Belly Tales

I am a working girl at last!  Finally, after weeks of overcoming bureaucratic hurdle after hurdle, I am finally working!  Today was my first day at my new job as a new midwife at a busy Brooklyn hospital.  I can’t even begin to describe to you how exciting it was to get an employee ID with my name and the credential of CNM on it, or my CNM “stamp” that I’ll be using to write prescriptions.  All incredibly official.  A little bit surreal.  I was issued sets of scrubs, two long, white lab coats, spent a portion of the morning talking to the benefits coordinator about my benefits, and then, in the afternoon, was plunked down in the middle of a busy prenatal clinic, in true dyed-in-the-wool sink-or-swim midwifery style.

And how fantastic it as to be back in the midst of pregnant women again!  Listening to fetal heart tones, doing  Leopold’s maneuvers, estimating fetal weights, listening to women complain about their swollen ankles and over-active bladders and sore backs (normal, normal, all totally normal).  The computer system is cumbersome, I’m really, really slow, I have absolutely no idea what paperwork is needed to be filled out for referrals or ultrasounds or triple screens, but I suppose I’ll get there eventually.  The slow, painful, very steep learning curve has begun.  I can’t wait to look back in 6 months and see all of the incredible progress I’ve made—that is the light at the end of the tunnel.  In the meantime, I’ll be exhausted, overwhelmed, and making a lot of mistakes.  Oh joy.  But yes, oh joy!  I’m actually an employed midwife now.

My Comprehensive Exams are in less than two weeks. Yes, you heard that right: LESS THAN TWO WEEKS!!!  Aaaaiiiiiieeeeeee!!!!  Two measley weeks in which to review all of well-woman gynecology, primary care, neonatology, antepartum, intrapartum, postpartum and professional issues.  Seems rather daunting and impossible, right?  I agree.  However, I’m doing my best not to dwell on the magnitude or impossibility of this task, but just devote myself to studying 6-8 hours a day, starting tomorrow.  Wish me luck!

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.

I’ve been under a lot of pressure lately to become much much MUCH faster at my clinic visits. My clinicals are at a very high volume clinic where the midwives (two to three, depending on the schedule) can often see about 35 patients in a day. This means that each midwife, on the days that there are three, has to see at least 10 patients during their 8 hour shift, and on the days where there are only two midwives….well, you sort of hope that a few of the patients won’t show up for their appointment (and in fact, there are often many who don’t come, for various reasons…either they went into labor and delivered already, or something else came up). Prenatal revisits are supposed to take about 15 minutes, and initial prenatal visits are supposed to take about 30 minutes. Add to this the fact that my preceptors are having to supervise me, and follow-up on all of my fundal heights, and be present in the room during all of my pelvics and bimanual exams…and, well…it gets a bit overwhelming at times.

I’ve been trying really hard to go faster, but try as I might, I am still really, REALLY slow. Really slow. A new visit will take me about an hour, and a revisit will take me about half an hour—sometimes 20-25 minutes, on a good day—and yes, I’m timing myself (my preceptors insist on it). Part of the problem is that I’m still very new at this, and there are still many, many visits where I’m presented with a problem or a complaint that I have never encountered before. Sometimes I do have an idea of what to do for the patient, but because I’ve never had to do this before, I always want to run it by my preceptors first to make sure that I have the right plan, or the right dose, or the right medication, which takes time. This happened the other day with a woman who was vomiting 10-12 times a day from her terrible morning sickness. She was eating and drinking okay, able to keep a little bit of it down, and she didn’t look dehydrated (good skin turgor, mucus membranes moist, no ketones in her urine), so I wanted to prescribe rectal compazine for her, to help get the vomiting under control, and then Vitamin B6, but I wasn’t sure if this was the right thing to do. Turns out, my preceptor totally agreed with me, and added some oral Reglan to the mix, but this required a 10 minute consult to work out. Other times, I have no idea what to do for the patient, in which case I need to talk with my preceptors anyway, just to sort of figure out how to wrap my head around the problem. Part of it, as well, is that because I’m new to all of this, I’m also a bit paranoid: I want to be as thorough as possible and I want to do this well, so I always try to cover as much information as possible in each visit and to teach as much as possible in each visit, to make sure that I’m not missing anything, and frankly, 15 minutes is just not enough time to cram in all of the teaching and talking which needs to be had during a revisit. And of course, I’m slow because I really enjoy listening to women, and I have a hard time interrupting them, or rushing them in order to get to the point of the visit. If they ask question after question, I answer question after question. If they have a slew of complaints—their round ligaments hurt, and they have sciatica, and what is this funny rash on their arms, and they keep getting leg cramps—I let them tell me all about it. I try to ask about their mental health: how are they feeling about the baby now? Still ambivalent? Getting excited about the impending birth? Worried about pain management? Maybe I shouldn’t be asking them any questinos, because it usually opens up a can of worms, and I think this is where I lose a lot of time…but I feel like this is important stuff. One of my preceptors told me the other day that I let them talk too much….I think they were saying this jokingly, but honestly, I thought one of the biggest parts of our job was listening to women??

