two minutes

two minutes 

Two minutes is nothing - a wait in the drive-thru line, a skim through an email inbox, the tidying of an unkempt living room (my life with two schoolage kids). A phone call with an expectant woman. The time between two contractions in hard labor.

And yet, two minutes can stretch into eternity; when you have to pee, and the person in the stall is (apparently) spending her jolly-good time methodically counting out the toilet paper squares into a prime number equal to or greater than 167. When it's *almost* time to leave work - but not quite. When it's just about bedtime, and someone, for some strange reason, taught your offspring how to tell time (leaving no chance of tricking --- um, convincing --- them that it really, TRULY is 8 p.m.).

Shoulders.

Any midwife, nurse, doula, birthing woman, goddess with a vague idea of the birthing process may have had an involuntary squeeze in the region of their kegels right there (sorry for any men that might have stumbled upon this particular post --- not sure what kind of physical response will be manifested there!). Shoulder dystocia --- or "shoulders" in the lay terms (that is, talk-fast-because-there-is-no-time-for-the-extra-three-syllables-dammit-get-the-stool-and-get-ready-for-suprapubic-pressure-NOW!!!") is one of the most terrifying, unpredictable, ready-or-not-here-I-come complications that may occur during childbirth. Sometimes you can get an inkling that shoulder dystocia may occur --- moms who have had previous deliveries with the complication, babies that are 'known' (* I could argue this "point" on and on, but we'll just leave it!) to be large, whether from serial ultrasounds or hands-on measuring, suspected pelvic anomalies, funky labor patterns --- but in the vast majority of cases, it's not until the bitter "oh meconium!" (midwife joke - hahahaha. sorry...!) moment that you realize just how deep things are going to get.

Backing up a tad, a quick refresher on shoulder dystocia. If you know all of this, go ahead and fast forward through this part. It's a bone-on-bone issue; while the first instinct one may have may be to cut a big ole episiotomy, few shoulder dystocias will be resolved by this. (The only benefit of slicing the vaginal tissue is to allow theoretical "roominess" in an otherwise snug tight area... more on this soon.) So what happens in a shoulder dystocia, for heaven's sake, if it can't be fixed with a big scissors and blood gushing everywhere?!


(Sorry if that sounded overdramatic... I imagined crazed readers, confused with the thought that a 'pis could fix everything, wildly glancing around at each other trying to figure out what the heck was going on here. I may have illusions of grandeur going on here. Also, there are a few people who could attest that though there was no snipping or clipping at any shoulder dystocias I have presided over... they still end up looking like massacres. In fact, all of the births I attend seem to resemble the Battle of 1812 for some reason. Let's pretend it's my own small rebellion at the outdated hospital curtains and furnishings, and little by little, I WILL get them all replaced...)

 Anyway. Woman labors, baby progresses through the cardinal movements (if you aren't familiar with these, I encourage you to do what any sane person would do and google that #&*%! In particular, look for some of the great videos out there, as well as the sites verbally outlining the process. I LOVE the Spinning Babies website - http://spinningbabies.com/about-spinning-babies/390-how-do-babies-rotate?start=1 - both in general and for their nice description of the 7 cardinal movements). So, in a nutshell, the baby has to do some funky dance moves during labor and delivery, and so does mama*. Things tend to go okay if both partners are dancing together and to the same music, but if someone's hearing salsa music and the other is into those love ballads I associate with my junior high dances and sequined, cheesy dresses (think "Stairway to Heaven" with a rapid latino underbeat), things aren't going to work as smoothly as you'd like. In this awful analogy, the love-ballad may be a mom who's not coping with the intensity of contractions, or is *too* relaxed with an epidural on board, or whose uterus is putting out wimpy little contractions for whatever reason (an effort to induce before her due date, or what-have-you). So the dance is on, but it -again, oddly reminiscent of that 8th grade homecoming dance - looks like the short kid with pimples and the gawky, tall girl with braces trying to slow dance to "Mambo No. 5". Then, on top of everything you could have a pair of left feet (does it matter if they're mine? Does it? Does it!?! Oh, wait... Back to the present....) --- or a less-than-ideally-designed-pelvis (did you know there are four basic pelvic types, with each one possibly predisposing babe to "fit" a different way? True story.), and things really get fun. Or not fun, depending on your sense of humor.

