ACNM 2007 Annual Meeting
Student Report

Greetings from the student midwives to the board members, fellows and all attendees of the 52nd annual meeting of the American College of Nurse Midwives here in Chicago. Twenty–two representatives from midwifery programs around the country and Puerto Rico met together to discuss points of concern and share experiences. Our meetings were filled with energetic, articulate women of diverse backgrounds motivated to tackle the challenges facing us today and in the future of our profession.

We wish to express our thanks and appreciation to the College and all its members for the continued support of midwifery education in the areas of professional guidance, preceptorship, scholarship, and friendship. We especially want to recognize the hours of effort invested by those midwives who have selflessly volunteered their time of to serve as preceptors to midwifery students, and ask that they stand and be recognized.

We acknowledge the college’s recognition of and efforts to respond to the concerns expressed by last year’s student representatives, as evidenced by the addition of the student identification badge ribbons, the student section in the general conference program, the first-timers meeting, and the warm and welcoming attitude we have encountered by many members. However, we continue to be concerned about issues related to publicity and marketing, policy, professional issues, diversity, and communication.

Publicity/Marketing
With regards to publicity and marketing, an area of concern to us as students is the public’s widespread misconceptions regarding the existence, competence and scope of practice of nurse-midwives. We consider it important in maintaining and promoting our collective profession to address this problem via educational publicity and marketing campaigns. Though we recognize that ACNM already holds this as a priority, areas that may benefit from increased resource allocation include:
• Partnering with major corporations similar to the Johnson & Johnson® campaign to address the nursing shortage.
• Employment of a marketing strategist or consultant to meet the aforementioned goals.
• Proliferation of midwifery related content on websites, magazines or other media sources related to women’s health.
• Facilitating placement of nurse-midwives as spokespersons at media outlets.
• Creating a long-term plan for a general audience media saturation campaign
• Specifically target women’s health, labor and delivery and neonatal nurses with positive midwifery images and information to facilitate amicable professional relationships and potential recruitment.

Policy
Advocacy and politics are in the forefront of the minds of midwifery students. We celebrate the growth of our midwifery profession, but are sobered by the under representation of midwives in certain regions of the country, specifically, the central and south central states of region 5. Currently, less than four percent of the births in these states are attended by midwives. Many of these states lack the population density to evoke significant political change on the national level. The rural nature of these states also creates barriers to health education and access to midwifery services. To combat these issues, it is our responsibility to identify all of the professional allies of midwifery. It is imperative that we continue to collaborate and network with our partners to increase public knowledge within these communities regarding the utility of midwives. Some of the barriers to the midwifery growth include the lack of respect among health care professionals and our equity as autonomous health care providers. In order to elevate and support the midwifery model, we recommend that every midwife take the initiative to influence policy at local, state, and national levels. As we gain strength within the political arena we can decrease the compromises we are forced to make, decrease the thinned practice of midwifery, and increase the availability of midwives to our patients who deserve our care. Lastly, it is crucial that we take action to encourage the government to reimburse at a more comparable rate so that the underserved population has greater access to quality health care.

Professional Issues
The American Association of Colleges of Nursing (AACN) has proposed the DNP as the entry to practice for advanced practice nursing by the year 2015. As student midwives, on behalf of future students in years to come, we have concerns regarding our educational future. We have read and agree with the position statement on the DNP outlined by the Directors of Midwifery Education (DOME) in Volume 52, Issue 1, of the Journal of Midwifery and Women’s Health, (the January/Febuary 2007 issue). We affirm that Masters level education for entry to practice is more than adequate, but in light of the national trend towards the DNP, we recognize that as midwives we need to stay competitive with other fields. We would like to see continued and increased discussion and clarification within the ACNM regarding the way in which the DNP would affect the educational requirements of currently practicing midwives, current students and future students, particularly in terms of educational cost, both financial and temporal, and feasibility of training and preceptorship. More importantly, though, because nursing in not the sole pathway to professional midwifery certification, and because we have a professional identity which predates nursing, with its own theory and disciplinary knowledge, we as students would like to see alternative post-Masters educational options available to us. We urge you to continue to pursue the development of the Doctorate of Midwifery, that would include, but not necessarily be limited to, practice as the focus, as an alternative to the DNP, which will support and validate midwifery as its own distinct discipline.

Diversity
The student representatives have identified the diversification of the profession as a priority. We hope that our midwife population can reflect those that we serve—women of diverse race, ethnicity, country of origin, sexual orientation, economic status, age, religious beliefs and ability. We propose four strategies to achieve this goal:

• Encourage nurse-midwives of the above mentioned minority groups to attend career days at their local high schools and colleges, or their alma maters, in order to increase visibility and reach out to prospective students who can identify with the midwife as a professional role model.
• Encourage program directors to devote more time and attention in the curriculum to the healthcare needs of these minority populations.
• Encourage the proportion of workshops and sessions dealing with the healthcare needs of the increasingly diverse U.S. population.
• Advocate for the unique needs of diverse patients in the clinical area, through research generation and existing research utilization, and through direct political action.

