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.
Monday, December 5, 2011
Thursday, September 1, 2011
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!!!
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!!!
Sunday, June 19, 2011
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.
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.
Monday, June 6, 2011
It's a whirlwind!
Much news to share:
I got a job!
I passed my final exam (a.k.a. master's project defense)!
I passed comprehensive exams!
Since I last wrote, lots has happened. Obviously. And really, nothing all that exciting to report because much of the last several weeks has involved studying for exams, preparing for a presentation (making a powerpoint, making notecards, etc), and doing paperwork things to ensure graduation happens. Not catching babies. Not seeing clients for exams. Just back home in my house in the big city, plugging away with academic stuff.
It feels strange to be away from my clients . . . I miss them. I decided to take a job at that lovely birth center where I did my last quarter of midwifery school. It just felt right there. So now, I've got the summer to take boards (the state licensure exam, to become a nurse practitioner), organize my stuff/life/sh!t, and say goodbye to the friends I've made here during my 13 year stay.
So, as I was saying, I miss my clients. The one who was due June 1 and really wanted to have her baby before I left so that I could be there. The one who is sad I won't be back until after her baby is due. Another couple who is due in July - they were my VERY LAST clients as a student! It seems strange not to be taking care of them during this time. And at the same time it seems very strange to be thinking about packing up and moving to a new place. I know it's the right job. I hope it turns out well for me personally, too.
So, as my dog snores, and my house is a wreck, I should probably go do more straightening up since my parents arrive in less than 48 hours to help celebrate graduation later this week. Yikes!
I got a job!
I passed my final exam (a.k.a. master's project defense)!
I passed comprehensive exams!
Since I last wrote, lots has happened. Obviously. And really, nothing all that exciting to report because much of the last several weeks has involved studying for exams, preparing for a presentation (making a powerpoint, making notecards, etc), and doing paperwork things to ensure graduation happens. Not catching babies. Not seeing clients for exams. Just back home in my house in the big city, plugging away with academic stuff.
It feels strange to be away from my clients . . . I miss them. I decided to take a job at that lovely birth center where I did my last quarter of midwifery school. It just felt right there. So now, I've got the summer to take boards (the state licensure exam, to become a nurse practitioner), organize my stuff/life/sh!t, and say goodbye to the friends I've made here during my 13 year stay.
So, as I was saying, I miss my clients. The one who was due June 1 and really wanted to have her baby before I left so that I could be there. The one who is sad I won't be back until after her baby is due. Another couple who is due in July - they were my VERY LAST clients as a student! It seems strange not to be taking care of them during this time. And at the same time it seems very strange to be thinking about packing up and moving to a new place. I know it's the right job. I hope it turns out well for me personally, too.
So, as my dog snores, and my house is a wreck, I should probably go do more straightening up since my parents arrive in less than 48 hours to help celebrate graduation later this week. Yikes!
Tuesday, May 17, 2011
4 births, 5 days
Birth #1: fun birth last week was a good reminder not to think we can understand the mystery of birth. A, a second time mom, came in Sunday, 2 cm. Monday 3 cm. Wednesday, 4 cm. She got in the tub (my trepidation was known), 15 min after her exam, SROM, 15 min later she asked me if she could push, and then with the next ctx said, "I can't NOT push . . . ugh - something came out!!!" Yep - the HEAD! Her baby was born 35 minutes after her exam. WOW! i didn't have gloves on (insert sad face here) so the LM caught the baby. Oh well. Fun birth.
Birth #2: M was a G1 who dilated quickly, and then pushed for hours without any change. I was pretty sure that her baby was military & LOP (what this means is that the baby's head was not flexed, and was basically sunny-side up - and her head was STUCK!). When we transferred TO the hospital (to an asshole doc, unfortunately), I asked him what position the baby was in. He said, "LOA, of course!" So after her cesarean, I looked at that head. Guess what? Bruising on the forehead, caput (swelling) just above that. LOA my ASS! (The point is, the baby's head proved that my assessment was correct. LOA is sort of the "best" position for a baby to be in as they begin to descend through the pelvis - which isn't a straight shot! It's actually a bit of a maze - babies have to rotate their heads and shoulders in different directions at different times . . .)*
Birth #3: I was in the car on my way to the birth center when I got a call to let me know that the birth had already happened. Bummer! This was a first time mom (G1) who woke up at 7:30 AM with contractions, thought she was being a wuss, told her partner she was in labor, he had a hangover so went back to sleep for an hour. When she woke him up again at 8:30, her water had just broken, and she felt like she needed to push. They arrived at the birth center at 9:00, and when the midwife made it to the car, (after a frantic dad came to get her!) and pulled the mom's pants down, the head was already out! The rest of the delivery happened right there in the car, and when I arrived, they were nicely settled in the birth center, getting to know their son. Crazy!
Birth #4: I had an amazing VBAC over the weekend - mom must have said 100 times "I just want this to be over, I just want to meet this baby . . ." and ONCE I said, "you need to dig deep," which didn't go so well. She said, "I am digging deep!" I decided not to use that line anymore. We did offer a hospital transfer for an epidural (gently) and her response was, "I'm having my baby here." She had a lovely birth in the end, with a 7#8oz baby with a nuchal cord, nuchal hand, minor periurethral skid marks. Score! She was an amazing and controlled pusher. Wow! (nuchal is a fancy way of saying neck - cord around the neck, hand up by the neck - a hand by the neck or face means an elbow by the shoulders, which make the baby even bigger, making descent (and pushing) usually slower!)
I do love it here. I love it that these ladies don't have epidural as a real option. I have to admit, every time someone asked for an epidural when I was training at the hospital, my heart broke just a little. I know it's not my birth, but it is just so amazing to be a part of an unmedicated birth, and to see the mom's utter thrill when she delivers her baby!
*Epidurals change labor. They really do. Sure, they make the mom more comfortable. But they also make it a lot harder for baby to rotate through the pelvis because mom is static, and usually laying down. An unmediated mom is moving around, rocking her pelvis, walking, lifting her legs, etc. - and all of this helps the baby negotiate the pelvis. Without movement, the baby is more likely to get stuck = more likely to have a cesarean.
Birth #2: M was a G1 who dilated quickly, and then pushed for hours without any change. I was pretty sure that her baby was military & LOP (what this means is that the baby's head was not flexed, and was basically sunny-side up - and her head was STUCK!). When we transferred TO the hospital (to an asshole doc, unfortunately), I asked him what position the baby was in. He said, "LOA, of course!" So after her cesarean, I looked at that head. Guess what? Bruising on the forehead, caput (swelling) just above that. LOA my ASS! (The point is, the baby's head proved that my assessment was correct. LOA is sort of the "best" position for a baby to be in as they begin to descend through the pelvis - which isn't a straight shot! It's actually a bit of a maze - babies have to rotate their heads and shoulders in different directions at different times . . .)*
Birth #3: I was in the car on my way to the birth center when I got a call to let me know that the birth had already happened. Bummer! This was a first time mom (G1) who woke up at 7:30 AM with contractions, thought she was being a wuss, told her partner she was in labor, he had a hangover so went back to sleep for an hour. When she woke him up again at 8:30, her water had just broken, and she felt like she needed to push. They arrived at the birth center at 9:00, and when the midwife made it to the car, (after a frantic dad came to get her!) and pulled the mom's pants down, the head was already out! The rest of the delivery happened right there in the car, and when I arrived, they were nicely settled in the birth center, getting to know their son. Crazy!
Birth #4: I had an amazing VBAC over the weekend - mom must have said 100 times "I just want this to be over, I just want to meet this baby . . ." and ONCE I said, "you need to dig deep," which didn't go so well. She said, "I am digging deep!" I decided not to use that line anymore. We did offer a hospital transfer for an epidural (gently) and her response was, "I'm having my baby here." She had a lovely birth in the end, with a 7#8oz baby with a nuchal cord, nuchal hand, minor periurethral skid marks. Score! She was an amazing and controlled pusher. Wow! (nuchal is a fancy way of saying neck - cord around the neck, hand up by the neck - a hand by the neck or face means an elbow by the shoulders, which make the baby even bigger, making descent (and pushing) usually slower!)
I do love it here. I love it that these ladies don't have epidural as a real option. I have to admit, every time someone asked for an epidural when I was training at the hospital, my heart broke just a little. I know it's not my birth, but it is just so amazing to be a part of an unmedicated birth, and to see the mom's utter thrill when she delivers her baby!
*Epidurals change labor. They really do. Sure, they make the mom more comfortable. But they also make it a lot harder for baby to rotate through the pelvis because mom is static, and usually laying down. An unmediated mom is moving around, rocking her pelvis, walking, lifting her legs, etc. - and all of this helps the baby negotiate the pelvis. Without movement, the baby is more likely to get stuck = more likely to have a cesarean.
Tuesday, May 10, 2011
Medicalization of Birth
Dear Student
In spite of the evidence that birthing outcomes are better with less interventions, the medicalization of birth continues. The cesarean section rates, the number of inductions and the generalized interference with the normal processes of birth are escalating each month. I am doing a short survey to seek your opinions. Your participation is voluntary and there will be no personal data collected. Your completion and return of this survey indicates your consent to participate. If you have any questions, please contact me . . . . Thank you for your time and participation. Sincerely, E
So, here are my answers:
1. What do you think are the main causes for the present medicalized approach to birth and the increasing interventions into the birth process in the United States.
History: OBs took birth out of the home, and into the hospital. In other countries, the midwives went with women, but not in the US.
Technology: Technology is fun! Right? Helps us do things faster, easier, etc. Use a machine rather than your hands. Ugh. During my training I was frustrated to work with wonderful family doc residents who didn’t know how to do Leopold’s maneuvers . . . so just used the ultrasound every time to check presentation at the onset of labor. Ugh. I kept trying to tell them that they won’t have access to ultrasounds at every hospital/labor floor!
Mainstream media: messages that birth is fast, furious, dangerous, scary. I cringe almost every time I see a birth on TV or in a movie . . . her water breaks, everyone freaks out, and the baby is born within minutes. Right. Or a movie where I saw the OB coaching an unmedicated woman to push . . . and then the mom died, somehow, but why that was never clear. Awful.
Media & history lead to: what women want. Women want epidurals because birth is painful. They have no idea about the effect of epidurals on their labor. And most don’t care, when you tell them. They just want to be distanced from the pain, the experience.
Fear: fear of clients and fear of providers. Watching someone in pain is not comfortable for many, and especially with the current cultural/hospital value of minimizing pain (pain scales, taking care of pain) – that works backwards in the L&D unit, where pain is an indicator of progress, of a normal experience, and when too extreme, of something going wrong. Clients/patients are scared of pain. Pain is not seen as good in our culture. We try to minimize pain, rather than learn to cope with it and learn from it.
2. How is your educational program preparing you for the reality of our Obstetrical/intrapartal care in addition to exposure to birth centers and/or home births? What is being taught to give you the skills to practice midwifery in the hospital/institution setting.
My education focuses/d on typical hospital intrapartum care. I think our clinical sites prepared us for the reality, at least as much as or more so than the book learning, but of course, each preceptor & each site plus luck of that shift give us the experiences that we get. Overall, I think our education is preparing us for what hospitals are doing now, rather than teaching us to make change in those hospitals, even though our professors (for the most part) are truly believers in the midwifery model of care.
We kept track of “skills” we learned, including IUPC, FSE, fetal monitoring, etc. We did not keep track of “skills” we learned, in terms of hands on or observational skills, unfortunately.
I had the opportunity to have some exposure to OOH birth three of the five quarters I had intrapartum clincials. Two of those quarters, I was with a CNM who offered both hospital and OOH birth; my Integration quarter I spent training at a Birth center that also provides home birth. I set up that site myself because I was motivated to learn more about & get more experience with OOH birth. I will have over 10 births OOH when I complete my program . . . and more than 20 in hospital.
3. How are you planning to make a difference when you graduate?
I will be working at a Birth Center/home birth practice after I graduate. I’m excited to be working in a place that lets women’s bodies birth without unnecessary interventions, and believes in the power of the human body to know how to birth.
After I get some experience, I will precept students in OOH birth. Then I will do some formal teaching – nursing school? We’ll see . . .
