reflecting, remembering back

Now that I've been a midwife for about a year, I'm precepting students, both student nurse-midwives, and professional midwifery students. In preparing some things for them, I came across this delivery note from one of my early births. It's fun to read, and then realize how far I've come in merely 2 years. The other fun thing is that 7/7/11 is the date I got certified/passed my boards. This was exactly one year to the day before that. Fun! 7/7/10

Delivery note: G2P1001 at 39 weeks 4 days. T labored well, changing positions often, first on her bed, then upright, then into the tub at approximately 0900. Active phase of labor was approximately 4.5 hours. SROM occurred at 0930, with leading membranes. Mom pushed gently and spontaneously, allowing for a very controlled, gentle descent and time for perineal stretching. The small room was nice & warm due to the “first day of summer.” Throughout, FHTs were stable, ranging in 120s to 140s, with accelerations over 150 heard during contractions on several occasions. After a 23 minute second stage, the head was delivered at 0952, followed by spontaneous rotation to LOP. Mom raised her hips above the water, no nuchal cord, delivered the anterior shoulder with mild traction and then the posterior shoulder and body. A viable female neonate was placed immediately on the mother’s abdomen where she was noted to be centrally pink with spontaneous cry. Care was taken to keep infant’s head above the water line. Apgars 9 & 9. Weight 7# 14 oz, 21 inches long. Placenta delivered Schultz at 1002 with third contraction after NSVD with mom standing, mild traction. Appears complete with three vessel cord. Mom then got out of the tub, and laid down for 3rd stage management. Hemostasis was easily achieved with fundal massage. Blood loss approximated at 300 mL. A first degree laceration of the right labia was repaired with 2 interrupted stitches using 3.0 vicryl and 1% lidocaine. Bilateral, periurethral tears were also noted, but required no repair. Baby was back in mom’s arms at 1015, and began breastfeeding almost immediately. RR=72, HR = 132, T=99.1 (axillary) Mom was stable postpartum, with BP=127/65, T=99.2. Big sister and grandparents met the new baby at 1020. At 1030, Mom walked to bathroom, voided, and then got into her bed. 600 mg ibuprofen and ice bag put on perineum taken at 1045 after reports of discomfort. Baby breastfed on both sides, and then fell asleep. Newborn exam completed at noon with no abnormal findings. Postpartum teaching done, including danger signs, when to call CNM. Family fed and resting when we departed at 1230.

Here is the journal entry I made (for school) regarding this birth:
 • I caught a baby all by myself. It was a lovely homebirth, with a waterbirth. Sally just stood there and let me catch. It was awesome. The whole experience was quite lovely, with a nice labor that I felt good supporting, managing. I had just met the couple in an AP visit two days before, and it was good to know the concerns the Dad had about the homebirth so that I could be sure to address them during the actual labor. Checking in with him during and after the labor, it seems that he felt good about the experience.
 • I delivered the placenta well – impressed Sally because I followed the curve of carus even though our client was standing up!
• I did at least one suture all by myself. :-) And there were only 2.
• Did another newborn exam. Still feeling somewhat awkward about the routine.

