Saturday, December 29, 2012

The labor of sitting...

I'm sitting here, fingers numb and skin goose-pimpled, with my mind forced to wander aimlessly between the usual time wasters --- Facebook, annoying yet addictive games, checking email. The same sorts of things that I would (to be honest I have to admit this) find myself doing if I was at home right now ... Except I'm not.

And, of course, my eyes flit (as moths to a flame) neurotically to The Machine. Or, rather, Machines, as they are spaced strategically throughout the Birthing Center so that even if one tried desperately to avoid glimpsing them, it would be nearly inevitable. The Machine dictates the majority of nursing decisions it seems, often causing panic among providers not even involved with a patient's care; the ability to see everything that's occurring within a woman's womb from meters and meters away can cause a flurry of activity and a rush of footsteps to a laboring woman's bedside. At times this may be helpful - at other times, privacy is invaded, quiet moments of solitude shattered, and situations being managed calmly and appropriately are elevated to unnecessary proportions of stress.

So... I try to consciously remind myself to focus my attention away from The Machine. I'll let the screen-saver take over. I'll read, I'll eat (oh dear, considering the table laden with holiday treats), I'll train these fingers in my newly budding crochet skills.

Or - I'll look over there again... Log back in...

And then glimpse at the clock (another Device of far too much consequence in this situation). There's a curve to be followed, although to be fair we fell off of that curve long ago. I don't mind - progress is progress, though slow but steady - although the whispers that provide The Machines and Devices may have other thoughts on this. Is it time to consult? Insert some sort of additional tube or device (even though this mama has just about every other tube and line you could imagine already...)?

My mind wanders to the peaceful, joyful announcements of my midwife sisters delivering in birth centers and homes: "a baby girl, delivered strong and healthy after a long, hard day's work into her mama's strong arms" ... "After many hours of dancing, swaying, and support a baby boy welcomed into her fathers hands..." I can only wonder, is the emphasis on Machines and Devices at these birth days, or on mamas and babies?

{ { pregnant ----- very pregnant ---- pause... } }

A day later, a conclusion. Two hours of pushing, tears and four-letter words of frustration later - a big, beautiful baby was cradled into *her* mama's arms. Even with the reassuring picture The Machine showed for every one of those 68,220 seconds (roughly) of the day's work, hands rushed to pull a stunned but transitioning babe quickly from her mother's breast. A steady heartbeat, response to stimulation and mama soothed me that babe -- though initially wide-eyed and breathless -- needed not to be "cut and run" (to the warmer to be "checked out") but rather allowed to remain with cord intact, pulsing oxygen-rich blood to her strongly-beating heart as she opened her lungs and breathed in new life.

But - again - slave to Devices and cowerer of those who oversee them, I am freshly new enough in my role to not want to step on too many toes, piss off the "wrong" types of nurses, get "that" reputation. I  bring young babe to mama's chest, (hopefully, or certainly tried to...) soothed with quiet reassurance of her strong heartbeat and response to a rubdown by the nurse. The cord stayed intact, babe with mom gaining tone and crying lustily, before I fumbled a cord clamp on and gave a tearful dad instructions to cut the tough bond between the double clamps, and finally seeing the break for baby to be removed for "the things we do".

It was not the labor or birth that I imagine my midwife sisters in other settings witnessing... But in the same thread, not the same mama, the same support system, the same overhead model of care either. I long for the "just sit on your hands!" keep-out-of-where-you-don't-belong MOA that I've been taught, and yet haven't quite built up the courage to implement it in practice here. In the months and years to come, maybe there WILL be more tea, more swaying, more breathing and back rubs and foot massages; fewer epidurals and elective inductions, less fear if the "what if's".

And  - maybe - smaller clocks...

Sunday, December 16, 2012

i am his sister...

Months after my last post, I'm back. Even though I've had plenty of themes plotted in my mind, they've never formed beyond that point; after driving home, working late, getting up too early, they all fade into the background.

Tonight, however, in the midst of the holiday baking and planning, I need to stop and write. And, again, it has nothing to do with midwifery. (Or, at least not directly...) Three days ago, media outlets exploded with the tragic news of an attack. Elementary students, teachers, administrators, terrorized only hours after the warm glow of their holiday concert the night before. So many lives broken, with too few answers...

Together we mourn, a collective heart ache, river of tears washing into a tumultuous whirlpool of angry, confused blame. The mother who provided access to the firearms, the system that allowed the sale of the guns, the school's security system (or lack thereof), the sensationalization of shooters... Anyone, everyone, no one are at fault for the loss of these innocent futures.

I don't have an argument for or against any of it. But, in reading Liza Long's reflection ( I recognized much of my own struggle with last week's events.  I woke up several times the night before, dreams of my brother haunting me; the same old guilt, longing, sadness lingering as I struggled out of the fuzzy sleep state and realized that I had nothing to give.  Throughout the long night and Friday morning - and intermittently since then - my "little" brother has been on my mind, more so than ever since last spring. Only after reading Long's piece does that really make sense.


If Liza Long is Adam Lanza's mother, I am his sister. My brother never lashed out at me with kitchen knives, never threatened to kill me or routinely verbally assaulted me out of anger - but in the last years of his life, he did frighten me. My brother lost the bright, clear eyes I'd always known; a haze and darkness replaced them. He abused over-the-counter pills, manipulated and stole, and drew further and further from the person he had been. He admitted to hearing voices, feeling as though he was re-living days, in an "alternate" world. At times he was the same old kid - fun, goofy, sensitive and caring, but in barely an instant could spin into an angry paranoia. Filtering truth from lies could be exhausting, and was heartbreaking.  Depression, hopelessness, despair filled his days; my brother used knives, hunting guns, pills to mark his pain. Together as a family, both with and without him, we traveled the path of reaching out to help our hurting kin; the ER, the county social service department, involuntary and voluntary behavioral health programs were all approached with little to no avail. Programs were full, or simply not accepting clients, or did not see "evidence" of mental health disease in my brother; with no cause for treatment, he could not be kept involuntarily. Third-party commitment was unlikely to work; in fact, the best likelihood for getting him into a real mental-health facility would be through the criminal justice facility. Pulling away to avoid enabling seemed to be the best option, but in the end, there were no options.

After going through the same trials over and over, we did pull away. We explained that we were afraid to have the Mini's seeing the fear, the anxiety, the confusion caused by these behaviors in the family, and that until he got help and got clean, he wasn't welcome in our home; in all honesty, we feared for our family, for the Mini's, for my elderly grandparents who said "no" to him, for those who were in his path when he was angered.  At the Mini's school, it was known that only the Warm One and I were to pick up the girls - no others.