Communication
Communication is a necessary tool in any successful organization, and is crucial in enabling student participation in various levels of the ACNM. We would like to propose three recommendations for consideration by the ACNM this year:

In the twenty-first century students across the country rely increasingly on internet sources for their information and communication needs. It is crucial for ACNM to accommodate this growing trend in order to both integrate the fresh energies of current students and reach out to prospective students interested in learning more about our profession. We suggest a student website be created linked to the ACNM homepage that is specifically created to foster student involvement and education about the College. We are aware that this suggestion was made during last year’s Student Report and were disappointed to see that such a development was not included in the recent improvements to the website.

This website would allow students from different programs to communicate with each other, the ACNM and the midwifery community. Additionally, it would serve as a resource for prospective students to learn about their educational options and contact student representatives from each program. Ideally this page would include:

• A School Directory including contact information of a student representative from each school
• Clear instructions on joining the student list-serve, along with a link to that site
• Opportunities to get involved in midwifery politics at the state and national levels
• A bulletin board highlighting updates in issues relevant to students
• A List of nurse midwives interested in precepting students

We are excited to be actively involved in this process.

We would also like to make a suggestion regarding the students in isolated regions of the country, distance-learning programs, or alone in their program. Many of these students are interested in participating in the chapter and/or state meetings and would greatly appreciate if these were web cast or recorded. This would benefit not only these students, but all ACNM members who are unable to attend meetings.

We appreciate having a voice during the conference, but to promote continuity we would ask the board to consider a permanent presence for a student or students on the board of directors to provide input and ideas. We are aware that this year, with new bylaws, we anticipate there will be a restructuring of the College, and we feel the division of education would be the most appropriate place for student representation. Other organizations such as ACOG, AMA, and Lamaze International have student members on their boards; we would like to see ACNM make this change as well. In addition, as we are dues paying members of the college and have our own unique voice, we seek representation through voting member status.

We appreciate this opportunity to present our concerns and recommendations in the student report. We look forward to your continued support and response.

My board exam is this Friday, at 9:00 am.  It’s 185 questions, and will take approximately 4 hours.  When I finish, I will find out immediately if I passed or not.  If I pass, I’m a midwife (!!!!!!!), certified and DONE and eligible to become licensed.  Mega-hella-w00t!  But I don’t want to get too far ahead of myself.  Today was IP cram day.  Yesterday was AP cram day.  Monday was Primary Care cram day.  Last friday was Family Planning/ Well-woman Gynecology cram day.  Tomorrow is PP and Professional Issues.  Tomorrow will also be practice-tests-until-your-fingers-fall-off day.  My birthday is on June 30th, btw.  I’ll be turning 30.  So, I will potentially be able to celebrate being a midwife and turning 30 on the same day.  How cool would that be????

But I don’t want to get ahead of myself.  One day at a time; for now, I’ve gotta get back to the nonstop STD/TB/HepB/pap management review.  Yeah, baby.

Which is exactly what happened a few weeks ago, on May 29th, at Carnegie Hall, with all of the usual pomp and circumstance. And there was MUCH rejoicing! (w00t!) But first, I’ve got to tell you the story of how I almost missed my graduation, and how I managed to get to Carnegie Hall on time only by the very barest skin of my teeth.

Remember how I was in Chicago the weekend right before my graduation, at the ACNM convention? And remember how I was leaving on a flight from Chicago at 6:00 am, to arrive at New York’s La Guardia airport at 9:02 am, which would have given me plenty of time to collect my things and take a taxi to Carnegie Hall? And remember how I swore up and down to the universe that NOTHING could go wrong, period? Well, as it turns out, EVERYTHING went wrong. It was an absolute disaster. Now, looking back, it sure as hell makes for one fabulous story, but at the time, I thought my graduation day was going to be spent at Midway Airport, in Chicago, and I was an absolute wreck.

So how did this happen? Well, like this: most flights are overbooked, i.e. over-sold, and most of the time, this isn’t a problem. The airlines do this to protect themselves against the inevitable last minute cancellations and the people who, for one reason or another, don’t show up for their flight. However, when a flight is overbooked, and everyone DOES show up for the flight, there’s a bit of a problem, and some people end up on the standby list. How do they determine who is on the standby list and who is not? By those who have a confirmed seat v. those who do not. So here’s a piece of free advice: make sure you have a confirmed seat! If, for some reason you don’t actually have a seat number assigned to you or chosen by you when you book your flight, you’re assigned a seat number at the airport when you check in, which is all well and good assuming that there are seats left. But if the flight is overbooked, your seat number is assigned only on a first-come, first-serve basis, and if all the seats have been assigned, and you don’t have a seat number, you are on the standby list, and if there are no extra seats, you are S.O.L. Which is exactly what happened to me at Chicago. It was the day after Memorial Weekend, I guess more people had shown up than they were anticipating, the flight was overbooked, and I didn’t have an assigned seat number. Apparently I was supposed to have called two weeks in advance to confirm my seat number, but that was in the very very very fine print of the online ticket confirmation itinerary, which I failed to read (and which most people fail to read). So, I had a ticket, but no seat.

