Tuesday, December 6, 2011

Being "with woman"

“Tiene otro?”  She nods her head, she places her hands high on the wall and leans into it.  Standing behind her I place my hands on her hips and apply a firm, squeezing pressure.  She sways gently and moans softly.  The beautiful toddler giggles and runs back and forth between her mommy and the wall-as if playing a game of “London Bridges.”  Between my little bit of Spanish and her sister-in-law’s broken English we are able to communicate effectively. 
The contraction releases and she takes a deep cleansing breath and smiles, then begins to again pace back and forth across the floor, the little girl following her every step.  Baby sister is on her way but daddy can’t be here, he’s working out of town.  The mother to be has her sister-in-law and her cousin at her side helping her bring the new baby into the world. 
“La palota?”  “Si.” I help her balance on the large red ball.  This makes the toddler giggle.  I bring in a smaller version of the ball for her to sit on-just like Mommy.  I sit behind Mommy and rub her back.  This is not as comfortable as walking, she stands up and walks.  She leans on the wall again.  I resume the hip counter-pressures.  The little girl wants to help.  She places her hands on the outside of mommy’s knees and presses in-she giggles.  Baby sister is getting closer.  Mommy can feel her moving down.  Standing is no longer comfortable, she moves to the bed.   Her soft, gentle moans are becoming louder.  I encourage her to work with her body-don’t fight it, let the baby come.  Tears roll from her eyes.  The little girl is scared.  She leaves with the young cousin that has just arrived.  They will go play with toys in the waiting room and return to meet baby sister.  Rose comes in to help me talk to Mom in her native language. 
She begins to bear down.  “Muy bien.”  “NO PUEDO, NO PUEDO, NO PUEDO!”  “Si, se puede, meja, si, su puede.”  We see the top of baby’s head.  She will be beautiful and have a full head of dark black hair. She digs deep down and finds the last bit of strength she needs to bring her baby into the world.  Rose encourages her and helps me coach her.  The head slides out easily, the shoulders follow and the baby slides into my hands.  I immediately place her on mom’s tummy.  Rose has tears running down her face.  I have tears in my eyes.  Mommy has tears of relief and happiness.  Aunt and cousin have broad smiles and tears. Baby is crying vigorously. 
Happy Birthday, Baby.  Your sister is here to meet you.  The toddler crawls up on the bed with mommy and gently touches her sister-smiling and laughing in delight.  Daddy is on the phone.  Daddy asks his sister to please thank the midwife for helping his baby come safely into the world…..and I know I have done my job. 

Sunday, September 11, 2011

Learning to Speak Fluent Midwifery

Two days ago I had an idea for my next blog entry, this morning I had a midwifery newsletter in my inbox with an article on the same subject I was thinking about so it must be important.  It’s the idea of learning to speak “midwifery.” 
The word “midwife” means “with woman.”  The very nature of the word implies a trust of birth and women’s bodies.
Tuesday evening I had the opportunity to hear two physicians discussing a birth.  Neither are physicians I work with nor are they even physicians that practice in Idaho Falls.  One asked the other how things were on the labor and delivery unit where they both practiced.  The female physician responded with “they just delivered the last one.”  The male physician then began to relate the experience he had with a woman giving birth earlier in the day. He shared with the female physician that she was a “primigravida that was 8 cm with a posterior baby.  I was about to do a Ceasarean but the nurse called and said that she might be making some progress.  I checked her awhile later and she was complete so I ‘let’ her push but I didn’t think she would make it but she did start to make some progress so I couldn’t do a C-section. Then she finally delivered-I couldn’t believe it.”  He appeared to be very upset about his inability to justify doing  a c-section because (the nerve of this woman) she was making progress. 
Several things about this conversation struck a nerve with me that caused me to bite my tongue.  First was the female physician’s response “they just delivered the last one.”  She took all credit and focus from the women giving birth and put the credit on the staff that “delivered” the babies.  The women giving birth were merely “jobs” for the staff to complete-another task to check off the list. 
The next thing that struck me was the attitude of the male physician toward the woman making “slow” progress.  There was no discussion of anything that was done to help turn this baby-only eagerness to cut the baby out.  He didn’t mention changing maternal position, he didn’t express any desire to have patience to let the baby come down on its own.  In fact, he seemed very disappointed that she had a vaginal birth instead of a surgical birth.   
I began to wonder how the same conversation would have gone between two practitioners that trust birth and trust women.   I imagine the female provider would have responded to the male provider’s initial question with something more like “the last mother in labor just gave birth.”  The discussion about the “primigravida” with “slow” progress may have been filled with excitement at the woman’s strength and power and trust in her ability to birth.  C-section would probably have not even been mentioned.  Instead of “I can’t believe she did it” the practitioners would have rejoiced in another successful birth with a healthy mom and a healthy baby. 
I absolutely love my job because to me, it’s more than just a job.  Pizzas are “delivered” in 30 minutes or less.  Births are a process to be trusted, celebrated and not rushed. 

