days—that I really want to capture on this blog! I can only hope that once a few of these exams are out of the way, I can finally catch my breath…and catch up on the things further down the list (i.e. poor abandoned Belly Tales). Until then, I’ll be catching babies. Bye!

Magic, magic, magic! I’m walking on air right now! Tired, elated, giddy, bouncy, prone to fits of giggling and wide smiles. I caught my first baby today!! Unbelievable. In fact, I couldn’t have asked for a better first day of clinicals. I am so blessed, and so very lucky.

The day started bright and early with report at 8:00 am at the busy Brooklyn hospital where I will be doing my clinical rotations this semester. The hospital is very unique in the fact that there are no residents there, only midwives and doctors. The midwives are employed by the hospital, and basically run the floor, with one to two doctors on the floor serving as back up, consults and managing the high-risk patients. This set up is very similar to the way they do things in England, I do believe. The midwives handle the majority of the births, admitting and watching the patients, writing orders, delivering the babies, and the doctors are there when needed, for difficult cases or emergency cesareans. Another very neat feature of this hospital is the fact that there are no private attending doctors bringing in their patients to deliver. The only women who come to this hospital are women who’ve attended the prenatal clinic run by this hospital. Everyone is a clinic patient, and I think this allows for far fewer inequalities among patient treatment, and far fewer egos and personalities to deal with. The population served is primarily Hispanic and Polish, with a fair mix of Haitans and West Indians as well.

I am pleased to announce that not only was I on time, I was early. Report was a bit chaotic, but the midwifery director was great when it came to introducing me to everyone and showing me around the unit, and really going out of her way to make sure I felt comfortable. While trying to fix the clock on the wall above me during report, she accidentally dropped it on me. In a way, I sort of feel like that was my good luck charm of the day, the ice breaker, sort of as if this hospital has claimed me as its own. I took it as a good sign, small lump on my head and all.

The preceptor I was working with today for most of the day was great. UNBELIEVABLY patient, and very laid back. We spent the morning taking care of three different women who were all being induced for oligohydramnios and were still in early labor, while at the same time keeping our eye on the only woman on the board who was in active labor. By 10:30 she was fully dilated, and after that I spent most of my time in her room, only stepping out briefly to check up on my preceptor, and to draw bloods on a woman in triage. Before I knew it, the head had come down to the point that you could see it in the vaginal opening even when the woman wasn’t pushing, and my preceptor was helping me to gown and glove. The baby continued to crown for awhile, but it just couldn’t quite pass through the vulvar ring, so my preceptor snipped one of the vaginal bands on the right side (these are the tight, stretchy bands of muscle which surround the inside of the vagina—I believe it’s the bulbocavernosus muscle, but don’t quote me on that). It wasn’t an episiotomy; she left the skin of the perineum intact. It was more like a small snip inside the vagina, just to create a little more give. My hands were on the perineum, gaurding and supporting, and occassionally my preceptor put her own hands over mine, showing me where to put my fingers, how much pressure to apply, etc. (I know many midwives advocate a hands-off approach, while many others believe in supporting the perineum. As a student, I was taught to support the perineum with my hands, and as a student I’m in no position to disagree with my preceptor about this, so for the time being, I’ll be delivering this way. But, for the record, the jury is still out, and someday I would like to try a more hands-off approach, just to see how that goes, and then make an informed choice about which method I prefer. But….now is not the time. Now, I’ll do it just the way I’m told, because what do I know? And how else will I learn this?)

Anyway, within three pushes after this, the head was out! I couldn’t believe it! I surprised myself with my calmness, because I’d anticipated absolutely falling apart at this point. Shaking hands, tears, gods only know…However, I think I was too busy concentrating on what needed to be done to even think about the significance of it (that didn’t hit me until later), and I did exactly what needed to be done. I checked for a nuchal cord. I supported the head while it restituted from direct OA to ROT. My preceptor helped me deliver the shoulders, and before I knew it, I had a squirming, very slippery, squalling and dusky pink baby in my arms!!!

Wow.

I dried the baby, placed it on the mother’s abdomen, tried to hold off on cutting the cord for as long as possible, but was eventually instructed to cut it, because we needed to take a sample for cord gases (again, a point of contention, and in my future practice, I hope to someday leave the cord intact until it stops pulsing, but this hospital has a policy that requires cord gases on every baby, and I’m not going to argue with that). And then we waited, for about 20 minutes, for the delivery of the placenta. (As it turned out, not only was there a true knot in the cord, but it was a two-vessel cord, instead of a three vessel cord, which was also supported by earlier sonographic findings. Very interesting stuff, although the baby seemed to be fine, without anomalies or defects, and the sonographic findings also supported this).

