Belly Tales

Last night was a very strange night. It wasn’t that busy, and yet, somehow, neither the other midwife nor myself were able to take a break. The pace was very steady. We kept expecting it to settle down, but it never did. Just as we were thinking “oh, as soon as this woman is discharged, we’ll be able to rest for awhile”, then another woman would walk through the door.

There were two deliveries. One was a grand multip (G6P5005) who came in 9 centimeters dilated with a bulging bag of waters. The other midwife ruptured her membranes at 3:40 am and she delivered at 3:41 am. I love deliveries like that! It’s always amazing to me how QUICKLY a baby can actually exit the human body, when all the conditions are right. It’s as if they’re on a greased slide, and they just whizz on out. If only all births were so quick and easy.

The woman I delivered was 16 years old, having her first baby. She was newly immigrated, and the father of the baby was back in Santo Domingo. She had her mother and grandmother with her, though, and they were a tremendous support team for her as the contractions were picking up, fanning her face and feeding her ice chips. She progressed remarkably fast for a first baby. We forget, sometimes, that teenager’s bodies are meant to give birth, and probably more so at this age than at any other time in their lives. Even though they might not be emotionally ready, their bodies are, and they often open up through labor as if it were the easiest and most natural thing in the world. This girl was having a labor like that.

When I came on at the start of the night she was 4 centimeters dilated and in a lot of pain. We discussed her pain options, but she didn’t think she needed anything just yet, and carried on with the support from her family. Two hours later, she was ready for something for the pain, and was thinking that she wanted an epidural. However, when I checked her, she was a whopping 8 centimeters dilated, and the head had moved down to zero station. I told her she was a superstar, she was doing amazing work and the birth would be really, really soon. I told her that she could have an epidural if she really wanted one, but that by the time she got it she would probably be fully dilated and ready to push, and that an epidural would just slow down the birth in the long run. She didn’t believe me (I can’t really blame her….the contractions were pretty intense at this point), but her mother and grandmother exchanged a look, and both of them rolled up their sleeves. We coaxed her into a sitting position, and her grandmother went behind her, rubbing her back, while her mother continued to fan her face. Less than half an hour later, she was fully dilated (there is a Russian doctor at our hospital who likes to call this moment “fully delighted”), and was pushing beautifully.

The baby came down quickly and was delivered 11 minutes after she was fully: a beautiful little girl with a really tight nuchal cord which had to ultimately be clamped and cut in order to allow for the birth, and a compound right hand that extended as the baby delivered and unfortunately tore the girl’s left labia, leaving a tender, open gash. The pediatricians were there to check on the baby due to the moderate meconium which had been in her amniotic fluid, but the tracing had been overall reassuring (we’re calling this Category II now…has anyone else moved onto the new NICHD guidelines? Our hospital has finally made the switch officially, despite the fact that these guidelines have been around and endorsed by nearly everyone [ACOG, AMA, ACNM etc. etc.] since 1997, but I must admit, I’m still finding it a bit strange) and the baby came out vigorous and screaming, waving her little pink arms around. An altogether beautiful and uneventful labor and birth, which took less than 5 hours in total. You couldn’t have asked for a nicer first birth than that.

The eventful part came next, unfortunately. Everything was looking good. I was checking her perineum (intact! the only tear was the labial laceration) and waiting for the placenta when there was suddenly a pretty forceful gush of blood. I figured it was a sign that the placenta was starting to seperate, so I gave a gentle tug on the cord, and the placenta quickly began to descend. Instead of coming out with the shiny, fetal-side showing first (Shultz presentation) it came out maternal-side first (Duncan presentation) and I immediately noticed that the membranes had been completely sheared off on one side. There was a thick tendril of trailing membranes which were still firmly attached somewhere up in the uterus, and were taut and unmoving when I tried to gently tease them out by spinning the placenta a bit. Rather than tearing the membranes and losing them, I cut the placenta away and put a ring forceps on the trailing end of the membranes, so that at least we had them. I quickly inspected the placenta and saw that there were hardly any membranes present, only the cotelydons of the placenta, and the cord. Which meant that most of her membranes were still inside, either retained or trailing, I wasn’t sure which yet. And all the while she was gushing blood.