I was eighth on the standby list. There were absolutely NO available seats, and 13 of us in total were S.O.L. I can’t even begin to tell you about the fear and shock and disbelief I went through when I saw the door to the loading ramp shut and the flight take off without me on it. I think I made a very compelling case for sympathy as I stood at the desk in front of the gate holding my graduation robes in my arms, sobbing and saying things like “But I have to be at Carnegie Hall at noon because I’m graduating!”, as if just saying it would somehow make the Universe respond, or make another flight appear out of nowhere, but sympathy obviously wasn’t going to get me very far. There were no other available flights to La Gaurdia leaving from Midway that would get to New York in time. The next available flight on this particular airline (ATA Airline, fyi….I would absolutley, 100% NOT recommend them to anyone, and I will never be flying them again, period) was leaving from O’Hare aiport at 1:00 pm. My graduation was at noon. Cue panic.

There was another man (I forget his name) on the standby list who had a lecture to give at noon in front of an audience of 300 people, and there was another woman (Sarah) who had a job interview that morning which she was going to miss, and the three of us were the most desperate out of all the rest on the standby list. The man pulled out his laptop and started looking for other flights online, I called my beloved boy in an absolute panic, and the woman started looking at the departures board. We found another flight leaving at 7:00 am on Southwest airlines, arriving at 10:00 am…not to La Gaurdia, but to this very obscure, very small airport smack in the middle of Long Island (McArthur Airport…and no, I had never heard of it before, either). So, the next thing I knew, I was buying a one-way ticket to fly to Long Island, calling my beloved boy, and trying to figure out who to get from remote Long Island to the center of Manhattan in under two hours. Long Island Railroad wasn’t going to work—there was no way I was going to get to the train in time (it left once an hour, at 10 minutes past the hour, and there was no way I could get from the airport to the train station in 10 minutes). So then what? Driving seemed to be the only way forward, with all of the traffic jam perils inherent in that.

As luck would have it, my father had flown in from Nebraska the night before for my graduation, and he was staying with my grandparents, who also happened to live on Long Island (although much closer to the city than McArthur Airport). They had been planning on taking the train into the city, but after a few frantic phone calls, they agreed to meet me at the aiport on Long Island instead, and then we would drive into the city and make a mad dash for it. So now, cue short, stressful flight with me in a cold sweat the entire time, then cue agonizing drive into Manhattan, where every minute spent stuck in traffic on the Long Island Expressway was an eon, I swear. I bit every scrap of nail available to me; I bit my fingers to the quick. I would have bitten my toe-nails if I was flexible enough to reach them. The clock on the dashboard kept ticking, and with each passing minute, I was simultaneously hopeful and devastated. We hit a large amount of traffic shoftly after passing Manhasset, Long Island, and then we had to make decisions: Midtown tunnel v. Triboro Bridge, FDR v. going down 5th Avenue or Central Park West? Aarrrgggghhh!! However, somehow, miraculously, we were nearing Columbus Circle around 11:45 am (they had wanted the graduates there promptly at 11:00 am to get us lined up appropriately). Stuck in traffic again, I actually got out of the car shortly after we’d passed Columbus Circle, fully clad in my graduation robes, and proceeded to flat-out run the rest of the way to Carnegie Hall.

I arrived sweating and panting, was barely able to explain to the ushers what program I was graduating from, but somehow got pulled along to the right place in line, where I had just enough time to slip in between the other, much less sweaty students, and then the music started and we were walking out into the hall to take our seats. The ceremony began while my dad (thank you so much, dad, for your amazing driving!!) was still parking the car, but he was able to get a seat during a break in the speeches. I was so grateful to be there! I just kept looking at the beautiful hall around me, the other graduates, the stage, the speakers, with so much wonder and gratitude; I didn’t care how I looked (a bit of a sweaty mess), I didn’t care that my cape was askew (a friend was able to fix it while we were in line before walking across the stage), I didn’t care that the speeches were long, and somewhat boring….didn’t matter. I was AT my graduation, I was graduating, I was there to walk across the stage and receive my diploma, and that was all that mattered.

I can’t even begin to describe what it feels like now, to actually be a graduated nurse midwife. This huge accomplishment, this goal I have been working towards for so long, has been achieved, and I can look out now from a place that I have dreamed about being at for so long now…it doesn’t quite feel real yet.

And now, on to the What Next part of this post. What next? How do you actually go from being a graduated nurse midwife to being a real, employed midwife, with a license and a degree and a job? Well…that is the new adventure I am about to embark upon. I’m taking the national midwifery board exam on June 29th. (Note to self: you really need to start studying more vigorously for that.) I’ve applied for a few jobs. I had one interview two weeks ago, and they seemed quite eager to hire me, but alas, they thought they had three available positions, and it turns out they only had two. So who knows what comes next. Hopefully successfully passing my boards, and then becoming employed, a real midwife with a real job, very very soon. I’ve been neglecting this site lately, but I will try to pick it up again, especially since this is such an exciting time in my life right now (although also a very stressful time) with lots of changes happening very quickly. I will certainly keep you posted.