Monday, July 11, 2011

To Each Her Own

As any reader of this blog knows, I am a huge fan of natural childbirth but even more than that, I am a fan of giving moms the birth experience they want.  I think there is something to be said for the feeling a woman gets when she conquers the challenge of an unmedicated birth.  It’s much like the “high” athletes get when they complete an extreme physical challenge.  Sometimes, however, athletes enjoy a nice drive through the scenery instead of a bike or a run.
Anna was pregnant with her third baby and desired an unmedicated childbirth.  Her two previous children had been born without the assistance of medications and she had done very well and thoroughly enjoyed the experience.  Anna came into the hospital in labor late on a summer evening.  She was handling the contractions very well and breathing through them.  We had discussed her plans many times in the office and had reviewed relaxation and breathing techniques.  I arrived at the hospital to see her shortly after she was admitted.  I walked into the room and very confidently she said “I have changed my mind, I want to have an epidural.”  She acknowledged that she was doing very well but just simply did not want to feel the pain of childbirth this time.  Her husband was present and he was very supportive.  We, of course, honored her wishes and called anesthesia and they promptly came and placed an epidural and Anna got some much needed rest.
While Anna rested I went and assisted with a c-section on another patient.  When I was finished I came back to check on Anna.  She was still very comfortable but feeling some pelvic pressure so we checked her and her baby was ready to come.  Anna asked for a mirror so she could watch the baby’s birth.  We positioned the mirror and she watched as the baby eased out into the world.  The full head of black hair, the cute little ears, the adorable button nose-they all slipped out easily as I sat there with my hands folded in my lap.  Then the shoulders began to gently slide out so I placed my hands on the baby’s head, as the shoulders slid out I encouraged Anna to reach for her baby.  She reached down and lifted the baby the rest of the way out of her body and up to her chest.  The baby began to cry vigorously and tears ran down mommy and daddy’s face as well.  A beautiful, healthy baby girl. 
Many times mothers that originally planned an unmedicated birth and then change their mind feel guilty and they often apologize to me.  I try to reassure them that they do not need to apologize to me at all-it is their body, their birth experience, not mine.  Anna had no guilt.  When the birth was over she told me that she was very happy with her decision.  She enjoyed watching the birth and participating and based on her past experience she didn’t believe she could have done that with the pain she would have been feeling. 
This was truly a successful birth in terms of giving the mother the experience she wanted-even though there was a change of plans…and giving moms the experience they want is what it is all about!

Thursday, May 19, 2011

The Little Midwife

Every time I think my job can’t get better, it does! 

This afternoon I had the opportunity to catch a darling baby boy, but this time, I had help!  This mama had lots and lots of family support.  Daddy was there, the grandmas were there and the big sister was there.  We’ll call big sister “Sarah.”  Sarah is six years old and she was SO excited to finally meet her new baby brother. Every time I would walk into the room she would ask me if it was time yet.  At one point she saw a little bit of blood on my glove after an exam and was a little worried.  The grandmas were amazing and promptly reassured her that it was OK and perfectly normal. It quickly became obvious to me that the mom and the grandmas had already done a great job of preparing Sarah for what she might see during a birth.  Her mom asked me if it was OK with me if she stayed in the room for the birth.  I always feel like I’ve failed a little if they have to ask me something like that-it’s THEIR experience, not mine.  I told mom that I was supportive of whatever they wanted. 
Finally the time was here to meet the new baby brother!  As mom pushed, Sarah became very interested in the process.  She was fascinated with seeing the top of her baby brother’s head as he was about to be born. Sarah started out standing next to her dad, daddy was more nervous than Sarah.  At one point, Sarah said to her dad “daddy, you’re shivering!  Stop shivering, it’s going to be OK.”   She progressively moved from the head of mom’s bed to my side.  I asked mom if it was OK if Sarah helped me catch the baby-she said it was so we asked Sarah if she wanted to help. She eagerly said “YES!”  In no time at all we had her outfitted with gloves and a gown so she wouldn’t get her “I’m a BIG Sister” t-shirt messy.  I gave Sarah instructions that I would help guide the head out and once the shoulders were out it was her job to “catch” the rest of the body with me.  As the head began to emerge Sarah was very “hands on” I gently supported the perineum and Sarah’s hands were right next to mine the whole time.  Then, two contractions later the baby boy was born.  Sarah did exactly as we’d discussed and she caught the baby’s lower body and together we put baby on mom’s tummy.  She was SO excited and asked so many very good questions.  She wanted to know everything there was to know about babies!  Once the baby was on mommy’s tummy Sarah wanted to take her gloves off and climb up next to them-which she did!  She touched the baby and talked to him-she took ownership of him!! 
Sarah’s midwifery skills didn’t stop with the birth.  The nurse rubbed mom’s tummy and checked her bleeding.  Five minutes later I looked over to see Sarah sitting on the bed next to mommy, pulling up her gown and rubbing on her belly!  Once mommy and baby were all stable, Sarah and I both signed the birth certificate.
I’m sure some people think I’m weird or crazy but that’s OK, Sarah will never forget this experience-and I’m sure her kindergarten teacher will get a kick out of “Show and Tell” this week!