We moved pretty quickly. I called the attending doctor, we asked the family to step out a moment, and started the IV pitocin running. I gave fundal massage and felt absolutely no fundus! I couldn’t find it anywhere (later on, the attending pointed out that that is exactly what an atonic uterus feels like…as if there’s nothing there). The attending began to remove the rest of the membranes by traction, gently teasing and working them down. We administered methergine, then hemabate, and finally 1000 mcg of cytotec rectally. We started a second IV line and used a catheter to help quickly drain her bladder. I was doing firm fundal massage all this time, and finally, after what seemed like quite some time, but was really about 8 minutes, I began to feel a hard, firm fundus balling up under my hand, and the bleeding had slowed down to a trickle. The doctor had managed to extract what looked like the rest of the membranes, and his sonogram later confirmed that the uterus was empty. And then, just as quickly as it had started, the bleeding stopped. The total loss was estimated to be between 800 - 1000 cc. But once the trailing membranes were finally out, and the fundus was finally firm, she was absolutely fine. I repaired the labial laceration, cleaned her up, and helped her breastfeed her beautiful girl.

Her hemoglobin and hematocrit dropped pretty precitously when we checked her CBC four hours later, but it was still in the range of normal (10.0/ 30%), so in the end she didn’t need any kind of blood transfusion. In fact, I’m still kind of astounded by the entire thing. It’s as if a huge emergency had been averted, and yet, at the same time, it felt really routine. We drill our hemorrhage protocol pretty regularly on our unit. It was really nice to see that when push came to shove, we were able to go down the steps of the protocol one by one, and amazingly (or perhaps not), they worked just the way they were supposed to, and lo and behold, the bleeding stopped! Nobody panicked, the nurses were prepared, the doctor was calm. Everyone knew what they were supposed to do, and we just did it.

Afterwards I was waiting for the shaky post-adrenaline terror feeling that often comes after emergencies, but it never came. It made me think about how far I’ve come in my first year as a new midwife. A year ago, this would have probably left me crying or near tears, shaking in the chart room, totally freaked out. Instead, I finished the paperwork, checked her bleeding again (it was fine) and carried on with the rest of the non-stop night. I guess this is what midwives do. They don’t panick, and they stop the bleeding, and that’s that. It was just a hemorrhage kind of night.

Here’s a lovely birth story to share, my 99th delivery:

We were all expecting a big baby. Her estimated fetal weight from Leopold’s palpation was judged to be approximately 4500 gms. The baby felt huge: fat and happy, and we were all duly nervous, because her first baby was only 7.5 pounds. She wasn’t a large woman, either, but her pelvis felt incredibly roomy, so we were proceeding very carefully, watching closely, wondering if things would progress.

She had an epidural, but even with the epidural, everything was hurting her: her back, her legs, her vagina. With the assistance of her partner, we kept turning her side to side, sitting her up and lying her back down, trying to alleviate some of the pain through what limited position change is available when someone has an epidural. She had cold packs on her forehead and sacral massage. Even so, it wasn’t helping much. She began to feel a lot of rectal pressure and wanted to start to push, but she still had a small lip of cervix in front of the baby’s head, so we breathed with her through her contractions and tried to keep her from pushing. She was really unhappy with us at this point; who wants to breathe when they feel like pushing?? It’s the hardest thing in the world, and she really struggled with it.

The thing is, even though her cervix felt nice and soft, and we could possibly reduce the small lip of cervix in front of the baby’s head, we didn’t want to. With large babies, there’s a lot of danger involved in reducing an anterior lip and bringing someone to fully dilated when maybe they’re not supposed to be. Sometimes there’s a reason for a woman with a large baby not making it to fully dilated. Sometimes it’s a message to you that the baby is actually too large, and it’s a warning that should be heeded. So we let her body work on its own, without forcing it, and eventually, after over an hour of being at anterior lip, the last remaining, stubborn piece of her cervix finally disappeared.

