Belly Tales

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.

Here you can see the lovely vaginas we cut out of our foam blocks to practice on. Notice that the eipisiotomy I cut is crooked. I’ve colored in the different layers: red = muscle layer, pink = submucosal, blue = subcutaneous, purple = subcuticular, and the edge is the mucocutaneous border. All so nice and neatly laid out: so NOT how it’s EVER going to look on a real woman, EVER.

The red vagina on the left is my very first attempt at suturing. Maybe the second attempt will go more smoothly? I’ve begun my anchor stitch in the submucosal layer.

Here I’ve tied off my anchor stitch, using an instrument tie that took at least 10 minutes to complete. Putting in an anchor stitch first, before suturing anything else, is only done if there’s a lot of blood coming from the apex of the wound, and the stitch is meant to tie off the bleeding vessels and help keep the rest of the wound as clean and blood free as possible. In theory. Notice how loose and baggy my anchor stitch is. I don’t think that would stop even the smallest vessel from bleeding.

Having botched the anchor stitch, I now move on to the muscle layer. The muscle layer has got to be the hardest to stitch, period. It’s so deep! And the stitch is supposed to go sideways, so that you don’t end up stitching through the woman’s rectum. Piece of cake, lemme tell you…

Here you can see where my first interrupted stitch through the muscle layer tore through the foam, and managed to absolutely not approximate the muscle together in any way, whatsoever.

My second interrupted stitch is a little better. At least it’s on both sides of the wound, ostensibly pulling the tissue together.

Enough with the muscle layer already! Suturing mucosa is such a blessed relief, after all of that deep stuff. This is an interlocking blanket stitch, in theory.

After suturing the mucosa above the hymenal ring, next comes a transitional stitch which dives under the hymenal ring, and comes up in the subcutaneous tissue in front of the hymenal ring. And then, what comes next is a descending continuous stitch down towards the perineal apex of the wound.

The descending continuous stitch continues.

After that, we sew our way back up the perineum, this time in the subcuticular layer, using a ladder stitch composed of interlocking C’s, if that makes any sense whatsoever. Trust me, it barely makes sense to me. Notice how taut and well approximated the subcutaneous layer is in the back *rolls eyes*. Honestly, though, how do you really do this on a live woman? If you draw up the sides of the wound together, how do you even get your needle in there to suture in the first place? Urgh, it defies me.

The finished product: well, it’s stitched up, at any rate. Not sure if it’s any good. Thank goodness this isn’t a live person yet!

Meanwhile, four more lacerated foam vaginas eagerly await my careful, skilled, well-controlled ministrations *snort*.

OPEN LETTER TO THE WOMEN OF THE WORLD: Do not fear! I am practicing this like nobody’s business! I promise you, before I even come within an inch of your perineum, I will be so much better at this! I will suture foam until my fingers fall off, then I’ll progress to raw chicken breast, and when I finally do suture the very first of you, it will be under the watchful guidance of a skilled, experienced midwife, who won’t let me place a single stitch unless it’s in the absolute right place. I will be so careful. I will keep working on this until I’m good at it. I promise you.

I feel like I’ve just barely been holding it together the past few weeks, and just barely (by the skin of my teeth) managing to keep on top of things…not that I’m even coming close to getting all of my reading and homework done, but I’ve been doing enough to feel like I’m working hard at it, and therefore, the stress has been kept somewhat at bay. Until today, that is. Today, it all came crashing down on me in one overwhelming heap. I blame the suturing.

Yes, ladies and germs, today I learned to suture—”learned” being a very generous word for what I actually did today. Mostly I flailed around with a needle holder. Usually I’d consider myself pretty competent at things: I’m smart, I catch on quickly, I can generally master most tasks I set my mind to in just a matter of a few tries. Suturing? Er, no. Suturing is going to take a lot longer than just a few tries.