Wednesday, May 4, 2011

The Amazing Melding of Midwivery and Medicine

Several weeks ago I caught six babies in a row in which mom used no medications, no interventions-they “went natural.”  I was amazed at each and every one of these amazing, strong women.  Over the past 24 hours I have been amazed by three more amazing women.
“Jenny” was one of the first moms that I saw for every one of her prenatal visits-from first to last!  Jenny was pregnant with her second baby. With Jenny’s first baby she labored for some time before having a c-section.  Many times during her pregnancy we discussed her options to attempt a vaginal delivery or schedule a repeat c-section, this was a difficult decision for her.  In the end, Jenny decided to wait and see if she went into labor on her own.  As her due date approached without contractions the thought of a scheduled c-section was becoming more desirable.  The experience of laboring for such a long time only to end up with a c-section was quite traumatic for Jenny-and an experience she didn’t want to repeat.  The day before her due date her cervix was still closed, long and firm so after much discussion,  we scheduled a c-section for the next day.  I assisted the doctor with the c-section and Jenny had one of the most beautiful baby girls I have ever seen!  I was again amazed at a strong woman who educated herself on her birth options and made a decision that worked best for her! 
“Maria” is a woman I had only met one time early in her pregnancy.  She had met my “partner in crime,” Susan, several times during her pregnancy but when complications developed her care was transferred to the physicians so she could get the level of care that she and her baby needed.  Maria’s complications worsened and it became necessary to induce her labor.  After many hours of labor and quite some time of pushing as well as an attempted vacuum assisted delivery it was determined by her physician that the safest route of delivery would be a c-section.  I was lucky enough to be in the right place at the right time and had the honor of assisting with the birth of Maria’s baby girl.  As soon as I saw her I was convinced the reason she wouldn’t come out was a very scientific diagnosis that I refer to as “cheek dystocia.” This sweet little girl had the chubbiest cheeks I have EVER seen.  What a cute, sweet little (big!) thing!!  What a strong woman to endure the treatments that were necessary to treat the complications of her pregnancy, to try so hard to push her baby out and then to be so brave in undergoing surgery to bring her baby into the world in the safest way possible.
“Tina” is a woman that began her care with a physician but I was so lucky to “inherit” her when her physician retired from OB practice.  Tina is such a sweetheart.  She is always smiling and I always look forward to seeing her.  When it came time for Tina to have her baby, the little princess had plans of her own.  Apparently, when it was time for her to make her grand entrance, she wasn’t quite ready. Her mama worked so hard to urge her out into the world.  She worked at it and worked at it and worked at it.  I was amazed at the strength this woman had after hours and hours of pushing she still kept at it.  Finally, there came a time when her drive and determination began to outlast her physical strength. This little princess was SO close but just needed a little extra help coming out.  I called one of my physician colleagues (at 4 am no less!) who, without complaint, came in to help us out!  With just a little assistance from a modern medical device, this woman was able to dig deep inside herself and find that last little bit of strength that she didn’t even know she had to push the guest of honor out to the party!  Tina said over and over that she felt like a “wimp.”  Wow! She was the farthest thing from a “wimp!” She pushed for over three hours-her strength and endurance is amazing!!!! 
So, women of the world, whether you “go natural” or utilize modern medicine in some form or another-you are amazing!!!  I am so grateful everyday to have the great honor to work with such amazing women!!!!! 