Our concern, of course, was shoulder dystocia, which is without a doubt one of the most dangerous of all obstetric emergencies. With shoulder dystocia the head is delivered but the shoulders get stuck, and you have only minutes to get the baby out before he or she begins to rapidly decompensate on account of the severe cord compression that occurs. There’s a whole list of maneuvers that you’re supposed to work your way through: first you pull the legs back, which helps to widen the pelvic outlet, and then you apply suprapubic pressure, which helps to pop the baby’s shoulder under the pubic arch and get the baby out. If that doesn’t work, you move on to other maneuvers, like Wood’s Screw or the Gaskin Maneuver (named after our favorite midwife, Ina May). You reach your hand in and try to delivery the posterior arm. Even though it’s not the perineum that’s the problem, but actually the bones of the pelvis, an episiotomy is often cut in order to ensure that there’s enough room to get your hands in to maneuver (and in our sick society, if a lawsuit is ever being brought to court on account of a shoulder dystocia, apparently if you haven’t cut an episiotmy, it’s a huge strike against you, since cutting is part of the “standard of care”. I’m not sure that I agree with that, but on the other hand, in such emergencies, you do what you have to do). You empty the woman’s bladder. You pray. You try the maneuvers again if they didn’t work the first time. The clock ticks so slowly, so that miliseconds seem like eons and all you can do is stare at this stuck baby with a face that’s slowly turning more and more purple. Sometimes nothing works. Sometimes you need to break the baby’s collarbone or humerus in order to get the shoulder out. I’ve never had a true shoulder dystocia yet in my short career as a midiwife, but I’ve seen a terrible shoulder dystocia in my work as a nurse, and I’ve heard the stories. It’s no joke. It’s one of the scariest things you’ll ever have to deal with in this profession.

So we were nervous, and rightly so. But she was making slow progress, on her own. She began to push once she was fully dilated, but she was tired, and her effort wasn’t great. She lost her fighting spirit, and began to cry, asking for a cesarean, telling us that she couldn’t push any more, telling us she wanted to die. This is all pretty normal stuff for the pushing phase, at least among the women we take care of at our hospital, but it only served to make us even more nervous. The four P’s of labor are the Powers (contractions), the Pelvis, the Passenger (baby) and the Psyche. If any one of those P’s are missing, you’re in trouble, and staring at this huge baby waiting to be born with a mother who’s psyche wasn’t in the best place was very, very worry-making. There comes a point in the labor as the baby’s head is just beginning to peek into view when you can really get a sense of just how big the baby is. You can put a finger on the baby’s crown and then palpate the baby’s rump through the woman’s uterus, and get a true measure with your hands for the first time, and let me tell you….this baby was HUGE.

But she was making progress. Slow progress, but progress. The baby’s head began to come into view during pushes, then would tuck back in again in between contractions. This is called Turtling, and it’s a sign of impending shoulder dystocia, and when we saw this, we really began to wonder what in the world we were doing by encouraging this woman to push. Slowly, though, it became clear that the baby was moving down, and was starting to stay down, even in between contractions. We could still get our fingers in, and could still feel lots of room in the sides and the back of her pelvis, and little by little, she kept pushing the baby down. Soon enough (well, after over an hour of pushing), she began to crown.

I was catching the baby, and was gowned and gloved and ready, running through the shoulder dystocia maneuvers in my mind. The doctor was standing next to me, also gowned and gloved. We had the pediatricians in the room, waiting. The back up doctor was also in the room, plus another midwife and 3 nurses. We had a stool ready, in case someone needed to stand on it to apply suprapubic pressure. We had broken the bed so there was plenty of room to get in close to her perineum, if need be (of all my births so far, I’ve broken the bed on only two deliveries, just to give you an idea). And there we all were, waiting, sweating, watching and waiting.

The head emerged, and it was huge and fat, with these chubby cheeks and tons of hair. I didn’t cut, but instead gave perineal support and pulled the perineum down around the baby’s face as he crowned. And there he was, in all his glory. It looked like she had the head of a young toddler between her legs, that’s how big he was. I don’t know about the rest of the staff, but my heart dropped into my feet when I saw that head. Surely this was going to be a shoulder dystocia. Surely we were all in a lot of trouble.