I did not fear my brother, but my brother was gone.

Eight months ago, my baby brother was found alone, dead, in the room being rented for him. My heart aches to think that he took his own life - he was working and seemed happier than in a long time - but deeper within myself, I recognize the loneliness and pain he felt, the struggle he knew.

~ * ~ * ~ * ~

But. My husband hunts whitetail deer in order to provide venison, which feeds our family throughout the year; this is not simply sport, but a matter of tradition and stability for families that might otherwise go hungry. Similarly, my father, my grandfathers, my uncles all own guns - all of which are known to my brother. (Even if in locked cases, accessible through broken glass...) If, in a simple cruel twist of fate, this tragedy had occurred in different circumstances, would I be villified? My elderly grandfather? Though the guns were all moved following my brother's attempts to harm himself... though he had never made any attempts to harm anyone but himself... though we had tried, and tried, and tried to get him help until we were desperate ourselves...

In all of this pain and heartache, there are no real answers. Perhaps that is the real answer.
Love, prayers, tears to all who hurt...

Friday, November 2, 2012

The Guilt Bone

~ the hip-bone connected to the, thigh bone... the thigh-bone connected to the, knee bone...
       the knee-bone connected to the, shin bone... the shin-bone connected to the, ankle bone.... ~

General anatomy and physiology. Core nursing curriculum for all students pursuing any health care field; after that initial introduction, the bones, muscles, tendons, and major organ systems of the body are again pounded into the student's head another 854 times before the end of the schooling. If you know anything by the time graduation rolls around, you know at minimum where things are and what they (should) do.

So - where's the guilt bone?  I don't remember seeing it in any of the A&P textbooks, and it definitely wasn't in the coloring study guide that I bought (and rarely scribbled in); none of lectures I struggled to stay awake through mentioned this one. None of the multiple pigs that I've dissected over the years have had a distinct ossification by this name - but then again, maybe pigs don't feel contrite.  (After all, pigs do what we expect of them - roll in mud, eat slop from a trough, grunt around; there seems to be nothing damning in those days...) I did, however, spend a few timid Advanced A&P labs with a human cadaver dissection-in-progress; granted, I didn't make it through the entire study and could have easily missed a small, delicate prominence, but when taken into consideration with the lack of mention anywhere else in the literature or diagrams, I'm stumped.

Is it just me? I'm certain I have this 207th bone, this extra verse to the old diddy. My guilt bone is connected to the "I'm sorry" muscle, with an antagonist "I wish..." tendon. Unlike many of my more commonly-recognized bones - possibly teetering at risk of frailty in years to come due to my ambivalence towards dairy - this little fella is strong as they come. I can't be sure, but through some sort of unusual anatomical configuration, it seems as though all of the weight of my shoulders may actually balance on this one small bone... crazy, huh?

When a laboring mama ends up with the words "failure to progress" scribbled somewhere on her chart and her support person gowning up in surgical gear - the muscles flex, that bone moves. When the charting runs long and calls keep coming, keeping the Mini's from their Mama - I feel the tightening. When the common cold spreads around and obligations aren't met - more tension. The phrases, "I'm sorry...", "I apologize...", "Next time...", slide off my tongue as easily and honestly as a warm hello to a close friend. Unfortunately, their prominence undermines their significance, and the frequency drains me of emotional energy: I know I am not at fault for anything and everything that happens. This life that I chose and path that I'm on is one of beauty, of faith, and of dedication.

Today, I forgive myself for taking blame that is not mine, and open myself to the world beyond...

~ * ~ * ~ * ~ * ~ * ~ * ~

Tuesday, October 16, 2012

Don't hate me, I'm pro-choice ... and pro-life....

(Foreward: --- aka warning --- this post deals with a controversial topic... it's my personal opinion, and I beg you to read it and recognize that I understand and respect all the very personal, intimate feelings about this. There are multiple ethical, moral, and religious aspects, and I grasp the enormity of even acknowledging another perspective - much less trying to be "okay" with one that defies your own personal beliefs. That said....)

~ * ~ * ~ * ~ * ~ * ~ * ~ * ~ * ~

Dear friends...

I love you all. I love your babies, the smooth chubby cheeks, the gurgly giggles and the snuffly coos as they snuggle into a chest for a nap. I ache with you when you share the sorrow of your losses - the babies born still, the grandchildren suffering unfair illness and the sisters desperately hoping for their own babes. My own uterus skips a beat with each sweet, slick gift of life passed from a mother's womb to her arms; there's not a thing I would not do or give to see a smile cross the face of my own Littles, and the thought of seeing them in pain causes an almost physical pain to take seed somewhere deep inside my soul.

Abortion.  (I said it --- I think I had to, right? We all knew it was coming, eventually...)  I can't imagine being in the situation of having to weigh the decision myself --- to continue a pregnancy or potentially terminate... and am thankful I have never found myself in that situation. Simply remembering the bungee-cord of emotions that were rampant with both of my pregnancies - enhanced by a history of depression - leads me to feel that much more pain for the burden of fear and anxiety placed upon the hearts of any woman led to consider termination. I was a married, employed, educated woman with a planned pregnancy and resources up the wazoo (and the knowledge to identify countless more), and still scared witless; to a woman (or young girl) without reliable employment or education, a supportive partner or family, limited or any resources, who becomes pregnant, the future may be terrifying.  

This post is not meant to be a religious rant, a political push, a vicious argument against the ardent "pro-life" community. I believe in life.  I'm as pro-life as I am pro-choice. I believe in a G*d, some Creator of us all, a balance of all that is right/wrong, happy/sad.  Life begins, when life begins. To split hairs and debate the moment of "life" versus living cell seems frivolous, when to the women whose wombs carry those cells are in turmoil.  

I care for women, for families, and for babies - all of these groups, none of them exclusively of the other. I will not, as a healthcare provider, perform elective terminations ("abortions") --- but I will counsel my clients on all available pregnancy options, and never judge them for the decisions that they make.  I do not believe I could ever choose to willingly terminate a pregnancy which has taken hold in my uterus... but unlike too many of the women I've met, I've never been gang-raped, never been homeless, never been to the point of opening the door and finding social services peering in the corners looking for evidence of drug use and threatening to take my babies away.  The hardest financial "struggles" I've faced have been wondering if I would be able to make my cell phone payment and cable bill on time, or if deferring my student loan payments would be necessary... our family hasn't sought emergency food assistance, or faced cold winter nights without electricity.