Wednesday, April 13, 2011

Tim McGraw, My Pedicure and the Demise of a Long Sleeve T-Shirt

The sun was bright and warm. The sand cushioned my freshly pedicured, bare feet.  The breeze gently lifted my hair away from my face.  I was enjoying a long walk along the beach accompanied only by the rolling waves and a man with a goatee and a sweet southern twang that introduced himself only as "Tim."  He was about to sing to me. I could her the strum of his guitar.  It became louder and louder, it was as if I could feel the vibration on my cheek.  Then, just as quickly as it all started, it all ended and I realized the vibration was not the musical work of a very hot southern man but, yet the ringing of my phone under my pillow.  I tried hard to simultaneously hold my eyes open and focus on the screen (as if I didn't know who was calling).  Just as I thought "L&D  208-557-2729."  I fumbled with the phone as I struggled in my state of semi-consciousness to recall which button on the screen to touch to connect with the person on the other end of the line. Ah, yes, I remember now, "Answer" that's the right one.  "Hello?"  "Hi" the all too chipper voice on the other end of the phone greets, "you have a patient here she is 39 weeks 4 days, contracting, she is 4 centimeters and she's worried that maybe she came in a little too early."  Four centimeters?  How many is that again?  How many weeks does she need to be? When does she need to come to the hospital? So many questions that my mind can't really sort out right now.  I take a deep breath, turn on the lamp next to the bed and open my eyes, hoping it will help me think.  "Ok have her walk for an hour and see if she changes if she doesn't and wants to go home for awhile she can, if she wants to stay, let me know." 

I turn the light out and wrap myself in the warm comforter.  I hope Tim waited for me.  I drift back to sleep but I can't seem to find Tim, he must not understand the life of a midwife-remind me to discuss this with him next time I see him.  An hour and a half later the phone rings again, this time I don't have as much trouble answering it.  "She's six centimeters now with bulging membranes."  I get out of bed and briefly consider just wearing my pajamas in to the hospital but then reconsider.  I put clothes on (a black short sleeve tshirt that says "I'm not a Gynecologist but I'll take a look" over a long sleeve white tshirt and jeans)  and slip sandals on my feet so I can show off my cute pink nails with the white flowers on the big toes. I walk out into the dark and get into the car.  As I back out of the driveway Tim McGraw comes on the radio "ah, there you are" I say right out loud.  I drive to the hospital singing like a karaoke queen the whole way there..."and it felt good on my lips!" 

Once I arrive at the hospital I change into scrubs (but make the mistake of leaving the long sleeve white tshirt on) and take a few minutes to read through the patient's chart-considering I have never met her-she's always seen the other midwife for prenatal care. I finish reviewing her prenatal record and I'm headed into the room when I see the call light pop on above the door.  I go in just in time to hear the nurse say "can you send Natalie in?"  I announce my arrival and I see the patient standing next to the bed and a large puddle of fluid on the bed-her water had just broke.  Just then she said, in broken English "I need to go to da bathroom."  Then with speed impressive for any human being, let alone a woman at 39 plus week pregnant, she ran into the bathroom.  Now, this ain't my first rodeo so I know better than just to assume she's going to empty her bladder in there so I follow her in.  She sits there for approximately 60 seconds with no results.  She then gets up and walks back to the bed, just as she sits down she jumps back up and runs to the bathroom again.  This time she makes soft grunting noises as she sits in the bathroom.  Between my little bit of Spanish and her little bit of English I am able to convey to her that the sensation she is feeling is the baby's head, but if she's more comfortable pushing on the toilet, I'm OK with that.  We realize that we need to make her more comfortable so we pad the pipes behind the toilet with pillows so she can lean back on them while she pushes.

OK, so we are going to have a baby in the bathroom.  We get the nursery nurse, Anna (who thankfully speaks Spanish) and we pull the cart with our equipment into the bathroom.  Anna looks at me like I'm crazy because I'm on my knees in front of the toilet wearing sterile gloves with my hands in the toilet (OK, not in the water) supporting the crowning head.  Now, in her defense, I probably am crazy. I ask Anna to please tell her that once the head is out she'll need to stand up because there is simply not room for the rest of the baby to come out while on the toilet. The mama says she understands this.  One contraction later the mama gently pushes the head out.  For anyone that's ever had a baby without medication-you know how intense this part is.  Once the head was out she had a bit of a hard time maintaining control.  Although she did stand up, she was having a hard time remaining standing and kept trying to sit-a few times right on the baby's head!  I could see this wasn't working so we helped mama to her hands and knees on a sheet on the bathroom floor. By this time we had noticed that there was meconium stained fluid (we hadn't noticed this before because her water broke on a green sheet!) so we had called for the respiratory therapist.  Soon after moving her to hands and knees she pushed the baby into my hands. The sweet, seven pound, six ounce baby girl cried right away!  The respiratory therapist arrived about this time-all I can say is the look on his face was priceless when he saw us all in the bathroom!  The baby was a little bit pale so she was handed over to the nursery nurse and the respiratory therapist, they took her to the warmer to check her out. 