I let the head restitute on its own without rushing it. The baby slowly turned into ROT, and I thought: well, might at least try to deliver the shoulders, just to see what happens. So I gently applied downward traction, little more, little more…and then, all of a sudden, there was the anterior shoulder!! Just like that. Just like a totally normal delivery. As soon as I saw the top of the anterior shoulder, I applied upward traction to delivery the posterior shoulder, and the shoulders were out. Getting the actual baby out required hooking a finger under each armpit and actually gently tugging the baby free, because this definitely wasn’t one of those births where the baby was just going to slide out. But the baby came quickly and easily, with hardly a pause between the delivery of the head and the delivery of the rest of the baby. He began to howl, wiggling both his arms and fingers (a good sign, indicating that there was no erb’s palsy going on), and we put the baby onto the mother’s stomach, and everyone just sort of stared in amazement.

He was enormous!! Guess how big….just guess. Much bigger than 4500 gms. He was actually 5150 gms. 11 pounds 5 ounces. The biggest baby I have ever delivered, and one of the biggest babies I have ever seen.

Delivered in a hospital, by a midwife, without the slightest whiff of shoulder dystocia. Oh, and one of the best parts: she didn’t tear, at all. Her perineum was intact. There was one nick which was bleeding, which required one stitch, and that was it. That was it!! Such a miraculous, miraculous birth.

Today I caught my 50th baby! She was born at 4:18 pm to a young woman from Puerto Rico who was absolutely thrilled and excited about her first pregnancy. She was an induction for postdates (per hospital policy, all women are induced if they’re still pregnant at 41 weeks); she’d actually had an incidence of preterm labor earlier in her pregnancy, but now, instead of the baby coming too soon, we had the opposite problem—a baby that didn’t want to leave. Because she was an induction, she was on pitocin, and because she was on pitocin, she pretty much had to stay in bed (again with the hospital protocols…). She was so strong and so tough, though, laboring in bed for the entire afternoon and refusing an epidural the entire time, through every single pitocin-induced, booming, more-intense-than-natural-labor contraction. The only thing she took for pain was a dose of stadol when she was around 5 cm dilated. I think her birth team made a big difference for her. Her mother and the father of the baby were at the bedside with her all afternoon, fanning her and bringing juice and ice water, putting cold packs on her head when she was hot, massaging her legs and arms. I couldn’t get over the father, in particular. He was such a young man (19 years old!), but his maturity was well beyond his years. He knew just when to be attentive, and just when to be quiet and not pester her with questions or ministrations or conversation (during transition, she didn’t want anyone to touch her). When she was pushing, he was so excited by the tiny glimpses of head we were seeing with each push; he couldn’t wait to meet his baby. He kept encouraging her to keep pushing, she could do it, soon she’d have their baby etc. etc. (I barely had to say a word of encouragement, he was doing such a good job of it all on his own). We pulled the mirror out after the first hour of pushing, and this really made a difference for her. Once she could see her progress in the mirror each push was better and better. The baby crowned in right occiput anterior, and she was able to breathe the baby out in between the contractions in such a way that she didn’t even tear her perineum (she did have a small laceration inside the vagina which required 5 stitches, but the actual perineum itself was intact). When the head restituted, the shoulders came out almost transverse rather than vertically. It was almost as if the baby were spinning inside her very roomy pelvis. The little girl (7 lbs, 2 oz.) started crying almost right away, and her beautiful family all burst into tears (especially the young father), which then made me tear up as well (seeing a family cry always gets to me, every time). The father cut the cord. Afterwards, the baby latched onto the breast like a pro and had a very tasty meal of colustrum while I did the small repair. There was no other midwife in the room with me (my preceptor was out at the nurse’s station, within shouting range, but minding her own business). The saying goes that somewhere around 100 babies, you start to get a clue as a new midwife. I guess that means that I have roughly half a clue, right now, but today, for the first time, I felt like…yes, I really am I midwife.