TOLAC & successful VBAC

TOLAC= TRIAL OF LABOR AFTER CESAREAN SECTION VBAC= VAGINAL BIRTH AFTER CESAREAN This week, I was honored to be part of an amazing, life-changing experience for several folks: the mom who succeeded in her TOLAC, and my student, who got to experience the thrill of that moment (and catch her 2nd baby). J felt that her first birth experience was incomplete - she had been pregnant, and then laboring, but then had a cesarean due to concerns about bleeding and some concerning fetal heart tones . . . friends thought she was crazy to choose a birth center for this birth, but J felt safe and well-supported by her midwives (me!). J came into the birth center early in the morning about 7 cm dilated, and got "stuck" there for much of the day. This was frustrating to her, but not to us . . . as out-of-hospital midwives, we have the luxury of patience . . .and don't jump to using pitocin as they do in the hospital (we only use pitocin for postpartum hemorrhage, since it is a dangerous drug for babies-still-in-the-womb). J's mother & sister were there, exuding energy that was lovely but not so conducive to laboring (aka, Sphincter Law, see below). So J labored all day with her husband and her doula. It was obvious to me that she was not suffering, so we supported her emotionally through her frustration and occasional "breakdowns," when she cried . . .she also stated a few times that she imagined having her baby at night, and it was a bright sunny mid-summer day! We sent J's family & doula home after a while, to see if the pressure of being "watched or "on-stage" changed her labor pattern or progress. Once evening came, things got more serious, and once it got dark, she started to feel "pushy." Laws in this state require that TOLAC clients have a 2 hour or less second stage (the pushing phase of labor), so I gave J a pep talk about pushing. Typically, I just let women figure it out for a while before I coach them. I think it is intuitive to push, and in most cases becomes spontaneous, but in this case, I wanted her to be sure to be effective and efficient. J got serious, and pushed out her baby in 47 minutes. She was sitting on the birth stool when she delivered. The head delivered, and the baby turned to look at me, with her eyes opened, and then started to breathe and whimper. I nudged the shoulders to deliver, and my student got to truly catch a baby (gravity makes the catch much more important than when someone is laying down), and then handed it off to me. J looked down at her baby, between her legs, and said, "It's a girl!" Baby girl was pink and gorgeous, breathing easily, looking up at her momma. J's mom said, "reach down and pick up your baby!" but J responded with, "I just need to look at her!" Then she said, "IT WAS SO WORTH IT!!!" J had a LONG labor. More than 24 hours at home before coming to the birth center, and then another 16 hours there. And at the moment of the birth (well, at least within the first minute), she was exclaiming the thrill of accomplishment! That brought tears to our eyes - all of us, I think. J reached down and picked up her secretly-wanted daughter. We cut the cord (the placenta had delivered spontaneously after 3 minutes, plopping down into the bowl under her), and moved J and her daughter to the bed to relax, get to know one another, and start breastfeeding. It was beautiful and moving and lovely. Baby girl turned out to be a healthy 8.5 lbs. In rehashing the birth, J wanted to know details that she didn't remember, and she's still trying to figure out why she got stuck. I call it emotional dystocia tied up with performance anxiety, complicated by her desire to deliver a baby in the dark. In the end, it all worked out. They were struggling for a name, and had several options to decide on. Once at home, they were rolling names around, and came up with one that fit. It means, "born at night." Beautiful! It is an honor to be at any birth, but there is something powerful and special about a successful VBAC, especially an unmedicated one. Women are immersed in the experience, and their accomplishment is so meaningful to them. I just love it! NOTE: Sphincter Law - Ina May Gaskin coined this term, and this is my understanding of what it means. The cervix is a sphincter, just like the urethral opening (where we pee from) and the anal sphincter. When we urinate or defecate, we typically prefer to do so privately, and any interruption can slow the process by closing the sphincter. Ina May (and I) believes that the cervical sphincter also operates this way. Women who feel safe and protected in their birth experience labor more effectively. Women who feel violated, unsafe, watched, surprised, etc. often have slower or stalled labors. In the story above, J was worried that her labor was "taking too long." She had a mom, sister, doula, husband and two midwives "watching her." During one vaginal exam, I actually felt her cervix start to close around my fingers (so I pulled them out right away!)! Once we reassured her that stalling was normal, we were patient, and sent her observers away, her sphincter relaxed, and her labor progressed. Go, Sphincter Law! Go!

a day in the life . . .

I really felt like a CNM this week. Here is a quick run-down of the end of my week (the early part was marred by a killer head cold!)

Thursday, I had prenatal clients in clinic. Saw one of my favorite ladies who has finally made it to 37 weeks for the first time (this is her 4th baby, and we cannot do homebirth before 37 weeks by law). Met a couple for their first visit. Saw repeat clients who are getting close to term, and excited about meeting their babies soon.

Friday, I did well-woman all day, and that consisted of: 3 paps, pulled out an IUD, put in an IUD, checked IUD strings, counseled about birth control, hormonal changes, nutrition, exercise, weight loss, tried desperately to diagnose lesions on a client's face, did 5 physicals, and more. I cleaned the room myself between clients, took their money, billed their insurance companies, and mostly stayed on time. (I would have been more on time if my clients had: a. remembered to bring their registration paperwork that they were sent; and b. if they had been on time!)