So, I basically have three weeks of intrapartum clinicals left. No school, no classes, just catching babies (wheee!). And then, assuming I passed my comps, all I have left to do is graduate, take the national Board exams, and then….and THEN…..oi, I can’t even say it yet. I don’t want to jinx it. I’ll keep all of you posted.

And in other news, today was my last day in the clinic for the next two weeks (in deference to the upcoming Comps)…and you know what?  I actually was feeling really comfortable there today, something I really wasn’t expecting.  My speed has improved dramatically over the past few weeks—in fact, today I found myself waiting for my preceptor to get around to double-checking my fundal heights etc. etc., instead of her waiting for me—and I’ve been working more consistently with just one preceptor for the last several clinicals, which has also really made a difference.  Today I did three initial OB visits and 4 revisits; I diagnosed an umbilical hernia, referred a woman for colposcopy, did a test of cure on a treated urinary tract infection, scheduled GTTs and GCTs and PPD readings and Hep B antibody testing and all sorts of other sundry lab work, did lots of amazing counselling, performed a very, very gentle speculum on an 18 year old having her very first pap, talking her through it and managing to not traumatize her in the process (I hope).  I felt like my paperwork was thorough while still being concise, I was dotting all of my i’s and crossing my t’s, managing appropriate follow-up on all of the abnormals (and recognizing the abnormals in the first place!).  I dunno…things just went really smoothly today, and I actually felt competent.  Wow, what a lovely feeling that is!  I’ve always loved labor and delivery so much more than my time in the clinic, but lately the clinic has really started to grow on me, and I’m enjoying it a lot too.  How ironic that I’m finally getting the hang of it and settling in just in time to leave (isn’t that how it always seems to go?). I only have three more weeks of clinicals after this, that’s it!  Argh, just when I’m getting useful and helpful and good, and really putting the pieces together…but at least I’ve gotten to end on a high-note.

The problem with this schedule is twofold. First, I am working a full-time midwifery schedule, approximately 42 hours a week, which means 2 clinic shifts and 2 labor and delivery shifts, which is probably highly acceptable and do-able if this is all that you’re doing, but on top of this, I am also up to my neck in schoolwork, which means that I never truly get a day off. My three days off during the week are spent trying to desperatley catch up on my classwork, which I am chronically behind in, and trying to sleep and maintain my fragile hold over my health at this moment in time. One of those days off is actually a school day, anyway, where I am in class for most of the day, so it’s not really a day off anyway.

The other problem with this is that none of this comes easily to me. It’s a really difficult schedule and a really difficult job, and the hours are really long, and if I were a midwife who had been doing this for years, sure, I’d have long, hard days, but there would be a routine-ness to them which would make it a lot easier to get through, and a knowledge and confidence which would also make it a lot easier. As it is right now, my brain is struggling all the time just trying to make sense of everything that’s going on at the clinic and on L&D: chart review, identification of problems and abnormalties, appropriate management of said problems, plus just trying to actually spend time with the patient, hold her hand (if at all possible) through at least one contraction (not always possible, because I’m doing the job of a real midwife, which means that if a patient comes into triage, I have to leave the laboring patient to triage the new one). When I come home at the end of the day, my brain hurts, and I am always so totally exhausted and worn out, physically and mentally, that sitting in front of my computer and trying to tackle my homework is absolutely impossible. I need my days off just to recover from my shifts, but alas, my days off are not really days off. My days off are spent trying to make headway on my homework. For example, next week I have a huge presentation on alloimmunization in pregnancy due, which is not exactly the easiest subject in the world to parse. This week I have a case study to do; we have a new case study to do every other week. Oh, and don’t forget our upcoming exam, or the huge, terrifying, awe-inspiring Comprehensive Exams which are just around the corner. And when I do spend time willfully blowing off my homework in order to rest and recover and try to replenish myself (physically and mentally and spiritually and emotionally), or spend time with my beloved boy (which is part of the replenishment), I feel inordinately guilty about it, because I know I have a mountain of homework waiting for me, which really needs to be tackled. Writing this post is willfully blowing off my homework.

And then of course, there’s the terror that runs through me when I think about the fact that essentially, I only have 6 weeks to go until all of this is over. That’s it! Just six more weeks of being a student, more or less. Just six more weeks before I qualify, and suddenly none of this will be under someone else’s license, with someone else watching my work and backing me up and making sure I don’t miss anything really important. Just six more weeks, and suddenly the full weight of responsibility will be mine, and mine alone (although, I do think that most jobs will offer an orientation to a new grad, which means there will be at least some cushion built in initially….assuming I can find a job). Argh.