Anyway, I’m slow. I’ve been working with my preceptors to try to find ways to make me faster, such as always approaching the visit the same way, and trying to save time by efficiency and hyper-organization. For example, on a revisit, this is what I do (or try to do), every single time, so that it becomes an efficient routine for me (that’s the theory, anyway): I open the chart, read the problems list page, read the labs page, look up her record in the computer, see if there are any new labs which need to be added to her chart, then I scan through her history and physical quickly, read her last ambulatory care note (if I have time), then call her in and talk to her. First I ask her how she’s feeling, then (when she’s finished talking, which can take awhile, see above), I tell her how many weeks pregnant she is, I tell her the results of her last lab test or sonogram, and then I talk to her about what routine lab tests we need to do today, and why we’re doing them, and what they’re for (GCT, quad screen, CBC and RPR etc.). I ask her if the baby is moving, if she’s had any vaginal bleeding, loss of fluid or contrations, is she taking her prenatal vitamins and iron, and then, up she goes onto the examining table. I measure her fundus, do my Leopold’s, we listen to the baby’s heart beat, and then I get my preceptor and have them come in to double check my findings. If she needs a pelvic or a wet mount or a clean catch, we do that too, and then I have to go look at it under the microscope (always time consuming)…and then prescribe the correct medication for her yeast infection or vaginitis, and order her chest x-ray or urine culture and sensitivity or glucose challenge test. Then, I try to reinforce her teaching, ask her about her diet, go over the tests we’re doing today, as applicable, tell her when her next appointment will be (2 weeks, 4 weeks), and send her on her way. Just typing all of this out has taken me nearly 10 minutes. Sheesh!

It really doesn’t seem possible to me, and yet I know it IS possible, because I see my preceptors doing it all the time. They work under incredible time constraints, and yet, somehow, I feel like they always manage to put the patient at ease, get to the point of the visit, provide excellent and appropriate care, and still make her feel like she was heard. How in the world do you do that??? It defies me!

Anyway, I am twice as slow as where my preceptors think I should be right now, so daily, in the clinic, I always feel like I’m not meeting expectations, or not performing to the level that I am expected to perform at. And, as you might have noticed, I tend to be a high achiever. It really bothers me when I feel like I’m not up to snuff, and has been wreaking a fair amount of havock on my self-confidence lately. I just keep thinking about the fact that pretty soon I’ll be doing this on my own, and how can I, if I can’t even do a 15 minute revisit? How will I survive as a real midwife in the world?

And here’s the other problem: when I go slow, at the pace I need to go at in order to absorb all of the information correctly, and process it, and figure out my plan, and take my time, I do very well. I’m thorough, I generally don’t miss anything, and my preceptors compliment me and tell me that I’m doing well (aside from the speed issue, which they’re always telling me needs to get better). A few times, now, we’ve been timing my visits, and I’m only allowed 5 minutes to go thorugh the chart prior to having the patient come in, and wouldn’t you know it…when I’m really worrying about my timing, and constantly glancing at my watch, and thinking in my head “faster, faster, faster!!!”, I make mistakes, I miss things, I don’t do a good job at anything, and I feel like a failure, all at the same time. And yet, when I go slow, I feel like I’m not meeting expectations, and not progressing, and not at the level I’m supposed to be at….and I feel like a failure, too. It’s just this glorious sense of just not quite being as good as I’m supposed to be at all of this, and it really kind of sucks.

But sometimes I wonder…am I actually not up to snuff, or are my preceptors’ expectations a little unrealistic? Is it possible that maybe I am actually at the pace and level that I should be, at this point in my education? I go back and forth about this a lot.