So, anyway, the dance is on. If you're rockin' out with a first time mama, the first movement (engagement) could happen days or weeks before labor ever kicks in; with moms who've been to the dance before, it might not happen until somewhere after the punch and crackers are served. Not too big of a deal either way, except Mama will need to find the bathroom more often once it happens, so be ready. From then on out, the dance starts to resemble more of a tuck-and-roll kind of craze; the babe needs to curl up in a snug little baby roly-poly bug (but cuter and covered in amniotic fluid yet), chin to chest - this is known as flexion; next the snug little bug head continues pressing down on the vaginal floor (descent) while rotating into the ideal position to pass through the pelvis (internal rotation). Once through the pelvic arch, the babe's neck extends (appropriately called extension!) and within moments her body rotates - or "restitutes" - to face either maternal side (rather than face down as her face had delivered), allowing first one and then the other shoulder, followed by the rest of her lovely body, to slide under the pubic bone (expulsion). Beautiful! Angels sing! The Macarena plays, everyone dances in unison, arms undulating, baby crying but doing so rhythmically to the music. A successful, textbook birth!

Except when it isn't, of course. Sometimes, for whatever reason (see that bad-dance analogy above...) some of us are tone-deaf in relation to music itself, some of us unfortunately get set up for bad labor/delivery/birth experiences, some of us are blessed to be "lucky" when it comes to baby-birthin' - and (I'm a firm believer in this) some of us are just not quite as lucky. For anyone who gets set up with a bad mix of techno and 1970's country, it can get messy fast in the birthing room. Many times labor will progress veeerrrrrrrrry sllloooowwwwwwwly - but not always. Same thing for pushing - it might take hours and hours and hoooours - but not always. Usually it will be a first time mom - but definitely not always! Sometimes after the delivery of a squashed little eggplant head, it will appear to be sucked back in (the ominous "turtle sign") - but not always.

Once in a while, it seems the baby gets messed up in his dance steps somewhere. Maybe that extra "left" shoe of a pelvis coaxes him into rotating before he descends fully, or somewhere along the line something (toss in whatever you can come up with here ---- history of childhood sexual abuse? chronic low back pain? anesthesiologist who is "on the floor but ready to go home now, so if there's any laboring women who want an epidural, now is the time, and I don't care if she's only 2 cm!"? artificially-strong pitocin-augmented contractions for SROM for 24+hours sans any symptoms of infection? etc) led his mama to get an epidural rather early along the line, leading to weaker-than-expected contractions that needed to be kickstarted again after the anesthesiologist left. Wimpy uterus, lax lower abdominal and pelvic floor muscles = no resistance to encourage flexion.... ? Someone encouraging mama to push too soon ("Oh! You're 10 cm and you don't feel a thing? Let's get you pushing!") or staving off the urge to push ("No no no! Oh no you don't ---- you can't deliver here, not without Dr. so-and-so, what if you had a bay-yuh-bee?!?!") for too long?

Once you have a baby head, and no sign of shoulders emerging --- you have trouble. You call for reinforcements - as many nurses as can roll into the room (something akin to the clowns trying to fit into the tiny car, only with fewer airhorns and absolutely zero humor), your back-up provider, a stool, a pediatric/NICU team if you're lucky - and jump into the HELPERR mode. Believe it or not, this does not mean looks at your helpers and then run like crazy from the room --- but rather calmly and systematically roll through a series of steps meant to (hopefully) dislodge one-to-two sticky little shoulders from one stubborn little pelvic ridge.  After getting that extra help, think about that episiotomy (what the whaaa?), legs waaaaay back, and ask a nurse to nudge babe's shoulder from the outside; if still no-go, you have to take things to the inside (which is where the episiotomy may come in handy - the vaginal opening is only so large, and in order to introduce the bulk of your hands into it, along with sufficient room to work with the fetal body.... you may need a bit of extra space. May.), and/or try to slip the posterior arm out. For some reason, many sources list "reposition" as one of the last "R's" in the handy-HELPERR mnemonic --- even though this can often open the pelvic diameters sufficiently to allow the babe to pass without the use of the  more invasive measures, and even women with epidurals (depending on the depth of the anesthetic block) can many times do this with assistance. Anyway. As an afterthought - and I hope that it rarely, rarely happens - mnemonics usually list "replace"... as in, try to hit the "rewind" button and get the baby's head back through the vagina and cervix, and rush to an emergency (like the ultimate, beyond-emergency-emergency) cesarean.

I've got no good answers, and suppose I've rambled on far too long, and far too far from the original point of this post. Suffice it to say, shoulder dystocia is (a) need-a-bath-and-a-good-stiff-drink (except you'll probably still be on-call, so good luck with that) scary, (b) thank the heavens/god/creator/karma/blogspot/nursing directors for nursing staff trained to jump in like they do it *every* day and be amazing when it happens (as well as to switch out non-scrubbable furnishings like nobody's business), and (c) watch out for those sneaky, rotten little roly-poly babes and their shoulders; they'll get you every time! Thankfully - the majority of shoulder dystocias - when handled appropriately (which includes the provider staying cool and calm -*not* anywhere reminiscent of my prepubscent dances - and great teamwork, communication, and dedication) end with a healthy, albeit crying little pink bug (and midwife). What more could you want?