Which is not to say that I’m not enjoying my final days as a student, because I am, on some level. But on some level, this really feels like boot camp, and it often seems like enjoyment is not what this is all about. Survival might be the better word. But hey, I seem to be surviving. Somehow (and really, I am continually surprising myself this semester), I actually seem to be holding up okay. At least, my grades are good so far, and all of the feedback I’ve been receiving from my clincial site has been positive and constructive. My preceptors think I’m doing great. They think I’m exactly where I should be, progressing at the level I should be progressing at, and have no doubt that I will pass with flying colors. They’re convinced that I’m going to be a fantastic midwife someday. From where I am in the trenches at the moment, though, I am not as convinced of this as they are.

I usually try to keep the details of the daily grind off of this blog, because really, who cares about the minor gripes and inner politics and daily ho-hum which is a part of any graduate school experience? And yet, when I speak to other graduate students, or to midwives fondly (or not so fondly) recalling their student days, it seems like there is a pretty consistent phenomenon which occurs towards the end of the program, and for the purposes of posterity, so that someday I can look back on this and remember exactly what it was like, I’m going to try to record all of this here. I think the phenomenon is something akin to: I am SO SICK OF ALL OF THIS, I JUST WANT IT TO BE OVER REALLY REALLY SOON. And yeah, that’s pretty much where I’m at. Feeling simultanelously very very ready to graduate, and simultaneously terrified of it.

So, this probably isn’t the post to read if you’re on the fence about going to school to become a midwife. Really, truly, it’s worth it. I know this deep down, and there have been so many amazing moments in the past 8 weeks that I can’t even begin to tell you about all of them, even if I actually had time to write about them. Some really, really amazing births. Some truly awesome prenatal sessions. Some days when I am so caught up in the middle of it, in the very thick of it, I think I am the luckiest women in the world doing the most amazing job ever, up to my elbows in vernix and amniotic fluid, teaching women about their bodies and contraception, helping them breathe through their contractions, catching babies. It really is a very special thing, this whole midwifery business, and those are the moments when I see the little glimmer that reminds me of why I wanted to do all of this in the first place. But the exhaustion is omnipresent, and on some days, the exhaustion outweighs the glimmer, by a long shot.

I guess on the bright side, when I am actually a midwife, and all I have to do is the work of a midwife, without all of the course-work on top of it, it will feel like a piece of cake by comparison. I. CANNOT. WAIT.

I’ve been meaning to post this post for ages, but was never able to finish it during the school year last year. All of this comes from the research project that I worked on last year for 2 semesters as part of my research class, and even though I had to radically alter the goal and purpose of my research proposal in the end, along the way I had the opportunity to do some of the research I was really interested in doing in the first place, and it definitely needs to be shared. This is rather a long post, and it gets somewhat technical in places, but bear with me; a lot of the information here can help you fend off an unnecessary induction or cesarean, so it’s well worth reading. And with that, here we go:

Premature rupture of membranes (or prelabor rupture of membranes, aka PROM) occurs when a woman’s water breaks before she actually goes into active labor. It can happen to women at any point in their pregnancy, and when it happens to women who are still preterm, the danger to herself and her baby is much higher, as are the risks of infection (and many studies have demonstrated that in fact, preterm PROM, aka PPROM, is often caused by infection in the first place). However, the majority of PROM occurs in women who are at term gestation (37+ weeks)—90% of all cases, in fact (Zamzami, 2005), and it’s pretty common, too: PROM at term occurs in 8% of all births. (Hannah et. al., 1996)

In our hospitals today, there is sort of an unspoken rule—let’s call it the 24-Hour Rule. It goes something like this: if you haven’t delivered your baby within 24 hours of breaking your water, something is going to have to be done. In many cases, this something is induction, and in many cases, waiting a full 24 hours before inducing is something that never happens. Providers are often way too impatient and antsy for that, and will generally talk a woman into induction long before the 24 hours has passed. Many providers have the policy of immediately inducing a woman with PROM, either by using prostaglandin gels like cervadil followed by IV oxytocin (pitocin), or by just starting on the pit right away. The rationale for this type of management (often called active management) stems from research that was done in the 1960s (Shubeck, 1966; Rusell & Anderson, 1962) which found that the longer a woman was ruptured, the greater the chance of infection, chorioamnionitis (an acute infection of the chorion, which is part of the placenta), and maternal and/or fetal sepsis.

These early studies advocated immediate induction, and were the beginning of active management. The idea that the length of PROM is responsible for maternal infection is something which has sort of been hard-wired into modern obstetrical practice right now, and in my own experience, I have seen the 24-Hour Rule in effect many a time. Providers often use it to justify the need for an induction or augmentation, i.e. “we need to get your labor moving along, because you’ve been ruptured now for 8 hours…12 hours…18 hours…and you’re still not in active labor”, and as studies have shown, inductions and augmentations, especially for PROM, often lead to cesarean (Mozurkewich & Wolf, 1997; Grant et. al., 1992; Tan & Hannah, 2001). I have seen this deadline held over women’s heads before, and in my most humble opinion, it does absolutely NOTHING to help a woman relax, labor effectively, and have a vaginal delivery. (What’s that old Bradley joke about telling a man he better orgasm soon or else his penis will have to be cut apart to get to the sperm? No pressure, now!)

