Belly Tales

The IUD, I’m beginning to learn, is a much maligned form of contraception. It got a terrible reputation in the US because of all of the furor surrounding the Dalkon Shield in the 1970s, however, the two modern versions of the IUD (ParaGaurd, aka The Copper-T, and Mirena, aka The Hormonal One) are actually safe, effective, more or less painless, and for many women, an ideal form of birth control. In fact, IUDs are one of the most popular forms of birth control in other countries—in most of Europe, actually.

Which is all well and good. In fact, great! Go IUDs. I will happily recommend them to all of my clients who want a no-fuss, highly effective, low cost (expensive at the outset, but cheap given that they last 5-10 years), low side-effect contracetive choice—especially my clients who have already been pregnant once. Nevertheless, tenaculums give me the heebies. The teeth of these gruesome little things are actually inserted into the tender flesh of the unsuspecting cervix, and then the instrument is gradually secured, one click at a time, followed by gentle traction in order to straighten out the axis of the uterus so that the IUD can be properly placed (and we spent most of the afternoon practicing this skill on models). And while I am well aware of the fact that supposedly the cervix has very few nerve endings, and antiseptic washes followed by anesthetic gels are applied before the tenaculum, and the entire procedure is done slowly and gently, one step at a time…even so: my initial reaction was a full-body grimace, and the mental thought of OUCH. Ouch ouch ouch. Poor cervix!

However, don’t let this bias you against IUDs! Insertion is not without its discomforts (usually cramping for the first few hours, which can be managed by a trusty dose of advil or motrin), but luckily, as a consumer of IUDs, you never have to watch the actual insertion process. As a student midwife, watching will probably be the least of it—actually using a tenaculum?? It makes my hair cringe just thinking about it (and the professors had the cheek to say, with eager, chipper voices “Hopefully you’ll get several opportunities to insert IUDs during your upcoming clinicals!”.) Yeah.

I. Can’t. Wait.

Yesterday was Everything You Ever Wanted to Know About Hormonal Contraception Day, EVAR. Yes, truly. Everything. We staggered out of class at the end of the day with pressure ulcers (read, bedsores) on our ischial tuberosities (read, butt bones), and heads that felt rather like over-full waterballoons ready to burst, or maybe gigantic blisters ready to pop, or huge, overstuffed armchairs that are slowly leaking fluffy white stuffing out of a tiny tear in the upholstery. And yeah, don’t get me wrong: hormonal contraception is way cool, but maybe not 6 straight hours of it in a row.

Today was a bit more varied. We began the day with antepartum vaginal exams and ended the day with our microscopy check-outs, with a 2 hour lecture on abnormal pap smears thrown into the middle for good measure. Management of abnormal pap smears: wow, there’s a lot to know about that (note to self: CONSULT!!). Microscopy: will be a lot more fun when we actually get to examine real yeast and BV and trich, instead of perfectly healthy vaginal secretions which just aren’t that interesting to look at (healthy vaginal epithelium, for example, just sort of sits there, whereas real live trichomonads actually swim around and wiggle! …). Vaginal exams: uh…well…good in theory, but I really have no idea.

It’s amazing how much of midwifery is in the dark. So little of your knowledge is gathered and assessed with your eyes; you “look” with your fingertips. Thing is, my fingertips are absolutely blind right now. They know nothing. I’ve done maybe three vaginal exams in my entire life. We talked for a good long while about effacement (the thinning out of the cervix) and dilation, and how to assess both, and how difficult it can be to even tell where the cervix is when it’s 100% effaced and paper-thin. Our instructor kept describing scenarios to us where we’d need to know to look for this, or know to check for that…where the outer os of the cervix might be open, but the inner os closed, how we’ll know that what we’re feeling is ruptured membranes versus intact membranes with the water displaced behind the head—she talked so confidently, and with such assurance, and she spoke as if it were all so simple.

Yet how can she lecture to us about the subtle differences between rim and fully dilated when we’re probably not even going to be able to tell the difference between 2 cm and 7 cm, or 50% and 100% effaced? It’s all a Mystery to me. Staring at my professor today was like staring at someone across a great gulf: I could see her there on the other side, brimming with her hard-won knowledge, talking matter-of-factly about things that seemed so straightforward to her, but to me, the uninitiated, it seemed like I’d never get to the other side. When I examine a woman’s cervix, let me assure you: I have no idea WHAT in the blazes I’m feeling! I have no idea when vaginal exams are going to start to make sense: 6 months from now? Two years from now? When will I be standing on the other side of the canyon, explaining the subtle differences between 0 station and +1 station? I have a feeling it will be a bit like learning a new language: you struggle, and struggle, and struggle, and then, one day, you overhear two people talking on the subway in that language and realize you just understood every word they said.