Of course, there are settings where no midwife is expected to do a 15 minute revisit. Homebirth midiwives and private practice midwives can take a lot longer…maybe even as long as they want. But I don’t think these are the settings I will be practicing in as a new grad. The market for midwives isn’t great right now, and I know I’ll pretty much take any job that is offered to me, and I’m fairly certain that this will be in a hospital setting, where I will be practicing (you guessed it!) in a clinic. Honestly, though, this is the job I want, because I’m certainly not ready for homebirth or private practice right now, and I need the experience and structure. But sadly, in these kind of settings, 15 minute revisits are pretty much the norm. And I really do want to be good at this. I want to be like my preceptors, fast AND good at the same time. And I DO think I’ll get there eventually….but maybe not during my Integration. Just give me a little more time, please.

Seems like I spend a lot of time telling women in labor to breathe, but I really need to take a moment to remind myself of this as well. And breathe again. “Overwhelmed” doesn’t even begin to cut it these days. Burnt-out seems closer to the truth sometimes. My schedule is relentless, and now that I am 8 weeks into my Integration, the pace is really beginning to take its toll. One of the worst things about my program is the way that our Integration coincides with our Complications class, which is, to put it very mildly, an extremely difficult class taught by a professor that is detail-orientated to the point of almost being obsessive. Luckily, my program has seen the problem in this, and I am part of the LAST class which will ever have to Integrate and take this class at the same time; future students will Integrate during the summer semester, after all of their classwork is done. Which is great news for them, but unfortunately, this doesn’t help me so much right now in the thick of things.

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.

Someone asked me once how I can stand to be around birth all the time, with all its sights and smells and liquids and mess. I told this person that honestly, I very rarely notice it, and it doesn’t bother me, obviously, or else how could I continue to do this day in and day out? In fact, many of the sights and sounds and smells of labor are very encouraging, and when you see them happen, you know that things are going well. The unique, clean, slightly chlorinated smell of clear amniotic fluid, for example, when a woman’s water breaks (at least, it’s always smelled a little chlorinated to me, or maybe that’s just because amniotic fluid is a base, as is chlorine, and I’ve come to associate chlorine with a basic smell)…and how reassuring it is to smell that smell as opposed to the smell of meconium, or foul amniotic fluid that smells of infection. Or when a woman is pushing, how reassuring it is to see her push out a little bit of stool with every push—when you see that, you know that a woman is pushing effectively, and that before long, you’ll be seeing the baby’s head. When you’re watching a baby crowning, the last thing on your mind is the stool. Birth is messy, sure, but it’s so beautiful that you hardly notice the mess, if you even notice it at all.

Even so, some births are definitely messier than others, and I think I just had one of my all time messiest births last Friday. The woman was a multip giving birth to her second baby. She came to triage in active labor, already six centimeters, and things were moving right along for her. We got her into her room, and she spent another hour walking around while we monitored her baby intermittantly. After awhile, she sat down on the birth stool and began to push a little bit, but because she had had a partial third degree laceration with her last pregnancy, we moved her off of the stool and on to the bed, where the delivery could be more controlled and her perineum better protected this time around. She was fully dilated at 7:00 pm, and her bulging bag of waters spontaneously burst at 7:05 pm, and didn’t just burst, but BURST, with water spraying everywhere. We cleaned up as much of it as we could, but there was a lot of it, and more of it continued to flow out with every push. The baby moved down quickly after that and was crowning in no time at all, with the usual amount of stool involved, and we let the head crown slowly so that the perineum could stretch.  The baby was born at 7:20 pm, a gorgeous, squalling 8 lb. girl, which we put on the mother’s abdomen while we went about the rest of the delivery, collecting cord blood after the cord had stopped pulsing, then delivering the placenta, and finally doing the repair (she only had a 2nd degree this time around, which is not great, but at least an improvement over the 3rd degree she’d had last time, and the head had been well controlled and the laceration had occurred in the same line as the original tear). While all of this was going on, the baby decided to demonstrate to all of us that all of her organs were working and all of her orifices were patent, and proceeded to pee all over the mother and then pass a healthy meconium as well. By the time we were done with the repair, the mother and her sodden hospital gown were covered in every possible human body fluid: amniotic fluid, blood, sweat, urine and meconium, and it wasn’t just on the mother, but all over the bed as well….even dripping off the bed and down into the cracks. It was a very impressive mess.