In spite of the evidence that birthing outcomes are better with less interventions, the medicalization of birth continues. The cesarean section rates, the number of inductions and the generalized interference with the normal processes of birth are escalating each month. I am doing a short survey to seek your opinions. Your participation is voluntary and there will be no personal data collected. Your completion and return of this survey indicates your consent to participate. If you have any questions, please contact me . . . . Thank you for your time and participation. Sincerely, E
So, here are my answers:
1. What do you think are the main causes for the present medicalized approach to birth and the increasing interventions into the birth process in the United States.
History: OBs took birth out of the home, and into the hospital. In other countries, the midwives went with women, but not in the US.
Technology: Technology is fun! Right? Helps us do things faster, easier, etc. Use a machine rather than your hands. Ugh. During my training I was frustrated to work with wonderful family doc residents who didn’t know how to do Leopold’s maneuvers . . . so just used the ultrasound every time to check presentation at the onset of labor. Ugh. I kept trying to tell them that they won’t have access to ultrasounds at every hospital/labor floor!
Mainstream media: messages that birth is fast, furious, dangerous, scary. I cringe almost every time I see a birth on TV or in a movie . . . her water breaks, everyone freaks out, and the baby is born within minutes. Right. Or a movie where I saw the OB coaching an unmedicated woman to push . . . and then the mom died, somehow, but why that was never clear. Awful.
Media & history lead to: what women want. Women want epidurals because birth is painful. They have no idea about the effect of epidurals on their labor. And most don’t care, when you tell them. They just want to be distanced from the pain, the experience.
Fear: fear of clients and fear of providers. Watching someone in pain is not comfortable for many, and especially with the current cultural/hospital value of minimizing pain (pain scales, taking care of pain) – that works backwards in the L&D unit, where pain is an indicator of progress, of a normal experience, and when too extreme, of something going wrong. Clients/patients are scared of pain. Pain is not seen as good in our culture. We try to minimize pain, rather than learn to cope with it and learn from it.
2. How is your educational program preparing you for the reality of our Obstetrical/intrapartal care in addition to exposure to birth centers and/or home births? What is being taught to give you the skills to practice midwifery in the hospital/institution setting.
My education focuses/d on typical hospital intrapartum care. I think our clinical sites prepared us for the reality, at least as much as or more so than the book learning, but of course, each preceptor & each site plus luck of that shift give us the experiences that we get. Overall, I think our education is preparing us for what hospitals are doing now, rather than teaching us to make change in those hospitals, even though our professors (for the most part) are truly believers in the midwifery model of care.
We kept track of “skills” we learned, including IUPC, FSE, fetal monitoring, etc. We did not keep track of “skills” we learned, in terms of hands on or observational skills, unfortunately.
I had the opportunity to have some exposure to OOH birth three of the five quarters I had intrapartum clincials. Two of those quarters, I was with a CNM who offered both hospital and OOH birth; my Integration quarter I spent training at a Birth center that also provides home birth. I set up that site myself because I was motivated to learn more about & get more experience with OOH birth. I will have over 10 births OOH when I complete my program . . . and more than 20 in hospital.
3. How are you planning to make a difference when you graduate?
I will be working at a Birth Center/home birth practice after I graduate. I’m excited to be working in a place that lets women’s bodies birth without unnecessary interventions, and believes in the power of the human body to know how to birth.
After I get some experience, I will precept students in OOH birth. Then I will do some formal teaching – nursing school? We’ll see . . .
Saturday, April 30, 2011
Babies
This week I had the pleasure/opportunity to participate in two births.
Both were fairly straightforward . . . mostly, but not entirely . . . and the babies were a little more challenging than I'd like.
The first was a first time mom who was 42 weeks. She'd been in to see the OB, who gave her the all clear to have her baby at the birth center because she was finally in labor! She labored for about 10 hours, and after 2 hours of pushing quite effectively, we opted to give her an episiotomy because her vaginal tissue would NOT stretch, and she was tearing further down her perineum. The baby was starting to have trouble, too, as she had been almost born for quite a while. As soon as the cut happened, the birth was within about 30 seconds. Finally!
The little girl went to her mom's chest, and overall looked good. She pinked up nicely, had good tone, and her heartrate was normal. However, her respiratory rate was high, so we watched her closely as she transitioned to life outside the womb. She did okay for a while, first held by her mom, then dad, then mom again. She was put to breast around 30 min of age, but didn't seem really interested in feeding. It broke my heart when the mom said, "she doesn't like it!" After giving it a good college try, including stimulating her, switching breasts, etc, I finally said - "anyone else have any ideas? She's just not that interested in eating." The midwife said, "Breastfeeding is a vital sign, so if she's not interested, it could mean that something is wrong."
The midwife took the baby, and did another evaluation. She was now almost 90 minutes old, and when we turned the lights up higher, it was clear that her skin was not quite as pink as we'd like, but more dusky. She also started to have retractions, meaning that she was putting a lot of effort into breathing. She hadn't been doing this on mom's chest. First we suctioned her, and then gave more oxygen, which did pink her up quite nicely. But her respiratory rate remained high. More suction revealed some blood in her throat, strangely. She'd sounded "juicy" and been spitting up "gunk" for a while, but it was all clear . . . until now. Not good. We recommended to the parents that we send her over to the NICU for more observation, so as soon as we'd copied records and called ahead, she was on her way.
According to the neonatologist, that night things were "touch and go" with her - she was put on a respirator with 100% oxygen. Fortunately, about 36 hours after her birth, she was improving in all ways measureable. They were calling it "blood aspiration" at the hospital, which really didn't make much sense . . . because the birth wasn't really bloody. So it's possible she had a pulmonary bleed. Why? No one will ever know. Maybe a familial clotting problem, or maybe a fluke.
Meanwhile, when we sent the Dad and the baby to the NICU, we stayed to complete the care for the mom. She was exhausted! We had her eat & drink, and then get up to go to the bathroom - all requirements for discharge. After sitting on the toilet for a minute, she got very lightheaded and almost passed out. We had her lying on the floor of the bathroom with oxygen on her, too. What a mess! After a while, we got her back to bed, put in an IV, and gave her 1500 mL of LR (a fluid with electrolytes & sugar). That perked her up for sure. By then, her husband was back from the hospital - it had been too much for him to handle, and he didn't really understand why it all happened or what it meant. But we packed them up and sent them back to the hospital because mom wanted to see her daughter, of course.
When we visited them in the hospital a few days later, they were still exhausted and a wreck. But mom was pumping a good quantity of milk, and they knew that their daughter was on the mend. There were questions and tears, so after talking with them for a while, we left when his family showed up, after arriving from another city. We'll keep in touch to see how things progress. Ugh.
It seems that we transferred care at just the right time. The baby girl just didn't look sick . . . and then she did. It was scary, but taught me a lot.
The second birth was a few days later. This was a second time mom, who had her first in a hospital with an epidural. I was called at 4 AM, arrived at the BC at 4:40 and the baby was born at 5:40. Mom was in the tub when I arrived, breathing through contractions. As they got more intense, she started saying "frick," and then "I can't do this anymore," then "I don't want to do this anymore," and then finally, "F@CK!" Of course, in my head, these are all good things, since transition (the end of labor, before pushing starts) is the hardest part. At the same time it is sad to watch, since I know how miserable it must be. For a second time mom who had an epidural first, it might even be harder, since usually the second time goes faster, is more intense, and you have no real comparison. Her husband was a terrific coach, staying with her and talking her through each contraction. When the midwife examined her, the cervix was mostly dilated, except for a thick and tough layer in the front. She suggested that she stand up, climb out of the tub and do a little dancing or walking. The mom stood up, stepped out of the tub, and hung on her husband through two contractions. (I thought she might pull him over!) Then we got her over to the birthing stool, where as soon as she sat down, the top of her baby's head was visible at the perineum - crowning, basically.
She had a nice slow & controlled delivery of her baby, with no tears. She was thrilled!
The baby came out with a cord wrapped tightly around his neck. He was pretty pale and floppy. Not my favorite. His heartrate & respiratory rate were okay, and with lots of stimulation, he started to breathe and cry. But we kept a close eye on him for a while. His color improved, but wasn't great. After a while, we took him from mom and gave him some oxygen. It helped a little, but then his color worsened again, so we tried again. With the second try, and about 10 puffs of air, he pinked up really well and stayed that way. Thankfully!
Throughout, I kept thinking in my head, "I do not want another bad baby! . . I do not want another hospital transport! . . Not again!" and things like that. I was glad to see him breastfeed very well three times before we sent them home.
The mom was THRILLED with her birth and pleasantly surprised at how great she felt afterwards. After we got her up to pee, she stayed up for a while, she was feeling so good. I love that!
So those were the week's highlights. Hope you enjoyed. I learned a ton!!!
Both were fairly straightforward . . . mostly, but not entirely . . . and the babies were a little more challenging than I'd like.
The first was a first time mom who was 42 weeks. She'd been in to see the OB, who gave her the all clear to have her baby at the birth center because she was finally in labor! She labored for about 10 hours, and after 2 hours of pushing quite effectively, we opted to give her an episiotomy because her vaginal tissue would NOT stretch, and she was tearing further down her perineum. The baby was starting to have trouble, too, as she had been almost born for quite a while. As soon as the cut happened, the birth was within about 30 seconds. Finally!
The little girl went to her mom's chest, and overall looked good. She pinked up nicely, had good tone, and her heartrate was normal. However, her respiratory rate was high, so we watched her closely as she transitioned to life outside the womb. She did okay for a while, first held by her mom, then dad, then mom again. She was put to breast around 30 min of age, but didn't seem really interested in feeding. It broke my heart when the mom said, "she doesn't like it!" After giving it a good college try, including stimulating her, switching breasts, etc, I finally said - "anyone else have any ideas? She's just not that interested in eating." The midwife said, "Breastfeeding is a vital sign, so if she's not interested, it could mean that something is wrong."
The midwife took the baby, and did another evaluation. She was now almost 90 minutes old, and when we turned the lights up higher, it was clear that her skin was not quite as pink as we'd like, but more dusky. She also started to have retractions, meaning that she was putting a lot of effort into breathing. She hadn't been doing this on mom's chest. First we suctioned her, and then gave more oxygen, which did pink her up quite nicely. But her respiratory rate remained high. More suction revealed some blood in her throat, strangely. She'd sounded "juicy" and been spitting up "gunk" for a while, but it was all clear . . . until now. Not good. We recommended to the parents that we send her over to the NICU for more observation, so as soon as we'd copied records and called ahead, she was on her way.
According to the neonatologist, that night things were "touch and go" with her - she was put on a respirator with 100% oxygen. Fortunately, about 36 hours after her birth, she was improving in all ways measureable. They were calling it "blood aspiration" at the hospital, which really didn't make much sense . . . because the birth wasn't really bloody. So it's possible she had a pulmonary bleed. Why? No one will ever know. Maybe a familial clotting problem, or maybe a fluke.
Meanwhile, when we sent the Dad and the baby to the NICU, we stayed to complete the care for the mom. She was exhausted! We had her eat & drink, and then get up to go to the bathroom - all requirements for discharge. After sitting on the toilet for a minute, she got very lightheaded and almost passed out. We had her lying on the floor of the bathroom with oxygen on her, too. What a mess! After a while, we got her back to bed, put in an IV, and gave her 1500 mL of LR (a fluid with electrolytes & sugar). That perked her up for sure. By then, her husband was back from the hospital - it had been too much for him to handle, and he didn't really understand why it all happened or what it meant. But we packed them up and sent them back to the hospital because mom wanted to see her daughter, of course.
When we visited them in the hospital a few days later, they were still exhausted and a wreck. But mom was pumping a good quantity of milk, and they knew that their daughter was on the mend. There were questions and tears, so after talking with them for a while, we left when his family showed up, after arriving from another city. We'll keep in touch to see how things progress. Ugh.
It seems that we transferred care at just the right time. The baby girl just didn't look sick . . . and then she did. It was scary, but taught me a lot.
The second birth was a few days later. This was a second time mom, who had her first in a hospital with an epidural. I was called at 4 AM, arrived at the BC at 4:40 and the baby was born at 5:40. Mom was in the tub when I arrived, breathing through contractions. As they got more intense, she started saying "frick," and then "I can't do this anymore," then "I don't want to do this anymore," and then finally, "F@CK!" Of course, in my head, these are all good things, since transition (the end of labor, before pushing starts) is the hardest part. At the same time it is sad to watch, since I know how miserable it must be. For a second time mom who had an epidural first, it might even be harder, since usually the second time goes faster, is more intense, and you have no real comparison. Her husband was a terrific coach, staying with her and talking her through each contraction. When the midwife examined her, the cervix was mostly dilated, except for a thick and tough layer in the front. She suggested that she stand up, climb out of the tub and do a little dancing or walking. The mom stood up, stepped out of the tub, and hung on her husband through two contractions. (I thought she might pull him over!) Then we got her over to the birthing stool, where as soon as she sat down, the top of her baby's head was visible at the perineum - crowning, basically.
