Forget the “bang”; our final semester of midwifery school started with a resounding “thud” as the largest module known to man or gods was laid upon us today. I’m only taking one class this semester: Maternal and Obstetric Complications. Trust me, it’s more than enough. In fact, paging through the module, it doesn’t really seem to be a class so much as a semester-long review of everything we’ve ever learned in midwifery school, ever. Which, on the one hand, is fine by me—gods know I certainly need such a review, especially the semester leading up to my Comprehensive Exam and Board Exam.
I’m also Integrating this semester, which is, in theory, the final culmination of all of my clinical learning to date, the semester when all of the lightbulbs finally turn on, when everything gels, when the pieces miraculously fall into place, and I find myself working the full-time schedule of a real midwife, and feeling (in theory) like a real midwife.
I think it’s all supposed to feel pretty exciting. Lately, though, I must admit I’ve been feeling dread more than anything else. I can’t believe this is my last semester! I’m not ready! And not only am I not ready, these days, more and more, I’m absolutely terrified! Pretty soon I’ll be out there in the world, a brand new midwife, with no friendly preceptor watching my back. Pretty soon it will just be me, alone in the room with a nurse and a woman in labor, and everyone will be looking to me like I have a clue….and what if I don’t? Pretty soon I’m going to have prescription privileges….when I can hardly remember all the drugs needed to treat everything from mastitis to UTIs to condyloma accuminata to chancroid, let alone the dosages.
This is the really terrifying thing about learning curves and the medical profession, the thing that no one really likes to acknowledge: you can learn something in theory out of a book, you can know it inside and out, backwards and forwards, but the very first time you actually have to DO that thing, in the clinical setting, you usually don’t do it that well.
Here’s a perfect case in point (and believe me, this is something that still haunts me, even to this day): as a brand new labor and delivery nurse I was taught neonatal resuscitation, I took the exam, I passed the course, I had a shiny card in my wallet that said I was a certified Neonatal Resuscitation Provider….but 3 months into my nursing career, just shortly after I had come off of my orientation and was working on my own, without friendly orientating nurses watching my back, I was confronted with my very first blue, floppy, nonresponsive baby in desperate need of resuscitation, and let me assure you, I made a mess of it. About the only thing I did right was scream for help, immediately. I hadn’t called peds, although I’m sure the more experienced nurse in me now would have taken one look at that tracing and had peds there minutes prior to the birth. I dried and stimulated: nothing happened. I fumbled with the oxygen, I got the bag and mask on the baby’s nose and mouth, but I absolutely botched the seal (note: hands were shaking uncontrollably), and every time I compressed the ambu bag, I was greeted with a loud farting noise, which I’m sure other providers will recognize as that very scary sound that indicates, sure as sin, that the oxygen is leaking out the sides of the mask instead of inflating the baby’s lungs. The Apgars were 4 and 7. Enough said. It was a terrible, terrible experience, only made worse by the fact that the Nurse Manager chose to reprimand me and review all of the mistakes I had made in front of everyone, at the nurses’ station. I think this is what they mean when they say that nurses tend to eat their young. It was incredibly traumatic, and I was a gibbering wreck for quite awhile afterwards.
So, I sat in on another NRP class, I reviewed neonatal resuscitation again and again, I assisted in a few other resuscitations as a secondary provider, instead of the primary provider responsible for initiating the resuscitation, and sure enough….I got better. The next time I was presented with a blue, floppy, non-responsive baby (which, thankfully, didn’t happen until almost a year later), I called for help, dried and stimulated, had the oxygen ready, got the mask on correctly, and was able to successfully bag and mask the baby until peds arrived, minutes later. Apgars were 6 and 9.
The point being, the first time (and sometimes the second and third and fourth time) you do anything, you’re not great at it. And the only problem with this is that as a midwife, you have that much more responsibility, and your mistakes can be that much bigger. If you really, royally screw up the first time you do something as a new midwife, what if that thing was a life and death thing? This is, I think, my biggest fear.
My first year as a real, working midwife is going to be a very painful year, because that’s the first year I’ll be on my own, making all of the terrible, learning-curve mistakes I need to make in order to get better, and giving less than optimal care in the process as I learn. And sure, my learning curve is very steep right now as well, and I am making and learning from my mistakes right now, as a student. But as a student I still have someone watching over me, and it’s not quite the same as when you’re finally on your own; as a student, if there’s a true emergency, this is usually the moment when your preceptor steps in and saves the day. You’re not really handling the scary stuff on your own until you’re finally, actually on your own. And sure, everyone’s first year as a new medical provider, be it nurse or doctor or nurse practitioner or physician’s assistant, is like this, but I don’t think anyone likes to admit it. It’s the very scary truth we tend to gloss over, feeding ourselves and each other bracing mantras like “it’ll get better” and “just takes practice” etc. And true, it DOES get better, but even so, this is why smart people never go to a hospital in July when all of the brand new doctors are freshly graduated and just starting their residencies.
