Belly Tales

The AMA has recently issued a resolution supporting ACOG’s Statement on Homebirth which agrees that the safest place to have a baby is the hospital, of course, where obstetricians work and get paid.  What’s really awful is that they’re using Ricki Lake’s movie, The Business of Being Born, as a tool to try to pass laws that would mandate that all births occur in hospitals, since hospitals are the “safest” place to give birth.  Nevermind that in this country (at least for now) all women have the right to make their own choices about their bodies and the health care they receive, or the fact that the U.S. has one of the worst rates of neonatal and maternal mortality among developed countries and that (wow, what a surprise) 90% of all our birth occur in hospitals, or that other countries with much better mortality rates wholeheartedly support and embrace homebirth and that there is strong evidence-based research which backs this up.  Nevermind all that.  In this country, it’s money that does the talking, and money which sets the agenda and passes laws….and now, the AMA, with all its money, has unsurprisingly agreed with ACOG’s ridiculous statement.

The Huffington Post has an article up detailing all of the furor, along with a raging debate in the comments section.  Please, if you care about this even a little bit, visit the article and post a comment.  The more comments the Huffington Post receives, the higher the likelihood that they’ll move the article to their “favorites” section, which will keep the article up on their website for days.  The more comments and press this topic gest in the blogosphere and in the media, the more women will hear this message, and the more this subject will become part of our national debate.  Every comment counts!  Here’s the link again: Docs to women: Pay no attention to Ricki Lake’s homebirth

Forget the Oscars (well, not entirely: Go, Juno, go!); the movie I really want to see is A Walk To Beautiful. Having already won several awards at film festivals around the world, the film follows five courageous women as they travel to the Addis Ababa Fistula Hospital in Ethiopa to find a cure for the obstetric fistulas they suffer from. Fistulas are an opening between the vagina and rectum or the vagina and urethrea which occurs after days and days of obstructed labor. In developed countries around the world, fistulas have become a thing of the past since the advent of cesarean birth (the last U.S. fistula hospital closed its doors in 1895), but in developing countries around the world, it’s still a very grim reality. Incontinent, with either feces or urine dripping from their vaginas, women with fistulas are often shunned by their communities, ostracized and forced to live lives of isolation. The cure for fistulas is a simple surgical procedure, but with access to modern health care often hundreds of miles away, the cure might as well exist on another continent. Just check out some of these facts:

• For every woman who dies from pregnancy-related complications, 20 women survive but experience terrible injuries and disabilities.
• In Ethiopia, there are 59 OB/GYNs and 1,000 midwives for a population of 77 million.
• One woman dies from pregnancy-related complications every minute worldwide; 95% of them live in Africa and Asia.
• More than 99% of The Fistula Hospital patients are illiterate. (The hospital teaches all patients the Amharic Fideles and the Oromiyffa alphabets.)
• Number of patients treated at the Addis Ababa Fistula Hospital every year: 1,200
• Number of obstetric fistula cases occurring in Ethiopia alone each year: 9,000
• Number of new obstetric fistula cases resulting from childbirth occurring worldwide each year: 100,000
• Number of new obstetric fistula cases resulting from childbirth occurring in the U.S. each year: 0.

The movie is playing at the Quad Cinemas in New York City right now, and has recently been extended through February 28th. I’m hoping to see it on Wed., and I’ll certainly write a review afterwards. Good stuff.

(Go Juno, go!)

I just discovered the most amazing videos over on You Tube about a traditional midwife working in Mexico. I’m sure many of you have probably seen them already, but I was just blown away!! It’s amazing to watch the way she uses her hands to massage, assess, palpate…turn a breech baby. A midwife’s greatest tool is her hands. I wonder how many of the women I see in the clinic come from traditional midwifery practices like this. American midwifery must seem very different to them. At it’s heart, I think the respect and tenderness and kindness to pregnant women remains the same, but we could learn so much from traditional practices like this. It makes me want to quit my job, fly down to Mexico and study with her for a year. In any case, enjoy!