So, you’re probably wondering how it’s going. I’m in the middle of my third week as a new midwife, and it’s going…okay…so far, I guess. I wish I could sound more confident and enthusiastic about it at the moment, but I’m having a hard time feeling very confident or enthusiastic these days. Which is not to say that I am not absolutely *thrilled* to be finally working as a midwife, or delivering babies, or taking care of so many beautiful pregnant women (I am!!!), it’s just that my general state lately has been one of extreme nervousness and tension and uncertainty. Which is, according to many of my loving and supportive preceptors, something that is expected, and something that is normal for a lot of new grads, but even so…it’s not a very pleasant place to be living in at the moment. Even if I did expect that it would feel like this.

I think the nerves and tension is all coming from the sudden onslaught of responsibility. I feel unbelievably responsible, for everything, at the moment. Heavy with repsonsibility. I’m taking my patients home with me, worrying about them at night. And I’m so scared, with all of this new responsibility, that somehow I will totally, terribly mess something up. Which I’m sure I will, given that I’m new, and bound to make mistakes, and that some of the best learning you ever do is from your mistakes. It’s just…I can’t make huge mistakes. I really can’t. These are people’s lives and bodies and pregnancies and babies on the line, so…no mistakes, right? Except that how can you learn a new job, as a new grad, and not make mistakes? Do you see where the tension headaches and the knots in the middle of my back come from?

I’m still on orientation at the moment. I have three full months for orientation, which means that my orientation will finish sometime around Jan. 10th. Ostensibly, I can ask for more time, if I feel like I need it, but I do recognize that there is a strong hope that by three months in I will be able to work like a fully functioning midwife, someone who can be an asset to the practice. And I hope the same as well, although at the moment, I’m a bit terrified of being on my own, and I certainly don’t feel ready for that. Have I mentioned lately how NUTS this practice is? How busy and crazy and overwhelming and exhausting it is? Which is fabulous, on the one hand, and is certainly one of the reasons I picked this job (after a year of this, just think of all of the amazing experience I’ll have)…but, on the other hand, is incredibly overwhelming, exhausting, crazy etc.

The sheer pace of the place is enough to knock you out: in the clinic, on average, the midwives are seeing about 25 patients a day, often more like 28-30. IN ONE DAY? Good lord, how do you even have time to say hi to that many women, let alone ask them all about their health and bodies and pregnancies, or deal with all of the many problems and questions they have? Just to give you an example: one of the women I was taking care of last week had had a positive chlamydia test two months ago, had been treated, had then slept with her partner again (who had not yet been treated), had contracted chlamydia again, and had then been treated again. She had also had a positive PPD test (for tuberculosis), an abnormal pap result, and a prior cesarean, in the Dominican Republic, and was desiring a vaginal delivery this time around. So on my visit with her, we were talking about safer sex and what that involved, abstinence until her partner could be treated, a referal for her partner to the male STI clinic, the need for a chest x-ray (to follow-up on the positive PPD test), the need for a colposcopy during her pregnancy (to follow-up on the abnormal pap smear), and the importance of getting the operative report from the hospital where she had had her cesarean in the Dominican Republic, so that she could be counselled for a VBAC and receive a trial of labor with this pregnancy (in order to have a trial of labor at this hospital, women need written proof of the fact that they had a low-transverse uterine incision during their cesarean, and are therefore at lower risk for uterine rupture). And then we went ahead and did all of the normal pregnancy visit things: is the baby moving? How’s your diet? Looks like you’re gaining a good amount of weight. Vital signs stable? Urine dip negative? Measure the uterus, palpate the baby, listen to the fetal heart, review warning signs and danger signs. Are you still taking the prental vitamins and iron? Any questions? And then, after all of that, we did a chlamydia test one more time to make sure that she’d been adequately treated. The entire visit took me about an hour. And rightly so. But technically, she was a revisit, and was supposed to only take about 15 minutes. On average, I’ve been seeing about 9-10 women a day, on a good day for me. I just can’t go any faster than that without missing something or forgetting something or not picking up on something…in essence, making a mistake.