We were all given large, thick blocks of foam rubber to practice on, and a set of instruments, and suture. We learned about the different types of suture today—chromic v. vicryl—learned about the sizes and shapes of needles, the instruments we’d need, knot tying (instrument and hand ties), how to cut an episiotomy if you absolutely have to (the indications for cutting one being, basically, almost never—except in cases of extreme emergency, or when you need to enlarge the perineal opening in order to perform additional manuevers, such as during a shoulder dystocia). We spent the entire afternoon trying to sew up the episiotomy we’d cut. Oye! Achor stitches defy me! How in the world do you manage to sew sideways through the muscle layer, instead of up and down, so that you don’t end up sewing through the woman’s rectum? I can’t seem to get the angle of the needle right, and all of my stitches are uneven and either too deep or too shallow, too close together, dimpling, too taut or too loose. And if this is foam I’m working with, and I still can’t do it…what am I going to when it’s actual skin and tissue and muscle, none of it neatly delineated, but all blurred together, and bleeding, no less?

This is actually the best motivation I can imagine for trying to preserve the perineum during birth: so long as the woman is intact, you don’t ever have to suture!

So, here’s what I’m taking this semester:

Intrapartum
Neonatology
Postpartum
Intro to Teaching

And eeegads, that’s a lot! IP and Neo alone are enough to snow someone under, and then they’re putting postpartum and teaching on top of that? When am I going to breathe this semester, let alone eat, sleep, work and blog? But it’s been absolutely wonderful so far, I can’t even begin to tell you! All we’ve done this week is talk about labor and birth. I’ve had more knowledge packed into my brain these past three days than I have all summer, and I feel like my understanding of labor and birth has already increased dramatically. Wednesday was all about normal labor: what it’s like, what it sounds like, what it looks like, the phases of labor, what to expect etc. etc., and then the afternoon was devoted to the mechanisms of labor, which just absolutely blew me away. The baby goes through 7 very specific manuevers in order to successfully navigate the maternal pelvis, and it’s such a tight fit! How in the world do those babies actually get through that bony pelvis? And yet they do it all the time, every day. It’s amazing how perfectly adapted for labor they are, and how the natural curve of the head, when it’s well flexed and in an occiput-anterior position, fits so beautifully into the natural curve of the pelvis. The two were absolutely designed for each other, with only ONE centimeter or so to spare! The widest diameter of a baby’s head (the biparietal diameter), when it’s well flexed, is 9.5 cm. The narrowest part of the pelvic cavity (the bispinous diameter, between the ischial spines) is 10.5 cm. That’s not a whole lot of wiggle room!

Six hours of class a day, with our model pelvis in our laps, and our dolls in our hands, going over the mechanisms of labor until we have them down cold: descent, flexion, engagment, internal rotation, extension, restitution, external rotation and then finally birth by lateral flexion. Pelvis, doll head-down and in, internal rotation, head out, shoulders turn, shoulders out, body out, and again. And then flip the baby sunnyside up (or “face to pubes” as our professor jokingly calls it), and go through the mechanisms all over again for posterior deliveries, both long arc and short arc. I’m telling you, this is the coolest stuff in the world! And having read a little bit about anterior and posterior babies in nursing school, and documented the position of the baby at countless deliveries (always by asking the doctor what position the baby was in, LOA, ROA, ROP, LOT etc. etc.) I finally feel like I understand it well enough on my own now that next time I won’t have to ask the doctor…I’ll just watch, and see for myself what position the baby was in as it restitues and externally rotates. Such a huge leap of knowledge in such a short span of time, and school has only been in session for 3 days.

Today was spent going over procedures we’re going to have to know how to do: rupturing membranes, how to check to see whether a woman has indeed broken her water or not, inserting scalp electrodes, and delivering a baby. Just a basic, standard delivery, with the baby in plain old Right Occiput Anterior (ROA), nothing fancy yet. But it’s an amazing start. And I have a lot of practicing to do. Where to put my hands while the baby is crowning, how to assist the head, then check for a cord wrapped around the baby’s neck, and then wait for the baby to rotate, and then support the shoulders as they come out. We have a rubber model of a woman’s torso, with a pregnant belly and a baby inside, and as your professor pushes the plastic baby out through the pelvis, and you stand there with your gauze and clamps, ready to catch, it begins to dawn on you: you’re actually going to be catching real babies, very very soon.