Saturday, I met with a client who was post-dates (getting close to 42 weeks - we also cannot deliver AFTER 42 weeks outside the hospital, also by law). Using my midwifery skills, I induced her labor naturally. It took a few hours, and she got walks and acupuncture between my exams, but it worked! She was in active labor by 8:30 pm, and had her baby in the wee hours this morning. A lovely birth, and a surprise little girl! (some of my clients opt NOT to find out!) As we said goodbye, the mom gave me a good hug, a real hug - you know, the kind where you can feel gratitude in their whole body? Left me feeling great.

Feeling more in the groove these days. Enjoying my clients, my work, feeling like I'm using my brain, my skills, and gaining expertise and awareness each and every day

So, this was a good week. I hadn't had a birth in a few weeks, so was a little sad about that. It has become a joke at work that when I'm on call, no-one goes into labor.

I'm still on call . . . heading to bed now. Hoping that little pager will chime to wake me up so I can be there to welcome another little one to the breathing world.

December

One birth in December that I was a part of from start to finish. That's all. And is just happened the other day.

It was a really great birth in retrospect. Healthy baby, healthy mommy, mommy very proud of her hard work, new papa pleased with the situation, etc. However in the moment, there were some challenges!

First, there was the grandmother of this new person. She was VERY nervous about this whole out-of-hospital thing. When I met her, she said something like, "She's really sick" in regards to her daughter puking her guts out. As a midwife who has attended 45 previous births in a midwife role and over 20 before that as a doula, I responded with, "This is really normal during labor," as I know it is. Not fun, but most bodily fluids make an appearance in most births. Wow, I got a look that would have killed. Nice to meet you, too, Grandma.

I KNOW she was really nervous, and I give her credit for being as supportive as she was throughout the labor, and afterwards, she did tell me, "You ladies are amazing." But some of her other lines included:

"No-one pushes this long!" After 90 minutes of pushing for a primip. Normal.

"Honey, maybe you need a doctor!" This was the only one that offended me personally, a little.

"Did she tell you how difficult my first birth was?"

I'm sure there were more. And truthfully, I really would have been happy to talk with her about her concerns, fears, worries - and I did, when I could - OUTSIDE THE BIRTHING ROOM. My biggest concern is that she would get into her daughter's head and ruin her labor. Slow it down. Make her give up. Get her worried . . . and she was already working harder than she'd ever worked in her life.

But the real point here is that most of us don't get the opportunity to see birth in a natural way. Birth is "supposed" to be in a hospital. It is on TV, right? It's where most of us were born. It's where there are doctors and nurses to come to the rescue at any moment. Especially those anesthesiologists! So most of us cannot fall back on anything familiar when we see a birth for the first time. It can be very stressful when we love the person who is laboring. She is in pain! She is moaning, uncomfortable, miserable, and talking about wanting an epidural or that she can't do it anymore, etc. But I know that all of these things are normal and okay. As long as the baby is okay, and there are no health concerns, I push these momma's to keep going, keep trying, think of only one contraction at a time. And most of these ladies are thrilled after-the-fact with what they have accomplished.

And you know what? There's good research that these momma's feel more confident as new mothers. Awesome, right?

So in the end, this grandmother learned something amazing, and she'll probably process it and remember it for her whole life. Hopefully, she'll tell her friends about it too, so that it doesn't seem quite as strange or crazy as they might think. Maybe.

One dozen births as a CNM

So obviously, I'm way behind on posting. I've been working as a CNM for over 3 months now, and have been a part of numerous pre-natal visits, too many IUD insertions to count, and a dozen births. I have not caught all of those babies, because sometimes my student midwives get to catch, and one delivered in the car . . . but I'm getting ahead of myself.

Here are some moments I remember from each of those births, in no particular order:

At my first (and only, to date) homebirth as a CNM, the mom's labor had stalled around 5 am, so I sent my student into town to retrieve some things we were missing in our births bags, and finished up charting at the tall counter between the kitchen and great room. I was standing there, focusing on my writing, thinking I was alone in the mostly dark room, while the mom was in her bedroom resting with her husband and doula. It was not quite 6 am. I heard the sound of another human in the room. Huh!? Strange. I looked around. Sitting on the long, sectional couch, amid several pillows, I finally spotted him. The almost-four-year-old. Wanting to be seen, but not wanting to be seen. I said, "Hi! Can I help you get back into bed?" I knew the mom didn't want him and his older brother up yet. He responded with, "Why are you here?" in a somewhat angry/protective voice. I said, "I'm here because your mom is having her baby." "Where's my mom?" "She's in her bed, resting. Can I help you get back to bed?" He looked at me some more, finally got up, and went back to his room. All by himself.