The thing is…the research from the ’60s, which forms the basis of the 24-Hour Rule, has more holes in it than swiss cheese. For one thing, these studies were retrospective, instead of prospective, which means that they relied on going back and looking at records after the births had already occurred, and never tried to control for any of the gazillion variables that might have affected these birth outcomes other than PROM. Similarly, these early studies were non-randomized, meaning that there might have been selection bias at play which could have muddied the findings. Additionally, both term and preterm pregnancies were mixed together when examining the effects of PROM, which seriously confounds results since preterm infants are much more susceptible to infection, and as I mentioned above, preterm PROM often occurs because of infection in the first place (McGregor & French, 1997). These studies had very imprecise definitions for infection, and the management protocols used were neither uniform or clearly discussed. And of course, NICUs and antibiotic therapy have improved so much in the past 40 years that many of the babies that died of infection in these early studies probably wouldn’t have died if they had been born today. So, as you can see, the studies from the 1960s had a lot of problems, and the fact that modern obstetrical practices are still based in part on the findings in these studies is an even BIGGER problem.

What have more recent studies shown? Well, many studies have shown that strict adherence to active management is often unnecessary, and in some cases, does more harm than good (seems to be a repeating theme when you start to look at obstetrical research—funny, that. And here is where it gets very technical. I’m putting the rest of this behind a cut, for those of you who are interested.)

Kappy et. al. (1979) challenged the 24-Hour Rule, asserting that active management unnecessarily increased the cesarean section (CS) rate, and that expectant management of PROM could reduce the rising CS rate while at the same time keep infection to a minimum. Using a prospective, nonrandomized, observational design, the rates of infection were studied in 110 women with preterm PROM and 78 women with term PROM. In both groups, patients were managed expectantly until they either delivered or signs and symptoms of infection appeared, at which point the patients were induced. No digital examinations were performed on patients until they were in active labor, and no tocolytic agents or prophylactic antibiotics were given unless a patient showed signs and symptoms of infection, at which point the patient was induced. Kappy et. al. found that only 13% of all term women had clinical signs of infection at delivery, and only 3% had chorioamnionitis. There were no maternal deaths, and no neonatal deaths attributed to sepsis. Unlike earlier studies, Kappy et. al. separated preterm and term births, used standardized and clearly defined indicators of PROM (sterile speculum exam to detect vaginal pooling, followed by positive nitrazine tests and microscopic ferning to confirm rupture) and standardized and precise definitions of infection (clinical signs confirmed by positive blood, sputum, spinal or placental cultures). The weaknesses of this study included its nonrandomized design, the fact that no effort was made to control for infectious risk factors such as GBS, and only infants showing clinical signs of infection were cultured. Nevertheless, Kappy et. al. were able to conclude that “the conservative approach in the term pregnancy with PROM…seems to decrease the incidence of cesarean sections without an appropriate increase in the infectious morbidity”.

Duff et. al. (Duff, Huff & Gibbs, 1984) supported these results with a randomized control trial that demonstrated that “expectant management resulted in a lower frequency of both cesarean delivery and intrapartum infection than…the practice of immediately inducing labor”. In this study, 134 women with PROM were assigned either to an oxytocin induction group or to an expectant management group where they were observed as inpatients until the onset of labor. The researchers found a statistically significant increase in the number of cesarean deliveries and intra-amniotic infections in the induction group versus the expectant group—20% versus 7%, p<0.05, for cesarean deliveries, and 17% versus 4%, p <0.05, for intra-amniotic infections. This study used a non-blinded, randomized, prospective design (in other words, one of the strongest study designs you can use, and the “gold standard” for research), standardized definitions for maternal and neonatal infection, and uniform and clearly defined indications for cesarean section. Women participating in the study were from a homogenous population of carefully screened low-risk women at term without complicating risk factors such as diabetes, postdates pregnancy, meconium-stained fluid, hypertensive disorders, intraamniotic infection or malpresentation. However, again no mention was made of GBS status, potential bias could have occurred in the use of two distinct management teams, not all neonates were screened for sepsis, and the use of antibiotics during management was not specified.

A study conducted by Grant et. al. (1992) also found that expectant management significantly lowered the cesarean rate while at the same time posing no additional infectious risk to women or infants. In this study, 444 term primigravidas with PROM were blindly randomized to either an immediate induction group or induction the following morning (9-33 hours later, depending on when the woman arrived on the unit). It was found that there were fewer cesareans in the group that was allowed to wait 9-33 hours before induction (11.1% versus 17.4%, p = 0.06) with no significant increase in the rates of neonatal or maternal infection. It’s also interesting to note that women in the immediate induction group were more likely to ask for epidural anesthesia (70.3% versus 57.3%, p < 0.005), which supports the idea that induction leads to increased demand for epidurals, and that epidurals lead to increased cesarean rates.