And labor and delivery…wow. Where do I even start? I’m going fine so far, I’ve delivered three beautiful babies so far, but that’s only because I’ve been sheltered by my preceptors so far, and am not truly doing the entire job yet. They’ve been giving me one or two patients to manage so far, or else they plunk me down in the middle of triage to sort out all of the incoming women, and that’s fine. But that’s about as much as I can do right now. And meanwhile, beyond the doors of triage, there are all of the women who are in labor, who I can’t really keep track of at all. Room 5 is 6 centimeters dilated, room 7 is 8 centimeters dilated, room 8 needs another dose of cytotec, room 10 needs another note written on her at 2:00 pm, and room 5 and 7 need a note written at 2:30, and room 10 will need a note as soon as the cytotec is placed, which will happen just as soon as one of the midwives gets a chance…I have no idea how to keep track of the floor. I have tunnel vision. Keeping tabs on one or two patients is about as much as I can handle, and that is plenty to keep me busy. More than plenty. Admitting a patient, and getting through all of the paperwork, takes me a solid hour or so. I’m being very thorough…I’m proud of my notes, but I’m slow.

And the thing is, it’s okay to be slow right now. No one is yelling at me to be faster….yet. But I know…I dread…that soon enough, too soon, I will be off orientation, and then I’ll be in trouble. And granted, I’m sure that my ability to handle all of this will increase tremendously in the next three months, and worrying about running the floor at this point is fruitless and stupid, because no one is asking me to run the floor yet. So why even worry about it at this point? And yet, I can’t stop myself from thinking about it. I find myself worrying about everything right now.

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.

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??

Magic, magic, magic! I’m walking on air right now! Tired, elated, giddy, bouncy, prone to fits of giggling and wide smiles. I caught my first baby today!! Unbelievable. In fact, I couldn’t have asked for a better first day of clinicals. I am so blessed, and so very lucky.

The day started bright and early with report at 8:00 am at the busy Brooklyn hospital where I will be doing my clinical rotations this semester. The hospital is very unique in the fact that there are no residents there, only midwives and doctors. The midwives are employed by the hospital, and basically run the floor, with one to two doctors on the floor serving as back up, consults and managing the high-risk patients. This set up is very similar to the way they do things in England, I do believe. The midwives handle the majority of the births, admitting and watching the patients, writing orders, delivering the babies, and the doctors are there when needed, for difficult cases or emergency cesareans. Another very neat feature of this hospital is the fact that there are no private attending doctors bringing in their patients to deliver. The only women who come to this hospital are women who’ve attended the prenatal clinic run by this hospital. Everyone is a clinic patient, and I think this allows for far fewer inequalities among patient treatment, and far fewer egos and personalities to deal with. The population served is primarily Hispanic and Polish, with a fair mix of Haitans and West Indians as well.

I am pleased to announce that not only was I on time, I was early. Report was a bit chaotic, but the midwifery director was great when it came to introducing me to everyone and showing me around the unit, and really going out of her way to make sure I felt comfortable. While trying to fix the clock on the wall above me during report, she accidentally dropped it on me. In a way, I sort of feel like that was my good luck charm of the day, the ice breaker, sort of as if this hospital has claimed me as its own. I took it as a good sign, small lump on my head and all.

The preceptor I was working with today for most of the day was great. UNBELIEVABLY patient, and very laid back. We spent the morning taking care of three different women who were all being induced for oligohydramnios and were still in early labor, while at the same time keeping our eye on the only woman on the board who was in active labor. By 10:30 she was fully dilated, and after that I spent most of my time in her room, only stepping out briefly to check up on my preceptor, and to draw bloods on a woman in triage. Before I knew it, the head had come down to the point that you could see it in the vaginal opening even when the woman wasn’t pushing, and my preceptor was helping me to gown and glove. The baby continued to crown for awhile, but it just couldn’t quite pass through the vulvar ring, so my preceptor snipped one of the vaginal bands on the right side (these are the tight, stretchy bands of muscle which surround the inside of the vagina—I believe it’s the bulbocavernosus muscle, but don’t quote me on that). It wasn’t an episiotomy; she left the skin of the perineum intact. It was more like a small snip inside the vagina, just to create a little more give. My hands were on the perineum, gaurding and supporting, and occassionally my preceptor put her own hands over mine, showing me where to put my fingers, how much pressure to apply, etc. (I know many midwives advocate a hands-off approach, while many others believe in supporting the perineum. As a student, I was taught to support the perineum with my hands, and as a student I’m in no position to disagree with my preceptor about this, so for the time being, I’ll be delivering this way. But, for the record, the jury is still out, and someday I would like to try a more hands-off approach, just to see how that goes, and then make an informed choice about which method I prefer. But….now is not the time. Now, I’ll do it just the way I’m told, because what do I know? And how else will I learn this?)