And here’s my note to self: It’s a huge, overwhelming amount of material. Lots and lots of mental stuff to cram into your overwhelmed brain, and learn, and relearn, and know. But in the midst of all this mental exertion, don’t forget about the heart. When you’re shaking and nervous and approaching your very first birth, EVER, in the role of the midwife, the one with hands out and ready to receive…remember that you’re standing in a holy place. Birth isn’t in the textbook. It’s in the mother, grunting and sweating with exertion. It’s in the father, kissing her forehead and urging her on with gentle words. It’s in the baby, wiggling, wriggling, working so hard to navigate that bony pelvis, pushing up towards the surface. Try to focus on that, while you’re struggling so hard to master all of the didactic knowledge, and clamp the cord correctly, and remember to check the placenta, and assign an apgar. Your heart has called you to this profession, this work, this path. Let your heart shine through, and not your nerves.

I’ve gotten out of the habit of blogging. Our move this summer created a long stretch without internet, and I must admit, once I got used to a life without daily internet needs, it was hard to return to the wired world. While I’m a bit disappointed with my somewhat less than inspired summer blogging output, it was actually a very nice break. However, today being the first day of the new semester, it’s time to turn over a new leaf. I am already regretting my steadfast refusal to crack a textbook all summer, because the amount of work that now awaits me is rather monumental. Honestly, though, it’s fantastic to finally, ACTUALLY be in IP (i.e., Intrapartum, i.e. the class that focuses on labor and birth). It feels like the real meat and potatoes of midwifery, the main course after eating appetizers for all of last year. I’m so excited about learning all of this that I came home from school and immediately threw open those summer-neglected textbooks, and I’ve been reading and studying and working on my IP module all night. Hopefully this burst of enthusiasm will last for quite awhile, because I’m sure I’ll need it.

It was also very nice to be reunited with my fellow student-midwife sisters, none of whom I saw over the summer. Lots of hugs and chit chat and catching up. Our school has the tradition of pairing returning students with new students, in a big sister/little sister arrangement, and today for the first timeI was a big sis, which was also an interesting new perspective. As returning students we were also responsible for the traditional first day potluck, and I’m pleased to say that we outdid ourselves. The table was heavy with food, just like this year is heavy with anticipation. May it be every bit as delicious as I hope it will be!

DONE!!!!

I’m done with the semester!!!!!!

Done! Done! Done!!!!

Omg, off to go party. Byeeee.

Have definitely gotten to the point tonight that nothing is sinking in anymore. I feel like I’m a sponge full of water, and if you add more water to my oversoaked brain right now, water is just going to end up spilling out of it. Our first exam is tomorrow (well-woman gynecology). I feel woefully underprepared, but maybe that’s because the topics are so overwhelming: abnormal uterine bleeding, amenorrhea, chronic pelvic pain, infertility…any one of these things could be caused by so many different things, and requires such extensive work ups that really…I just have no clue. And the answer can’t be to refer to a physician all the time, but honestly…it’s all just a bit too overwhelming. My eyes keep glazing over. If I don’t know it by now, there’s no way I’m going to be able to learn it tonight. I guess that means it’s time for bed.

When I’m swamped, I usually don’t have time to post anything here, which is a shame, because it doesn’t allow the faithful reader a full blow-by-blow account of the ins and outs of being a student. So, here’s a five minute post just to render the reality of studenthood a little more clearly for those who’re interested: aaaaaaahhhhhhh!!!

Each semester the students are given modules to complete with the core competencies written down for every class. The modules are long. Here’s a small sample, from our antepartum module:

8.3 Discuss the components, timing, purpose, indications, contraindications, risks v. benefits, normal and abnormal results and appropriate followup for deviation from normal for the following tests:

Right…and that’s just section 8.3 of the 13 sections which makes up the first competency of our antepartum class (there are three competencies in antepartum). And then there’s a module for Well-woman gynecology, and a module for OB Pharmacology, and a mini-module for Professional Issues, and a module for Research. And, in a glorious climax of stress and work, we’re getting to the end of the semester, where all of the final exams occur, and the papers are due, and the modules are supposed to be completed. So, we’re working our butts off to get everything done in time, and then, once the modules are completed, we can actually hunker down and begin to study. So, yes, the life of a student…

(And this is not in any way trying to scare or deter any of you future student midwives out there who are reading this and starting to freak out…I’d like to say that it’s all worth it, and you make it in the end, except that I’m not quite there yet, and at the moment, I can’t see the forest for the trees…and I spend at least a few minutes every day saying to myself “why in the world am I putting myself through this??”…however, I guess if you’ve been called the way most midwivery students are called, you don’t have much of a choice in the matter).