She had a nice slow & controlled delivery of her baby, with no tears. She was thrilled!
The baby came out with a cord wrapped tightly around his neck. He was pretty pale and floppy. Not my favorite. His heartrate & respiratory rate were okay, and with lots of stimulation, he started to breathe and cry. But we kept a close eye on him for a while. His color improved, but wasn't great. After a while, we took him from mom and gave him some oxygen. It helped a little, but then his color worsened again, so we tried again. With the second try, and about 10 puffs of air, he pinked up really well and stayed that way. Thankfully!
Throughout, I kept thinking in my head, "I do not want another bad baby! . . I do not want another hospital transport! . . Not again!" and things like that. I was glad to see him breastfeed very well three times before we sent them home.
The mom was THRILLED with her birth and pleasantly surprised at how great she felt afterwards. After we got her up to pee, she stayed up for a while, she was feeling so good. I love that!
So those were the week's highlights. Hope you enjoyed. I learned a ton!!!
Saturday, April 23, 2011
What a week!
On Friday, I found out that I did not get the job I mentioned earlier - the one that pays well and is in a group practice with OBs and CNMs. I didn't think they'd offer it to me, and I was pretty sure I wouldn't take it even if they did! So that made for an easy decision.
I have no idea what I did on Saturday. Oh yeah, I went to the opening Farmer's market in my new town. Great stuff!
On Sunday, I got offered another job. This one is in a place that I would probably consider top choice, but it is only a part time position. Flattering, nevertheless. Then I helped groom the horses. Fun!
On Monday, I helped put in an IUD. More on that later. I also did a well-woman exam, including a physical, a pelvic exam, complete with PAP, and fitted her for a diaphragm. She had complained of rectal itching during the interview, but I forgot to look at her rectum for hemorrhoids. Darn it!
On Tuesday, I called one of my job offers, and told them that I wasn't ready to make a decision, and that their offer was probably not going to provide me the lifestyle to which I have become accustomed. (ha ha! - no really, it wasn't going to let me pay my bills, including at least $60K in loans!!!)
On Wednesday, my client who had her baby last week came in with a persistent headache. Not good. Her blood pressures had been up during labor, and day 1 and 2 postpartum. Now that she was day 8 postpartum, I was worried that she'd developed pre-eclampsia. Postpartum, you ask? Yes, it can happen. Remember, we don't really understand the disease, and despite the fact that we often say that it is "cured" with the birth of the baby (really the placenta), that isn't always true. We made a game plan to care for her if that was in fact the case - really that means to refer her to an OB - but when she arrived, her BP was back down to her normal range (110s over 60s) which was very reassuring, and she had no other symptoms of pre-E. Phew! For me, this was a great opportunity to use my skills of deduction and memory. What do you do to figure out if someone might have pre-E? I had to go through my list and get the information from her - some subjective (do you see bright spots in your vision? are you having any upper abdominal pain?) and some objective (is there protein in her urine?). It was a moment of realization that I've learned a bit - actually a ton - and can put it to use.
On Thursday, my IUD client returned, complaining of abdominal pain, tenderness, and cramping. She also said that she couldn't feel her IUD strings. Again, we prepared, this time for a perforated IUD. Where would we send her? First to the ultrasound or first to the OB? Should we do some testing first? When she arrived, we looked at her cervix. Yay - strings there, looking just as long as they did on Monday. Then we felt her uterus, from the outside and the inside. It felt huge! Like 16 weeks pregnant huge. She'd had a negative pregnancy test. We did an in-office ultrasound, which confirmed large uterus, no pregnancy, but we couldn't see the IUD. Is that because our ultrasound isn't strong enough? Because the IUD has migrated? Wish we knew. I also did a urine culture, a gonorrhea and chlamydia test, and a wet mount. I have to wait for the first two, as they go to the lab, but on the third, I could see lots of PMNs, a type of white blood cell, which indicates likely infection. After a consultation call to a local OB, we put her on an antibiotic for 10 days, and will plan to see her back next week. Again, I felt great about my management of her case. And worried about her!
On Friday, I called both of the women mentioned above, and they reported that they are feeling much better. Then I got called into a birth during second stage. She was laying flat on her back with her knees up by her chest. Isn't this the position we use in the hospital? Isn't the whole point of having an out-of-hospital birth to NOT be in this position? Oh well. Apparently, the midwife in charge had tried to offer a different position . . . to no avail. After watching for a while, and listening to the baby's heart rate go down after contractions (recovering quickly, I might add) and remembering that she'd been having unexplained bleeding throughout labor, I got a little nervous with the lack of progress. I suggested a different position, since that position just isn't very effective usually, and clearly was not being effective at this time. She tried hands & knees for a few pushes, and then the bleeding started again. A lot of bleeding. We got her to the birth chair, and I encouraged her to really get this baby out. She did, on the next contraction. What a momma! Her bleeding continued . . . but the baby came out crying. Good boy! It's nice to only have to worry about one of them! Pitocin given IM, and delivery of the placenta about 15 min later slowed her bleeding to almost nothing. Yay! Beautiful baby boy, 9#!
Saturday, I got a call at 0755 to head in to the birth center. Then about 0820, she told me to wait to come until we were sure this was really going to happen. Her cervix was posterior, long, thick, and closed. The baby was still floating above the pelvis. Oh well. I stayed home, had some coffee, and worked on a paper on GBS prophylaxis during labor. As it turns out, she was having crazy contractions that eventually started making change, but she took herself to the hospital for an epidural. She's 6 cm now & sleeping. The doc ruptured her membranes, and they got thick meconium. Her labor has slowed down a bit. Hopefully she'll have the VBAC she wants. Last time she only dilated to 4 cm, so she's done better this time! Best of luck to her.
Anyway, It's been an exciting week. I'm feeling oh so much more confident, like I know what I'm doing, at least most of the time. The funny thing for me is that here at the Birth Center, I am definitely the most MEDICAL of the bunch, and therefore sometimes the most conservative. I was the most nervous when that momma was bleeding and her baby was having decels. I was first to suggest antibiotics for the infection. I am first to suggest hormome methods of birth control. Why is this funny? Because until now, I've always been the most NON-MEDICAL of the group, whether it be in SNM cohort or at the other practices where I've trained. I'm usually the one opting for low or no intervention, and second-guessing myself when I choose them. I'm the one who defends the momma with the birth plan, when everyone else poo-poos it. It's great to be on the other end this time - I think it will balance me out, and I also think I am offering the folks here some new information and a new way to think about caring for our clients.
I have no idea what I did on Saturday. Oh yeah, I went to the opening Farmer's market in my new town. Great stuff!
On Sunday, I got offered another job. This one is in a place that I would probably consider top choice, but it is only a part time position. Flattering, nevertheless. Then I helped groom the horses. Fun!
On Monday, I helped put in an IUD. More on that later. I also did a well-woman exam, including a physical, a pelvic exam, complete with PAP, and fitted her for a diaphragm. She had complained of rectal itching during the interview, but I forgot to look at her rectum for hemorrhoids. Darn it!
On Tuesday, I called one of my job offers, and told them that I wasn't ready to make a decision, and that their offer was probably not going to provide me the lifestyle to which I have become accustomed. (ha ha! - no really, it wasn't going to let me pay my bills, including at least $60K in loans!!!)
On Wednesday, my client who had her baby last week came in with a persistent headache. Not good. Her blood pressures had been up during labor, and day 1 and 2 postpartum. Now that she was day 8 postpartum, I was worried that she'd developed pre-eclampsia. Postpartum, you ask? Yes, it can happen. Remember, we don't really understand the disease, and despite the fact that we often say that it is "cured" with the birth of the baby (really the placenta), that isn't always true. We made a game plan to care for her if that was in fact the case - really that means to refer her to an OB - but when she arrived, her BP was back down to her normal range (110s over 60s) which was very reassuring, and she had no other symptoms of pre-E. Phew! For me, this was a great opportunity to use my skills of deduction and memory. What do you do to figure out if someone might have pre-E? I had to go through my list and get the information from her - some subjective (do you see bright spots in your vision? are you having any upper abdominal pain?) and some objective (is there protein in her urine?). It was a moment of realization that I've learned a bit - actually a ton - and can put it to use.
On Thursday, my IUD client returned, complaining of abdominal pain, tenderness, and cramping. She also said that she couldn't feel her IUD strings. Again, we prepared, this time for a perforated IUD. Where would we send her? First to the ultrasound or first to the OB? Should we do some testing first? When she arrived, we looked at her cervix. Yay - strings there, looking just as long as they did on Monday. Then we felt her uterus, from the outside and the inside. It felt huge! Like 16 weeks pregnant huge. She'd had a negative pregnancy test. We did an in-office ultrasound, which confirmed large uterus, no pregnancy, but we couldn't see the IUD. Is that because our ultrasound isn't strong enough? Because the IUD has migrated? Wish we knew. I also did a urine culture, a gonorrhea and chlamydia test, and a wet mount. I have to wait for the first two, as they go to the lab, but on the third, I could see lots of PMNs, a type of white blood cell, which indicates likely infection. After a consultation call to a local OB, we put her on an antibiotic for 10 days, and will plan to see her back next week. Again, I felt great about my management of her case. And worried about her!
On Friday, I called both of the women mentioned above, and they reported that they are feeling much better. Then I got called into a birth during second stage. She was laying flat on her back with her knees up by her chest. Isn't this the position we use in the hospital? Isn't the whole point of having an out-of-hospital birth to NOT be in this position? Oh well. Apparently, the midwife in charge had tried to offer a different position . . . to no avail. After watching for a while, and listening to the baby's heart rate go down after contractions (recovering quickly, I might add) and remembering that she'd been having unexplained bleeding throughout labor, I got a little nervous with the lack of progress. I suggested a different position, since that position just isn't very effective usually, and clearly was not being effective at this time. She tried hands & knees for a few pushes, and then the bleeding started again. A lot of bleeding. We got her to the birth chair, and I encouraged her to really get this baby out. She did, on the next contraction. What a momma! Her bleeding continued . . . but the baby came out crying. Good boy! It's nice to only have to worry about one of them! Pitocin given IM, and delivery of the placenta about 15 min later slowed her bleeding to almost nothing. Yay! Beautiful baby boy, 9#!
Saturday, I got a call at 0755 to head in to the birth center. Then about 0820, she told me to wait to come until we were sure this was really going to happen. Her cervix was posterior, long, thick, and closed. The baby was still floating above the pelvis. Oh well. I stayed home, had some coffee, and worked on a paper on GBS prophylaxis during labor. As it turns out, she was having crazy contractions that eventually started making change, but she took herself to the hospital for an epidural. She's 6 cm now & sleeping. The doc ruptured her membranes, and they got thick meconium. Her labor has slowed down a bit. Hopefully she'll have the VBAC she wants. Last time she only dilated to 4 cm, so she's done better this time! Best of luck to her.
Anyway, It's been an exciting week. I'm feeling oh so much more confident, like I know what I'm doing, at least most of the time. The funny thing for me is that here at the Birth Center, I am definitely the most MEDICAL of the bunch, and therefore sometimes the most conservative. I was the most nervous when that momma was bleeding and her baby was having decels. I was first to suggest antibiotics for the infection. I am first to suggest hormome methods of birth control. Why is this funny? Because until now, I've always been the most NON-MEDICAL of the group, whether it be in SNM cohort or at the other practices where I've trained. I'm usually the one opting for low or no intervention, and second-guessing myself when I choose them. I'm the one who defends the momma with the birth plan, when everyone else poo-poos it. It's great to be on the other end this time - I think it will balance me out, and I also think I am offering the folks here some new information and a new way to think about caring for our clients.
Wednesday, April 13, 2011
Sitting on our hands
I'm not quite recovered from the first birth I attended here at the Birth Center where I'm doing my last bit of training before I graduate. On Monday, a woman came in, laboring well. She'd been having contractions over the weekend, and when examined, was about 6 cm dilated, with a mostly effaced cervix. This was her first pregnancy, and those births often take a long time, but she was already 6 cm when she arrived, so we were all hopeful.