After the repair (which went pretty well, though slow, with my preceptor telling me exactly where to put the sutures, and helping me identify landmarks etc.), the woman asked me if it was my first delivery. I told her that it was. She seemed relieved when she learned that I was in fact 29 (she told me that I looked like I was 20). And then I told her that no matter how many babies I caught from here on out, I’d always remember her, because she was my first. And she told me she’d always remember me as well, because I had caught her first baby. And then we smiled at each other in a very special way, and I must admit, this brought tears to my eyes. What a spectacular day!

I also did several vaginal exams, for the first time ever, and was able to identify cervical dilation pretty well, although station and effacement absolutely mystifies me. I placed two doses of cytotec in two of the women who were being induced for oligohydramnios, did lots of explaining and teaching, took a history, did an admission and physical exam….altogether, an absolutely, breathtakingingly beautiful, amazing day.

And now, I’m going to lay my weary bones down, get a brief 7 hours of sleep, and wake up tomorrow morning to hopefully do it all again (and perhaps catch the babies of some of the women I met today who were in the early phase of their inductions, but will hopefully be ready to give birth by tomorrow morning! Woo!)

My IP clinicals begin tomorrow, bright and early, a 12 hour day shift at the Brooklyn hospital where I will be doing my intrapartum clinicals. So, in less than 12 hours, I’ll be on the labor and delivery floor, in my scrubs, a student midwife about to catch her very first baby!!! Nervous? Hell yes! Excited?? OMFG, I can’t believe this is actually happening! *squeeee*

In response to the highly publicized nurse-in at Toys ‘R Us a few weeks ago, Daily News writer Tracy Connor decided to conduct her own test of NYC’s breastfeeding tolerance by nursing her 3 month old daughter in a variety of public places around the city. You can read the entire article over at Hip Mama.

Crosstown bus: We board a M79 at midday, taking a seat opposite the driver. At the next stop, the bus starts to fill up and we get down to business.

The baby wriggles around, exposing a few inches of skin - and all around me, riders develop the kind of glazed-eye look usually reserved for panhandlers and the mentally ill.

Finally, one passenger pipes up, “Can you do that someplace else?” But she’s not talking to me - she’s barking at a man talking loudly on his cell phone.

When we get to the end of the line, the driver tells me I’m his first breast-feeder passenger. He’s not sure what the Transit Authority’s policy on nursing is, but he has his own. “I don’t see no objections to it,” he says.

Overall, it seems that most New Yorkers are pretty cool when it comes to public breastfeeding, although Connor’s nursing prompted an admonishment from a Babys ‘R Us worker, which the corporate spokeswoman was quick to point out went against store policy. Guess they learned a thing or two from their partner company, Toys ‘R Us, but it sounds like their workers could still use a bit more training.

Funny how IP will just knock the wind out of you. You wake up on a Friday morning and realize that it’s been National Midwifery Week ALL week, and you haven’t said or done a thing about it. However, it’s not too late to celebrate! This year, like last year, our local NYC ACNM chapter, along with Friends of the Birth Center will be hosting the 4th annual Miles for Midwives, a 5K Run/Walk race around Prospect Park, this Sunday starting at 10:00 am, rain or shine. Registration costs $15, and all proceeds go to Friends of the Birth Center and the NYC ACNM Chapter. There are great pictures up from last year’s event, and I can’t even begin to tell you how much fun it was. This year is slated to be even bigger, with more people expected to participate (last year we had about 200), and maybe even a politician or two. The beloved boy and I, as well as many of my fellow sister students from midwifery school will all be there, so if you’re in the area and you’re not doing anything on Sunday, come for a jog! Bring your children, bring your dogs, bring rain gair if it’s raining, and come hug a midwife or two and learn more about the wonderful profession of midwifery, and everything we have to offer you.

We had the mother of all check-out exams today. Not that they’re actually called check-outs: they’re really called competence perfomance evaluations, but are known informally as check-out exams. Basically, you have to demonstrate your hands-on practical skills to your professors by going through the motions and talking her through the mechanisms of labor, an occiput-anterior delivery, mangement of the 3rd and 4th stage of labor, suturing, vaginal exams, amniotomy, placement of an internal scalp electrode, local anesthesia and a pudendal block. The check-out involves stating the reasons why you’re doing such and such action, how you would prepare the client for it, position her, drape her, coach her (if needed), how and when you’d time various maneuvers, the rationale behind putting your hands here v. there, the reason why you’re using such and such suturing material, when you’d cut an episiotomy, and how you’d do it, what the contraindications are, what the safety precautions are, what you’d look for and feel for and smell for, how you’d clamp the cord, assign apgars, hand tie, instrument tie, how a baby moves through a long arc rotation from left occiput posterior to left occiput anterior, etc. etc. etc.