Anyway, within three pushes after this, the head was out! I couldn’t believe it! I surprised myself with my calmness, because I’d anticipated absolutely falling apart at this point. Shaking hands, tears, gods only know…However, I think I was too busy concentrating on what needed to be done to even think about the significance of it (that didn’t hit me until later), and I did exactly what needed to be done. I checked for a nuchal cord. I supported the head while it restituted from direct OA to ROT. My preceptor helped me deliver the shoulders, and before I knew it, I had a squirming, very slippery, squalling and dusky pink baby in my arms!!!

Wow.

I dried the baby, placed it on the mother’s abdomen, tried to hold off on cutting the cord for as long as possible, but was eventually instructed to cut it, because we needed to take a sample for cord gases (again, a point of contention, and in my future practice, I hope to someday leave the cord intact until it stops pulsing, but this hospital has a policy that requires cord gases on every baby, and I’m not going to argue with that). And then we waited, for about 20 minutes, for the delivery of the placenta. (As it turned out, not only was there a true knot in the cord, but it was a two-vessel cord, instead of a three vessel cord, which was also supported by earlier sonographic findings. Very interesting stuff, although the baby seemed to be fine, without anomalies or defects, and the sonographic findings also supported this).

After the repair (which went pretty well, though slow, with my preceptor telling me exactly where to put the sutures, and helping me identify landmarks etc.), the woman asked me if it was my first delivery. I told her that it was. She seemed relieved when she learned that I was in fact 29 (she told me that I looked like I was 20). And then I told her that no matter how many babies I caught from here on out, I’d always remember her, because she was my first. And she told me she’d always remember me as well, because I had caught her first baby. And then we smiled at each other in a very special way, and I must admit, this brought tears to my eyes. What a spectacular day!

I also did several vaginal exams, for the first time ever, and was able to identify cervical dilation pretty well, although station and effacement absolutely mystifies me. I placed two doses of cytotec in two of the women who were being induced for oligohydramnios, did lots of explaining and teaching, took a history, did an admission and physical exam….altogether, an absolutely, breathtakingingly beautiful, amazing day.

And now, I’m going to lay my weary bones down, get a brief 7 hours of sleep, and wake up tomorrow morning to hopefully do it all again (and perhaps catch the babies of some of the women I met today who were in the early phase of their inductions, but will hopefully be ready to give birth by tomorrow morning! Woo!)

In a valiant attempt to work myself into a limp and bloody pulp, I decided to go to work last night because they were understaffed and desperate for an extra nurse, and were begging and pleading, and I thought that even though I had already spent 8 hours on my feet all day doing clinicals, working another 12 hours probably wouldn’t kill me. In retrospect, this probably wasn’t the wisest decision I’ve ever made, although I did survive the night. Our unit was absolutely slammed, and none of us got breaks, and by the end of the night (well, the early morning of today), I was bleary-eyed, and double-checking everything I was doing because I was certain that I was bound to make a mistake from being so tired. How do residents do it? Or midwives on call who have back to back delivieries?? Yikes.