This woman was incredible. She was young - 24 years old, strong and confident. She was willing to try or do anything we suggested to help her labor along. That proved to be important in this story. She was not at the birth center for long, before she was moaning well - in a way that makes us smile because it sounds like discomfort that actually makes a cervix change - and we were pleased. We settled in for the night. She continued to labor well, with her husband and doula at her side. Her baby seemed well, also, with a heart rate that reassured us every time we listened.
Being at a birth center, we don't check the cervix too often - we try to do it only if and when we feel it is necessary, or when the client asks. Often the woman's reactions to her contractions tell us a lot. But after hours had passed, it seemed prudent to check her again, and her cervix hadn't changed much, except that it had changed position, possibly due to a change in the baby's head. No big deal. But when another chunk of hours had passed again, and her cervix still wasn't much different, or maybe even less open than it had been before, we started to wonder what was going on or how we could help her continue to progress. She seemed to labor well in the tub, in the dark bathroom, and when she was left alone. We tried all of that. She seemed to have more cervix on the left side, so we had her try positions that would help the baby's head push on the left side to help it open more. We suggested walking the stairs, doing lunges, going for a car ride, laying down to rest. We offered to break her bag of waters, we offered to give her some meds to help her sleep. She tried everything we suggested (except the meds), although breaking her water took her a while to feel okay about. Finally, sometime around 24 hours after she had arrived at the birth center, her cervix was 9 cm dilated! Progress! A couple of the midwives did some relaxation work with her, using the rebozo, and also used it to help move the baby into the best position possible, with the back on the mom's left side. That must have been uncomfortable for her, but she did it with grace, and was willing to do more. At the end, while the rest of us ate a dinner of pizza & calzones, she went in to the birth room alone to labor on her left side - a position she hated, but knew would help move things along.
Throughout all of this, this woman never complained, ate, drank, peed regularly, and kept her sense of humor. She was amazing.
Around 10 PM, her cervix was completely dilated, except for an anterior lip. One of the midwives held her cervix aside while she pushed, attempting to get that lip around the baby's head. As it turned out, getting her into a hands & knees position while doing that worked well - it was easier for the midwife, and allowed the baby's head to use gravity for assistance as well. At last, pushing commenced! She pushed well for about 2 1/2 hours, in hands and knees, on her side in bed, and for a long while on the birth stool, with her husband sitting behind her.
With a slow, deliberate effort, she delivered an 8 lb 9 oz healthy baby girl just after 1 AM Wednesday morning. Her perineum was intact, a midwife's way of saying that she had no tears! And she was absolutely thrilled with the experience - she did itHer baby was breastfeeding well within 35 min of the birth, and other than feeling weak and tired (like we all did!), she looked no worse for wear. Her mom and in-laws came to the birth center around 3 AM to meet their granddaughter, and help them get home.
The report today is that she's doing well. We'll do a home visit tomorrow to check in. What a happy ending.
The sad thing is that if she'd been in a hospital, she would have had a cesarean due to "failure to progress." Sometimes women just need time to let their bodies do it. And we need to remember that sitting on our hands and doing "nothing" can be best. Doing nothing is really hard- and truthfully, we were doing something really important: believing in the process, in her body, and making sure that she and her baby were okay.
I'm exhausted. And thrilled. I teared up several times today just thinking and processing the experience. It was peaceful and joyful and exhausting for all of us. I'm honored that I got to play a part in helping this woman bring her daughter into the world in such a lovely way.
This woman was incredible. She was young - 24 years old, strong and confident. She was willing to try or do anything we suggested to help her labor along. That proved to be important in this story. She was not at the birth center for long, before she was moaning well - in a way that makes us smile because it sounds like discomfort that actually makes a cervix change - and we were pleased. We settled in for the night. She continued to labor well, with her husband and doula at her side. Her baby seemed well, also, with a heart rate that reassured us every time we listened.
Being at a birth center, we don't check the cervix too often - we try to do it only if and when we feel it is necessary, or when the client asks. Often the woman's reactions to her contractions tell us a lot. But after hours had passed, it seemed prudent to check her again, and her cervix hadn't changed much, except that it had changed position, possibly due to a change in the baby's head. No big deal. But when another chunk of hours had passed again, and her cervix still wasn't much different, or maybe even less open than it had been before, we started to wonder what was going on or how we could help her continue to progress. She seemed to labor well in the tub, in the dark bathroom, and when she was left alone. We tried all of that. She seemed to have more cervix on the left side, so we had her try positions that would help the baby's head push on the left side to help it open more. We suggested walking the stairs, doing lunges, going for a car ride, laying down to rest. We offered to break her bag of waters, we offered to give her some meds to help her sleep. She tried everything we suggested (except the meds), although breaking her water took her a while to feel okay about. Finally, sometime around 24 hours after she had arrived at the birth center, her cervix was 9 cm dilated! Progress! A couple of the midwives did some relaxation work with her, using the rebozo, and also used it to help move the baby into the best position possible, with the back on the mom's left side. That must have been uncomfortable for her, but she did it with grace, and was willing to do more. At the end, while the rest of us ate a dinner of pizza & calzones, she went in to the birth room alone to labor on her left side - a position she hated, but knew would help move things along.
Throughout all of this, this woman never complained, ate, drank, peed regularly, and kept her sense of humor. She was amazing.
Around 10 PM, her cervix was completely dilated, except for an anterior lip. One of the midwives held her cervix aside while she pushed, attempting to get that lip around the baby's head. As it turned out, getting her into a hands & knees position while doing that worked well - it was easier for the midwife, and allowed the baby's head to use gravity for assistance as well. At last, pushing commenced! She pushed well for about 2 1/2 hours, in hands and knees, on her side in bed, and for a long while on the birth stool, with her husband sitting behind her.
With a slow, deliberate effort, she delivered an 8 lb 9 oz healthy baby girl just after 1 AM Wednesday morning. Her perineum was intact, a midwife's way of saying that she had no tears! And she was absolutely thrilled with the experience - she did itHer baby was breastfeeding well within 35 min of the birth, and other than feeling weak and tired (like we all did!), she looked no worse for wear. Her mom and in-laws came to the birth center around 3 AM to meet their granddaughter, and help them get home.
The report today is that she's doing well. We'll do a home visit tomorrow to check in. What a happy ending.
The sad thing is that if she'd been in a hospital, she would have had a cesarean due to "failure to progress." Sometimes women just need time to let their bodies do it. And we need to remember that sitting on our hands and doing "nothing" can be best. Doing nothing is really hard- and truthfully, we were doing something really important: believing in the process, in her body, and making sure that she and her baby were okay.
I'm exhausted. And thrilled. I teared up several times today just thinking and processing the experience. It was peaceful and joyful and exhausting for all of us. I'm honored that I got to play a part in helping this woman bring her daughter into the world in such a lovely way.
Monday, April 4, 2011
birth #25
My most recent birth was with a 20 year old first time mom. She was laboring well, got her epidural, and continued to labor rather quickly. During 2nd stage (pushing), she really hated the intense pressure in her pelvis, and had trouble for a while pushing through it. I asked the nurse to get me some sterile water to make a wet compress for perineal support, and then turned around to grab it. The midwife I worked with that night was holding the mom's leg, and said, "Quick! Turn around!" As I did, the head popped out. Oh well - so much for perineal support, right?
The rest of the birth was rather quick, despite my directions to move the baby out slowly . . . she had some tearing - great practice for me, sad for her. Overall, it was a fun one, though, with a great team of nurses & staff.
The rest of the birth was rather quick, despite my directions to move the baby out slowly . . . she had some tearing - great practice for me, sad for her. Overall, it was a fun one, though, with a great team of nurses & staff.
So much to tell . . .
After pondering, I think I'll just write quick notes here, rather than detailed stories, since it's been over a month since I last posted.
In no particular order:
I had a job interview in another state. They flew me out, paid for my car rental, and arranged a 12 hour day of interviews! Breakfast with the midwives, meet with administrators, lunch with docs and NPs, more meetings with administrators, a tour of 2 clinics, and then dinner with docs, midwives, and NPs. They never really interviewed me. Interesting, huh? They also never really gave me the chance to interview them, so I asked for a follow up meeting the next day with one of the midwives to get my questions answered. Here's what I learned: Everyone's philosophy there seems to be different. This is quite challenging when sharing patients! One of the docs doesn't like women to get out of bed AT ALL during labor. YIKES! I also learned that it is a loan repayment site. What this means is that they pay off my student loans in a matter of 3-4 years. I really liked the location of this job. Friends nearby, lots of places to go play outside. But it would be a tough job to be the new kid, especially straight out of school.
I finished up my training at the hospital where I worked for 6 months. It was sad to go - I learned so much and became friends with quite a few folks. Good people there, even those whose politics were very different from mine. And I think I'll be lifelong friends with one or two of the midwives I met there. Wonderful women!
I moved to another state for my last quarter of midwifery school: Integration. Today was my first day. It was awkward and awesome, like many first days anywhere. I'm working at a birth center that does only out of hospital births - about 70% at the center, and the other 30% at homes. More on that later.
I'm living on a horse farm for the next 2 months. There are 6 horses, 6 hens, 1 rooster, 2 cats, and 3 dogs (Rhodesian Ridgeback from Africa, Australian Shephard, and an English Mastiff). I've always wanted to live on a farm . . My commute is kinda long, but I think it will be worth it.
This post is dedicated to eco.
In no particular order:
I had a job interview in another state. They flew me out, paid for my car rental, and arranged a 12 hour day of interviews! Breakfast with the midwives, meet with administrators, lunch with docs and NPs, more meetings with administrators, a tour of 2 clinics, and then dinner with docs, midwives, and NPs. They never really interviewed me. Interesting, huh? They also never really gave me the chance to interview them, so I asked for a follow up meeting the next day with one of the midwives to get my questions answered. Here's what I learned: Everyone's philosophy there seems to be different. This is quite challenging when sharing patients! One of the docs doesn't like women to get out of bed AT ALL during labor. YIKES! I also learned that it is a loan repayment site. What this means is that they pay off my student loans in a matter of 3-4 years. I really liked the location of this job. Friends nearby, lots of places to go play outside. But it would be a tough job to be the new kid, especially straight out of school.
I finished up my training at the hospital where I worked for 6 months. It was sad to go - I learned so much and became friends with quite a few folks. Good people there, even those whose politics were very different from mine. And I think I'll be lifelong friends with one or two of the midwives I met there. Wonderful women!
I moved to another state for my last quarter of midwifery school: Integration. Today was my first day. It was awkward and awesome, like many first days anywhere. I'm working at a birth center that does only out of hospital births - about 70% at the center, and the other 30% at homes. More on that later.
I'm living on a horse farm for the next 2 months. There are 6 horses, 6 hens, 1 rooster, 2 cats, and 3 dogs (Rhodesian Ridgeback from Africa, Australian Shephard, and an English Mastiff). I've always wanted to live on a farm . . My commute is kinda long, but I think it will be worth it.
This post is dedicated to eco.
Monday, February 28, 2011
Job interview #2
I got another job interview! I will be flying to a far away state for this one. It is in a level 1 hospital, in a practice with OB/GYNs, midwives, and family nurse practitioners. In a pretty small town. Pretty meaning beautiful and pretty small meaning about 16,000 people in two zip codes. Could be fun! Would be very, very different from the life I've been leading in the city for most of my life. And a very different kind of job than that I looked at before.
Fortunately, I have a month before I actually fly out there to figure out all of my questions. And there are many. And there are many I probably don't even know to ask. One that they won't be able to answer is the number of intelligent, cute, outdoorsy single men who are looking for a woman. But if they want me to come & stay, maybe they should consider wooing me in more ways than one.
Leaving my hometown sounds awful and exciting and scary all at the same time. Only time will tell where I end up when this job search ends. I'll keep you posted.
Fortunately, I have a month before I actually fly out there to figure out all of my questions. And there are many. And there are many I probably don't even know to ask. One that they won't be able to answer is the number of intelligent, cute, outdoorsy single men who are looking for a woman. But if they want me to come & stay, maybe they should consider wooing me in more ways than one.
Leaving my hometown sounds awful and exciting and scary all at the same time. Only time will tell where I end up when this job search ends. I'll keep you posted.
Not quite time for an epidural . . .