But first, the struggle. Clinicals are going to be a blast, aren’t they? You gotta love it when the learning curve is an 85% incline, straight up.

Today was devoted to the flora of the vagina: what’s normal, what’s not, what happens when yeast decides to take up residence, or when the lactobacilli flee in droves, or when all sorts of unfriendly sexually transmitted diseases invade. Our professor referred to the vagina as the secret garden, and that’s such a beautiful name for it that I think I’m going to have to steal it and start using it myself. It really IS a secret garden, full of amazing quantities of healthy bacteria that keep the pH nice and low, self-clean and prevent unfriendly bacteria from taking over: such a delicate, yet tenacious, balance. Honestly, the more I learn about the female body, the more amazed I become. We’re so friggin’ cool! I already thought we were cool before school even started, but now the coolness quotient is somewhere up near the “awe” level. I can’t wait to become a midwife and teach other women about just how cool their bodies are. What a dream job.

You know you’re in midwifery school when you find yourself examining your own vaginal secretions under a microscope during your class on microscopy. All of us dutifully trooped off to the bathroom with our Q-tip swabs to collect our specimens, then hurried back to the classroom to make our slides—there were a few nursing students in the hallway watching us with puzzled looks on their faces. It reminded me of the time last semester when a fellow student got told off by a nursing instructor for washing her speculum in the bathroom sink after the peer pelvics. You’d think that by now they would have gotten used to the whacky midwives they share the 7th floor with. Anyway, in theory, I can now distinguish between yeast buds, trichomonas and bacterial vaginosis under the microscope, but thankfully, the only thing I saw on my slide were normal squamous epithelial cells from the walls of my very own secret garden.

The curse, the red tide, my period, my monthly, my friend, on the rag, on the spurt, and on and on. All the jokes, all the whining, all the bitching, all the unfair media portrayal, the cultural stigma, the fear, the shame…menstruation gets such a bad rep that, at the very least, I felt it deserved to be paired with a word like “magical” for a refreshing change of pace, if for no other reason than its very complexity. Do you have any idea how many hormones are involved in your monthly menstrual cycle? Take a guess: 2 hormones? 3? 4? I can’t even tell you. Our lecture today covered the ups and downs of the 5 major hormones that are involved, but the lecturer kept slipping in little comments like: “and of course, prostaglandins, and inhibin, and [insert other hormone names that I wasn't even able to catch] also play a part, but I’m not going to get into that today.” Damn straight it’s magical. It’s absolutely amazing! If we ever tried to reproduce the entire cycle in a laboratory setting, there’s no way in hell we’d ever be able to get it right. Do you have any idea how many things are all happening at once? It’s a bit mind boggling.

Mind-boggled. Yup, that’s pretty much how I feel right now. This semester is going to be a TON of work. I have so much on my plate already that I don’t even know where to start (hence, this delightful post: why start in on your homework when you can procrastinate and post to your blog instead?). And as for the menstrual cycle…this is something we studied in nursing school, and I had a hard time grasping it then. This is something I’m going to have to go over again and again and again until I know it forward and backwards, because it’s so damn important (and so damn complex). This is the reason and the beginning, the why and the how, of pregnancy. The hypothalamic-pituitary-ovarian axis, the follicular phase, the proliferative phase, the secretory phase, the luteal phase…all these names for something that your body does automatically, naturally, without fuss and often with very few mistakes, every single month for most of your adult life.

Lecture today was great. The guest lecturer was smart and sassy and a lot of fun—material that could have been really boring was actually made fascinating, which says a lot. And lots of little fun facts tossed in for good measure. For example, did you know that bleeding is not actually necessary at all during the cycle if you’re on birth control? Because of the presence of progesterone from the very beginning of the cycle, the lining of the endometrium doesn’t ever proliferate very much at all, but just stays steady at about 2 mm of development, and can stay that way for quite some time, if you ever want to just go through a few pill packs back to back and skip the week of placebos that allow for bleeding. In fact, apparently the only reason the placebo week was structured into the pill cycle was because of a decision made by a very Catholic man in the 1950s, who felt that monthly bleeding was necessary in order to help remind women of Eve, and the fact that they’re women, I guess. There’s a new pill out now that will charge you an arm and a leg for the privilege of only bleeding four times a year (Seasonale), but you might as well save some money and just take your regular pills back to back (although talk to your midwife/health care provider about it first, of course).