The other day I discovered a postcard at my local yoga center urging women to participate in a birth survey, which instantly piqued my interest; apparently this survey has already been going on for some time, although I have only now heard about it. A little research has revealed that the Coalition for Improving Maternity Services (CIMS) has launched a new program entitled The Transparency in Maternity Care Project, which is intended to research and explore maternity care in this country, with an emphasis on improving the transparency of maternity care. Unlike other areas of medicine, hospitals and maternity care providers are still pretty cagey when it comes to being open with their numbers. What is the c-section rate for specific doctors or hospitals? What is the VBAC rate? How many providers perform episiotomies? How many elective cesareans or inductions occur annually? Hard numbers like this are always notoriously hard to come by. And of coruse, beyond the actual numbers themselves, women’s experiences with maternity care providers and services and overall satisfaction is often something which is overlooked. It seems like The Transparency in Maternity Care Project is trying to fix all of that, and is acting as a follow-up to the Listening to Mothers surveys which occurred in 2002 and 2006. Like Listening to Mothers I and II, a survey lies at the heart of The Transparency in Maternity Care Project, which can be found at the following website: www.TheBirthSurvey.com. The pilot survey is occurring in New York City right now, between July 2007 and July 2008.

There were many reasons to choose New York City as our pilot site.

First: New York is a large, high profile city offering a wide variety of birth options.

It is a densely populated and well-networked urban center. There is easy access to multiple press/media outlets. Approximately 125,000 births occur in NYC per year. Forty-four hospitals provide maternity care services. The majority of the country’s obstetricians are trained in NYC. Two Free-standing Birth Centers are in operation. An established homebirth community thrives. Nearly 10% of births in NY are attended by midwives.

Second: The Grassroots Advocates Committee will be piloting the project in partnership with Choices in Childbirth (CIC), an active grassroots organization based in NYC.

CIC is well connected with the NYC birth community. CIC publishes The New York Guide to a Healthy Birth – in 2007, 20,000 copies advertising The Birth Survey will be distributed free to the public. A member of the GAC and CIC is based in NYC and will be engaged in the day-to-day oversight of the pilot.

Third: New York State is one of only two states with a Maternity Information Act.

The MIA provides the public with legal access to intervention rates at the facility level. Choices in Childbirth is connected with the NYS Department of Health and has already collected the intervention rates for all New York hospitals.

So, if you live in NYC and have given birth in NYC, here’s your chance to discuss your experience and provide valuable information and feedback about birth in our country. Please participate in the birth survey ASAP. As for the rest of the country, the project plans to unveil a national survey next summer, but if you’re super motivated, you can provide feedback about your birth experience at www.drscore.com.

Who ever would have guessed that this would be possible: a blood product substitute made from plastic, and which may be available for use in the next few years.  Unbelievable.  What will we come up with next??

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.

Rachel commented, in response to my Worry-wart = New Midwife post: “I was interested to see in your description how “medical” the treatment of the L&D patients seems to be, despite having a midwife on hand. Any thoughts on that?”

Of course I have thoughts on that!

First of all, this is hospital midwifery and hospital birth. Unfortunatley, you almost have to think of it as a different species of midwifery all together. Because this is occuring inside a hospital, and there are hospital regulations to follow, there are protocols in place which limit the amount of freedom a midwife has to manage her clients in a more traditional “midwifery” manner, and there is a constant push-and-pull of politics and power at play. Who ultimately gets to make the calls? Is it the women themselves, who are educated and empowered enough to demand the kind of birth experience they want? Is it the midwives, fighting and advocating for these women? Is it the doctors, whom the midwives collaborate with? Is it the nurses, who often choose to ignore the breastfeeding-friendly initiative that’s been established in our hospital, and try to bring the baby to the nursery as quickly as possible after the birth in order to limit the amount of work they have to do right after the birth?