When I close my eyes, and drift into dreams, I imagine a world where every strong "pro-life" family takes in a family coping with an unintended pregnancy (literally or figuratively), providing shelter, support, understanding, hope --- a home for a baby, ultimately, if needed.  (Of course this is in a land of lolly-pop trees and cotton-candy clouds... the logistics are nutty and no one's house would actually be large enough to accommodate an extra family - but work with me people!) To be serious, the crux of the matter - at least from the limited viewpoint that I've dealt with it - truly is the lack of support and resources generally available to women who find themselves immersed in unplanned pregnancies. 

Resources, education, support... oh my!  I dream, too, of a day when access to contraceptive options (including emergency contraception and preventative care/medical visits to discuss and explore different options) is readily available - without judgement, prohibitive cost, or excessive delay - to all women, with coverage from all providers. My faith is that I need to care for the women and families that I see, giving compassionate, holistic care; for some women, this will be supporting them as they continue pregnancies they weren't prepared for. For others, this will be counseling regarding termination. For all, it will include reliable contraception counseling talks, discussion of support services, and continued communication for months after our initial encounter. Though it is not up to me to weigh the life of the baby-to-be against the mother and family's emotional/financial/physical health and well-being, I have a strong faith that the G*d I trust in will deliver peace to the souls of every life involved...

Please open your heart and mind to those who hurt... be blessed...

Monday, October 15, 2012

THAT midwife... (Or, let's just be honest, eh?)

You know. THAT midwife - the kind that schedules elective inductions, has short prenatal visits, tells laboring women, "if we break your water, it may help speed this process up a bit." {{shudder}} I disdain that midwife --- or doctor, or whoever --- and rolled my eyes at her throughout my training. No way would I disrespect my clients or gamble with their health and well-being.


I might as well get it tattoo'ed right across my cheekbones. It's me!! I'm her! I'm THAT midwife! *sob* I realized last week how blurred the line has become for me; of the babes I've caught since I've come here, only half (give or take) have been spontaneous labor. The ones that have been induced have rarely been for good, solid medical reasons. Epidurals run rampant - and I don't talk mamas out of them. Initial prenatal visits include a pre-canned speech including reassurance that choosing a CNM-assisted birth does not automatically rule out pain medication or epidurals; women whose eyes widen at the thought of going into spontaneous labor on one of the six days in a given month when my partner or I are not on-call are quickly comforted with a subtle promise, "depending on how you're doing and how favorable your cervix is..."

Who have I become?!

Part of me bristles at this recognition. I don't want to be a "medwife". For every 5-10 minute, tummy check/dopple/how-ya-feeling? prenatal visit, there are four times as many that last three times as long (not to mention the "well" woman visits, gyne exams, and primary care...) As a general rule, our patient population needs *midwives* , not medwives; so many of our families are wrapped in generations of epidemic substance use, alcoholism, violence, and broken families. To be "with woman" consistently - providing unbiased, compassionate care for months and years without fail - seems like the best gift to offer these women, both those who seem to be desperately seeking it and those who push it away. On the other hand, to balance this, time gets away... the "good" patients get quick visits... and unfortunately sometimes things get missed. (I know that this has to happen --- the quiet, sad-eyed primip? During a brief, mid-pregnancy visit when I'm focused on the drug-addicted mama I had just seen --- or worrying about the postterm multip who had again been a no-show --- I might miss the cues that she's giving that something is wrong. I might not ask the right questions, give her the time she needs to feel comfortable to open up to me. Shit.)

But - the realistic part of me knows that some of this had to happen. Inductions happen; so do epidurals, and so --- knock on wood --- will c-sections. Without generalizing the women I am so blessed to work with --- I don't practice in a population that will (can?) embrace the granola-crunchy, no-interventions-please philosophy. (Happily, they don't generally fit the "yes sir, whatever you say, Doctor" mold either... these mamas are strong, and will do whatever they know is best in their situation).

My hope is that I can continue to cultivate growing relationships with each woman and family I work alongside, as well as the community itself, to find the "right" plan for her situation. No glibly tossing out the "I" word, giddily skipping down the L&D hallway to pop a bag o' water, or passing out epidural tubing and meds like candy at a 4th of July parade - simply trusting the relationships and our communication to find the path to a healthy, happy end.

Friday, August 24, 2012

Long time gone...

Hey, nice to see ya! Where've you been?!  Oh, wait, I guess maybe it's where I been, eh?

So, needless to say, this post is loooooong overdue.  I think this blog's last posting was somewhere around, oh, six months ago?  Huh.  I guess it's been a busy half-year.  Since our last rendevous, old friend, I've packed up and picked up everything to move half a days drive away, officially gaining entry into the world of a practicing (and paid!!!) nurse-midwife, and gloriously helped a powerful mama pull her newest into her arms, standing alongside her bed... (my first out-of-bed birth - woohoo!). I've said goodbye to so many friends --- and in a heartbreaking moment that doesn't end, to my baby brother, standing alongside each of my family members as we realize the swiftness with which goodbye can be missed; I've lain awake at night and struggled with my own internal guilt, fears, remorse, anxieties - both professional and personal.  I worry about meeting the expectations of my clinic administrators, meeting the needs of my clients, about being thorough yet not over-ordering or falling behind; I fret about when the golden hospital privileges will finally be mine, how stressed my partners are in the meantime while they await that day and how tiring it must be to have to back me up until then.

And, of course - I yawn, I drag, I sleep only halfway 98% of the time, hoping/not hoping my pager will go off... if it does, if that next mama's water finally breaks, it will be one more babe closer to independent privileges and a bit of relief for everyone all around (but if it doesn't, of course, it means a bit more sleep for everyone on the home front.) Officially, I'm on call something like four nights a week - but unofficially I've been sleeping with my pager under my pillow just about 24/7 since starting in April - or at least since getting permission to get near hospital patients a month or two ago. It doesn't beep at me often ... yet I still dream that it does, or that it did and I slept through it, or that the batteries died and someone's been frantically trying to find me, yadda yadda....

Oh, but the catches - the sweet, slippery, lovely babes!  (Really, isn't that what it's all about??) When it's down to that moment, the rest of the stress, the worrying, the anxiety melts away.  Until, that is, the hemorrhaging afterwards... or the placenta sticks... or mama passes out later on.... you know, those sorts of things....  But the catch itself, usually, is a rush!
I pledge, from this point forward, to stay more loyal to this blog.And I hope you'll stay here, too.  Like any good things, any journey worth taking, it may be a long road, but hopefully worth the travel....