Another interesting fun fact: the Morning After Pill (aka EC or Emergency Contraception) really truly IS birth control, and not an abortifacient, and yes, I already knew this, but now I understand why. EC is basically just pure progesterone, and it works best during the follicular phase of the cycle, where the sudden burst of incoming progesterone is enough to prevent the release of leutenizing hormone that triggers ovulation. In other words, EC works best if it’s taken before ovulation occurs, in order to prevent ovulation. However, if ovulation has already occurred, the surge in progesterone may slow down fallopian tube motility and therefore possibly prevent implantation (in which case, I guess I could see how conservatives could potentially argue that this prevention of implantation is in fact the killing of a baby, but I do think it’s a rather thin argument). However, the little fun fact I didn’t realize is this: as soon as you’re pregnant (i.e., as soon as the trophoblast has implanted), the corpus luteum begins to make progesterone in vast quantities, and if you happen to take EC at this point in the cycle, it won’t disturb or prevent the pregnancy in any way whatsoever. In other words, if you’re already pregnant (i.e., the trophoblast has already implanted), EC does not end or harm your pregnancy in any way. In other words, it’s NOT an abortifacient. As soon as that trophoblast implants, the corpus luteum is working its ass off to produce massive amounts of progesterone anyway just to keep the pregnancy afloat until the placenta can take over hormone duty; a little extra squirt of EC progesterone at this time does NOTHING to disrupt this. FYI. (Why do I feel that if more people actually understood how EC worked, so many of the objections to it would just disappear, and the FDA might finally get around to approving it for over-the-counter use? Righto. Get the word out, ladies.)

One exam down. Two to go. One massive paper to finish. And a final discussion question to answer for Research.

I have one week left to accomplish all of this. The paper and discussion point are due next monday. The two exams are next Tuesday. My hope is to finish the paper today or tomorrow, and then I can start focusing on studying for the exams.

I can’t wait to have all of this DONE. I’m very ready for the semester to end.

There’s not much on my plate this week, schoolwise, so it’s easy to let your gaurd down, especially with Thanksgiving this week, and that lovely holiday feeling in the air, but Note To Self: it’s only the deep breath before the plunge! Starting next week, and moving into December, things are going to get Very Busy ™. Next week (the 29th), my presentation on hyperthyroidism is due for primary care; we’ll also be receiving our final take-home exams on class on that day, due the following week (12/6). Then the week after, I have the second chapter of my Research proposal due on Dec. 5th (i.e., a veritable TON of writing to get done); I also have an exam in Physical Health Assessment of Women that day. So, basically, next week will be crazed, writing my research proposal chapter, and studying for all of these upcoming exams. After that, though, the semester is nearly finished, with only one more exam to go on 12/13, but it will be a doozy: our Pelvic Assessment of Women exam, which will include all the muscles of the perineum, all the bones of the pelvis, pelvimetry, speculum exams, specimen collection and the external and internal anatomy of the female. Good lord!! I’m getting a bit stressed just thinking about it. I better make the most of this coming week.

Amazing how much of midwifery school has absolutely NOTHING to do with pregnant women, or babies, or birth, AT ALL. I’m up to my neck in a presentation on hyperthyroidism at the moment. Haven’t even discussed anything pelvis or speculum related for the past two weeks. Le sigh. At least our clinicals start tomorrow, at a county abortion clinic. Weee-ha, bring it on.

I’ve been a bad blogger, lately, and haven’t been writing posts nearly as often as I should. Which is not to say that nothing has been happening lately (in fact, I’ve been quite busy, and have been having a hard time finding a moment to write), but none of it has seemed particularly news-worthy. School continues at its steady pace. We’ve gotten through our first round of mid-semester exams, which was stressful and is thankfully over, our check-out exams are done, and clinicals start next week for me. We had a spectucular 4 hour lecture on urinary tract infections in Primary Care last week, which was very cool, but didn’t seem to merit an entire post. Although I will mention this cute little factoid: did you know that a woman’s urethra is approximately 2.5-3.5 cm long, while the male urethra is approximately 16.5-18.5 cm?? I mean, obviously the male urethra is longer, but I had no idea it was that much longer. No wonder women get so many more UTIs than men! It seems a bit unfair.

On the work front, I’ve been doing nothing but postpartum lately, which has been a bit depressing. Not that there’s anything wrong with postpartum—it’s fabulous to see all the women and their babies, and to take care of them during a time when they so desperately need nurturing, and you can make such a difference in a woman’s life by helping her with the breastfeeding—but even so, postpartum is a bit more routine and repetitive than Labor and Delivery, and you end up taking care of 8 patients at a time, which can be stressful and frustrating, since you never feel like you get nearly enough time with any of them! Sadly, as a per diem nurse, I don’t have much say in where I end up working. If L&D is well staffed, but they need nurses on postpartum, I am always the first person to get floated. It’s been weeks now since I saw a birth, and that makes for one very very grouchy student midwife. I’m working tonight, tomorrow night and the next night, though, so hopefully I’ll get to see a birth again fairly soon.