We helped mama get up so we could get her into bed to deliver the placenta and make any needed repairs.  As we walked from the bathroom out into the room she looked over to the warmer and I realized this was the first time she'd seen her baby so I said "do you want to go see her?"  She did.  So, with the umbillical cord in my hand I walked her over to the warmer to see, touch and kiss her baby.  I wish I would have had a picture of the RT's face when he saw me holding the umbillical cord that was still attached to the placenta that was still inside the mama! 

We had such a FUN time with this delivery. I had to throw my shirt away because it was covered with blood, I got blood on my cute toes and my sandals while I walked mama to the warmer to see the baby, and as a special treat, my dear friend Roz-who was also the labor nurse, was kind enough to model the position in which the mama gave birth!

Even the mama had a great time!  When I saw her the next day she laughed about her baby being born on the bathroom floor-I told her whatever works for her works for me!  That's the beauty of being a midwife-I let the mama make the rules!

Saturday, March 26, 2011

Losing My Hat

First, I want to apologize for taking such a long time to make this post.  I forgot my log in information and it took me awhile to recover it! 

Before I started my clinical experience as a student last year, I traveled to Frontier School of Midwifery in Hyden, Kentucky for an orientation.  At the end of the orientation each midwifery student is given a baby hat to give to the first baby they catch-or to a memorable patient.  As it turns out my first was also very memorable.  This is the story of how I lost my hat!

I have changed the names and many details to protect privacy.  Enjoy!

