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...