Maybe I'm mean, but these are really fun births for me! This mom arrived at the hospital at 7 cm with a bulging bag, requesting an epidural, handling contractions beautifully. It took about an hour for the anesthesiologist to arrive, since it was the middle of the night, and when she got there, the woman stood up to reposition for her epidural, her water broke, and 3 contractions later, her little girl was in her arms. She didn't even push. That little baby just came right out with the uterus doing all of the work. Very cool. I think in the end, the mom was happy about how it went. She could get up after I was done repairing her minor perineal tear and take herself to the bathroom since she didn't have a catheter.
Any midwife preceptor would be proud of how quickly I put on my sterile gloves. I was even faster than the CNM!
However, I still have a lot to learn about maintaining a sterile field. Argh.
Any midwife preceptor would be proud of how quickly I put on my sterile gloves. I was even faster than the CNM!
However, I still have a lot to learn about maintaining a sterile field. Argh.
Sunday, February 20, 2011
2 babies this week!
The first was a woman pregnant with her second little girl. She had more protein in her urine than we like, and on top of her chronic hypertension, we called her pre-eclamptic, since she was term at 38+5 weeks, so brought her in for induction. She had a ripening agent called misoprostol overnight, and then the pitocin started around 0700, around the time that my shift began. She was pretty sure she wanted an epidural, and talked about "what a wussy" she'd been during her previous labor. I encouraged her to wait until she was 4-5 cm before getting the epidural, in order to prevent the epidural from slowing things down (hopefully). She relaxed in bed for the better part of the morning, and around 11 AM started getting more uncomfortable. My nurse checked her, and she was 4 cm! She got up and went to the bathroom, reporting some pressure, and a need to poop. SIDE NOTE: I love it when women need to poop in labor! It means that their body is either cleaning itself out because they're having a baby soon, or that the baby's head is actually pushing the poop out. Either way, things are looking good! So, back to the story, she ended up hanging out and laboring on the toilet for a while, pooping, and moaning, and crying. When I went in to see her, she really wanted her epidural NOW. I encouraged her through a few contractions, and calmed her down a bit. She was actually coping quite well, but didn't believe me when I told her that. When our nurse returned and said that anesthesia was on the way, I helped her get up to bed. Her epidural was placed just before noon, and when I checked her, her cervix changed during the contraction I felt from 6 to 7 cm! I ruptured her membranes (broke her water) and then left the room to write a note. Within minutes, I was back in the room, and she was pushing her baby out. We noticed that as the contractions built up, the baby would start pushing herself out, so we let her assist in her own birth. That was very cool! A lovely little girl weighing 8 lbs 13 oz was born at 12:32 pm. She had a tight nuchal cord, so I somersaulted her out, and put her right up on mom's belly. She had an awfully long cord, and I let it pulse for a few minutes before cutting it. Collecting cord blood was very messy - I'm not so practiced at that - but I did it, eventually. Then out came the placenta, complete and quite large, but with some calcifications, which can decrease blood flow to the baby. They may have something to do with the pre-eclampia. She had a midline perineal tear that I sewed up . . . great practice for me, and in the end it did look nice. By the time I left the room, baby was breastfeeding and mom, dad and big sister were all very pleased with the experience.
My second baby was a little boy born to first time parents who came in later that day, maybe around 1800 (6 pm), on their due date. This was a very young, very cute couple very excited to meet their son. Mom was in active labor when she arrived, at 4 cm. She wanted her epidural soon, although she seemed to be handling labor quite beautifully. Her labor continued, but slowed down a bit after the epidural, so I watched it for a few hours. Sometimes, an epidural will slow things down for a bit, but once the body adjusts to the new surroundings (the hospital) and the new physiology (epidural), things kick back in. But her labor was still somewhat spaced out, so we added a "whiff" of pitocin, starting at 1 mU/min and slowly increasing over several hours to 4 mU/min. Her contraction pattern got a little strange - not bad, but strange, with mild contractions one after the other for about 4 minutes, then a 1-2 min break, then a moderate contraction, then repeating that strange sequence. The nurse (one of my favorites!) and I decided to turn the pitocin off, to see if that would reset her contractions. Within about 20 minutes, her contraction pattern looked much better, and we never turned the pitocin back on.
About 2330, I went upstairs to get some shut eye. about 0100, my nurse called and told me she was feeling lots of pressure, so I went back downstairs to check her. She was 6 cm by this point, and the baby was getting lower. I ruptured her membranes, and her cervix changed to 7 almost immediately. I tried to determine what position the baby was in. Earlier, I had thought the baby was in ROA, with the front of his head turned toward her back. But this time, I wasn't so sure. Now that I could feel the head directly, rather than through the bag, I thought I felt the familiar 4 points of the anterior fontanel toward her pubic bone. Uh, oh. But I wasn't convinced, and her labor was progressing nicely. Her awesome nurse had been turning her from side to side, sitting her up, changing her position about every 30-45 minutes throughout the night. That can help baby find their position in the pelvis, and with an epidural, mom can't move around in the same way she would without, so rotating her often can make a difference in helping the baby find its way through the pelvis. This baby was finding his way. When she reported even more pressure at 0330, I checked her again, and the cervix was gone - melted away around the baby's head, which was now quite low. We sat her up and allowed her to labor down, meaning we just let her body push her baby down through her pelvis. Around 0430, it seemed prudent to begin actively pushing, since she was getting even more uncomfortable, and having uncontrollable shakes. But my nursing staff was busy getting someone else ready for a cesarean section, so we waited until just before 0500. That little lady pushed effectively for about 11 minutes before delivering a healthy little boy, born in a direct OP (occiupt posterior) position, or sunnyside up! He turned himself toward his mom's right side, then delivered his own anterior shoulder and right hand! I put him up on his mom's belly, where he took a big breath and cried out, turning pink. Good boy! The placenta delivered itself almost immediately, and it was a good looking placenta, with some minor calcifications. That little guy was 7 lbs 12 oz, and had some swelling on his head just above his forehead from his position in the pelvis. Otherwise, he was quite cute! Mom had a perineal tear, also, a second degree, but barely. Another repair - what good practice for me, and the midwife I was working with had some great coaching/instructions to help me do a neat job. That little guy was eager to breastfeed, and those parents were thrilled to finally meet him! The other fun part about that delivery was how involved the dad was. He had said earlier that he probably wouldn't watch, but he got pretty excited about it, and ended up standing on my left several times, watching the birth of that head. Mom was eager to feel her baby, so from time to time, she'd reach down and feel the head and get so excited to feel her baby so close. They were both so excited and into their birth experience, and it was fun to be a part of that with them.
Lovely!
My second baby was a little boy born to first time parents who came in later that day, maybe around 1800 (6 pm), on their due date. This was a very young, very cute couple very excited to meet their son. Mom was in active labor when she arrived, at 4 cm. She wanted her epidural soon, although she seemed to be handling labor quite beautifully. Her labor continued, but slowed down a bit after the epidural, so I watched it for a few hours. Sometimes, an epidural will slow things down for a bit, but once the body adjusts to the new surroundings (the hospital) and the new physiology (epidural), things kick back in. But her labor was still somewhat spaced out, so we added a "whiff" of pitocin, starting at 1 mU/min and slowly increasing over several hours to 4 mU/min. Her contraction pattern got a little strange - not bad, but strange, with mild contractions one after the other for about 4 minutes, then a 1-2 min break, then a moderate contraction, then repeating that strange sequence. The nurse (one of my favorites!) and I decided to turn the pitocin off, to see if that would reset her contractions. Within about 20 minutes, her contraction pattern looked much better, and we never turned the pitocin back on.
About 2330, I went upstairs to get some shut eye. about 0100, my nurse called and told me she was feeling lots of pressure, so I went back downstairs to check her. She was 6 cm by this point, and the baby was getting lower. I ruptured her membranes, and her cervix changed to 7 almost immediately. I tried to determine what position the baby was in. Earlier, I had thought the baby was in ROA, with the front of his head turned toward her back. But this time, I wasn't so sure. Now that I could feel the head directly, rather than through the bag, I thought I felt the familiar 4 points of the anterior fontanel toward her pubic bone. Uh, oh. But I wasn't convinced, and her labor was progressing nicely. Her awesome nurse had been turning her from side to side, sitting her up, changing her position about every 30-45 minutes throughout the night. That can help baby find their position in the pelvis, and with an epidural, mom can't move around in the same way she would without, so rotating her often can make a difference in helping the baby find its way through the pelvis. This baby was finding his way. When she reported even more pressure at 0330, I checked her again, and the cervix was gone - melted away around the baby's head, which was now quite low. We sat her up and allowed her to labor down, meaning we just let her body push her baby down through her pelvis. Around 0430, it seemed prudent to begin actively pushing, since she was getting even more uncomfortable, and having uncontrollable shakes. But my nursing staff was busy getting someone else ready for a cesarean section, so we waited until just before 0500. That little lady pushed effectively for about 11 minutes before delivering a healthy little boy, born in a direct OP (occiupt posterior) position, or sunnyside up! He turned himself toward his mom's right side, then delivered his own anterior shoulder and right hand! I put him up on his mom's belly, where he took a big breath and cried out, turning pink. Good boy! The placenta delivered itself almost immediately, and it was a good looking placenta, with some minor calcifications. That little guy was 7 lbs 12 oz, and had some swelling on his head just above his forehead from his position in the pelvis. Otherwise, he was quite cute! Mom had a perineal tear, also, a second degree, but barely. Another repair - what good practice for me, and the midwife I was working with had some great coaching/instructions to help me do a neat job. That little guy was eager to breastfeed, and those parents were thrilled to finally meet him! The other fun part about that delivery was how involved the dad was. He had said earlier that he probably wouldn't watch, but he got pretty excited about it, and ended up standing on my left several times, watching the birth of that head. Mom was eager to feel her baby, so from time to time, she'd reach down and feel the head and get so excited to feel her baby so close. They were both so excited and into their birth experience, and it was fun to be a part of that with them.
Lovely!
Saturday, February 12, 2011
What kind of midwife?
I'm really struggling to figure out my next step after I finish school this spring. Obviously, I want a job, I want benefits, I want a PAYCHECK! But there are some options to what kind of job, and that comes attached to what kind of benefits & paycheck. Here are two options:
1. Out of hospital birth, aka OOH. This involves working with women very intimately during their pregnancy, being with them for hours and hours during the birth, and then caring for them postpartum. The clinic where you see them for visits is homey, comfortable, and no stirrips are present for any type of exam, whether it be for a pap smear or a cervical check. Prenatal and postpartum visits, alike, last 60 minutes. It is incredibly time consuming and wonderfully fulfilling. You create relationships that can last through several more babies, and sometimes even turn into friendships. When you sleep at night (when you can), you feel great about the work you do. On call 10 days per month, where you can be at home if no-one is laboring, or at a labor for hours and hours until that baby is born and mom & baby are safely out of the scary transition period after birth. And the pay is about $60K. Some benefits included. (Sounds great, right? I never made that much as a teacher!!!)
Or
2. Hospital birth. This involves working in a practice with a group, usually between 5-7 other providers. You see patients in typical clinic rooms for their prenatal visits, and depending on your schedule, their schedule, and other factors, you may or may not see the same patients over and over. Their visits are 20 minutes long. You may be on call at the hospital when they arrive in labor, or you may take over their care when your shift begins. Your shift is 24 hours long, not longer, not shorter. You leave when your patient is undelivered, possibly leaving her with a provider with different values about care, even though you are in the same group, and that doc is really a very nice person. And leaving a laboring woman can wreck havoc on her labor, causing a stress response, which can slow down labor, or cause it to even stop sometimes. (Of course, sometimes there is no change at all, but you never know!). Relationships with patients are good, the job is fulfilling, but the intensity and lifelong relationship just isn't there. With this job, there are 5 days on call for 24 hours each per month. 4 weeks of vacation, benefits, and $90K.
Yikes! More sleep and $30K more money!!! What's the decision, right?
Well, as you know, if you know me, I'm a smart cookie who spent her first "life" being a teacher. Enjoying work every day (or at least most of them). But NOT making a lot of money. I could have quit teaching and made tons more money. But I chose to be a role model for children instead. Middle school ones. I must be crazy, right? So I guess I'm a sucker for punishment. I like feeling great about my job, instead of just having lots of money.
But, you say, you'll have 40-50K of debt when you finish school. Don't you want to pay that off?
Great thought. Yes, I do. As soon as humanly possible. So again, it seems like a no-brainer.