His sister was born about 4 hours later, on the floor in his parent's bathroom, apparently less than a foot from where he'd been born almost exactly four years earlier. He and his brother were very excited to meet the new baby! After things had settled down, I made some eggs for us to eat. By then, he and I were friends. When it came time to eat, he wanted me to eat with him at his "toddler" table. But one of the chairs was in his parent's room being used . . . so there was only one chair at his table. I offered to sit on the floor, and while I was serving eggs to others, he pulled up a chair from the adult table to his table so I could eat with him. I was glad we ended up being buddies after the scare I gave him early in the morning!

The car birth . . . funny and sort of sad, with a happy ending, thankfully. This was a second-time mom who had a long early labor, and was pretty cranky that we would not let her come to the birth center for the birth. "It isn't time yet" we kept telling her, knowing from her strange contraction pattern that if she "moved" in, we'd all be there for a long time, maybe days. She'd asked one of my midwife partners at 4 AM Monday morning, and again around 6 PM the same day. She paged me at midnight, and again at 2 AM, wanting to meet at the birth center at 3. When I suggested she call me back in 30-60 minutes to give me an update, and then woke up 4+ hours later, I was sure she'd taken herself to the hospital to see if they would admit her. But she was still home, trying to sleep between contractions that were 6-7 minutes apart.

We met at the birth center at 8:30 AM. Baby sounded fine. Her cervix was only 2-3 cm open. She was pretty frustrated, and even more embarrassed. I sent her home with a pep talk and an Ambien, so that she could try to sleep, not having had much in the past 2 nights. She called back around 4:30. She'd had 4-5 hours of sleep, and her contractions were still in a similar pattern, although they sounded longer and stronger on the phone. She didn't want to come in at that point - she was tired and embarrassed - just asking for another sleeping pill. I called in a prescription . . . only to get a call from her at 5:15 saying she'd just had a "10 minute contraction with only a few seconds of a break, and now I feel like I have to push." I suggested she head into the birth center. Now.

She lived 5-6 miles away. Not far, right?? Her husband called back at 5:33 to tell us that "she thinks the baby is coming, and we're stuck in rush hour traffic." (NB: I live in a pretty small city. This is not LA or DC traffic we're talking about . . . to be clear. But it's all relative, right?) He wanted to know if they should just keep driving, which I encouraged him to do. I asked him to hand her the phone, and I talked her through her contractions, trying to convince her to breathe through them rather than push with them. I'm not sure I succeeded much, though, and later she said, "I'm really sorry I didn't listen better." But as the baby's head gets lower, the instinct to push is VERY strong . . . and I know that. I asked her to put her seat back (she was in the front) and lie on her side, rather than sitting up. I breathed into the phone like I wanted her to breathe (panting, sort of), rather than pushing. I tried to calm her down. I asked where they were a couple of times, surprised that she knew. Eventually, as I could tell the baby was closer, I asked her if she had her pants on . . . and then told her to take them off! (Every so often, I'd hear the dad say, "Oh MY GOD! OH MY GOD!") Then "the head came out" and then "the head went back in" (must of been crowning), and then was really born. I asked her to talk to her baby, and rub her back, "I need to hear the baby crying" - knowing that crying is breathing. The arrived at the birth center at 5:44, 3 minutes after the baby was born. The newborn was pink and healthy, the mom was overwhelmed, and the dad was shaking and crying as he got out of the car. We were waiting for them in our parking lot, wearing gloves, with towels, cord clamps, etc. We dried off the baby, cut the cord, and Dad took her inside with one of the midwives. We got mom up and out of the car, and inside too, where we delivered the placenta. By the time they were discharged a few hours later, they were laughing about the experience, and we were all happy with the good outcome.

As for the others, each has a story. There was the woman who marched around the birth center until her water broke in the waiting room, then crawled/walked/scooted across the room towards the bed, delivering in a standing position. There was the intense laboring mom who wanted to make eye contact, chanted, sang, moaned . . . and ended with a lovely water birth. There was the mom who finally got herself into labor just before 42 weeks with castor oil. When she arrived at the birth center she looked like a deer in the headlights, her contractions were so strong and she was just holding on to control . . . but then calmed down and regained her ability to deal with them. There was the 23 year old VBAC whose cervix was so far back my colleague couldn't reach it at 5:30 PM, and had her baby before midnight. If we hadn't acted faster, she would have delivered at the Motel 6, where they were staying, since they were from out of town.