Thankfully, the mother was too overjoyed and caught up with her baby to even notice, and we were quickly able to clean up her perineum, take off her gown, give her a clean one, swab her down, change the chux, and get her and her husband comfortably settled in with their new baby. Even so, she definitely still needed a thorough shower, the baby needed a bath, and my own scrubs needed to be changed as well. No one ever said birth was clean, but have you ever seen a more beautiful mess?

The strangest vaginal exam I’ve ever had so far happened two nights ago, on my first night-shift clinical rotation, when a woman in early labor came to triage. She was full term, she’d had some light spotting, hadn’t felt the baby move as much as normal in the past 24 hours, and was contracting about every 5-10 minutes. I took her history and started my physical exam. We were most concerned about the lack of movement, since this is often an indicator of fetal distress, and the tracing didn’t look that hot. I palpated her abdomen and I had a difficult time figuring out where the baby’s head was, but I assumed it was vertex (head down) because we were auscultating the fetal heart below the woman’s belly button, which is usually a good sign that the head is down. I’m a student and my Leopold’s maneuvers aren’t expert by any means, so I figured it was due to my poor Leopold’s that I wasn’t able to tell for certain where the head was.

We moved on to the vaginal exam. My preceptor checked first per usual, and smiled at me as she pulled her hand out and said “this is going to be a great vaginal exam for you.” I began my exam cautiously, figuring the woman was 2-3 centimeters dilated, and wondering what my preceptor was talking about. I felt the cervix right away, and indeed, she was 2 centimeters dilated and about 80% effaced….but where was the head? I didn’t feel the head anywhere. My preceptor told me to put my fingers inside the cervix and feel the bag of waters….and OMG, what is that???! Not a head at all! Some kind of strange, small, hard little thing bobbing up against the intact bag of waters, clear as day. I almost gasped in surprise (but managed not too, thank goodness!). What in the world is that? My preceptor mouthed the word “foot” to me, and suddenly it all clicked in to place. It was indeed a foot, I could feel the outline clearly, I could tell where the heel was and where the toes were….I was basically tickling the baby’s foot, and she was in a footling breech position. An ultrasound scan quickly confirmed what we’d felt, and the head, rather than being in the fundus (or over the symphysis pubis), was actually way off to one side, almost transverse more than anything else. The woman said the head had been down at her last check-up a few days ago, so I wonder….did the baby flip all of a sudden, and is that why the woman thought the baby wasn’t moving as much as normal, because all of a sudden she wasn’t feeling the usual movements in the usual places?

She was committed to having a vaginal delivery, so we referred her to the physicians on the floor, who offered her an external cephalic version in the operating room. As they were trying to turn the baby, though, the heart rate decelerated, and she ended up giving birth by cesarean. To be honest, the tracing, even in triage, never looked fabulous…there were never any accelerations, and the variability was occassionally flat, and as it turns out, there was a cord wrapped very tightly around the baby’s head. So everything happens for a reason, and I do think that sometimes babies have a mind of their own when it comes to how they want to be born. This little one wanted to come out foot-first!

One of the greatest concerns with a breech delivery is that the cervix will not be open enough to allow the large head to pass through, even though the smaller body might have already been delivered, and then you end up in the dangerous situation of a body fully born with a head entrapped by the cervix. While vaginal deliveries may be possible for other breech presentations, like a frank breech or complete breech, because at least the breech (i.e. the rump) is hard enough and unyielding enough to press against a cervix and help it fully dilate, with a tiny little foot presenting, the chances of the cervix opening fully are very small. Because of this, footling breech presentations are the most dangerous type of breech presentation to deliver vaginally, and I’m really glad this woman came in when she did and was able to give birth via cesarean, expecially once it became clear that a version was impossible and that the baby wasn’t doing that well with her tight nuchal cord. So, here’s to cesareans done for a good reason; they really can be lifesaving when they’re truly indicated. And as for me…I will never forget this vaginal exam for the rest of my life!