My "birthingway" necklace ... or "mamalove" necklace... or "I Catch" necklace" ... or ??? 
(I'm open to suggestions!) ... for every babe, a bead <3 

Wednesday, February 29, 2012

Happy Birthday, Memories...

Happpppy Birthday To You........ (or) I just want to eat sweets!!!

It's a time for nostalgia. All the inner turmoil (where to go, what to do...) sometimes causes me to curl into a ball within myself, rather than seeking outward direction. Today, in that mode, I happened to click on AtYourCervix's most recent blog entry, which begged the question (at least to me): How, as a midwife, can I empower women to be true partners in the pregnancy and birth they want?

The more I pondered this, with Judge Judy and a roaring fire in the background, the more I realized I hold this as a cornerstone of my own midwifery philosophy. If women (and their families) don't feel that they are invested and active participants in their own care, how do we - as providers - expect to build a close, trusting rapport that will endure through the long, scary, demanding hours/days/weeks that build up to the actual birth of the precious babe? The emotional, physical, and mental toll that the process can have on a relationship (whether marital, familial, or provider-client) is immense, and only by working together and "sharing the load" - rather than one member of the duo gifting all of the 'power' to the other - can the weight be used to strengthen rather than risk breaking the bonds that tie.

Or something.

And this thought train eventually wandered off the tracks and into some rocky, dirt lanes through the woods.... to early last year. I thought I could blurb a little something like the above, link to a post from sometime late last winter/early spring, and, voila! But, as I dug back - I realized that I had very, very briefly glossed over the birth I had in mind for this post. The one that so perfectly exemplifies how shared decision making and informed consent could have been (or should have been) utilized -- and very blatantly wasn't. In retrospect - still a very beautiful, touching birth. But from the provider perspective, so very painful. The family --- an amazing, strong mother-woman, supportive partner steady at her side, and longed-for babe finally brought into their waiting arms --- could not have been more incredible. (I've been blessed to be able to keep witness here and there - hopefully in a not-creepy sort of way! - and am delighted that not only has the small family blossomed into a gorgeous example of two loving parents doting on a beautiful young'un --- but they also seem like just so much "fun"! And maybe that's the crux of this whole post; seeing someone who I really identified with, who I could see as possibly being very close friends with, had our paths crossed at another time, hurt in this way...)

So, if you'd like to sit back, relax, and listen to a little story about informed consent, shared decision making, and all of that good stuff - let's all take a big step backwards (away from the angst of when-is-the-phone-going-to-ring and blizzards and job worries of my current life, and back to the days of my early clinical rotation...), shall we? Here goes...

(cue dimming of the lights)

(maybe a little mood music... something...)

(Oops, wait - cut the atmosphere. Remember, no real names, no actual pictures of the client, the babe, details changed, etc, etc.... c'mon now, folks! Protecting privacy here :) Okay, rewind back to that warm, cozy story-in-front-of-the-roaring-fire-again... where were we?)

The Story

The patient (we'll just call her "Mama" for the sake of privacy, ease of typing, yadda yadda) and her husband (oh heck, why not call him "Papa", eh?) had transferred care to the midwife I was precepting with sometime towards the end of her pregnancy; not at the end-end, but sometime between the end of her second trimester and final weeks of her pregnancy. The couple had learned there was a nurse-midwife in the area and - being well-informed in the pregnancy and birth process, and knowing they wanted to seek a more natural, low-intervention birth experience - were excited to meet her in the hopes of increasing their chance of finding this sort of birth. The pregnancy had been perfect - Mama had no risk factors, no concerns, no red flags. As of the forty-week prenatal visit, everything was as "textbook" as any pregnancy could be classified.

Like many babes of first-time Mama's, however, Little One had no particular plan for working its way out. Home -- aka the uterus -- was quite plush and cozy, particularly in the cold Midwestern winter days before spring finally hit. So when that forty-week appointment arrived with no signs of impending labor, my preceptor had already mentioned the possibility of nudging the Little One on its way via an artificial method or two; Mama had politely declined, reminding the midwife I was working with that she and Papa hoped to avoid as many interventions as possible unless there was a true medical intervention. Since Mama felt good (she was doing amazing at this point, from my outsider's point of view; I remember when I passed the 38... then 39 week mark with the Mini-est -- after delivering right at 37 weeks with the Mini-er -- and thinking that e v e r y single day d r a g g e d on l o n g e r than the one before it. As my due date loomed before me, I know I looked nowhere near as calm and simultaneously energetic as Mama did!) and Little One showed no indications of distress - and there was no evidence-based rationale to push induction at this point - an appointment was made (following a reactive non-stress test) to see Mama back the next week. My preceptor hesitantly agreed to allow the pregnancy to continue and re-visit the induction topic at that point, all depending on Mama's cervical status, how Little One "performed" on the upcoming non-stress test and biophysical profile, and, of course, any other surprises in the meantime. (My memory is hazy at some of these details; I seem to remember, however, that my preceptor's plan -- which seemed to me as more of a begrudging negotiation to Mama's continued decline of her offer of induction -- was to induce at 41.5 weeks at the latest. Again, I may be mis-remembering these details... but in the end, it's more or less a moot point.)

Fast forward another long/short Midwestern almost-spring-but-still-the-last-hurrah's-of-winter week. (Excuse me a second while I slip into something a little more comfortable ... present tense now...)

Mama checks in for her scheduled appointment, doing great, no concerns for the assistant who rooms her and checks her blood pressure. A few minutes later, I step into the room and start visiting easily with Mama, who laying back on the exam table resting. I tease that Little One must be a girl; that she's "in there" doing her hair, taking her time to get "all pretty" for the big day, and that must be why things are taking so long. We joke about my freezing cold hands (as always), talk about the usual important questions - any leaking of fluid? funny vision changes? crazy pains? bleeding or baby movement changes? - while I wash my hands and find the tape measure, doppler, gel, and anything else that I usually forget. Little by little, I work my way back to the reclined exam table where Mama is still laying back, resting as comfortably as possible at this stage. Finally, I get my hands on that belly; my inexperienced student hands work to try to determine fetal position and lie (is that a breech? Feels like a back along this side... I think that's a head working its way closer to engagement...), and then go ahead and assess cervical dilation as instructed by my preceptor, who is curious about any changes from the previous week's assessment. Not much of anything. (I don't remember the exact details... Mama was not crowning, anyway.)