I had the great pleasure of meeting Emma on February 10th when she came to the office for her routine prenatal visit. Emma is the type of person that is always smiling and always has a positive attitude.  I was able to meet her husband at her next prenatal visit on February 17th. He was equally pleasant and very funny.  They were a perfect couple!  Emma and Matt were expecting their first baby, a boy to be named Jacob; he was due on February 25th, 2010. They had a strong desire to have a natural and unmedicated birth. My preceptor, Susan,  and I encouraged Emma and Matt at their prenatal visits, we gave suggestions for comfort measures at home while in early labor and told her when she should come to the hospital.  We assisted her in writing her birth plan and discussed it at length at her visits. She was very excited and very motivated to have this baby naturally.
On  February 12th,  I met Ashley and Brett.  Ashley was 36 weeks and 1 day pregnant with their first child, a girl whose name was yet to be decided. Ashley’s blood pressure was 144/90, she had 3+ pitting edema and mild headaches. We ordered a CBC and a hepatic panel as well as a 24 hour urine. We also did a non-stress test and an ultrasound to check AFI. All labs were normal that day, but she did have a significant amount of proteinuria  in the 24 hour urine test the next day. We discussed the diagnosis of PIH with Ashley and Brett and sent Ashley home to bed rest, discussed PIH precautions and gave her the cell phone number to call to reach us. We also began to let her know that if the disease progressed we would probably have to induce labor early. Ashley began to cry but her husband was at her side comforting her. She also had a strong desire for a natural birth with minimal intervention. We reassured her that we would do everything we could to make that happen but we all agreed that a healthy baby and a healthy mom was everyone’s goal.  I was able to see them again about 4 days later and Ashley’s blood pressures were about the same and she was feeling much better.  She was able to get her company to allow her to work from home thus easing some stress on her from being on bed rest. They had also chosen a name for their baby girl but wanted to keep it a surprise.  Ashley and Brett went home that day to come back in three days for another NST and blood pressure check.  On Friday February 19th she returned to the office for her appointment.  Ashley’s blood pressure had increased to 158/108 and she was beginning to have more headaches. She was now 37 weeks pregnant and her cervix was a fingertip, 50% effaced and baby was at a -2 station.  After discussing her situation with our consulting physician we all decided that it would be best to induce her labor after cervical ripening with cervidil. Ashley and Brett were comfortable with that and also felt it was best. We had them go home to get their bags and come back to Labor and Delivery.
Shortly after Ashley and Brett arrived at the hospital, Susan and I visited them and I placed a cervidil then we returned to the office to see patients. That afternoon Wendy came in for a labor check. She was 38 weeks pregnant with her third baby-the first girl for her and her husband, John.  She had been contracting every 5 minutes off and on all day. Her cervix was 4cm/50/-2. We told her she would probably continue to contract and we’d probably see her in the hospital this weekend.
After office hours, Susan and I decided to go check on Ashley before going home so we went upstairs to labor and delivery. We found a picture perfect Ashley and Brett sitting in the bed together eating dinner.  We saw their camera sitting on the table so of course we took pictures of them-it was a very precious picture! We again discussed the plan and assured them that the nurses would call us if she started to get uncomfortable and we would be right in. After spending a few minutes with the happy couple we went to the nurses station to write a progress note.  Susan co-signed my note, I closed the chart and replaced it and we stood up to go home…..just as Emma came around the corner-her smiling face was red, she was bent over and holding her abdomen with one hand and her husband’s hand with the other. The unit secretary asked “can I help you” Emma smiled and excitedly replied (mid contraction!) “yes, I think we are having a baby!” Susan and I walked up to her and began to help get her to a room.  She noticed it was us helping her and her eyes lit up. “I am so glad you are here, that is just crazy that you were right here when I came in!”  The labor and delivery unit was buzzing with activity and unfortunately, there were no rooms open at the time. We took Emma to the c-section recovery room and helped her get onto the gurney. I checked her cervix and she was 5cm/100%/0 station. The baby’s heart rate pattern was perfect. Susan, Matt and I stayed at her side and did counter-pressures during contractions. Before long the nursing staff had a room ready so we moved her to the room, filled up the tub and helped her into the water. Emma labored in the tub for quite some time. She changed positions frequently-we got creative about keeping her comfortable and as a result we ended up with Emma and five bath towels in the tub. Between contractions we talked, she ate and drank and Matt encouraged her. Soon Emma began to feel intense back pressure, almost unbearable. We offered her sterile water papules which she accepted-Susan and I and two other nurses injected the papules-which instantly took away the pressure. She tolerated her labor very well.  She compared labor to her experience as a cross country runner-her husband also being a runner was able to understand what she was saying and used that to encourage her. As the contractions became more intense Emma would remind herself of her chosen mantra which was “pain with purpose.”
As we supported Emma in the tub a nurse came in and requested that we come review Ashley’s fetal tracing. Susan asked me to go look at the strip (she told me she trusts my judgement since I am a fetal heart monitor instructor)I saw minimal variability, some late and some variable decelerations. I discussed my plan with Susan and I ordered an IV fluid bolus and oxygen as well as a position change . I also rechecked Ashley’s cervix and removed the cervidil; unfortunately she had not changed. Her blood pressures were beginning to rise to the 165/110 range. We decided to re-evaluate after the bolus.