The largest study to date, the TERM PROM study (Hannah et. al., 1996), examined 5041 women from 72 centers throughout Canada, Israel, Australia and the UK with PROM at term who were randomized to one of four groups: immediate induction with oxytocin (induction-oxytocin); immediate induction with vaginal prostaglandin gel first, followed by oxytocin if active labor had not started (induction-prostaglandin gel); expectant management for up to 4 days unless signs of infection or fetal distress were noted, followed by oxytocin induction if labor had not started after four days (expectant-oxytocin); and expectant management for up to 4 days, followed by induction with prostaglandin gel (expectant-prostaglandin). The study protocol was standardized and well-defined, and the randomization process was blinded (i.e. a very rigorous study design). Vaginal exams were discouraged; however, approximately one third of the women, equally divided among all four groups, received vaginal exams during the initial cervical assessment. Approximately 78% of the women in both expectant management groups went into labor spontaneously within 4 days of PROM and did not require induction. The researchers found no differences in the rate of neonatal infections or cesareans, but an increase in maternal infectious morbidity was noted in the women of the expectant management groups, with 8.6% of the expectant groups developing clinical chorioamnionitis versus 4% in the immediate induction groups.

Unlike earlier studies, a similar number of babies in all four groups were sampled and cultured for neonatal sepsis, regardless of what management group their mothers had been assigned to. Overall, this study presented a very strong case for arguing that immediate induction does not increase the cesarean rate, and that expectant management may increase maternal infection rates. Nevertheless, it still had a few weaknesses. For one thing, multiparas were pooled with nulliparas, and there was no standardization of Bishop’s score (cervical ripeness); 6-15% of the women had ripe cervices, versus 29-54% which were considered unripe, and in 33-65% of the women, the cervical status was unknown. Additionally, the researchers stated that “digital vaginal examinations were avoided,” but the expectant management groups had considerably more digital vaginal exams than the immediate induction groups. This is very important to note, given that digital vaginal exam after PROM has been found to be an independent risk factor for maternal and fetal infection.(Shutte et. al., 1983; Lenihan, 1984)

Even more recent studies (Zanzami, 2005) have found that in the absence of other obstetric and maternal or fetal risk factors, PROM at term is not an additional risk factor on its own. “Expectant management of PROM at term enhances a patient’s chance of normal delivery without an incrase in fatal and/or maternal morbidity.”

Now, this is not to say that other studies haven’t found the contrary to be the case. For example, Wagner et. al. (1989) found an increase in infection rates in babies born to women with PROM who had been managed expectantly versus actively, although this study also found that the number of vaginal exams performed increased the infection rate (which other studies have confirmed). Rydhstrom & Ingemarsson (1991) found no difference in the cesarean rates in a randomized trial between active management and expectatant management, and Akyol et. al. (1999) actually found that the cesarean rate was lower in the immediate induction group of their study when compared to the expectant management group who were randomized to induction after 24 hours had passed. However, it’s important to note that this increase in cesarean rate was in a group of women who had already failed to go into spontaneous labor within 24 hours. The majority of women will go into labor within 24 hours, so inducing those who didn’t might imply other variables at work which would make induction particularly unsuccessful.

My thoughts on the subject? If your water breaks and your labor doesn’t start right away, that’s fine: 8-12% of all women experience this problem, and it happens most often at term. If the fluid is clear and you can feel the baby moving, call your provider by all means and discuss your options with her, but try to stay home for as long as possible! Go for a walk, bake some cookies, scrub out the bathtub, do some yoga, try to get those contractions to kick in (just don’t have sex, now that your membranes are ruptured). Most women will go into labor on their own within 24 hours, and so long as NO digital vaginal exams are performed (i.e. using fingers; a sterile speculum exam is somewhat better, but still isn’t 100% risk-free), the risks of infection are low. If your provider urges an induction, ask for more time; studies have shown that inductions for PROM often don’t work that well, and women who are induced have a higher risk for developing an infection or having a cesarean (Zanzami, 2005; Hannah et. al., 1996), in part because once the induction process begins, vaginal exams and other interventions which increase the rate of infection, like internal monitoring, are often done.

Talk with your provider about giving your body AT LEAST 12 (and preferably 24) hours to get going on its own, and chances are very good that it will. If, after 24 hours you’re still not in active labor, don’t panic; about 15-20% will not do so within 24 hours (Kappy et. al. 1979). In a clinical trial that measured a 12-hour expectant management regimen versus a 72-hour regimen, the rates of infection, chorioamnionitis and neonatal morbidity were the same in both groups. (Shalev et. al, 1995) In other words, you can probably wait up until 72 hours, so long as no signs and symptoms of infection occur (although your risk of infection does marginally increase the longer you’re ruptured, especially after 24 hours). Also, keep in mind that one of the side effects of an epidural is fever! One of the warning signs of infection is a rising temperature, but if you’ve just had an epidural, it could be from the epidural, and not really an infection at all—especially if your provider has kept his/her fingers out of your vagina! (Goetzl, et. al. 2001)

(Having just issued all of this advice, though, please go read my Quick Disclaimer before you go forth holding my word as gospel. I’m not a midwife! I’m a student, and I have NO idea what your personal situation might be. Each labor and birth is unique, full of a million and one variables, and needs to be handled individually by a health care provider you trust.)