It's been fun and exhausting and wonderful. Every time I wonder how long it will take, how strong this woman will be, if she'll think she can do it, if I'm helping enough or too much. Every time I'm amazed with the process - watching the mom labor, and then push, and then finally seeing the head, and then wow - there's the baby! Into momma's arms. Taking a first breath, turning pinker, opening eyes, looking around. Amazing. Watching partners and families interact is also quite entertaining, interesting, intriguing. The whole experience is such an honor to be a part of.

More later . . . there's an update for now.

My first 3 clients as a CNM

So, now that I've moved to a new town (got here two days ago, late at night), work has begun! I think I've previously mentioned that I got a job as a midwife in a birth center. I work with one other CNM and several LM/CPMs (licensed midwife/certified professional midwife). The other CNM is out of town for a couple of weeks. So . . .

I was called in yesterday (the day before my official start date) to choose a med & write a prescription for a UTI (urinary tract infection). This client is 4 weeks postpartum, with "allergies to penicillin & sulfa drugs" (and quotation marks because it's really her father's allergy, so she's always avoided them. . . not sure how I feel about that since those meds are often first line choices for many types of infections!), so I gave her ciprofloxacin, which I would not have been able to give if she was still pregnant. Hope it works!

Today, my scheduled client was 14 weeks and complaining of vaginal itching. I diagnosed a yeast infection. Exciting stuff! But I spent quite a bit of time with her, and she felt great about our appointment. When I did her vaginal exam, I didn't use stirrups, - generally my clients love it that I don't use stirrups. :-)

My exciting client of the day was a woman just starting her third trimester who came in complaining of contractions. I just figured it was a UTI or vaginal infection (like yeast or an STD). She peed in a cup for me before her exam, so that I could do a urine culture, and then in the exam room while undressing, had a puddle at her feet. Not pee. So sad. My sterile speculum exam showed lots of obvious pooling of amniotic fluid, fern & nitrazine positive (quick test we can do to confirm that it's amniotic fluid rather than just vaginal mucus), and a baby's head through a dilated cervix - probably 3-4 cm from what I could tell. I could actually see the baby's head moving. Even sadder. After some discussion with her about what to expect, I sent her off to the hospital for an examination there, and hopefully some treatment of her pre-term labor to give her a few days more pregnant. (What is often done is to give medications that reduce contractions, and also give steroids to help the fetal lungs complete development. This helps preemies breathe better at birth). I called the charge nurse at the hospital to let her know that I was sending a client over, and had a great interaction with her. Now I just have my fingers crossed now that the baby is okay! Most likely all will be fine . . . but it will be a stressful beginning for them both.

So, those are my first 3 clients as a CNM! Let me tell you that I left work today with adrenalin PUMPING from my system!!!

Summer "jobs"

While I was walking into the hall for graduation, a professor looked me and said: "Oh no, you're graduating? I needed you this summer!" My reply was, "I need a summer job - hire me!"

So she did.

I am co-teaching a junior level class at a very reputable nursing school this summer - in fact, the very same nursing school I attended. It is a health assessment class, and I've been spending way too much time thinking about it and preparing for it at a time when I really wanted to be relaxing, organizing my life (namely my crazy messy apartment), and getting some much needed exercise.

But it was difficult to turn down. They are paying me! Quite well, I might add. And I can do anything for 8 weeks, right? Especially when that something adds a great job to my resume.

So I'll be lecturing on Mondays in the morning, and teaching a lab section in the afternoon. Should be fun. And challenging!

This professor has been my ally for quite a while now. Two years ago, when I was a brand new graduate student, I happened to have my desk near her office. She decided that I was worth knowing, and has found me TA jobs throughout my tenure at the university, thus helping me earn, and save, money throughout school. I had her as a professor my very first summer as a nursing student - 3 years ago. But she's kept an eye on me ever since. What a sweetheart.

My other summer job is to take care of my best friend's son on Tuesdays. He's 12 months old, and lots of fun, and still naps (usually) twice a day. So it's a mellow day. I love hanging out with him!

Hopefully, I'll find time this summer to do some fun things, too.