Finally, after all this goofing around, I make it to the important stuff --- baby beats! Goop on the doppler, doppler on the tummy, beats in our ears. Initially, we hear a nice steady rate --- 120's. And then... Ba-dump, Ba-dump, baa- duuump, baaa-duuuuuuump, baaaaa-duuuuuuuuump... baaaa- duuuuuuuuuuuump... (Okay. I admit it. I haven't quite figured out the best way to translate an audible, deliberate drop from a happy, normal Little One's cardiac reading from an external fetal monitor to an oh-crap-I-don't-know-if-I-like-that-so-much sound. But, if you've worked labor/delivery - I have a feeling you might know just the sound I'm trying to describe here.) Suddenly, my lovely 120's kiddo is picking up in the 70's-80's range; uck. And, unlike those instances where I've had cause to wonder if I might have started picking up maternal, I was quite certain that it was still Little One's heartbeat; I had been picking up a strong, steady heart rate (discernible from the maternal heart rate by the sound), and had heard it fall beat by beat; a quick pulse check from Mama could easily confirm this as well.

Well, of course - a decel is a decel, and like any deceleration, it makes an OB nurse think a little bit. My first thought was to get Mama moving a bit (and certainly once I had a few seconds to think straight, a head-slap was directly in my future for setting up the whole situation... but that was later), and off of that laying-back position she'd been hanging out in for probably a good 20-30 minutes by this time. Within seconds, as expected, Little One was giddily climbing right back up and cheerfully chugging along around baseline, anywhere from 120's to 130's. I was feeling better. But. (There's that "but" again... we've talked about that before, eh?)

But. My precepting midwife had walked in in the midst of the heart rate, as I was working to help reposition Mama; the decel did not excite her at all (understandably) and she quickly explained to Mama the importance of expediting delivery for the "health of the baby". (By this point, I had not had a chance to explain the circumstances leading up to the deceleration, either to the precepting midwife or even to Mama, who was equally understandably upset by the midwife's reaction to this.) To condense a hectic, emotional office visit, my precepting midwife - after learning of the extended time that Mama was laying fairly flat and likely compressing her vena cava, possibly contributing to the decel (which lasted I would estimate 90 seconds or so) - modified her initial plan of care, which very strongly suggested an ambulance ride to the hospital (about ten minutes away) complete with IV fluids and cesarean prep, to "allowing" Mama to drive herself to the hospital and meet both of us there to begin an immediate induction.

(During the commercial break between "this calls for an emergency c-section NOW!" and the latter decision, Mama had been hooked up for her scheduled non-stress test, which was beautiful. Little One never strayed from the baseline s/he had demonstrated in previous weeks, had gorgeous variability, accelerations up the wazoo, and no further decels.) Outside of Mama's door, my preceptor turned to me and explained that "You never, ever let a patient leave undelivered if you hear a decel like that in the office." On the other hand, Mama was on the phone with Papa, trying to relay all of this sudden rush of news; she was in tears, unsure what any of it meant, frantically worried about the health of their baby. In the middle of it all, I was left to try to assert my newly-forming role; I felt on so many levels that Mama wasn't getting the whole story from my preceptor, yet (based on other things that were already happening in the clinical setting) I wasn't sure how aggressive I dared be. I wanted to tell Mama that everything truly was okay; of course we couldn't be 100% sure that there was nothing going on that contributed to the decel (can we ever be truly 100% about anything?), but the fact that so many things had led up to it - or just the fact that we know variable decels are a part of normal labor and delivery, and if transient/not repetitive/not prolonged/etc, they are usually benign? Or, that if we monitored every pregnant woman continuously from the 24th week of her pregnancy until she delivered - without intervening - we'd probably all pee our pants at the kind of things we'd see that happen on a semi-routine basis (yet that don't actually cause harm). I wanted to tell Mama to question what other options, besides immediate induction, were available; I wanted to offer a biophysical profile to complement her reassuring non-stress test, or, maybe a stay in the antepartum suite overnight with a repeat NST and BPP in the morning for further reassurance. Or a consult with the MFM specialist. Or even simply ask if she and Papa which plan they felt comfortable with.

Sans the "dead baby" card. (For those of you unfamiliar with this ploy, it's basically as straightforward as it sounds... the provider, for fear of liability --- i.e. I am going to tell you that if you don't listen to me and do as I say, your baby could die/have a serious ill effect/etc; this way, if you don't listen, I can say "I told you so!" and my ass is covered... --- , for convenience, or just out of some deep-seated love of power. Or, I suppose, a handful of other reasons. Anyway. Unfortunately, that's what my preceptor did, without using the specific words "dead baby". She tiptoed around the phrase, strongly encouraging (although really, when your doctor/midwife/care provider "encourages" you to do something - particularly if you just had what seemed to be a pretty scary, dramatic few minutes - it's not really encouragement at all... it's an order, a telling, a demand... isn't it?) Mama and Papa that it was time to induce this labor. No, she knew it wasn't what they planned on; but, Mama was now 41 weeks, the placenta was getting old, and the baby was clearly stressed. Opting to wait to induce at this point could be a very bad idea, and unfortunately it's not something you want to look back on with regret when it's your precious baby's life ... do you?

Oh dear. Of course you don't...

So - Mama and Papa agree hesitantly, but with great love and worry for Little One, to be induced that afternoon. A medication is given to help begin the process (intervention number one), continuous monitoring is done (intervention number two), and a few hours later, Mama's water is broken to help things continue progressing.

Throughout these hours, Mama and Papa - with the help of a wonderful support team - are unbelievable. Like few other couples I've seen, they bravely open themselves to each new change in their birth plan as if it is not an unwelcome intervention but rather like it is a glad gift to ease the coming of their babe. Contractions made stronger by the inevitable pitocin (intervention number three or four, I lose count eventually of course) are greeted with smiles of enduring strength rather than requests for pain medication, and hours and hours of long labor - meant to be spent quietly at home, their prepared soundtrack playing them along - pass instead in the fluorescent hospital room, with staff coming and going. Antibiotics, internal fetal monitors - nothing sways this team.

Finally, the time has come to meet Little One. The babe greets the world as some do, a little surprised and needing just a bit of help getting going - but otherwise beautiful, strong, and looking for Mama. Yet, instead, without skin-to-skin or a chance to feed - it's off to the NICU for "fluids" since the birth must have left a wee one somehow low on fluids, maybe a bit too "blue" for the NICU NP's liking. (I have to butt in here - sorry - but as an OB nurse at a critical access hospital... I was appalled at the number of babies taken to the NICU for "fluids" or because they weren't "pinking up" as quickly as the NICU staff - called often if the staff expected a possible issue at birth - liked... babies would be crying and have great tone, color, and respiratory effort after the initial 1-minute apgar, yet they would end up separated from their mothers for 24 hours for these reasons. Hmmm.... It seemed like - and I heard rumors to this effect - a case of "we have NICU in house, so we have to use them or lose them.") Mama and Papa had worked soooo hard, for soooo long to birth this Little One - only to watch the NICU team wheel the bassinet upstairs, for an unknown length of time. (This, of course - the biggest and most obscene intervention of all; the cascade of the others, from the very induction that should have been discussed as an option along with all other possible alternatives, led to Mama being kept from her Little One for an incredible, infuriating amount of time. She could not see or touch her baby in the NICU until she had eaten, been up to the bathroom, and showered; the nursing staff refused - per policy - to simply assist her to a wheelchair and allow her to go to see her infant.)