As you can see, a totally easy, no-sweat, low-stress day, with very little information to know or master. No nerves involved. Nope. None.

SO, I set my alarm for 7:00 am. My first check-out is at 9:00 am. I leave on time, 8:20 am. Not late, but on time (but then again, not early, either—which, as you shall see, was my fatal flaw). My beloved boy and I stop to get coffee before heading to the train, as we usually do every morning. We get to the platform, and we wait. And wait. The wrong train arrives. No use to us, so we wait some more. A second wrong train arrives. Still no use. 15 minutes pass as we watch a procession of the wrong trains blithely sail by. Now getting anxious. Look at watch: time is 8:40. It usually takes me 30 - 35 minutes to get to school. I now have 20 minutes to get there. Slow realization that I’m going to be late. Stress begins to mount. This is not how I wanted to start the morning of my check-outs. Correct train finally arrives. Correct train is packed, because it’s so late. Takes twice as long to get onto train as it normally does, because train is stuffed, and people are moving in very slowly, and trying to squeeze on more passengers than comfortably should, and people keep holding the doors. 2 stops to my transfer, both very slow stops, because of packed conditions. Mad dash from one line at the transfer point to the second line. Enter platform just as the train I need (the train I need!!) is pulling out. Look at watch: 9:00 am. I should, at that exact moment, be at school, beginning my check-out exam. Panic, followed by despair, a good round of nail biting, stress, self-excoriation for not having left early instead of on time, a nice heaping of self-blame, followed by some more nail-biting. Correct train arrives. I spend most of the short ride trying to deep breathe, calm down, there’s nothing I can do now about being late, devise excuses, abandon excuses and need for excuses as weak and pathetic, prepare to face whatever the professors have to dish out about how a responsible student gets to her check-outs on time. Feel like the most irresponsible midwifery student ever to walk the face of the earth. Get out at final platform transfer to wait for final train to school. Usual delay. Correct train finally arrives. Emerge from subway (infernal, godforsaken) system at 9:20 am. Walk to school (5 minute walk). Get to correct floor. Professor who’s doing my first check-out of the morning (pudendal block) has been waiting for 30 minutes now. Informs me that she’s going to have to do my check-out at the end, because she can’t reschedule everyone else on the schedule to accomodate my lateness. I tell her I need to be at my clinical site this afternoon to meet with my preceptor and schedule my clinical rotations. She gives me the “well, you should have been on time” look, and says we’ll have to try to squeeze me in.

So, she goes off with the next student who was scheduled to do her pudendal check-out at 9:30, and I briefly flop in the hallway to bemoan my fate and receive some comfort from a fellow sister student, who’d had the presence of mind to arrive early to her check-outs. And then, punctually at 9:30 am, I begin my first check-out of the day (what should have been my second check-out, by then): Delivery Technique.

Just as I’ve started to get into my rythym, gloved and gowned and mid-sentence, a different professor pokes her head in the door to ask me why I’m not where I’m supposed to be. Baffled, I tell her I was where I thought I was supposed to be, i.e. doing my delivery technique check-out from 9:30-10:00. She tells me I’m supposed to be suturing with her. I tell her my suturing check-out wasn’t supposed to start until 10:00, but according to the schedule, from 9:30-10:00 I’m doing delivery technique. She tells me that I’m behind because I didn’t get my pudendal check-out done, and that I was late, and that they can’t change the schedule. Then she very gently says: well, this is why you can’t be late to your check-outs. That’s it. Very gently. She leaves…and I burst into tears.

Not my finest moment, by a long shot. The professor who was in the room with me doing my delivery technique check-out had me count to 10 a few times until I calmed down, as if she were coaching me through a contraction.

I’m happy to report that after all the drama, I was actually able to get through all my check-outs in one piece. I went to suturing next, and received an “excellent job” in the comments section, and was able to squeeze my pudendal check-out in next, because I finished my suturing early. All good comments. Nerves slowly dissipated. By noon, I was finished with all of my check-outs, and was so relieved I found myself humming to myself on the way back to the (infernal, godforsaken) subway.

However, needless to say, I’m a bit embarrassed by the tears. Especially given that none of my professors were horrible to me (I was much harder on myself than any of them were or probably ever would be), and even though I was late, I was able to get everything done on time AND get to my clinical site in the afternoon. Insert something here about all’s well that ends well etc. etc.

I almost didn’t post this post, because it’s that embarrassing. But this is supposed to be the chronicle of my adventures in midwifery school: the good, the bad, and the ugly embarrassing. So here you go. Enjoy. With bonus sage note to future midwives of the world (and duh, don’t you think this is something I should have known already?): on the day of your almighty check-out exams (or equivalent), make sure you leave early, and not on time.