I ended up having three patients and two deliveries: one cesarean birth, and one vaginal delivery. My third woman was an induction for Premature Rupture of Membranes, aka PROM (a subject which has become very close to my heart, as my research proposal is on this topic); she was on pitocin, but she wasn’t progressing that quickly, and didn’t deliver during my shift. The vaginal delivery was the most fun. The woman came in at 4:15 panting and moaning. The initial exam found that she was 5-6 centimeters dilated at that time. It was her second child, and her first labor had only lasted 3 hours, so we were definitely scrambling to get a room ready. We didn’t even have a completely clean room to put her in, given that we ended up having 12 deliveries last night and we didn’t have a nurses’ aid, either, to help us get the rooms ready, so another nurse and I ended up swapping out the dirty bed in her room for a clean bed which we prepared in the hallway. We got her into the room, started an IV on her and gave her Penicillin because she was GBS positive—this was finished by 4:32 am. She was begging for an epidural, but she didn’t have time, given that she was fully dilated by 4:35 am. The baby was born at 4:39 am, after three pushes. It was all so lightning fast: first an IV, then, the next thing we knew, her water broke, then the doctor was shouting for a table, and boom, I had just gotten the oxygen and suction hooked up for the arrival of the baby, and the baby was out and screaming before I’d even turned around. Now that’s the way to give birth! What a crazy, fun, awesome precipitous delivery. Afterwards, I told the woman that she was just amazing, super strong, and then casually observed that obviously she didn’t really need that epidural after all, and she agreed with me, and said that next time, she wasn’t going to ask for one, she was just going to have her baby instead.

Mwuahahahahaha. Subversive midwifery at work! Any day I can gently convince a woman that she doesn’t actually need an epidural is a good day, indeed.

At certain points throughout the night, I just kept thinking in disbelief that only that morning, I had been doing speculum exams on women at the Family Planning clinic, and inserting an IUD. It seemed like a lifetime ago. I thought of all the women and vulvas I had seen in the past 20 hours, and was rather stunned (but pleased) by how high the number was. That’s a lot of women! Although, given how exhausted I was by the end of my shift, if work ever tries to call me in again after a day of clinicals, the answer will be a resounding NO!!

Just a few thoughts, to counter all of the doubts and questions I was asking a few posts ago. I saw a beautiful birth this morning. The woman had high blood pressures (150s/80s - 160s/110s), but her pre-eclamptic labs had come back negative, and she didn’t have any of the toxic signs or symptoms that often indicate preeclampsia (blurry vision, headache, epigastric pain, nausea, vomiting, protein in her urine, etc etc.), although her doctor had decided to treat her as if she did, just to be on the safe side. She was 37 weeks and 1 day, just barely term, and her body really wasn’t ready to go into labor at all, so naturally, she had every intervention under the sun. Instead of using cytotec or cervidil (prostaglandin gels that help ripen the cervix), her doctor decided to use a balloon catheter to manually stretch her cervix to three centimeters, and then she got more pitocin after that. Epidural, foley catheter to drain her bladder, oxygen mask on her face because the baby started having variable decels (surprise surprise, the cord was wrapped once around the neck, loosely), magnesium for the high blood pressure, epidural top-off because she was in transition, a small median epsiotomy to crown it all, and you know what? It was still a beautiful birth. The love in the room was overwhelming, and an absolute joy to watch. The husband was the woman’s rock, she clung to him through every contraction, and he was constantly whispering words of encouragement in her ears—we both were, in fact, and she pushed with such strength and determination that the baby was out within fifteen minutes from the start of the 2nd stage of labor (the pushing part). Both the mother and father were crying as the baby was born. The head crowned, and then slowly emerged, and the little one started screaming immediately. She was tiny and pink and adoreable, waving her arms around in outrage, Apgars 9/9, sweet little peanut of a baby, only 5 lbs 5 ounces. So, hospitals…yeah, we do a lot of things that don’t need to be done, and it’s infuriating, and disappointing, and frustrating and sad, but amazingly (miraculously, even) the beauty of birth is still there, shining through all of the unnecessary interventions. Modern technocracy hasn’t yet found a way to dim the miracle of it, and in so many ways, the manner of the birth is so much less important than the fact that the baby is being born, period (although, of course I still think that the woman’s satisfaction with the experience, and trying to make the birth as high touch, low-intervetion as possible will always be important and worthy goals). But birth is birth is birth. I can’t imagine ever seeing a healthy birth (no matter what the circumstances) and not thinking that it was beautiful, although some births you’re just swimming in love, like the onen I saw this morning, and that certainly makes the beauty glow all the more obviously. Ahhh. *contented smile* It was a long, gorgeous night. I’m off to bed.