39 weeks pregnant now, everything is ready.  Our fridge is full of food and drinks (gatorade, coconut water) for the birth. The birth tub has been inflated and set up close to the bathroom, ready to be filled. I’ve prepped postpartum pads with witch-hazel and stashed them in the freezer so they’ll be nice and icy-cold for sore postpartum perineums.  The diaper changing area and co-sleeper are set up and waiting. The birth kit is in the corner, with its attendant sheets/ towels/ washcloths/ plastic drapes/ shower curtains etc.  We have a birth ball.  And a rocking chair.  A moby, a baby bjorn, newborn clothes washed and folded and tucked away in dresser drawers.  We have everything except actual contractions…

It’s the strangest thing, this state of limbo.  I stopped working last week, at 38 weeks, which was a relief because work was becoming very difficult.  Two weeks ago, at 37 weeks, I attended a birth with a four-hour push at the end of it, and although I never doubted that the woman would be able to push her baby out, I did doubt if I would have the strength to get through it, heavily-pregnant and tired as I was. In the end, another midwife from our practice came in and helped assist during the last hour or so of the pushing, because my energy was really flagging.  And at some point, as a pregnant woman, you begin to want to focus all of your energy inward, on yourself and your baby, and it feels very hard to take that energy and give it to other women in labor.  Not that I’m being selfish about my energy, but I have reached the point where my own pregnancy is becoming paramount, and taking up more space in my head and heart than my midwife-self.   At which point I’m not much of a service to other women in labor anymore.  The time has come to be just a pregnant woman now.

And these last few days which have been given to me are wonderful. Days when I can still lounge around, stop by the nail salon and get a pedicure just because I have the time and the inclination.  Nights where I can sleep as long as I like (broken only by getting up to pee 3-4x/night).  Nights which I can spend with my husband, going out for dinner or watching movies together, cherishing these last few moments when it’s just the two of us, before it becomes the three of us.

I have told myself throughout my pregnancy that I will carry my baby to term.  It’s been a mantra of sorts, because I know many nurses and midwives who’ve had issues with preterm contractions and preterm births, predicaments which are certainly not helped along by their jobs.  While at work I was always very careful to hydrate myself constantly, and to sit whenever possible, and to try to leave the heavy-lifting to others during births.  But maybe so much of my mental focus was spent telling my body to keep the baby in, that now that I am finally full term, my body is having a hard time letting the baby go.  Or maybe I am just hyper-analyzing this.  First babies tend to come late, past the due date, and this is a first baby.

I am trying to not be too impatient, just because I am so eager to finally meet this little one!  I trust my body, and I trust the timing of my body and baby.  And really, my baby will come at the right time, when he is ready.  In the meantime…I can catch up on my blogging.

South Dakota’s Measure 11 was soundly defeated: “South Dakotans have affirmed by their votes tonight that no vague law can account for every individual circumstance. And that is precisely why women and families, not the government, should make these personal healthcare decisions,” said Sarah Stoesz, President and CEO of Planned Parenthood Minnesota, North Dakota, South Dakota.

The New York Times, in the midst of all the election craziness, published an article on new links between depression and premature delivery which have been recently reported in the Journal of Human Reproduction. The study interviewed 791 women and ultimately gave them scores based on how many depressive symtoms they exhibited–the higher the score, the worse the depression. The study found that the higher the score, the greater the risk of preterm delivery, even after controlling for prior preterm deliveries, miscarriage, socioeconomic status, education and other variables. This is particularly fascinating considering that so little is known about how depression affects pregnancy, and vitally important since depression during pregnancy (and the mental health of women during pregnancy in general) are so often overlooked in prenatal care.

The New Space for Women’s Health (formerly Friends of the Birth Center) is having a fundraiser on November 18th at Babeland called Women Come First. The event, which is co-sponsored by Ricki Lake and The Business of Being Born, offers an opportunity to not only raise money for the new free-standing women’s health and birth center in New York City but an exclusive cocktail party and shopping opportunity. Sounds like a lot of fun! I’d be there if I wasn’t already working that day…

Finally, I’m sure this is going the rounds on the internet, but I think everyone, everyone, needs to watch Keith Olbermann’s special comment on Proposition 8:

I can only imagine how birth, which can be so traumatic in its own right, can bring up so many terrifying memories and associations with trauma and rape. Birth is another situation where she can potentially feel vulnerable and exposed, in a situation that she can’t really control, experiencing pain, perhaps feeling helpless and angry and powerless (and keep in mind that this will be a hospital birth and not a woman-on-her-own-turf-at-home-birth). So here’s my question to all you midwives and doctors and nurses who’ve been doing this a lot longer than I have, and who have probably been present at births with women who have a history of trauma or rape (or women who have survived rape or trauma and gone on to birth yourself). Do you have any suggestions? When it comes closer to the time of the birth, what should we focus on? I have many thoughts about where to start: avoiding vaginal exams during the birth, offering early pain relief if desired (maybe a prophylactic epidural before the strong contractions even begin), letting her dictate when and how to push, making her environment as calm and serene as possible…what else am I missing? Any good books on this topic? Any posts that you’ve written which I should read? Anything at all would be helpful, because I still have another 8 months of prenatal care with this woman prior to her birth, and I want to try to make it as healing and empowering as possible (or, at the very least, not compound the trauma with more trauma).

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.

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.

“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.

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.