Ultimately, it’s a combination of all of those things which impact the overall birth experience. This is a midwifery service located in a very busy urban hospital in a very poor, underserved section of Brooklyn. Our clients are women from all over the world. Many of them are recent, first-generation immigrants, and presumably many of them are here illegally (we never ask). Many of them don’t speak English—they speak Spanish, Urdu, Polish, Hindi, Arabic, French, French Creole and Patois, predominantly. On the whole, many of these pregancies are unplanned. Home situations vary incredibly. Sometimes the father of the baby is supportive, sometimes they’re married, certainly sometimes it’s a planned and wanted pregnancy, but sometimes the woman and her partner are no longer on speaking terms, sometimes there’s a court order against him, sometimes the aunts and mothers and grandmothers of these women will be raising the baby while the woman goes back to finish high school. Planning for the pregnancy and birth is often done under very difficult circumstances. By and large, these women are not showing up to labor and delivery with doulas and birth balls and birth plans, having read all the latest childbirth books and having bought the latest, most ergonomic birth sling. They’re not online, with internet access, reading blogs like ours or doing research about their birth choices. But most importantly, these women are not choosing midwifery care. They’re coming to our hospital clinic because they can get prenatal care for free with us if they don’t have health insurance and they qualify for medicaid and WIC and PCAP. They’re being taken care of by midwives because their pregnancies are predominantly low-risk and healthy, and because the hospital finds midwifery care to be cost-effective and economical, but are these women seeking us out, or looking for the midwifery experience? Not really. And are these women really after a natural childbirth experience? Again, for the most part, not really.

Women generally see one midwife for their prenatal care, but unfortunately, labor and delivery is covered in shifts. It’s a 24-hour service, so there are always two midwives on L&D at any given time of the day or night, but it may not necessarily be the midwife who took care of you during your prenatal care. Which means that when you come to the hospital to give birth, the midwife you know and are familiar with may be there to deliver your baby, but there’s also a good chance that she won’t be. It’s not ideal, by a long shot, but this is the difference between private practice midwifery, which is often a luxury item reserved for those who can afford it, and hospital midwifery, which serves underserved populations with excellent care, but isn’t set up in such a way that the midwives are on-call for their clients.

So, in a hospital setting, where does the midwifery care come in? We don’t have a birthing center, and there really isn’t a birthing center vibe to the place. However, I think the midwifery aspect comes into play in many areas which aren’t immediately obvious because they’re subtle, but I do think it makes a big difference overall. For one thing, the number of women getting epidurals on this floor seems to be much less to me than in other hospitals where I’ve worked as a nurse (and these were all private hospitals predominantly served by private doctors). I chalk the decreased epidural rate up to the increased labor support the women get from the midwives and the nurses. The c-section rate is also much lower in our hospital than it is in many other hospitals in the city (22% last year, v. 30-35% in other hospitals in NYC, and certainly much lower than the national average), and our VBAC rate is much higher than in many other hospitals in the city, as well as higher than the national average (I think this comes from the fact that there is one dedicated VBAC counselor who counsels all the women, and the midwives really work hard to find the op report and talk to women about the benefits/risks of VBAC). Women are allowed to eat clear liquids (juice/jello etc.) during labor, which is a big improvement over many other hospitals where women STILL aren’t allowed to eat anything (and which is still occurring on a regular basis at other hospitals). Women can get out of bed if they’re not on pitocin (again, something which doesn’t occur that often in other hospitals). We push in side-lying or sitting positions, we push with squat bars, we let women push on the toilet or standing (hanging) in a suspended squat.

More than any of this is, though, is the midwifery philosophy which is held by the midwives, and which is always at work in the hospital. I’ve been working here for only about 4 weeks, but a lot of that time has been spent advocating for natural childbirth and breastfeeding and trying to find a way to limit the number of interventions performed in labor and delivery. As the midwife, it’s a constant struggle. Sometimes it means jumping through hoops, or presenting patients to the doctors in a such a way which highlights the positive (she’s making change, just slowly…but no, I don’t think she needs pitocin or a cesarean or etc. etc.) and downplaying the negatives. It doesn’t mean changing the facts, it just means fighting and doing everything you can to let a normal birth unfold, even in a hospital. It’s a crazy balancing act, balancing so many different needs and agendas and pressures and desires. I think this philosophy can be seen in the amount of patience which the midwives display, the effort put into offering a humane, hands-on touch, and the deeply held belief that BIRTH IS NORMAL, that women CAN do it, that all women deserve respect and informed choice, that they deserve explanations, that no one is going to just walk in and rupture their membranes without talking to them about it first and making sure it’s okay. To me, the midwifery philosophy, at its very core, means LISTEN to WOMEN, DON’T JUDGE, and return the power of labor and birth back to the WOMAN, where it belongs. We don’t deliver babies, we catch babies; it’s the woman who does all the hard work. It’s the woman who delivers her baby. It’s her body, it’s her baby, and it’s her birth. Women in this hospital are powerless in so many ways, and are often so used to giving up there power. They don’t always ask questions because they don’t realize that they have a right to ask questions—that they can ask questions. The midwifery philosophy at work in a hospital helps to correct this imbalance and inequality, even if only a little bit. So much of midwifery care is education, and education is power.