If I’m not posting much in the coming week or so, it’s because I’m working on my never-ending modules. However, Lobby Day is this coming Tuesday, so I’m sure I’ll have a few things to say about that. (Lobby Day is a day organized by NYSALM for the very specific purpose of gathering as many midwives as possible in Albany, and talking/lobbying with our congress[wo]men for the bills which the midwives of New York State are supporting, and generally promoting the profession of midwifery etc. etc. I went two years ago and it was a lot of fun—I’m sure this year will be just as satisfying.)

But first, another AAAAAHHHH!!!! And then…back to work on the modules.

We take time out now from our regularly scheduled Revolution to give you this small homework update. This week, like last week, is going to be a killer week. Chapter Three of my research proposal is due on Monday, two case presentations in two seperate classes are due next Wednesday, and the mother of all antepartum exams is THIS Wednesday, covering embryology, gestational diabetes and bleeding during pregnancy. All of which are such small, unimportant, simple topics that of course I got my studying done weeks ago and am looking forward to acing this exam. *cough* The embryology in particular is a black hole capable of devouring small villages, goats and all. You wouldn’t believe how complicated it is (or maybe you would). Day one, zygote, day three, morula, day four, blastocyst, day five the blastocyst divides into an embryoblast (aka future baby) and trophoblast (aka future placenta). Every three to four days, the growing organism gets a new name. The embryoblast goes on to become the bilaminar disc, composed of the epiblast and hypoblast, which then goes on to become a trilaminar disc, where the hypoblast morphs into the endoderm, the epiblast morphs into the ectoderm, and both contribute to the formation of the mesoderm. Meanwhile, back on the ranch, the trophoblast has become two parts as well: the syncytiotrophoblast (try saying that nine times fast…pronounced sin-sish-oh-tropho-blast) and the cytotrophoblast. Syncytiotrophoblast goes on to invade the endometrium (aka implant), while the cytotrophoblast encircles the baby and aspires to someday become the chorion. And this brings us up to day…seven.

I really don’t have a handle on this material at all yet (and the exam is…Wed???). Day one through ten is easy compared to all the bits about the differentiation of the chorion and the decidua, the formation of the primary, secondary and tertiary villi, the eventual fusion of the chorion leavae with the chorion frondosum, which in turn (I think) fuses with the decidua basalis, which then somehow fuses together to become the amniochorionic membrane…I think. It’s all a bit cloudy.

I wish we could somehow break it down into simpler terms, something along the lines of: bunch of cells, cells divide, eventually, around 3rd month, you’ve got amnion, chorion, and embryo. 6 months later, baby. Voila.

I think my brain is going to implode shortly. That must mean it’s time for bed.

Well, I didn’t fail my Antepartum exam last Friday by any means, but I didn’t do nearly as well as I had wanted to do. When I left the exam, I was actually feeling pretty confident about it. Somehow, my grade did not quite reflect this confidence, which is a bit distressing, especially given that 1) this is antepartum, i.e. all about prenatal care and pregnant women, i.e. REALLY IMPORTANT and 2) I hold myself to pretty high academic standards, and generally, I’m able to meet those standards well enough, but this grade was altogether diappointing. My first disappointing grade since I started this program, in fact.

I’ve made an appointment with the professor to go in and review the exam and figure out where the gaps in my knowledge were, and I’ve made a few promises to myself to work a little bit harder on my modules and studying etc. etc. (although, to be honest, I feel like I already do work pretty hard on this stuff, as is, but obviously, my last bout of studying didn’t quite cut it). Anyway, I guess there are always days like this in every student’s career.

In other news: clinicals start next week. Aaaaaaiiiieeeee!!