So, my first week of clinicals ended last week, and I am only just now having an opportunity to sit down and write about it. Let me tell you a bit about my schedule: clinicals take up roughly 42 hours a week—2 labor and delivery shifts and 2 clinic shifts—plus one day a week in class, and every other spare moment devoted to either sleeping, eating or studying (well, and blogging…and watching the occassional episode of 24). Labor and delivery shifts start at 7:30 am for postpartum rounds and don’t finish until 9:00 pm. To get to the hospital on time, I need to leave my house around 6:30 am to account for the vagaries of the subway, which means waking up around 5:45 am (did I mention that this hospital has an absolute THOU SHALT NOT BE LATE policy? If I’m late once, we talk about it. If I’m late twice, I’m sent home. If I’m late three times, I need to find a new clinical site). It’s dark when I leave for the hospital, and dark when I come home. Not a very bright prospect for a certain student who really loves her sunlight. I thought I was going to be doing clinicals, but in fact, I think I’m in midwifery boot camp. I must have missed a memo somewhere along the way.

However, clinicals are going well. Much better than I had anticipated—in fact, most of the feedback has been very positive so far, and the preceptors I’ve encountered so far have been a lot of fun to work with. My second shift on labor and delivery involved working with one woman for most of the day. She was a multipara—first baby was 3500 gms, second baby was 4000 gms, and this one was feeling very large as well (we estimated 4000 gms), but she wasn’t diabetic, and she had a large, roomy pelvis, so we weren’t sweating (although we were watching closely, and we had a stool in the room just in case suprapubic pressure was needed in a hurry). She spent the first half of her labor out of bed and walking around (how about that! A hospital that actually has intermittent monitoring protocols that 1) work and 2) get utilized appropriately), but she wasn’t progressing quickly (about 1 cm every 2 hours), and certainly not as quickly as you would expect a multip to progress. We began to worry that if things didn’t continue to progress at a steady pace, the residents on the floor would begin to poke their heads into the room and want to start pitocin…and yes, I know! Progressing one centimeter in 2 hours is just fine, really, and not a problem if you’re at home or in a birthing center…but when you’re on labor and delivery, unfortunately there is a clock that is constantly ticking, and as a midwife on a hospital floor you have to take that into account. So we decided to rupture her membranes to see if that would help get things going. Not a benign measure, by any means, but preferable to pitocin. And sure enough, rupturing her membranes did the trick, and before we knew it, her labor was much more intense, and she was asking for an epidural, which she got.

Things slowed down a little bit after that, but she continued to make steady progress, and by 4:30 pm she was ready to push (we’d been laboring with her for the entire shift, since 8:30 am). We turned the epidural down so that she could better feel the contractions and the urge to push, and began the slow work of pushing that big baby down. Again, it took longer than we had anticipated, and she wasn’t the strongest pusher in the world, but finally, the baby began to crown. And crown. And crown. And we did, indeed, begin to sweat.

The woman had a very short perineum, and there was a little bit of scar tissue from what looked like a prior episiotomy, and her skin integrity was not that great. I gave perineal support as the head was coming out and we got the head over the perineum more or less intact. Once the head was out, my preceptor continued to apply perineal support while I worked on the shoulders. The head wasn’t rotating quickly…it definitley needed some gentle nudging to help it turn. We were concerned about a dystocia, but when I reached up I was able to feel the top of the anterior shoulder, so we knew for certain it wasn’t stuck. Nevertheless, this definitely wasn’t the type of baby that just slips out once the head is born. In fact, instead of holding the baby with both my hands gently supporting the head and neck, I actually had my hands on the shoulders, with one finger hooked under each armpit, and was gently tugging the baby out, bit by bit. I think I finally understand what is meant by “tight sholders” now. It’s not that they were stuck…but it wasn’t an easy fit.

When the baby finally came out, he looked HUGE! As it turns out, he weighed 4400 gms (not quite macrosomic)…but even so, a pretty hefty baby. Definitely took some muscle to lift him up onto his mother’s abdomen, where he proceeded to cry after about a minute of stimulation. Very adoreable baby; he looked like a 2 month old. Welcome to the world, fat and happy baby. There was terminal meconium, and when we had a chance to look at the perineum, there was a pretty nasty third degree laceration there, which baffled me since I was pretty sure the baby’s head had crowned without ripping. My preceptor told me that, given her short perineum, poor skin integrity, prior episiotomy, and just the sheer size of the kid, there was not much else we could have done to prevent it. Even so, I wonder if there was anything I could have done during the delivery of the posterior shoulder that could have prevented such a terrible tear.

In any case, the doctor came in to repair the sphincter, and we finished up the rest of the repair after that, and thus ended my 26th delivery. Tight shoulders. The largest baby I have caught to date.