By this time, Emma was feeling more pressure and was having a hard time getting comfortable in the tub, she decided to get out and try the birth ball. She sat on the ball, Matt sat on a chair in front of her with pillows on his lap and she leaned on them. After a few contractions she decided that was not comfortable and requested to lie down. Shortly after lying down she began to feel an urge to push. She pushed a few times and soon the membranes were bulging out of the vagina, after a joke or two about being in “the splash zone” we decided to rupture her membranes (since Matt didn’t want to be “splashed"). Emma pushed spontaneously with only encouragement to listen to her body. Thirty –five minutes after the urge to push began, she was now crowning. Two pushes later, she pushed “Little Man Jacob” gently into my hands-I instantly placed him on her tummy so she could enjoy the sound of the healthy cry. She greeted her 5 pound 13 ounce son with a smile and tears-as did his daddy.  A family was born.
We tucked Emma, Matt and Jacob in for a rest and we went to check on Ashley again. I reviewed Ashley’s fetal monitor strip and I was concerned. The baby now had persistent late decelerations and minimal variability and no accelerations. Her cervix had still not changed and she was only having mild contractions and they were irregular. I discussed my concerns with Ashley and Brett and told them I would consult with the physician but there was a fairly strong chance that we would need to do a c-section, they were disappointed but understanding. Our consulting physician was on the L&D unit so I asked him to consult-he agreed that a c-section was the safest way to deliver the baby. The decision was made and the staff began preparations.
Just as we were about to take Ashley to the OR, Wendy came in reporting ruptured membranes two hours ago with irregular contractions. My preceptor went to the OR with Ashley and I stayed out on L&D to care for Wendy. I checked her cervix and it had not changed from my earlier exam in the office. We discussed options-Wendy also had a birth plan that included little or no intervention. We decided to watch and wait through the night.
Shortly before midnight, Ashley and Brett’s baby was born. They finally revealed her name after her birth. Sarah weighed in at 4 pounds, 11 ounces. Sarah had a bit of difficulty transitioning to extrauterine life but after a few minutes of oxygen therapy and time, she came around and did well. She was able to join her parents in the surgical recovery room within an hour for a midnight snack.
Susan and I said goodbye to Ashley, Emma and Wendy and told them we would see them in the morning unless they needed us sooner. We asked the nurses to please call if Wendy became more uncomfortable with contractions.
I came home to find my two little girls had taken over my bed but I was able to slide in next to them. I slept lightly and restlessly for a few hours. At 6:30 am Susan called to say that Wendy had not started to contract yet and her cervix had not changed so she ordered pitocin augmentation. We both decided we would shower and then meet at the hospital. When we arrived, Wendy was still not having many contractions but was very comfortable with the idea of pitocin augmentation. The plan was to use a low dose and turn it off when she began to have regular contractions and cervical change. We visited our other patients then Susan went to the office to take care of some paperwork and I met my husband and children at McDonald’s for a quick breakfast, then we both returned.
Several hours later, Wendy became more uncomfortable so we turned off the pitocin and encouraged her to change positions.  Wendy began to become more vocal and the contractions were more intense. Just as we could tell transition was near, a nurse came into the room and frantically said “I need you in room one, you have a patient here that is 35 weeks and she is 9 cm!” The new patient only spoke Spanish so Susan (who speaks fluent Spanish) left to go check on the new patient. I rechecked Wendy and she was 7 cm. Susan sent a nurse to get me so I could catch Maria’s baby.  John took over the counter-pressures and a nurse stayed with Wendy. 
Maria’s baby was in a right, occiput posterior position and despite pushing well, the baby was not moving down. Maria was in total control and smiled and laughed with her family between contractions. I told them I would do my best to speak only in Spanish and they were more than welcome to laugh at me if I said something wrong.  I kept my promise and spoke almost exclusively in Spanish. We rolled Maria to her left side and within two pushes she was crowning. She asked if the baby had hair-I reassured her that he did have a lot and with a wink, I told her it was blonde.  She laughed and said “oops!”  her husband also laughed and they joked about the “blonde” hair. The next contraction she eased her baby boy out over an intact perineum. I placed baby right where he should be-on mom’s belly. Because he was a little early, the pediatrician was being conservative and prior to birth ordered direct admit to the NICU for at least 24 hours.  We let mom keep baby for several minutes-he was very vigorous and appeared to be very healthy. The nursery nurses then took the baby for evaluation. Gabriel weighed 4 pounds 15 ounces. Just after the placenta delivered, a nurse came in to tell us that Wendy said “the baby is coming.”
Susan and I rushed to Wendy’s room and checked her-she was still 7cm but feeling the urge to push so she pushed. After a few pushes she wanted to change position so she moved to her hands and knees and the urge to push went away. After several contractions it returned. She soon became uncomfortable on her hands and knees and said she was more comfortable on her back. She pushed a few more times before we discovered her baby was also in a posterior position so we turned her onto her left side, she pushed twice and delivered “Miss Mariah” very controlled and gently, over an intact perineum. I handed baby right to her and she was thrilled, mom and dad touched the baby, noticed her features and compared them to the other children. After the cord stopped pulsating I clamped the cord and dad cut it. Mariah stayed with mom and all newborn procedures were performed while Wendy held Mariah. Wendy began to bleed a little heavier than I would like so we gave her some pitocin and she asked that the nurses weigh Mariah while we got her bleeding under control. Miss Mariah weighed in at 6 pounds 9 ounces. After some pitocin and Mariah nursing, the bleeding slowed.
By this time it was Saturday afternoon.  Susan and I finished our documentation, made one last visit to each of our patients and went home for the day.  Sunday morning we returned for rounds, we visited each of the patients-all were doing well, all babies were nursing well and all mommies were feeling good.  After visiting everyone, I returned to Emma and Matt’s room and presented them with their hat for Jacob and told them the story of Frontier. They loved the story and asked me many questions about midwifery.  They had no idea how much care midwives provide but were thrilled to learn that most of Emma’s healthcare could be provided by a midwife. I thanked them profusely for allowing me to be a part of their birth experience.  I truly could not have asked for a better two days to start out my clinical experience!!!