References:

Akyol, D., Mungan, T., Unsal, A. & Yuksel, K. (1999) Prelabour Rupture of the Mmebranes at Term—No advantage of Delaying Induction for 24 Hours. Australia and NZ Journal of Obstetrics & Gynecology, 39(3): 291-295.

Duff, P., Huff, R.W. & Gibbs, R. (1984) Management of Premature rupture of Membranes and Unfovarable Cervix in Term Pregnancy. Obstetrics & Gynecology 63(5): 697-702.

Duncan, S.L.B & Beckley, S. (1992) Prelabour rupture of the membranes—why hurry? British Journal of Obstetrics and Gynaecology, 99: 543-545.

Ezra, Y., Michaelson-Cohen, R., Abramov, Y. & Rojansky, N. (2004) Prelabor rupture of the membranes at term: when to induce labor? European Journal of Obstetrics & Gynecology and Reproductive Biology, 115:23-27.

Grant, J.M., Serle, E., Mahmood, T., Sarmandal, P., & Conway, D.I. (1992). Management of prelabour rupture of membranes in term primigravidae: a report of a randomized prospective trial. British Journal of Obstetrics & Gynaecology, 99(7): 557-562.

Goetzl, L., Cohen, A., Frigoletto, F., Ringer, S.A., Lang, J., & Lieberman, E. (2001). Maternal Epidural Use and Neonatal Sepsis Evaluation in Afebrile Mothers. Pediatrics, 108(5): 1099-1102.

Hannah, M.E., Ohlsson, A., Farine, D., Hewson, S.A., Hodnett, E.D., Myhr, T.L. et. al. (1996). Induction of Labor Compared with Expectant Management for Prelabor Rupture of the Membranes at Term (TERM PROM study). New England Journal of Medicine, 334(16), 1005-1010.

Kappy A.K. et. al. (1979) Premature Rupture of Membranes: A conservative approach. American Journal of Obstetrics & Gynecology 134(6): 655-661.

Lenihan, J.P. (1984) Relationship of Antepartum Pelvic Examinations to Premature Rupture of the Membranes. Obstetrics & Gynecology, 83(1): 33-37.

Marshall, V.A. (1993) Management of premature rupture of membranes at or near term. Journal of Nurse-Midiwfery, 38(3): 140-145.

McGregor, JA, French, JI. (1997) Evidence-based prevention of preterm birth and rupture of membranes: infection and inflammation. Journal of the Society of Obstetricians and Gynaecologists of Canada, 13: 835-852.

Mozurkewich, E.L. & Wolf, F.M. (1997) Premature rupture of membranes at term: a meta-analysis of three management schemes. Obstetrics & Gynecology, 89(6):1035-1043.

Rhdhstrom, H & Ingemarsson, I. (1991) No Benefit from consevative management in nulliparous women with premature rupture of membranes (PROM) at term. Acta Obstetrica Gynecologica Scandinavia, 70: 543-547.

Russell, K., & Anderson, G. (1962) The aggressive management of ruptured membranes. American Journal of Obstetrics and Gynecology, 83(7): 930-937.

Shalev, E., Peleg, D., Eliyahu, S. & Nahum, Z. (1995). Comparison of 12- and 72- hour Expectant Management of Premature Rupture of Membranes in Term Pregnancies. Obstetrics & Gynecology, 85(5): 766-768.

Shetty, A., Burt, R. Rice, P & Templeton, A. (2005) Women’s perceptions, expectations and satisfaction with induced labour—A quastionnaire-based study. European Journal of Obstetrics & Gynecology and Reproductive Health.

Shubeck, F., Benson, RC., Clark Jr, WW., Berendes, H., Weiss, W., & Deutschberger, R. (1966). Fetal hazard after rupture of membranes. A report from the Collaborative Project. Obstetrics & Gynecology, 28(1), 22-31.

Shutte, M.F., Treffers, P.E., Kloostermoan, G.J. & Soepatmis, S. (1983) Management of premature rupture of membranes: The risk of vaginal examination to the infant. American Journal of Obstetrics & Gynecology, 146(4): 395-400.

Tan, BP & Hannah, M.E. (2001) Oxytocin for prelabour rupture of membranes at or near term (Cochrane Review). In: The Cochrane Library, No. 2., Oxford: Update Software, 2001.

Wagner, M.V., Chin, V.P., Peters, C.J., Drexler, B., & Newman, L.A. (1989) A Comparison of Early and Delayed Induction of Labor with Spontaneous Rupture of Membranes at Term. Obstetrics & Gynecology, 74(1):93-97.

Zamzami, Y. (2005) Prelabor Rupture of membranes at term in low-risk women: induce or wait? Achives of Gynecology and Obstetrics, Oct. 6: 1-5 [e-pub. ahead of print.]

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.

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!)