So, we found out last week where our clinical placements for integration will be. Sadly, I will not be returning to the same hospital where I did my Intrapartum rotation. Honestly, I think that site was one of the best placements a student could hope for: it was busy, with lots of births, the population was amazingly diverse and so much fun to work with, there were no residents, the midwives were respected and involved in the management of everything from preterm labor to hypertension, and the midwives themselves (well, at least my preceptors…I can’t speak for every midwife in the service, since I didn’t have the opportunity to work with all of them) were warm, patient, intelligent and caring. All in all, I feel like I really blossomed under their preceptorship; my skills improved tremendously, my confidence in my ability to manage births, triage, take histories, put puzzle pieces together grew, my SOAP notes and management became much more focused and precise, I felt like my input and opinions were valued, and I would wake up every morning on the days of my clinicals and jump out of bed, thrilled and excited about the prospect of the day that lay ahead of me. It was lovely.

I have always believed, as I’ve travelled down this road towards becoming a midwife, that the experiences I have are exactly the experiences I need, at that specific moment in time, in order to teach me whatever lesson it is that I need to learn in order to become the best midwife I can be. About halfway through my IP rotation, I began to feel like I really wanted to stay at that clinical site for my Integration as well, and I started to talk to my preceptors about this. Some of them thought this was a great idea, and that I would continue to grow and progress and learn a lot from them during my Integration (and I’m sure this would have been the case, had I stayed); I must admit, the thought of continuing to grow in such a nurturing, excellent environment was very appealing to me. A few other preceptors, though, felt very strongly that I needed to go somewhere else for Integration. Their reasoning was that 1) as a student, you should go to as many different sites as possible, to learn and experience the broadest spectrum of midwifery care possible, 2) they felt that my skills were strong, and that the next lesson I needed to learn was to trust in my skills and in my judgement, and to have to defend my choices and decisions to others in an environment that was more challenging and not quite as nurturing, 3) from a job perspective, it would be to my advantage to make myself familiar to as many different clinical sites and clinical directors as possible, and 4) other students deserved the delicious, dark chocoloate experience that this site had to offer, and having enjoyed it for one entire semester all to myself, it was time to move on and let someone else have it.
On some level, this was hearbreaking. Why throw yourself to the wolves if you don’t have to? But I guess on another level, this made sense to me, and the idea of going to a different site sunk deep within and took root, so that when it came time to discuss my integration placement with my professors, instead of saying very strongly, without hesitation “I absolutely, positively want to stay at the same site, thank you very much”, I said “I would be very happy to return to the same site I was at for IP, but I would understand if I was sent to a different site instead, and if it does turn out to be a different site, I’d like to request site A and site B”.

So, I left it up to my professors. Which is another way of saying I left it up to the gods, and just trusted that I would end up wherever I needed to be. And so, as it turns out, I am not returning to the same site where I did my IP rotation, and it sounds like the site that I am going to instead is indeed going to be very challenging. I’ve heard from other students that the midwives there are incredible and passionate, but also a little bit understaffed, and that they don’t always get to take as much time with their students as they would like. I’ve also heard that they have very high expectations for their students, and that if I don’t know something, I will be asked to go home that night, look it up, and return to them the next day with the information. Which is fine, I can certainly do that, and I would have done that on my own anyway, even without the prompting. I’ve heard from other students that they’re not always the most nurturing of midwives, but that you also learn a huge amount, and get to be a part of many, many beautiful births. And of course, this is all heresay. Who knows what it will be like; my experiences might be very different.
In any case, I’m keeping an open mind. I’ve been gearing myself up for a challenge. I’m prepared to work hard, prepared to be questioned, prepared to be critiqued. I’m sure I’m going to learn a TON at this new site, and I am very excited about it, but also very nervous. This will be quite a test for me, I have a feeling.

I’ll find out soon enough. My clinicals begin this coming saturday, bright and early.

Last week I had an exam in Neonatology, and my teaching project and a presentation in Neonatology all due at the same time, so it was a bit hectic. This week, the only thing on my plate is a few modules and some studying for the upcoming final exams, and a write-up of my teaching presentation, so I’m taking a justified, (albeit brief) break, and blogging for a delicious change.