In the end, like with so many other instances of less-than-true-informed-consent, it worked out: everyone is fine, and lovely. Little one is gorgeous, Mama is happy, and Papa is, well, a proud Papa. My preceptor ended with a healthy mama and baby, and no fear of litigation or a peer review from her collaborating physicians. I, though, ended with a family that still haunts me; I am grateful for the beauty of their birth story - beyond all that was done to them, they remained strong - yet am saddened for the lack of informed consent that took place (and that, truly, exists in most facilities regarding pregnancy, labor, delivery - and inductions in particular).


Happy Birthday, Memories!

Tuesday, February 28, 2012

North by North West...

That - is the question.

At the end of the last post, I alluded to some internal conflict between the two sites where I recently had interviews. The first site, dibbed "North", is located about 5-6 hours from where my family has always called home. It's got quite a few things going for it; the pay is nice (relatively - I don't know what the other nurse-midwives that graduated in my peer group are being paid, for the most part, but the rough starting pay I was quoted for this position is about what I was expecting based on my searches for this area). The site is also a HRSA (Health Resource Service Administration) designated site, and the position is eligible for loan reimbursement --- which means that by committing to work in the role for at least two years, I would say buh-bye to a nice chunk of my student loans (and by working a third year, one more of those big ole monkeys would also take a hike... leaving me just about free and clear on the loan front). My partner would be a midwife who developed the nurse-midwifery practice at the site ten years ago, and has worked to build a great relationship with the handful of family practice doctors who she works alongside (by the way, I LOVE family practice doctors - not such a fan of OB's --- most likely because I simply have worked with very few, but also what I have heard of them hasn't been so favorable...). The main clinic at this site is located in a rural area and is very full-service, offering clients a range of services from x-ray and lab to WIC and massage; the practice also has a secondary site in a large city about 30 minutes away, with limited services (but just as vital care for recipients in the urban area). Call would be shared, possibly 2-2.5 days a week and 1 weekend a month (with an estimated 50 births annually); clinic would be 4 days a week split between the two clinic sites. After visiting "North" --- I felt good, confident, ready to go. I had a strong feeling that I was going to be offered the position, and that I would probably take it.

But. (That "but" is always there, now, isn't it?) In the days that followed our return from our visit, a few things nagged at me. At the end of my visit with the midwife at "North", I asked a few questions (thankfully) regarding the specifics of her midwifery practice. Did she feel that she did a lot of inductions? (She felt like she actually probably did more than she should... red flag?! red flag!! Her rationale? She did take days off - understandable, since she was a solo midwife and had been for the past 10+ years; she stated that she did offer induction at times to her patients before she went on vacation. Hmmm. So - on one hand, this seemed OK. On the other... something to ponder.) What about continuous monitoring versus intermittent? (Answer: If a woman specifically wanted to be off the monitors, she was good with that - but if there was no preference either way, she didn't push for intermittent monitoring either... ???!!? Rationale for this one --- The nursing staff tended to be low, and this made IA difficult to impossible at times. The unit did have telemetry, so continuous monitoring didn't necessarily =/= a patient that was stuck in bed --- but then again, MY unit also has a telemetry unit... which sucks. As much as I'd like to say telemetry means a patient can labor while ambulating, or in the shower, or on the toilet or squatting or standing on her head --- not necessarily. Especially if she's on continuous EFM for nursing/provider convenience in the first place. S0 - another thing to ponder. While again I can understand the reasoning behind using EFM versus the additional time necessary to IA --- and am glad she had that explanation rather than that she needed the security blanket of the paper/electronic strip to ensure babe was doing all right --- I still get nervous at the idea of having hours and hours of paper strips staring at the nurse... and resident... and whoever looks at them and starts seeing oogie-boogie monsters in the shadows of innocent variability or the occasional benign decel.) Those were the two biggies on my "hmmm" list... From just a facility point of view, it would take a while to get used to LDRP's that are half the size of the ones at "my" rural critical access hospital, some of which have shared bathrooms. And residents (I've never worked with residents in my life - they seem like a whole different species!). And - while I won't say specifically which states, I will say that "North" is in a neighboring state which has a longstanding, sometimes vicious football rivalry with our NFL football team. And the Warm One is a diehard football fan.

So there are at least a handful of things that "stick", if that makes sense. Not that I'm not seriously considering things --- it's just not 100%, yet...

And then - there's "West". I flew out there last week and fell in love. I texted the Warm One immediately (or maybe it was after dinner with the midwives - either way, I hadn't been there long) and emphatically told him that I would cry if I didn't get the position. Throughout the course of my two days with the midwives at the "West" practice, my position on the area and their care philosophy didn't change. At all. I want to go there. The town where this practice is located? Beautiful. It's twice the size of the small town I live in; I'm a small town girl, so I can handle that. Their practice? Gorgeous. Clinic exam rooms that are spacious, with huge, full-sized "beds" (seriously, I have no other way to describe them) covered in pillows created for expectant mothers to lounge --- alongside big brothers and sisters, or dads-to-be as well --- and chat, listen to that precious heartbeat, and learn. Beautiful birth-inspired, earthy artwork everywhere. No sterile white walls or ugly, plain paintings meant to be aesthetically neutral. All of my questions - "Do you induce a lot?" "How do you feel about VBAC's?" "Are you open to a new grad?" - are met with just the right answers ... yes, inductions are necessary sometimes --- but not just 'because'! And they do VBAC's, and waterbirths, and LOVE students. It's amazing just to pick up the calm, reassuring vibes as they answer questions - to picture these two women as mentors is mindblowing. The call/clinic schedule is specifically geared to give each of the three midwives a rejuvenating period frequently; at least once every three weeks, each midwife gets a 5-day off stretch (that is, five STRAIGHT DAYS OFF in a row. Heaven. No clinic, no call, nothing, for five days.). Clinic and call are intermixed, often with stretches of 3 days off in a row as well. As one of the midwives stated, "When we are on-call, we usually work hard (the group of three midwives delivers between 250-300 babies annually) - but when we're off, we also 'rest hard'." I can dig that. To be able to serve my patients AND my family? Awesome-sauce. And the hospital is about 2-2.5 larger than 'my' OB unit --- so larger, but not as large as "North"; the nurses were great, and loved the midwives. Downfalls? Cost of living! To find a house under $200k may be impossible, and we would have to trade in one of our cars for an AWD or four-wheel drive; the pay "West" is also significantly ($10-$15k - ish) less than "North", with 2 weeks less vacation time and likely less benefits in other areas, particularly no loan forgiveness. Big things the Warm One is concerned about. And, of course, being a plane ride away from Home. Where the hearts are.