I’ve recently had a birth which really illustrate these points, and which I’ll write about below, but in any case, I do think the difference is palpable. Yes, it’s hospital birth. Yes, there are lots of monitors and beeping machines, there are hospital protocols which must be followed, women get epidurals (but only if they want them), we use pitocin, there aren’t tubs, and unfortunately no one has time to rub lavendar oil into anyone’s back (simply because this is an incredibly BUSY hospital, and you rarely have time to pee, let alone massage someone during labor), but I think we still provide excellent midwifery care to our clients. Even if it wasn’t necessarily the kind of care they were looking for in the first place, I think that many women find that they really enjoy midwifery care, because we as midwives are trying so hard to give them choices, to help them take control of their bodies and their births, to be able to say no to treatments or procedures they don’t want, and of course, treating them with dignity and respect (again, things which aren’t always in large supply in hospital settings).

Case in point: last week I was taking care of a woman who was laboring with a baby that was Occiput Posterior, meaning that the baby was face up instead of face down, and that therefore the back of the baby’s head (the hardest part of the baby) was up against the woman’s back. OP happens quite frequently during birth, and can make labor a lot longer and more difficult, because it’s not the optimal fetal position for a quick and easy birth. And indeed, this woman was making progress, just SLOW progress. She was 6 cm dilated at 8:00 am when we first came on our shift, then she was 8 cm at 10:30 am (when I broke her water because she was asking for something to speed the process up). She was 9 cm at noon, had progressed to anterior lip at 2:00 pm and was finally fully dilated at 4:00 pm. I was getting really nervous because she was gong so slowly and I was conscious of the hospital pressure which always exists, and which goes something like this: as soon as you’re admitted to the hospital, you better be moving towards birth, and moving at a pretty regular, pretty rapid pace. It was my preceptor that day (a big, loud-mouthed woman who’s been a midwife for 10+ years, possesses loads of confidence-born-of-experience—which I don’t yet possess—and is not afraid to tell the truth, whatever that may be) who was the calm rock of this birth. She’s the one who told me to quit checking our patient, to just sit tight and watch her labor unfold and trust that everything is going the way it should. So that’s what we did.

Because our patient didn’t have an epidural and she didn’t have pitocin going (she just had two fabulous midwives, sitting in her room with her because it was a quiet day), we got her out of the bed and let her sit on the toilet for awhile, let her walk a little bit, but eventually she wanted to get back into the bed, so we helped her back into bed and then helped her roll side to side every 20 minutes or so. Position change is a key to managing OP birth, as I’ve been learning; just keep changing position, and eventually the baby will slowly rotate and work its way into an anterior position (that’s the hope, anyway). Luckily, the tracing was beautiful—we couldn’t have asked for a nicer tracing, with these huge, reassuring accelerations into the 170s with almost every contraction—so we weren’t under a time crunch to get the baby out quickly. Everything was going smoothly, just slowly.