*warning: bad analogy ahead 

**Genetics, biology/anthropology, diet/exercise, knowledge, mind-over-matter, all of these or none of them, whatever - but I do believe that some of us just are "luckier" when it comes to birthing. That being said, those of us who care for birthing women have the largest responsibility in ensuring that we do all that we can to level the playing field --- avoiding unnecessary inductions, minimizing interventions, providing the education and support that's not there.

what the what, Hudson?!

Please see Stand and Deliver's recent blog post (http://rixarixa.blogspot.com/2013/03/support-patient-autonomy-breech-birth.html?showComment=1363060400394#c2198476714344743307) regarding new restrictive policies at Hudson Hospital in Hudson, WI. In a nutshell, the hospital is severely restricting the practice of its birthing staff, specifically mandating cesarean birth for all breech presentations (which were previously able to be delivered by a provider with many years of experinece in vaginal breech birth), as well clamping down on VBACs, waterbirths, etc. Below is the letter I'm sending out tomorrow in response to the new policy --- won't you join as well? (Also, please note that Rixa at Stand & Deliver is having a giveaway to thank those who join the campaign advocating for the women who delivery at Hudson --- join in!!) "Dear Ms. Hegelberg, I am writing to you in regards to the recent policy change in relation to birth practices at Hudson Hospital. As a certified nurse-midwife providing care to women throughout the lifespan, I am deeply saddened to learn of the new stance being taken by the leadership and administration at your facility, specifically as it relates to the withholding of informed consent to women during childbirth. According to Hudson Hospital's own "Patients Rights and Responsibilities", provided to each patient upon entrance into the care system, your patients are assured the right to be informed of care options, treatment plans, and alternatives; similarly, the document ensures patients they will be given the opportunity to consent to any procedure prior to its undertaking, as well as the right to refuse any treatment with informed consent. According to the newly released policy, the practice of employing medical interventions is a national standard, and implementing this will allow Hudson Hospital to become consistent with other regional and national centers; yet I am aware of no other facility which denies a patient the legal right to refuse any treatment which he or she deems unnecessary or inappropriate after receiving informed consent. Please recognize, Ms. Hegelberg, that this is a legal and moral right of all competent, informed individuals, and denying it would appear to be treading on a very fine ethical boundary. The announcement that Hudson hospital will be forcing medical interventions on women and infants, regardless of their informed consent or screams of refusal, is unacceptable. As a healthcare provider, I recognize the increasing pressure on providers to perform flawlessly and prevent any errors; I have heard far too many lectures on risk management "from leadership's point of view". Whether these measures are being initiated following increasing insurance rates, in an effort to increase reimbursement rates, or to avoid hypothetical bad outcomes (which according to multiple research articles are much more likely with surgical birth) - they are directly in contrast with Hudson Hospital's purported commitment to providing "excellent patient outcomes". I urge you, and the rest of the board, to reconsider this ban on vaginal breech births, increased restrictions on water births, and forced interventions. Should these restrictions stand, I strongly consider you to make all changes publicly known to the women who have utilized your facility in the past; relying on your obstetrical providers to relay this information to the women and families who will be most affected by these alterations (and who may be most likely to change their birthplace as a result) is neither fair nor appropriate. With respect for the birthing practices that have made Hudson Hospital a supportive, welcoming haven in the past, I will await your reply in the days to come. In the meantime. I will recommend other facilities (including those who support vaginal breech birth, particularly with the experienced hands of skilled providers as recommended by the 2006 American College of Obstetricians and Gynecologists statement on the practice) to area women. Sincerely, {{me}}

surprise!

A recent CNN article demonized a Pennsylvania doctor who is accused of providing abortions to women in what are described as incredibly filthy, dangerous, deplorable conditions ( http://www.cnn.com/2013/03/04/us/pennsylvania-gosnell-trial/index.html). Records show that the terminations occurred well after the legal cut-off for abortion, and that the man and his staff repeatedly manipulated records and communication with clients to portray pregnancies as being within the legal allowable limits. Without going into the more gruesome, heartwrenching accusations of the story - nor the spectrum of sociopolitical questions that it raises - I have to admit that I got caught up in the "comments" section of the article. (A bad habit of mine --- trying to defend what I see as the under-defended, unheard, unspoken --- and getting riled up by the trolls who exist simply to do just that online, it seems!)