Speaking of home.... And hearts. It's a hard thought to think of leaving everyone that I/we love behind us. As much as I always suck at returning messages, emails, phone calls, etc --- it's even harder with all of this going on. Part of me wants to ignore that any of this is happening - that any changes are coming - but to do that it also means ignoring any references to change. Whether we go "North" or "West" ... or anywhere else ... it hurts. And it's scary. But it will be okay, too.

For the time being, I'm waiting for a phone call. A phone call from "West" could be making a decision that we go that way - throwing caution to the wind and hoping that the cost of living will balance out - or the other way. Or, perhaps, no call, but a "thank you, but no thank you" letter (as they did have two other candidates yet to interview...) leading us "North" ...


In the meantime, I'm content to be back on the edge of that abyss, arms wide open, and leaning in, knowing that wherever the fall leads, I will land gently...

Saturday, February 25, 2012


That last post? It was the darkening before the dawn... the cold, bitter rains of March right before springs first tentative blooms poke through the thawing ground... the tensing of every last muscle, stressed, fearful, fatigued -- and then a loved one's arms are there to encircle and release it all to the universe itself.

Do I need to step back a mile or three? Maybe that would help...

From a career/baby-catching standpoint - you could say that the last post was somewhat colored by the sludginess I've felt in my job search. (Which, in itself --- seems somewhat silly... I didn't expect to come out of school with a job in hand, as nice as it would have been. But still - now that it's been five months, I'm getting a little antsy...) Every day that I go without that delightful weight sliding into my hands, without gifting mothers with the words "here's your beautiful child" ... it weighs on me. Sure - I can still go to work as an L&D nurse; I can still whisper forbidden encouragement into the ears of hardworking mama's ("go ahead... eat some crackers... nibble on that granola bar..." ), but it's not the same. The mothers, the fathers - they know I am the nurse; they have only just met me, and even if we have "clicked" and even if they can sense that I am there for them and their babe --- I am still, just, the nurse.

I've sent resumes, CV's, emails of inquiry. I've had an ongoing email chain, complete with an powerpoint proposal, to the physician group that I've worked with for the past five and a half years - a handful of great family doctors who practice this close to the midwifery model of care. Throughout my clinical rotation with Dee, there was the shadow of a promise of her practice adding a second CNM. Nothing. Zipzilchzerozuess. "My" doctors decided that while they felt there would be interest in a CNM in our area, they feared "there would not be enough demand for a full-time position". A few attempts to get in touch with Dee (after a promising email before the holidays that her administrator was going to start the process to try to get the wheels going...) weren't returned. A promising position - complete with loan forgiveness via the HRSA program - seemed very likely and suddenly... *poof*! Que sera, sera.

But. On top of this, I live in the Midwest. In winter. A gray, long, cold Midwestern winter. The task of looking for a job - refreshing the same search engines, day after day (many times multiple times daily) - combined with more and more student loan payments being auto-debited as the days stayed devoid of sunshine ... you get the picture. Little by little, negativity begins to replace the fresh enthusiasm of graduation; did I really just sacrifice three arduous years and an incredible sum of blood/sweat/tears/trees/memories/etc (not to mention indebtness to the good old Department of Education/Loan Repayment Program), only to continue to work very part-time as a labor and delivery nurse?! Am I undesirable as a CNM?? Is there something that screams "don't hire this girl, for pete's sake!!" on my resume? Do I need to eat more chocolate - will that help??

So - anyway. It was a long couple of weeks, and maybe that post reflected some of that. In the end, I resigned myself -- or liberated myself -- to the old "letting go, and letting God" (or the Creating, or the Universe, or destiny, or karma, or what have you... I'm not entirely sure, myself) take over.

And - it worked.

Not long afterwards, I heard back from the site that seemed like it could be the "perfect" fit (we'll call that site "North" for the sake of, well, easy-ness). It turned out the midwife's mother had been ill and unfortunately passed away; that had prolonged the interview process, but ultimately within the next week or so I spoke with the midwife and HR folks, and set up a time to go up and meet them all in person and tour the site. I also sent a CV to a second site - this one a private midwife practice out west (we'll call this one "West" for those of you following along), and had some nice back-and-forth communications with them via email. After my first Skype interview (interesting enough), I was invited to fly out there and meet them in person as well. Both visits/meetings went great, and now I sit with one likely offer (from "North", pending the approval of one final committee) and a call back next week from "West", where there were still 2-3 other applicants to be interviewed.

My dilemma may or may not be solved by next week's call by "West" ... but that's another post!

Friday, January 27, 2012

The Abyss

I waver between two different realities. One, I stand on the edge of a total, all-encompassing darkness. My bare skin is chilled - goosebumped - but invigorated. Behind me is all I know, everything familiar, the things that have always been. In front of me is... what? Nothing? The steep, sudden chasm at my toes should frighten me, yet I feel nothing but an overwhelming sense of calm now; that fear - fear that should envelope my entire self - has vanished along with the light from this space. I know that to step off could end everything - but it could also be the beginning of everything. With the slightest step into the unknown I will open my wings and fly to the place of my dreams, or simply land where I'm meant to be: a pillow of soft clouds, the waiting arms of a One who created me, or the place of my family's future. A soft wind's push, a strong legged-leap, a quick stumble... any of these things would move me on, and yet - I pause at the edge of the question marks beyond.

Then there's the second place; the place where the Fear lurks. Down a constricted, narrow earthen tube - barely wide enough to descend, long enough to make the late afternoon light little more than a tarnished penny above - lies the insignificant yet crucial room. Constructed of thick steel, lined in double layers of thick and splintering wood, barely larger than a bathroom stall (and certainly less than five feet tall)... it smothers, it suffocates, it shrieks. Time stands still at the same moments that it races by; in the silence of the box, the deafening darkness threatens me with insanity. I stand at this fissure, knowing the only way to complete this journey - to pass this test - is to descend the long ladder downward, to endure my time inside with my Fear, and fight my way back up and through the long, tight passage back... and I struggle, I fight. I know I can do it, and I know I should do it - go down, do my time, and emerge victoriously, proud of my dirt and raw, rubbed skin; I know the struggle is the true origin of my Fear.