And still I struggle with the decision. What kind of care do I want to provide to women?? Where will I make the most difference?? Where will I feel more fulfilled?? Where will I be able to balance my life and my work most effectively??
I guess I have some time to figure it out. Until then, I guess I won't close any doors . . .
1. Out of hospital birth, aka OOH. This involves working with women very intimately during their pregnancy, being with them for hours and hours during the birth, and then caring for them postpartum. The clinic where you see them for visits is homey, comfortable, and no stirrips are present for any type of exam, whether it be for a pap smear or a cervical check. Prenatal and postpartum visits, alike, last 60 minutes. It is incredibly time consuming and wonderfully fulfilling. You create relationships that can last through several more babies, and sometimes even turn into friendships. When you sleep at night (when you can), you feel great about the work you do. On call 10 days per month, where you can be at home if no-one is laboring, or at a labor for hours and hours until that baby is born and mom & baby are safely out of the scary transition period after birth. And the pay is about $60K. Some benefits included. (Sounds great, right? I never made that much as a teacher!!!)
Or
2. Hospital birth. This involves working in a practice with a group, usually between 5-7 other providers. You see patients in typical clinic rooms for their prenatal visits, and depending on your schedule, their schedule, and other factors, you may or may not see the same patients over and over. Their visits are 20 minutes long. You may be on call at the hospital when they arrive in labor, or you may take over their care when your shift begins. Your shift is 24 hours long, not longer, not shorter. You leave when your patient is undelivered, possibly leaving her with a provider with different values about care, even though you are in the same group, and that doc is really a very nice person. And leaving a laboring woman can wreck havoc on her labor, causing a stress response, which can slow down labor, or cause it to even stop sometimes. (Of course, sometimes there is no change at all, but you never know!). Relationships with patients are good, the job is fulfilling, but the intensity and lifelong relationship just isn't there. With this job, there are 5 days on call for 24 hours each per month. 4 weeks of vacation, benefits, and $90K.
Yikes! More sleep and $30K more money!!! What's the decision, right?
Well, as you know, if you know me, I'm a smart cookie who spent her first "life" being a teacher. Enjoying work every day (or at least most of them). But NOT making a lot of money. I could have quit teaching and made tons more money. But I chose to be a role model for children instead. Middle school ones. I must be crazy, right? So I guess I'm a sucker for punishment. I like feeling great about my job, instead of just having lots of money.
But, you say, you'll have 40-50K of debt when you finish school. Don't you want to pay that off?
Great thought. Yes, I do. As soon as humanly possible. So again, it seems like a no-brainer.
And still I struggle with the decision. What kind of care do I want to provide to women?? Where will I make the most difference?? Where will I feel more fulfilled?? Where will I be able to balance my life and my work most effectively??
I guess I have some time to figure it out. Until then, I guess I won't close any doors . . .
Thursday, February 10, 2011
Challenges
While I could write about the great day of clinic I had last week or the fun day on call that I had this week, and even complain about how tired I was on Tuesday after sleeping maybe 4 hours, or how I didn't get to actually catch the baby because once that momma decided to push, it took less than 8 minutes until delivery, and the CNM beat me there, what I'm going to do (other than write ridiculously long run-on sentences) is write about me when I'm tired.
On my interview last week, one of the questions was, "What are you like after 30 hours of no sleep?" At the time, I wasn't sure. I've never gone 30 hours without sleep, and said so. I still haven't, but I've had time to reflect on who I am when I'm tired and overwhelmed. So here it is:
I get cranky. Not with those around me, but with myself. I get really upset at my lack of brain power, organization, ability to complete a task. Little things that I can usually blow off make me more upset than they should. I'm more likely to spill things (drinks, a bowl of cereal) and then get angry that I have to clean up. I am later than usual getting things done. And sometimes, hopefully rarely (but you'll have to ask those around me), I throw a little tantrum. Like this morning. I'm tired, but slept last night and the night before, so I've gotten 4+6+7=17 hours of sleep in the last 3 nights. Not really that bad (although I'm much nicer with 24 hours of sleep in three days). I'm behind on my school work, which is stressing me out, since it feels unlikely that catching up is possible. And then my phone died last night in the middle of a conversation. Not like it died and needed to be charged, but it died. Not working. Which meant that this morning when I was supposed to be calling another state for a phone interview, I couldn't. (I'm writing from the Apple store where my iPhone is now restored).
So the short story is that all of this stress caused me to have a temper tantrum about not being able to find a check that I wanted to deposit. Out loud, around a friend. Not directed toward her, but she had to see me just getting angry about something fairly unimportant. Ugh.
Fortunately, she's a good friend. She tried to calm me down. She still loves me.
And I'll get over it, move on, and try not to throw such a fit next time.
On my interview last week, one of the questions was, "What are you like after 30 hours of no sleep?" At the time, I wasn't sure. I've never gone 30 hours without sleep, and said so. I still haven't, but I've had time to reflect on who I am when I'm tired and overwhelmed. So here it is:
I get cranky. Not with those around me, but with myself. I get really upset at my lack of brain power, organization, ability to complete a task. Little things that I can usually blow off make me more upset than they should. I'm more likely to spill things (drinks, a bowl of cereal) and then get angry that I have to clean up. I am later than usual getting things done. And sometimes, hopefully rarely (but you'll have to ask those around me), I throw a little tantrum. Like this morning. I'm tired, but slept last night and the night before, so I've gotten 4+6+7=17 hours of sleep in the last 3 nights. Not really that bad (although I'm much nicer with 24 hours of sleep in three days). I'm behind on my school work, which is stressing me out, since it feels unlikely that catching up is possible. And then my phone died last night in the middle of a conversation. Not like it died and needed to be charged, but it died. Not working. Which meant that this morning when I was supposed to be calling another state for a phone interview, I couldn't. (I'm writing from the Apple store where my iPhone is now restored).
So the short story is that all of this stress caused me to have a temper tantrum about not being able to find a check that I wanted to deposit. Out loud, around a friend. Not directed toward her, but she had to see me just getting angry about something fairly unimportant. Ugh.
Fortunately, she's a good friend. She tried to calm me down. She still loves me.
And I'll get over it, move on, and try not to throw such a fit next time.
Tuesday, February 1, 2011
Job interview
I think I choose employers who have different/unusual types of interviews.
For example, when I interviewed to teach at the school where I worked for 10 years, I was asked to "audition" as a teacher, meaning I had to plan two lessons to teach to kids I had never met, while those considering me for employment observed. It was fun and scary all at once. I guess I did okay, since I got the job.
Well, now that I've started my job search, I've entered a new type of job interview. This weekend, I interviewed with a small out-of-hospital birth practice in a small town. The woman interviewing me picked me up at the airport, drove me around town, took me for a short hike, and then arranged for me to meet her co-workers and students, as well as some other folks in town, by hosting a potluck dinner and teaching event at her house that night. The teaching event was to practice putting in IVs, so we each took turns practicing. We went over how to put in a "bleb" of lidocaine (like a TB test) to make the IV hurt less. It really works! But feels funny, too. Anyway, I put one IV into an experienced nurse, and felt very awkward about it . . . it was my second one ever. Then it was my turn to get one. I learned that my forearms have really difficult-to-find veins, so she had to try my wrists, and the first one blew out, leaving me with an impressive bruise! Good to know what our patients feel, right?
The next day was the actual "interview." The same woman (the owner, and a midwife) took me out to breakfast with her office manager, who is a midwife wanna-be, and apparently pretty good at catching babies all by herself if necessary! We had a great meal, and they had a long list of questions for me. It was fun! One of the questions was about how I act after 30 hours of no sleep - basically they wanted to know if I was a bitch to coworkers. Ha! I hope not! (Guess it's good question, but what am I going to answer? Yep. When I'm tired, I rage around the office! Right!) They wanted to know about teamwork, cooperation, how I feel about LMs, my perfect job, etc. Overall, terrific questions, which allowed for a fantastic conversation.
Then we headed back to their office, where I got to see the clinic in action. I did attend two visits with one of the midwives - we saw a 4 week postpartum mom, with her baby and husband. What a fun & cute family! We then saw a 22 week prenatal visit of a pretty strange couple, who really didn't have much to say. I had fun, anyway, and it was nice to see this midwife in action, since I hadn't had a chance to chat with her much yet.
After one more spin around town, we stopped for sandwiches and then headed for the airport. Overall, it was a pretty fun interview! And really, it was my first official interview since 1998.
Will I leave my current city to move to this small city? That is a tough question. The job is pretty perfect. Everyone there was so nice, and seem like great people to work with. The practice is well established, growing, and running well. It's pretty much the perfect job! But leaving my life here seems like a huge move. There's no easy answer for this one . . . and either way, I don't get what I want!
I got another e-mail today asking for a phone conversation later in the week in another small town far from home. I guess this is really happening . . . who knows what the next 6 months will bring!
What kind of midwife do I want to be? Who do I want to work with? How far from home am I willing to move? These questions are milling around in my head . . . fortunately, I don't have to answer them now.
Okay, gotta go study. Three exams to take in the next week!
For example, when I interviewed to teach at the school where I worked for 10 years, I was asked to "audition" as a teacher, meaning I had to plan two lessons to teach to kids I had never met, while those considering me for employment observed. It was fun and scary all at once. I guess I did okay, since I got the job.
Well, now that I've started my job search, I've entered a new type of job interview. This weekend, I interviewed with a small out-of-hospital birth practice in a small town. The woman interviewing me picked me up at the airport, drove me around town, took me for a short hike, and then arranged for me to meet her co-workers and students, as well as some other folks in town, by hosting a potluck dinner and teaching event at her house that night. The teaching event was to practice putting in IVs, so we each took turns practicing. We went over how to put in a "bleb" of lidocaine (like a TB test) to make the IV hurt less. It really works! But feels funny, too. Anyway, I put one IV into an experienced nurse, and felt very awkward about it . . . it was my second one ever. Then it was my turn to get one. I learned that my forearms have really difficult-to-find veins, so she had to try my wrists, and the first one blew out, leaving me with an impressive bruise! Good to know what our patients feel, right?
The next day was the actual "interview." The same woman (the owner, and a midwife) took me out to breakfast with her office manager, who is a midwife wanna-be, and apparently pretty good at catching babies all by herself if necessary! We had a great meal, and they had a long list of questions for me. It was fun! One of the questions was about how I act after 30 hours of no sleep - basically they wanted to know if I was a bitch to coworkers. Ha! I hope not! (Guess it's good question, but what am I going to answer? Yep. When I'm tired, I rage around the office! Right!) They wanted to know about teamwork, cooperation, how I feel about LMs, my perfect job, etc. Overall, terrific questions, which allowed for a fantastic conversation.
Then we headed back to their office, where I got to see the clinic in action. I did attend two visits with one of the midwives - we saw a 4 week postpartum mom, with her baby and husband. What a fun & cute family! We then saw a 22 week prenatal visit of a pretty strange couple, who really didn't have much to say. I had fun, anyway, and it was nice to see this midwife in action, since I hadn't had a chance to chat with her much yet.
After one more spin around town, we stopped for sandwiches and then headed for the airport. Overall, it was a pretty fun interview! And really, it was my first official interview since 1998.
Will I leave my current city to move to this small city? That is a tough question. The job is pretty perfect. Everyone there was so nice, and seem like great people to work with. The practice is well established, growing, and running well. It's pretty much the perfect job! But leaving my life here seems like a huge move. There's no easy answer for this one . . . and either way, I don't get what I want!
I got another e-mail today asking for a phone conversation later in the week in another small town far from home. I guess this is really happening . . . who knows what the next 6 months will bring!
What kind of midwife do I want to be? Who do I want to work with? How far from home am I willing to move? These questions are milling around in my head . . . fortunately, I don't have to answer them now.
Okay, gotta go study. Three exams to take in the next week!
Thursday, January 27, 2011
Clinical judgement . . .
This week, I had a great learning experience that ended with a healthy baby, but a cesarean section, making me sad, and wondering how I could have managed the labor differently. Clinical judgement is just that - judgement. Did I use good judgement? Did the doc? This was the kind of situation that I wish could be replayed with just one thing changed to see if the outcome was the same, or different. That's the thing - even if I had one thing differently, the outcome could have been exactly the same, but I will never be able to find out. Frustrating.