Then, once she’d been pushing for about an hour, one of the doctors stormed in (having just finished a c-section) and threw a little hissy fit, right in front of the patient: why is this woman STILL pregnant?!? Why haven’t you started pit? What are you guys doing in here? Start pit! This is ridiculous. Etc. etc. Nevermind the fact that he hadn’t been paying attention to her all day; she was a midwifery patient, and we had been managing her, but now that it was 5:00 pm and he was signing off to the oncoming doctor he suddenly wanted her to have been delivered ages ago (I guess it looks bad to the oncoming doctor that he’s had a patient all day who still hasn’t delivered yet? Again, this is part of the hospital pressure mentality which says “as soon as you’re admitted to the hospital, you better be moving towards birth, and moving at a pretty regular, pretty rapid pace”). This doctor kept saying: she was 6 cm at 8:00 am, what are you guys DOING in here?? She should have had her baby already!! etc. etc.

And to be honest, I was absolutely, 100% cowed and terrified. As a new midwife, in my near-constant state of terror, I have very little confidence in myself or my management skills, and unfortunately this translates to a whole lot of fear right now; fear of birth, fear of doing something wrong, fear of making a really big mistake etc. etc. If it had been me alone in that room, I probably would have burst into tears. I had already been wondering to myself if we should have started pitocin. But no, thankfully my preceptor was in the room with me, and she very calmly, tranquilly and firmly told the doctor to chill his pants. She basically said: we’ll start pit if you absolutely insist (he is the doctor, after all), but she’s having an OP baby, she’s making progress, and things are fine and NORMAL in here, so please leave and let us do our thing. And what do you know…he left! And then we started pit (and actually, for what it’s worth, the incoming doctor got into an argument with the outgoing doctor at the board, stating that our patient probably didn’t really need the pitocin. If her contractions were enough to get her to fully dilated, albeit slowly, then they were probably enough to get the baby delivered.) But anyway, we started pit, and she pushed and pushed and pushed. And here, I think if she’d had an epidural, she wouldn’t have been able to push that baby out, but thank goodness she didn’t have an epidural so she could really feel the urge to push with each contraction, and eventually the baby did a long-arc rotation and was born from right occiput anterior at 5:39 pm, screaming his head off, and voila!….a totally normal labor and birth.

Would that birth have been different if she hadn’t had midwives taking care of her? Yes, I think so. Maybe she would have had an epidural, and been unable to push her baby out. Maybe a different provider would not have accepted her slow progress, and started pitocin on her a lot sooner. Maybe someone else would have considered her lack of progress as “failure to progress” and she would have been taken to the back for a cesarean. Maybe if no one had gotten her out of bed, or sat with her in the bathroom while she pushed on the toilet (something the midwives have to do, because the nurses won’t take responsibility for the patient if she’s off the monitor, so unless the midwife is in the bathroom with her or walking with her, they don’t let her out of bed), maybe if she hadn’t been walking and changing position so much, maybe that baby wouldn’t have rotated. Who knows. The point I’m trying to make is that midwifery care, admittedly in a somewhat altered and modified form, is alive and well in a hospital setting. Unfortunately, there are just more rules to conform to, more egos and personalities to manage, more pressure and time-crunch, and there isn’t that lovely, private-practice one-on-one kind of care which is one of the hallmarks of midwifery care in other settings. Is there still a lot of things which can be changed? Yes, of course. Is there still a lot of things which are far less than ideal in our set-up? Undoubtedly. But I think the midwives are giving excellent care to our patients, in the best way we can, and I think it really does make a difference.

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.

The BBC has put together an amazing series of articles on birth and maternal mortality in developing countries. This year, at the half-way mark towards the Millenium Goals set for 2015, we’re not even close to reaching the desired 75% reduction in maternal mortality. These articles explore the reasons behind these failures: everything from lack of US funding for the United Nations Population fund (ostensibly because the UNFPA doesn’t outlaw abortion) to the low status of women in developing countries, the low priority given to women’s health issues, unsafe drinking water, lack of access to medical facilities and skilled birth attendants, infection, poor nutrition and low birth weight.

“These women are dying not because we don’t have the means to save them, but because we (the world) have not determined whether they are worth saving.”

Why women still die to give birth

Action needed on maternal deaths

“They thought I was cursed” (article on maternal fistulas)

In pictures: fighting maternal mortality

Check out the older articles from 2005 and 2006 as well. Really excellnt, but really sobering reading.

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.