Thursday, January 27, 2011

My Journey to being “With Woman”

My quest to become a midwife; which directly translated means “with woman,” began in the early evening hours of June 10, 1973.  This journey began when I simultaneously took my first breath and picked up the scissors that had been placed on my mother’s abdomen.  The next several years were spent growing up and my road to midwifery was soon forgotten.
Shortly after the birth of my second child I finally decided to fulfill my adolescent dream of becoming a nurse.  My dream was to become an emergency room nurse.  I had no interest in any other kind of nursing.  Three years later I was approaching graduation and enrolled in my last course, Maternal Child Nursing.  Within days of beginning the course I realized that my dream of traumas in the emergency room had rapidly been replaced by dreams of crying babies in delivery rooms.  Shortly before graduation, the almost unheard of happened and I was offered a job in the labor and delivery unit.  New graduate nurses simply do not get jobs in labor and delivery, they usually must serve their time on a medical or surgical unit. 
I quickly confirmed what I had suspected all along-I am an adrenaline junkie.  I would never wish a major trauma on a mother, I would never wish an emergency c-section on anyone (especially those very special c-sections we refer to as “dash and slash” c-sections) but if it had to happen I wanted to be there.  The busier the better.  The more patients I could care for at one time, the happier I was.  The more complicated the patient, the better.  What better way to make a situation complicated than to add a bunch of stuff that isn’t really necessary?  I loved pitocin, I loved epidurals, I loved continuous monitoring, I loved scrubbing in on “dash and slashes.”  I hated seeing mothers in pain when it was so easy to give them drugs, I didn’t understand it, I didn’t understand what they had to prove.  I’m not sure exactly when it happened, but it happened-that all changed.
Several years into my new career I began to become frustrated with what I would later learn is called the Medical Model of care in labor and birth. Epidurals were not only the norm but patients who declined them were considered “weird” “freaks” “granola crunchers” and often received less care and attention from the nurses when what they really needed was more support. Nurses who barely knew the mother-to-be provided nearly all of her care and the doctor would come in at the last minute to catch.  As any labor and delivery nurse knows this is always a fine balance; don’t call too early and don’t call too late.  It’s debatable which is a worse offense.  Be sure to call if there are complications but don’t, under any circumstance, bother the doctor unless there is a true complication that cannot be resolved by a good labor and delivery nurse. Be sure to give the doctor appropriate updates and at appropriate intervals-don’t wait too long and don’t call too often.  Most mothers were unpleasantly surprised by the lack of physician presence during their labor experience. There are many reasons for this-physicians are simply too busy to provide one on one care in labor so, although not ideal, it’s understandable why this is the way it is.  I also began to wonder if the things we do to mothers while following this Medical Model were in fact the very cause of the complications that were so thrilling to adrenaline junkies, like myself.
I knew I was frustrated with the process but everything I’d ever heard about midwives was highly unfavorable.  Midwives didn’t shave their legs, they wore tie-dyed broomstick skirts and no bra.  Midwives delivered babies at home and denied mothers and babies life saving treatments if they needed them.  Midwives made their patients give birth without medications. Midwives gnawed through the umbilical cord with their teeth and fed the placenta to the new mom.  No way was I going to be one of them.
Then, something strange happened.  I found my vocabulary changing, “deliveries” became “births”  “natural birth” became “unmedicated birth.”  Suddenly, things like letting the cord stop pulsating before clamping it didn’t seem so strange.  The idea of intermittent fetal monitoring and changing mom’s position to help labor progress and, heaven forbid, water birth, started to sound like favorable options for women.  The idea of women being empowered by understanding their bodies started to make sense.  I began to see the disempowerment of women in the suggestion that they were unable to give birth to a healthy baby by encouraging induction of labor one, two and sometimes more weeks before the baby was due.  It may seem insignificant to some but the message is a powerful one-“I am here to save you from yourself.  I will give you medicine to make your body do what it’s supposed to do because it’s obvious your body can’t figure it out on its own, then I will deliver your baby. Your baby will be healthy and beautiful because I saved you from harm.”  I began to see that the medical establishment, physicians and nurses alike, is narcissitic and often has a super-hero complex.  I began to accept the idea that going five days over a baby’s “due date” was not a medical emergency but rather still within the normal gestation range of thirty eight to forty two weeks.
So, 35 years after my journey began on that late spring, Sunday evening, I began midwifery school.  For the next three years I had my nose in a book nearly every waking moment. I began to appreciate how the medical model and the midwifery models of care can co-exist. My appreciation of birth as a natural process became deeper.  My knowledge base grew.  At times my previous experience was a life saver, at other times I had difficulty reconciling what the evidence tells me I should do and what I’ve done for years in caring for women. My passion for birth was fueled and I discovered a new passion for women’s health.  Throughout this journey, I shaved my legs and armpits on a regular basis and I must admit, I do own a broomstick skirt or two.
In August 2010 I graduated with my Master’s Degree in Midwifery. In October 2010 I passed the American Midwifery Certification Board exam and shortly after I began my new career as a midwife.  This blog is a journal of my experiences.  While reading my stories please keep in mind that these are my stories, told from my perspective.  I will never use a patient’s real name nor will I discuss the events near the time they happened  and I will not discuss situations in great detail. All stories are subject to some creative liberties. I look forward to having my friends and family join me on this journey!