In other news, I’ve found yet another really cool website which is well worth checking-out (there are so many of them out there!): Spinning Babies. I’m going to post it as a link under the Labor and Birth –> Vaginal Birth sections, since the information here is really helpful for women trying to turn their babies, or learn about the optimal positions for birth, and ways to help get their babies into these positions. Gail Tully, the homebirth midwife (CPM) and doula educator who is the driving force behind Spinning Babies, offers workshops on her techniques, and there’s a workshop in Boston next Feb., which I would really like to attend. There are so many conferences and workshops I’d like to attend next year! Guess I’d better get saving…

Anyway, more posts to come, I promise. I’ve been working on a doozy of a post on premature rupture of membranes, and I discovered some amazing birth art just a few blocks from my house, so stay tuned.

I didn’t get a chance to write about this yesterday, because it was a pretty busy day, but we had our check-out exams in the morning, and they both went very smoothly. There were de facto slip-ups, of course, but both my partner and I did well, even though I was so nervous that my hand was visibly shaking when I held up the penlight to check her extraoccular movements. I didn’t completely blank on anything, though, and I didn’t fumble too much, and the minor things which I did forget I was able to go back and correct on my own. The good news? Both my partner and I passed with flying colors, and even got a compliment from the professor about how organized we were, which is a bit surprising, since I felt so nervous, and we both felt like we had made lots of smalle gaffes. It took me three attempts to find the Southern Belle’s cervix during the speculum exam, even though I was always able to locate it right off the bat during all of our practice attempts! The even better news? It’s over!! We’ll be starting clinicals next week, and examining actual patients, instead of each other, so it feels a bit as if the really fun part is about to begin (not that examining your partner isn’t fun, but you know what I mean.) Our clinicals for this class will be held at an abortion clinic, actually, which should be a very interesting, and certainly a good way to get to examine lots of different women at different stages in their pregnancies. I’m a bit nervous about it, for sure, but mostly excited.

Worked last night…started out in antepartum, where I was taking care of one woman with severe pre-eclampsia, one woman with preterm premature rupture of membranes and oligohydramnios, and one woman with a complete placenta previa and vaginal bleeding. Then, around 3:00 am, I was transferred to postpartum to help with the sudden influx of admissions. Sadly, I didn’t get to see a single birth. It’s starting to feel like it’s been awhile since I’ve seen a one. I haven’t been working that often, and when I do work lately, either none of my patients deliver, or else I’m in postpartum. Hopefully a pattern that will break next week. It was a long, exhausting night, and I’m glad it’s over. Plans for the weekend? Sleep!

Just a brief update on the peer pelvic experience: overall, absolutely stellar. They were fun, intimate, very educational, and only marginally uncomfortable (we were in groups of three, which meant one person was examined twice by each of her peers, and let me tell you…by the end of the second exam…boy, were you ready to have that speculum removed!). The strangest part of the entire experience? Having a professor perform a bimanual on you. Honestly, I had totally forgotten about that aspect of it until this morning in class, but basically, the professor went in and examined each of us and recorded the findings so that she’d know what was there, and then the student would have a go at it. This way, if the student thought she was feeling the uterus to the left, and it was really to the right, the professor could correct her and help her find the right position. The recorded findings will be given to the professors who are grading us during the check-out exams, so that they’ll know what the student is supposed to be feeling/finding, if that makes any sense at all. Our professor (different from the one who taught us pelvimetry, but another good egg) was lovely throughout the entire thing, cracking jokes where appropriate, gently guiding us through it, putting us at ease. Amazing to see the beautiful variation in all of our bodies, even among only three of us. Women’s bodies are so neat! By the time we were up to the last person, we’d already gotten so much faster at doing the exams, and were much more comfortable with our speculums. We even practiced pelvimetry on each other. I found out that I have a totally adequate pelvis, mostly gynecoid, with some anthropoid features. So, in other words, when I finally get around to being pregnant, it shouldn’t really be a problem getting a baby through my pelvis. That’s always nice to hear! However, it’s been a long day, and in the interest of my sanity, I have decided to blow off the homework for an evening, eat some ice cream, possibly watch a movie, and get some sleep. My partner, the Southern Belle, will be coming over tomorrow night so we can run through the exams again and again and again until we both have it down cold, because…

CHECK OUT EXAMS ARE ON THURSDAY!!!!!

Right. Where’s that ice cream??