I was looking back over some of the posts I’d written about hospital birth over the past year and a half, and I feel that the time has come to eat some crow. Not a huge amount of crow—not a grilled crow steak with onions and salad and the works, but maybe a crow kebab or crow pie appetizer. I think I was feeling very burned out this past summer, very very tired of all of the hospital birth BS, and I think a lot of that had to do with how very tired I was of working as a nurse. I was (and am) ready for change, and ready to be working as a midwife, and now that I’m actually more than halfway through my IP clinical rotation, and am finally (FINALLY!!!) catching babies, it’s as if a large piece of the puzzle has fallen into place. Suddenly, everything feels right in the universe, and I’ve been so ridiculously happy lately, now that I am actually doing what I have wanted to do for so long—this glorious, miraculous, beautiful work that has called to me for over 5 years now. So, the burned out feeling is gone, and in it’s place is a refreshing sense of growth, because I am learning so much right now, and heading in such a fantastic direction, and things finally feel like they’re moving. It’s slowly dawning on me that school will in fact be over (probably much sooner than I’m ready for), and that I will indeed be a midwife someday (really, truly!!).

The point being, the hospital where I’m currently doing my clinical rotation flips a lot of the hospital-birth stereotypes on their heads, and maybe this has a lot to do with the fact that midwives are employed by this hospital, and respected by this hospital (and the OB Dept., which says a lot right there), and do a lot of the work of running the labor and delivery floor. I can only write from my experience, and this is what I’ve seen: 3 years of working as an L&D nurse in two seperate hospitals, and I’d say that at least 90% - 95% of all births involved an epidural. A woman without an epidural was either making a huge and difficult point to labor “naturally”, or had simply managed to show up to the hospital fully dilated and unable to recieve one in time before she delivered. I can’t say that the majority of births I’ve seen have had at least a 1st degree laceration, but I do feel that at work, an intact perineum is often a rarity, and a very pleasant surprise. Women, as a rule, are not allowed to eat or drink during labor. The squat bar often sat gathering dust in a corner, the birthing balls were rarely (if ever) used, and getting a woman out of bed was always a very rare and unexpected treat, that often required a lot of fighting for. It was never the norm.

And this is not to say that there are no fights to be fought at the hospital where I am currently doing my clinicals, but I’ve been paging through my delivery book (21 births so far, believe it or not!!!) and noticing that more than halfof the woman I’ve worked with haven’t had any analgesia or anesthesia on board (14 out of 21, to be exact). The majority of them have had intact perineums. I’ve used the squat bar more times in the past 7 weeks than I have used it or seen it used in the past year at the hospital where I’m working. The women on the floor are almost always given clears to drink, which is a much better deal than being NPO (i.e., not allowed to eat or drink anything), and some women are even allowed to eat some lunch in the early part of their labor or induction. And while getting a woman out of bed still causes a lot of eyebrows to be raised, I’ve seen it happen at least 4 times so far, and once we even got the woman out of bed, off the monitor, and into the shower, where she would have remained if only someone could have stayed in the room with her to fend off the anxious nurses trying to get her back on the monitor.

Oh, and VBACs! Did I mention that this hospital does VBACs? And not just attempted VBACS, but actual, squalling-baby-born-vaginally type VBACs?? Very very pleasant surprise. I think I can possibly count on one hand the number of successful VBACs I’ve seen at Tried and True Hospital.

And have I mentioned lately how much I’m enjoying my clinical rotation so far? And these births!! All these beautiful births!! I’ve caught so many babies so far! I feel so blessed, and so lucky, despite the exhaustion and over-worked brain and tired legs and mounds of homework. I stayed late one night and caught three babies in a row, one right after the other—women I’d been laboring with all day, and had been examining all day, and watching as their cervixes changed from 2 cm to 6 cm to fully dilated, and was then lucky enough to be able to catch all of their babies. Afterwards, at around 2:00 in the morning, as I was finally leaving, I stopped by the postpartum room of the first woman I had delivered that night (she was a successful VBAC!!) to say goodbye. She had been wearing a gorgeous woven cloth rosary around her neck throughout her entire pregnancy and birth, and she pulled it off and gave it to me, and I walked down to the lobby with tears in my eyes, cradling the beautiful rosary. It is such an honor, and such a gift, to be able to be with women at the moment of their births, and to be able to catch their babies. Some days I can’t believe my luck and good fortune, because that’s really what it feels like to me. I am such a lucky woman! This really is the best job in the world.

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

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

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

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

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

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