And yet - I still stand here, at the edges. Aquiver.

Monday, January 2, 2012

The Most Wonderful Time of the Year... ~ Or ~ When Things Look Bleak (But Aren't Really That Bad, Right?)

A happy and blessed Christmahanukwanzakah and New Year to all! Pardon my hacking as I make it through the six weeks of dust being knocked off the blog as I start typing through this post *blush* ... (I guess it's been a while. Oops.)

Where've I been? Bouncing between the new-found freedom that comes with ((drumroll please)) no more schooling, the excitement of two Mini's and impending snowflakes and thoughts of Christmas time, and the gnawing concern that my baby-catching days are becoming further distant with each day that passes with no job opportunity at hand.

(Now, this post isn't meant to be a mopey, woe-is-me sort of thing... what fun is that?? As you may have gathered from previous ramblings, it may just lazily wander around this topic and - hopefully - come to some sort of resolution by the end. Over the past week or two, these thoughts have built into a strong mental blizzard, worrying at me like a six-year-old wiggling a loose tooth. It's amazing, though, how cathartic putting such thoughts out into the universe can be... I'm looking forward to that sense of peace that I know I'll find after hitting "publish" and sharing this with the world, even if no one actually reads this blog any more.)

Anyway - back on track. No time for anxiety or worrying too much about the job situation in the first weeks of December; our family celebrates Christmas, so between the holiday preparations themselves (taking the Mini's out to my dad's to find the 'perfect' tree, then trimming the tree and decorating the house, etc) as well as holiday concerts for both girls, cookie baking, the traditional trips to see the big red man, and all the other festivities, I was content to wait. (As of the first of December, I had contact with both Dee and the physicians I work with considering adding a CNM; I also had an interview lined up for a part-time CNM position at a family planning clinic...) It was only after all of the "fun" ended - including the last-minute shopping runs, an unexpected slippery couple of inches of snow (pretty to give us at least a bit of a white Christmas, festivily enough --- but oh-how-slick!), and a surprise attack of fevers, aches, and slug-mimicking for the Mini-est - that everything caught me. And by everything, I mean everything. I realized that just about ALL of my student loans were suddenly coming into repayment (which, considering I have not only my graduate school loans to repay, but also those for my ADN-to-BSN bridge program, and my ADN program, and the assortment of loans I had as I was waiting to get into a program... it sucks. Did I ever tell you the story of how it took me six years to get my 2-year associate degree, by the way? Good times, good times....). My student loans, and the Christmas bills (which, of course we tried to go low, we ALWAYS do... but isn't this how it is every year?! Suddenly *someone's* favorite team is selling 'stock' - which by the way is non-transferable and pays no dividends, but does look good on the wall... and who else owns a piece of America's team, right? - and this other thing is on the best, most SPECTACULAR, *AwEsOmEsT* SALE EVER!!! so it needs to be bought now... but if s/he gets that, then of course this one needs this, and yadda yadda.... Oh hey, isn't this Brazil?! How'd we get so far off track here, and can I even use these sweet new snowshoes south of the equator? Where's that map?!) are coming in, and no one was as excited with the gifts that I worked so hard to get *just right* for them, and I was exhausted, and my schedule at work wasn't right and I ended up bawling like a baby because I was exhausted when I saw it to begin with (and I HATE crying, especially when I'm upset/angry/trying to discuss something...) and why was I on a night shift to begin with on Christmas Eve night - my holiday is Christmas Eve, evening, arrrgh?!? and it was just the longest week ever.... and so on, and so on.

And it just kept going. And the family planning job, that I thought I had interviewed fabulously for, apparently was a big bomb. Was it exactly the perfect job I wanted, and was I a wonderful candidate who interviewed like a rockstar? Uh, not so much probably - but on the other hand, I thought I was pretty good and would (all in all) fit in well and enjoy the job. The biggest downside, of course, was the no-baby-catching. My biggest downside - I thought - was that in my typical fashion (ha, ha, pun ahead!) I neglected to actually try on an outfit for the interview until 11:30 p.m. the night before, and the outfit I planned to wear - a sweet little black and teensy, thin blue pin-striped suit... - had somehow gotten a couple of sizes too big (!%@^*), leaving me flustered in the wee a.m. hours trying to decide if I would try to pull it off with some sort of cinching (sans belt loops, of course) or go a little more casual. Anyway, it's starting to look like we're in the tropics again here, so I'm going to leave the interview territory and my fashion deficiencies (for proof of my fashion sense, see right), and go back to my other worries now.

I was assured that I would hear back in about a week about the position, and truly did expect to; the clinic had been short-staffed for awhile, they needed help, all the signals I picked up were a 'go'. I waited... and waited... and waited... (and sent a 'thank you' email...) and waited some more... and nothing. No "thanks, but no thanks" call, no polite "we've gone another way" rejection letter, nada.

I've also just been hanging with both of the nearby clinics; I emailed Dee a few days ago, gently hinting that I'd love any updates if she had any from her clinic administrator (who had started the process of checking into adding another CNM around the end of November, and had thought she would know more one way or the other in three weeks...). Checking my email neurotically - the one where messages from either Dee or my current physician group would contact me - doesn't seem to be doing much more than giving me little blisters, so I'm at a loss. It seems to be a fine line between being pushy, persistent, and the perfect amount of persuasive... it's just so difficult to read where things are at.

At this point, honestly, I'd just love to not be in this no-man's land. If all three (really, just the clinic groups - I've more or less written off the family planning clinic, although I may call the director just to touch base) facilities would just give me an answer, one way or the other --- I'd be happy, even if it's not the answer I really want to hear.

Even working as an RN in L&D is getting to be a struggle now. It's difficult to not step on toes, and to remember my scope of practice... and I miss being the midwife, making the calls, being able to do (and not do - or to be able to say, "we're not going to do this - we don't have to do this, everything is fine.") ... or if a baby is coming too quickly for the physician to make it, having to try to stay back and have another nurse 'catch', or have a mama try to not push --- one of the worst feelings in the world, and not good for mama or baby --- to provide the assurance needed to everyone that I wasn't trying to "take matters into my own hands" on some level. Awkward, awkward....

Soooooo, about the IHS.... 23 pages of application for *possible* loan reimbursement, if funds are ever available? Oh heck, why not. What else do I have to do???