She was a primip (first timer) who presented in active labor around 10 AM. She labored well unmedicated until she reached about 6 cm, then got an epidural. (Epidurals are great for pain relief, but they do slow down labor. Most women don't know that, and many who do, don't care. But they do change the course of labor.) After an hour or so of rest, she was at 7 cm and I decided to rupture her bag of water, which was incredibly easy because it was ready to pop! Baby was low in her pelvis and didn’t seem to like that, showing us by lowering his heart rate to a range that made us nervous for 8-9 minutes. Her cervix changed rapidly after that, reaching at least 9 cm in less than 20 minutes. It was hard to monitor the baby's heart rate, so I put an internal monitor onto the baby's head, and still we had a difficult time keeping the baby’s HR on the monitor, probably because the baby had some head swelling. I also put in an internal pressure monitor because it was hard to monitor her contractions from the outside, and we added some saline solution to see if fluid around the baby would help his heart rate recover back up to his normal range. The nurse then called in the OB (without waiting to find out if we midwives wanted her to), and he pretty quickly decided to do a cesarean section.
As I said above, I wish I could have a “re-do.” I’d love to rewind and see what would have happened if I’d let her bag rupture on its own. I wish I had been more assertive, and seen if pushing could have helped bring the baby down. Yes, she was “only 9” cm, but that cervix was so thin, not all the way around the head, and that head was so low, so much already through it, that I think pushing may have just finished it off, and brought the baby down. She was a strong girl . . . but the baby's heart rate decelerations were making everyone nervous.
The baby came out screaming and had Apgars of 8/9 (10 is the highest!). Breastfeeding is going well. Mom is having some bleeding from her wound that we're watching closely. She's not all that upset about her cesarean, definitely not as upset as I am. Mostly, I’m beating myself up for not being more assertive and giving her a chance to see if pushing worked, and the baby tolerated it.
I did get to assist on the cesarean section, and remove the placenta. That part was cool.
She was a primip (first timer) who presented in active labor around 10 AM. She labored well unmedicated until she reached about 6 cm, then got an epidural. (Epidurals are great for pain relief, but they do slow down labor. Most women don't know that, and many who do, don't care. But they do change the course of labor.) After an hour or so of rest, she was at 7 cm and I decided to rupture her bag of water, which was incredibly easy because it was ready to pop! Baby was low in her pelvis and didn’t seem to like that, showing us by lowering his heart rate to a range that made us nervous for 8-9 minutes. Her cervix changed rapidly after that, reaching at least 9 cm in less than 20 minutes. It was hard to monitor the baby's heart rate, so I put an internal monitor onto the baby's head, and still we had a difficult time keeping the baby’s HR on the monitor, probably because the baby had some head swelling. I also put in an internal pressure monitor because it was hard to monitor her contractions from the outside, and we added some saline solution to see if fluid around the baby would help his heart rate recover back up to his normal range. The nurse then called in the OB (without waiting to find out if we midwives wanted her to), and he pretty quickly decided to do a cesarean section.
As I said above, I wish I could have a “re-do.” I’d love to rewind and see what would have happened if I’d let her bag rupture on its own. I wish I had been more assertive, and seen if pushing could have helped bring the baby down. Yes, she was “only 9” cm, but that cervix was so thin, not all the way around the head, and that head was so low, so much already through it, that I think pushing may have just finished it off, and brought the baby down. She was a strong girl . . . but the baby's heart rate decelerations were making everyone nervous.
The baby came out screaming and had Apgars of 8/9 (10 is the highest!). Breastfeeding is going well. Mom is having some bleeding from her wound that we're watching closely. She's not all that upset about her cesarean, definitely not as upset as I am. Mostly, I’m beating myself up for not being more assertive and giving her a chance to see if pushing worked, and the baby tolerated it.
I did get to assist on the cesarean section, and remove the placenta. That part was cool.
Saturday, January 22, 2011
Brief summary of my week
Lots of midwife lingo in this post. Here is a key:
IUD= intra uterine device.
TOLAC = trial of labor after cesarean section
R/O= rule out, meaning that's what we're worried about, so testing/observing to determine
SVE=sterile vaginal exam
misoprostol - a medication used to ripen a cervix, or get it ready for labor.
IOL = induction of labor, usually with pitocin.
PPROM= pre-term premature rupture of membranes (water breaking before a baby is ready, and before labor has begun)
CST= contraction stress test
NOB= new ob visit (prenatal)
PP = postpartum visit, usually at 6 weeks
Put in another IUD.
•Did complete informed consent with a patient for vaginal birth & blood transfusion.
•Learned to do SVE with my left hand – think it might be easier, somehow feels better.
•Managed 2 multiparous inductions, but no births before my shift was done.
*One was a 40+6 induction for postdates, given the option to come back next week. Fun lady. 100 mcg of misoprostol got her contracting, so I’m hoping it just kicked her into labor without further induction. When I left, she was 3 cm.
*IOL at 37+4 for G6P3002 (6 pregnancies, 3 deliveries, 2 live children) for previous fetal demise at 38 weeks. Had a great time working with her – she had LOTS of anxiety over losing this baby, guilt over inducing early, etc. Spent a lot of time with her talking about what her options were and why, and just helping her understand the whole process. Her induction was with pitocin, despite the fact that her SVE was 2 cm/50 %/-3 station because her baby had some strange variables, so it didn’t seem prudent to use misoprostol, and it doubled as a CST.
R/o PPROM at 21+1 weeks. Thankfully, did rule it out! History of PPROM at 27 weeks, and her story sounded pretty convincing, but her cervix was long and closed, and with ultrasound we could see lots of fluid on the other side.
NOB visit with a client in a drug treatment program. History of food addiction, gastric bypass (Roux-en-Y) then bowel obstruction surgery, then chronic pain, then narcotic addiction. Unplanned pregnancy. We had a long visit, then confirmed a 10 week pregnancy with ultrasound.
6 week PP visit with a woman who had PP blues/depression. Talked about self care, getting help from others, eating better! Referral for counseling.
Transfer OB visit at 24 weeks with an interesting client who wants a TOLAC. Good candidate overall.
IUD= intra uterine device.
TOLAC = trial of labor after cesarean section
R/O= rule out, meaning that's what we're worried about, so testing/observing to determine
SVE=sterile vaginal exam
misoprostol - a medication used to ripen a cervix, or get it ready for labor.
IOL = induction of labor, usually with pitocin.
PPROM= pre-term premature rupture of membranes (water breaking before a baby is ready, and before labor has begun)
CST= contraction stress test
NOB= new ob visit (prenatal)
PP = postpartum visit, usually at 6 weeks
Put in another IUD.
•Did complete informed consent with a patient for vaginal birth & blood transfusion.
•Learned to do SVE with my left hand – think it might be easier, somehow feels better.
•Managed 2 multiparous inductions, but no births before my shift was done.
*One was a 40+6 induction for postdates, given the option to come back next week. Fun lady. 100 mcg of misoprostol got her contracting, so I’m hoping it just kicked her into labor without further induction. When I left, she was 3 cm.
*IOL at 37+4 for G6P3002 (6 pregnancies, 3 deliveries, 2 live children) for previous fetal demise at 38 weeks. Had a great time working with her – she had LOTS of anxiety over losing this baby, guilt over inducing early, etc. Spent a lot of time with her talking about what her options were and why, and just helping her understand the whole process. Her induction was with pitocin, despite the fact that her SVE was 2 cm/50 %/-3 station because her baby had some strange variables, so it didn’t seem prudent to use misoprostol, and it doubled as a CST.
R/o PPROM at 21+1 weeks. Thankfully, did rule it out! History of PPROM at 27 weeks, and her story sounded pretty convincing, but her cervix was long and closed, and with ultrasound we could see lots of fluid on the other side.
NOB visit with a client in a drug treatment program. History of food addiction, gastric bypass (Roux-en-Y) then bowel obstruction surgery, then chronic pain, then narcotic addiction. Unplanned pregnancy. We had a long visit, then confirmed a 10 week pregnancy with ultrasound.
6 week PP visit with a woman who had PP blues/depression. Talked about self care, getting help from others, eating better! Referral for counseling.
Transfer OB visit at 24 weeks with an interesting client who wants a TOLAC. Good candidate overall.
Reflecting on my growth this past year
A friend of mine posted something on Facebook about feeling awkward during her clinical rotation this quarter - her very first one, doing gynecological care. My gut reaction was to reassure her and offer stories about my first clinical in order to help her see that this is a growth process, much like adolescence all over again. Here's what I wrote:
I saw your post on FB, and thought I’d just offer my experience. Remember I was NEVER a nurse, so always felt very behind in clinical. Last year, my best friend in midwifery school got to see patients on her own the first or second week. I did not. At first I felt very sad/behind/stupid/insecure/etc about it, but then realized that going slow has its advantages. First, I got to see an amazing NP in action! Second, I got to learn slowly. I think the best thing I learned, and told patients sometimes (when appropriate) is that having a student actually is advantageous for them – they get two brains instead of one, and often twice as much attention! Anyway, slowly I’ve become more and more confident during the last year. I’m now really comfortable seeing patients – at least in terms of rapport – for a variety of reasons. It’s the clinical judgement piece that takes a really long time. Some subjects I’m really comfortable with (birth control, normal prenatal visits, etc) but some I’m at a loss – mostly due to lack of experience. It’s a slow process, where you move back and forth in feeling great or feeling stupid. For at least my first three quarters of clinical I pretty much felt like an idiot most of the time. Finally, that’s not so true anymore!
So there’s the pep talk that my friend didn’t really ask for. Maybe I just needed to do some reflecting on my own growth as a midwife, so I thank her for that.
I saw your post on FB, and thought I’d just offer my experience. Remember I was NEVER a nurse, so always felt very behind in clinical. Last year, my best friend in midwifery school got to see patients on her own the first or second week. I did not. At first I felt very sad/behind/stupid/insecure/etc about it, but then realized that going slow has its advantages. First, I got to see an amazing NP in action! Second, I got to learn slowly. I think the best thing I learned, and told patients sometimes (when appropriate) is that having a student actually is advantageous for them – they get two brains instead of one, and often twice as much attention! Anyway, slowly I’ve become more and more confident during the last year. I’m now really comfortable seeing patients – at least in terms of rapport – for a variety of reasons. It’s the clinical judgement piece that takes a really long time. Some subjects I’m really comfortable with (birth control, normal prenatal visits, etc) but some I’m at a loss – mostly due to lack of experience. It’s a slow process, where you move back and forth in feeling great or feeling stupid. For at least my first three quarters of clinical I pretty much felt like an idiot most of the time. Finally, that’s not so true anymore!
So there’s the pep talk that my friend didn’t really ask for. Maybe I just needed to do some reflecting on my own growth as a midwife, so I thank her for that.
Thursday, January 20, 2011
Typical clinic day . . . ?
I had a great clinic day yesterday. I am learning in a setting with five different midwives who are all fantastic to work with. When I got there yesterday, one of them had an IUD insertion for her first visit, so I asked if I could join in, even though I was supposed to be with another midwife. She said, "sure thing!" So we went in to consent the patient, and then had an easy and fast IUD insertion. Wonderful! I think that's the 5th one I've put in. The more I can do as a student, the better.
Then I went off to work with Midwife A. She's a really fun lady, easy to work with, and her patients love her. She was having a tough day. Something about a patient with fainting spells . . . but being that she was trying to get out of work, this somehow didn't seem quite as believable as it might under other circumstances. When I walked in, A was practically cross-eyed in trying to figure out how to deal with this client. One of the OBs was there, and they were discussing it. I'm not really sure what happened . . .
In the meantime, I took her next patient, a lovely woman who was transferring her care because she had just moved back to Washington after living in Italy for 3-ish years. She was there with her 2 year old daughter, a blond cutie who was quick to warm up to me. We had a lovely visit, doing an intake, which can take a long time. I really like long visits. I enjoy building rapport with women, learning about their lives, their medical and personal histories, etc. She told me her birth story - laboring for 3 days (really just 48 hours), and then finally having a cesarean section. At 9 centimeters! Bummer. It was an induced labor, and those always go more slowly and painfully - and I don't mean only pain in the true sense of the word, but figuratively, also. Poor thing. She wants to try to labor this time, so we discussed what that might look like. She mentioned that she got really sick of being pregnant last time at about 38 weeks. Not uncommon, but if she really wants a trial of labor, she'll have to be more patient this time! Waiting for spontaneous labor is always trying on one's patience, but it is the best thing to do if you want to have a vaginal delivery, especially after a previous cesarean section!