My first year as a nurse was so painful. I still remember it so clearly; I got yelled at by everyone. I made a ton of stupid mistakes. I messed a lot of things up. And it’s one thing as the nurse, where ultimate responsibility for the patient is usually not in your hands, and quite another thing as a midwife, where you’re responsible for making management decisions, accurately interpreting strips, cutting the episiotomy, correcting the anemia, repairing the laceration, recognizing the early signs of sepsis, successfully handling the shoulder dystocia, managing the hemorrhage, etc. etc. There are still so many things I’ve never seen and never managed. I can drill the steps into my head like clockwork night and day from now until that very first shoulder dystocia happens, but how do you really know you can do it until you’re presented with it? And do you really think you’ll do it well, the very first time you try? My hands will be shaking, for sure. I’ll certainly call for help immediately; that much I can do. And I’ll certainly learn from the experience. But what if the outcome is not nearly as good as it could have been, because of my inexperience?
We talk so openly about the fear of childbirth, the fear of pain, the fear of pregnancy, the fear of change…but much less is said about the fears of midwives. The fear of a bad outcome. The fear of harming a mother or a baby, of not taking the right action at the right time (or taking the wrong action at the wrong time). And, even more unspoken, the fear of being held accountable for it: the fear of litigation, the fear of having to defend our actions, of having made mistakes that are undefendable or unforgiveable, the fear of being held up before a court and reprimanded as thoroughly as my old nurse manager once reprimanded me at the nurses’ station. Only this time it will be your license on the line, your career, your passion, your livelihood. No matter how hushed up these fears might be, let me assure you, they’re here, and very present, and very real. I’ve met so many midwives who’ve told me that at some point in her career, almost every midwife is called in for a deposition. It almost seems like a rite of passage, of sorts. Or if not the deposition, the really bad outcome. I know that this is just a fact of midwifery, that eventually it’ll happen to me too. Just for the record, though: I’m scared.
These are my fears. I fully admit. Lately, when I think about midwifery, as I approach practicing on my own, it’s the fear that bubbles up more than anything else. At the start of my midwifery studies I wrote a post about the poem in the front of Varney’s Midwifery, Holy Births and Howling Babies by Dana Quealy, CNM, MSN, and while I enjoyed and admired the poem at the time, I felt that its undercurrent of fear and anxiousness wasn’t the most positive way to start of a midwifery student’s education. But now, as I approach the end of my education…as I come that much closer to being a real midwife, all of a sudden this poem makes a lot more sense to me. I find it resonating much more deeply with me. I get it now. So true.
I don’t think I’m a bad student. In fact, I think I’m a good student. I think, actually, I am probably exactly where I need to be right now in terms of my learning, and I think that so far my care, under my preceptor’s watchful gaze, has been safe and effective. But just for the record, let it be known that I am scared. This is normal, right?? Do all the rest of you midwives out there feel this way too? Is a little bit of fear necessary to make you become the best provider possible? To ensure that you dot all of your i’s and cross your t’s? Is this something you get over, with time? Is this just a phase I’m going through? The “really scared of everything” phase? I hear and read the stories about the midwives who’re able to trust birth so completely, so fearlessly, that they can deliver the meconium stained baby at home, handle the shoulder dystocia at home, pull off the breech delivery flawlessly. Are these midwives not scared in the same way I am? How can you take a chance like that, without the fear of the bad outcome, or the fear of the court trial? Does my fear come from a lack of trust in the birth process? Or is a healthy dose of fear my quality control? How do you stike the balance between trusting birth, trusting yourself, and at the same time fearing the process enough to check and double check your work, to make sure the stool is in the room, to prepare for every emergency, even while hoping for the best?
I do know that the only thing that makes all of this better is actually just doing it. I feel confident in my ability to resuscitate babies now, but not so long ago it absolutely terrified me, and I had to go through that first horrendous experience and come out on the other side to get to where I am now. I’m sure that 25 years from now, after I have three or four shoulder dystocias under my belt, I’ll be a fabulous midwife. But I haven’t been tested yet, and I don’t yet know, without a flicker of doubt, if I am equal to the test: if I’ll be able to think and act quickly enough, under pressure, in the face of a true emergency. Confidence and competence comes from mistakes. I’m just scared of my future mistakes, as necessary as they might be.