My next patient was a 6 week postpartum visit. Sadly, she didn't bring her baby for us to meet . . . but that's selfish on our part. :-) Her parents were visiting, so she left the baby at home with them, and with her two year old son. She seemed pretty sad. She said she'd been having some postpartum "blues" and needed some help. We talked about ways to take care of herself while also being a good mom and wife. Her husband sounds like he helps a lot when he's around, but has long working days. He encourages her to take care of herself, too, which is good. She's staying well-hydrated, but not eating much. She stopped breastfeeding after about a week because it "took too long." Her daughter is a slow eater, so she felt like that's all she was doing. Poor thing. I'm sure she's right, but the thing is that breastfeeding can help with mood by giving you good bonding time with your baby, AND by releasing hormones that make you feel good. Too late for that now. I just wish she'd known that. Anyway, she'd done some counseling the last time she had some blues during postpartum, so was happy to get referred for counseling. I hope she eats and takes good care of herself in the weeks and months to come.
Then I scarfed down some lunch in about 5 minutes!
On to midwife C for the afternoon. She's been a midwife for years and years, and has amazing experience and expertise. She's done home, birth center, and hospital birth over the years. Our next client was 36 weeks pregnant, just in for her weekly checkup. Her baby sounded great, and was head down. Her belly measured well. It was a quick visit. She asked about taking a birthing class, and said she wanted to try an unmedicated labor. Good for her! But, hmmmm . . . most of the time, women (in this country) take a birth class to learn some coping techniques, and do lots of reading, and more . . . but I guess that's not true everywhere. She has a friend coming to her labor, who can hopefully act as a doula, so I hope she does well. She's young and healthy! And the epidural is there if she needs it.
Side note: When I visited a friend in Saipan last year, I observed on the L&D floor while I was there. They don't offer epidurals to everyone. It just isn't done in that hospital. Epidurals are saved for cesarean sections, or other surgeries, not for normal birth. So women there did not have that choice, so they just labored. They just did it. It was SO DIFFERENT from the way things are done in this country, generally. Now, even at most small community hospitals, epidural is offered to almost everyone. This was not the case 20 years ago . . . or even just 10 years ago. There was something really nice about women just laboring. There wasn't as much fear of the process, either. I liked it.
My last patient of the day was a woman who had gotten pregnant accidentally while using her birth control pills continuously. Well, except for that week when her prescription ran out, and she didn't have any more, and then her husband came home from a business trip . . . she's 27, and excited about this pregnancy. Her history is fascinating, though. She was morbidly obese 2.5 years ago. She had high cholesterol, high blood pressure, and a bad family history of high blood pressure and heart attacks. (Her father had a quadruple bypass at age 40!!) So she was able to qualify and get a Roux-en-Y - a version of gastric bypass surgery. And she's down to 150 pounds - less than half of her previous weight! Awesome! But then, about 4 months after her surgery, she got a bowel obstruction, which can be quite dangerous (life-threatening) so she had surgery again. All better, except for some chronic pain from nerve damage done during the surgery. Pain killers were required, and then she became addicted to them. After a year or more, she went into an inpatient treatment center and got clean. She's just finishing up her treatment now, and will continue counseling for the next year or so. She's been clean for 6 months. And now she's pregnant! Pretty intense. Baby looked great when we did the ultrasound. Wiggling around, moving, pushing against the wall of her uterus - just having a great time. I hope mommy can work out her problems and make her addiction something positive, like being a great mother, or studying to finish her degree. I think this lady has lots of potential, but I also worry about her because she's been dealing with a lot recently. Best of luck to her!
Then I went off to work with Midwife A. She's a really fun lady, easy to work with, and her patients love her. She was having a tough day. Something about a patient with fainting spells . . . but being that she was trying to get out of work, this somehow didn't seem quite as believable as it might under other circumstances. When I walked in, A was practically cross-eyed in trying to figure out how to deal with this client. One of the OBs was there, and they were discussing it. I'm not really sure what happened . . .
In the meantime, I took her next patient, a lovely woman who was transferring her care because she had just moved back to Washington after living in Italy for 3-ish years. She was there with her 2 year old daughter, a blond cutie who was quick to warm up to me. We had a lovely visit, doing an intake, which can take a long time. I really like long visits. I enjoy building rapport with women, learning about their lives, their medical and personal histories, etc. She told me her birth story - laboring for 3 days (really just 48 hours), and then finally having a cesarean section. At 9 centimeters! Bummer. It was an induced labor, and those always go more slowly and painfully - and I don't mean only pain in the true sense of the word, but figuratively, also. Poor thing. She wants to try to labor this time, so we discussed what that might look like. She mentioned that she got really sick of being pregnant last time at about 38 weeks. Not uncommon, but if she really wants a trial of labor, she'll have to be more patient this time! Waiting for spontaneous labor is always trying on one's patience, but it is the best thing to do if you want to have a vaginal delivery, especially after a previous cesarean section!
My next patient was a 6 week postpartum visit. Sadly, she didn't bring her baby for us to meet . . . but that's selfish on our part. :-) Her parents were visiting, so she left the baby at home with them, and with her two year old son. She seemed pretty sad. She said she'd been having some postpartum "blues" and needed some help. We talked about ways to take care of herself while also being a good mom and wife. Her husband sounds like he helps a lot when he's around, but has long working days. He encourages her to take care of herself, too, which is good. She's staying well-hydrated, but not eating much. She stopped breastfeeding after about a week because it "took too long." Her daughter is a slow eater, so she felt like that's all she was doing. Poor thing. I'm sure she's right, but the thing is that breastfeeding can help with mood by giving you good bonding time with your baby, AND by releasing hormones that make you feel good. Too late for that now. I just wish she'd known that. Anyway, she'd done some counseling the last time she had some blues during postpartum, so was happy to get referred for counseling. I hope she eats and takes good care of herself in the weeks and months to come.
Then I scarfed down some lunch in about 5 minutes!
On to midwife C for the afternoon. She's been a midwife for years and years, and has amazing experience and expertise. She's done home, birth center, and hospital birth over the years. Our next client was 36 weeks pregnant, just in for her weekly checkup. Her baby sounded great, and was head down. Her belly measured well. It was a quick visit. She asked about taking a birthing class, and said she wanted to try an unmedicated labor. Good for her! But, hmmmm . . . most of the time, women (in this country) take a birth class to learn some coping techniques, and do lots of reading, and more . . . but I guess that's not true everywhere. She has a friend coming to her labor, who can hopefully act as a doula, so I hope she does well. She's young and healthy! And the epidural is there if she needs it.
Side note: When I visited a friend in Saipan last year, I observed on the L&D floor while I was there. They don't offer epidurals to everyone. It just isn't done in that hospital. Epidurals are saved for cesarean sections, or other surgeries, not for normal birth. So women there did not have that choice, so they just labored. They just did it. It was SO DIFFERENT from the way things are done in this country, generally. Now, even at most small community hospitals, epidural is offered to almost everyone. This was not the case 20 years ago . . . or even just 10 years ago. There was something really nice about women just laboring. There wasn't as much fear of the process, either. I liked it.
My last patient of the day was a woman who had gotten pregnant accidentally while using her birth control pills continuously. Well, except for that week when her prescription ran out, and she didn't have any more, and then her husband came home from a business trip . . . she's 27, and excited about this pregnancy. Her history is fascinating, though. She was morbidly obese 2.5 years ago. She had high cholesterol, high blood pressure, and a bad family history of high blood pressure and heart attacks. (Her father had a quadruple bypass at age 40!!) So she was able to qualify and get a Roux-en-Y - a version of gastric bypass surgery. And she's down to 150 pounds - less than half of her previous weight! Awesome! But then, about 4 months after her surgery, she got a bowel obstruction, which can be quite dangerous (life-threatening) so she had surgery again. All better, except for some chronic pain from nerve damage done during the surgery. Pain killers were required, and then she became addicted to them. After a year or more, she went into an inpatient treatment center and got clean. She's just finishing up her treatment now, and will continue counseling for the next year or so. She's been clean for 6 months. And now she's pregnant! Pretty intense. Baby looked great when we did the ultrasound. Wiggling around, moving, pushing against the wall of her uterus - just having a great time. I hope mommy can work out her problems and make her addiction something positive, like being a great mother, or studying to finish her degree. I think this lady has lots of potential, but I also worry about her because she's been dealing with a lot recently. Best of luck to her!
Friday, January 14, 2011
Differential diagnosis
For those of you not in healthcare, a list of differential diagnoses is a way of considering all of the disease/condition options that explain the symptoms that a patient describes and/or that you see during a physical exam. Last week, I got scared by one of my differentials, but was so happy I knew enough to be scared, and follow up appropriately.
My patient was a 20 year old 39-week pregnant woman. She was there for her weekly pre-natal visit. While I washed my hands, I asked her how she was. There was a long pause and a sign on the way to saying, "fine." I didn't believe her, and said so. In a nice way, of course. That's when she started to cry, and tell me about her leg and how much pain she was in. This was not something I had seen in her chart that I had reviewed on her way in, so I sat down to comfort her and hear her story.
As it turns out, her legs had been swelling, and over the course of the previous week, had increased in size considerably. One of them was not only more swollen than the other, but she was having considerable pain in the the inner thigh region. Her jeans were significantly tighter than they were the week before. She had noticed no discoloration in her leg, upper or lower, or her feet. She did not have any tingling or numbness.
Since she wanted her cervix checked, and I wanted to see this leg undressed, I left so that she could do just that. The cnm I was working with was in seeing another patient, so I left a note on her desk to come see me ASAP. I was nervous.
Back to differentials. My differential diagnosis list included:
normal (but excessive) swelling of pregnancy.
DVT (deep venous thrombosis) or in english, a blood clot.
Maybe I should have considered others, but that DVT option scared the hell out of me, so right there, I wanted proof that this was not the case. The reason they are scary is that a clot in the leg can be released at any given moment and travel to the lungs (pulmonary embolism) or the brain (brain embolism) both which can be life threatening. NOT GOOD.
I went back into the room to assess her leg. As she'd said, no discoloration. Her legs were HUGE. I measured them both . . . the painful one was significantly larger in circumference than the other, but both were very swollen. Poor thing. After her cervical exam, I had her get dressed and sent her down to radiology to get a venous ultrasound.
An hour later, the terrific news arrived. NO DVT!!!
So I sent her home to rest WITH HER FEET UP until she delivers this baby. And hydrate. No more work for her!
I followed up with her again about 5 days later. She was still pregnant, but feeling better. Thank goodness.
My patient was a 20 year old 39-week pregnant woman. She was there for her weekly pre-natal visit. While I washed my hands, I asked her how she was. There was a long pause and a sign on the way to saying, "fine." I didn't believe her, and said so. In a nice way, of course. That's when she started to cry, and tell me about her leg and how much pain she was in. This was not something I had seen in her chart that I had reviewed on her way in, so I sat down to comfort her and hear her story.
As it turns out, her legs had been swelling, and over the course of the previous week, had increased in size considerably. One of them was not only more swollen than the other, but she was having considerable pain in the the inner thigh region. Her jeans were significantly tighter than they were the week before. She had noticed no discoloration in her leg, upper or lower, or her feet. She did not have any tingling or numbness.
Since she wanted her cervix checked, and I wanted to see this leg undressed, I left so that she could do just that. The cnm I was working with was in seeing another patient, so I left a note on her desk to come see me ASAP. I was nervous.
Back to differentials. My differential diagnosis list included:
normal (but excessive) swelling of pregnancy.
DVT (deep venous thrombosis) or in english, a blood clot.
Maybe I should have considered others, but that DVT option scared the hell out of me, so right there, I wanted proof that this was not the case. The reason they are scary is that a clot in the leg can be released at any given moment and travel to the lungs (pulmonary embolism) or the brain (brain embolism) both which can be life threatening. NOT GOOD.
I went back into the room to assess her leg. As she'd said, no discoloration. Her legs were HUGE. I measured them both . . . the painful one was significantly larger in circumference than the other, but both were very swollen. Poor thing. After her cervical exam, I had her get dressed and sent her down to radiology to get a venous ultrasound.
An hour later, the terrific news arrived. NO DVT!!!
So I sent her home to rest WITH HER FEET UP until she delivers this baby. And hydrate. No more work for her!
I followed up with her again about 5 days later. She was still pregnant, but feeling better. Thank goodness.
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