One comment that particular irked me came in response to a comment I made which offered some defense of the women who may have sought this man's supposed "care" (I use the word lightly --- as much as I wish to presume his innocence until court proceedings are complete... the mama/baby lover in me is broken up reading and hearing the stories of the women who survived procedures at this clinic). In the midst of hundreds of comments calling for the women who had been victimized to be charged with murder, I related that for many women, an unintended pregnancy is not just a momentary emergency or stress that can be more or less resolved once the shock has passed, and resources found, support gathered; I posted details that had been published in several news outlets previously (the story had broken over a year earlier) to clarify that many of the women had been deceived into thinking they were much earlier into their pregnancies, and that several related stories of being forced against their will into completing the procedure after having second thoughts.

Following this plea for understanding and empathy, another commentator argued (repeatedly) that "the idea of 'unintended pregnancy' is the most ridiculous thing I have ever heard" (or something similar - I cannot pull up the actual thread today). This particular person's feeling was that by engaging in sex, the woman was asking for pregnancy and therefore responsible for the intention of it when the pregnancy did occur. And, as with any argument - there was no negotiation. According to my newest friend, the purpose of intercourse is solely procreation; sex = babies, and for any woman to deny that fact - or to deny the product of the act, specifically, by seeking an abortion, is absurd. If you're having sex, suck it up and have the baby, apparently.

Clearly, contraception may be a moot point for this fellow (for the sake of convenience I will imagine this poster was a male, although it may have just as easily been a woman of course). The argument that women who take EVERY single precaution to avoid pregnancy can still become pregnant was irrelevant. You know, like the woman who is taking oral contraceptives (which are supposed to be 95%+ effective --- so pretty darn good --- and doesn't miss a single one) and still ends up missing her period, and ... surprise!! Or, the couple who religiously uses a condom every single time they have sex --- but apparently there is a failure... surprise!!! Or... the mom who has an IUD placed (the one that is 99% effective...) yet still ends up with you-know-what ... surprise!!! Or --- these are always my (not) favorite --- the mother who *just* gave birth, is coming back to the clinic in two weeks for her first postpartum checkup to discuss contraception (and was under strict instructions not to have anything near her vagina until then for several reasons, including but not limited to increased fertility) --- but who is pressured (or forced?) into sex within a few days of birth... surprise!!

And that doesn't even go into the *unusual* cases --- you know, the incest cases, the rapes, the pregnancies which result from forced prostitution or that risk a mother's life...


What would a "surprise!" be in your life? Ten years ago, it would have been --- a surprise, all right! The Warm One and I wouldn't have been married, but I imagine we would've figured it out. Our families may have been a bit disappointed, but as with most families I think a baby can be enveloped with love and understanding --- especially given that (at that point) we had been together several years, well into our college educations, and stable for the most part. A struggle - but okay. Five years ago? Well, five-ish, years ago, anyway --- the Mini-ist would have just been born... the surprise would have been completely overwhelming. I was deeply buried in the shadows of postpartum depression, begging my provider for help and barely mentally/emotionally/spiritually alive. The presence of another life - even the glimpse of that thought in the year ahead - may have been enough to topple me over the precarious edge that I teetered on. Today? A surprise would test us, again, in many similar ways; the fear of coming to that same cliff, pulling the Warm One and the Mini's along (much less another blessed life) terrifies me.

Yet, if my 99.8% effective contraceptive method failed, and our path in life led to these hypothetical crossroads? We'd deal, I think. The same comforting thoughts that come to me picturing that surprise 10 years ago kick in --- family, the Warm One, faith in "what will be, will be..." Somehow, I think, a child would be loved. My sister and her girlfriend? My brother and his wife? Here, with us, to affirm my own faith in my body and mind --- that I am not broken, that I can be a mother even in those first hard weeks when everything fell apart last time?

And then I think about the women I see, and the differences in what a "surprise" means to them.... less food (or no food) for the children they have. Beatings from their partners. Knowing that the growing life in their body is being bathed in chemicals as often as they take them in. Another child,longed for --- only to be taken away "to a better/safer/cleaner home". Lost hope.

How would your surprise fit?

If

 If

If you've felt the release of the shoulders
then the weight of your babe in your arms...


If you've caught a nine pound son,
or the tears in his father's eye...

If you've grasped the hand of a laboring mom,
then stroked the silky hair so long awaited...

If you've walked away soaked to the knees in birth,
filled to the brim with hope and light...

If you've waited hours and hours with those unknown to you,
then rejoiced alongside to meet the one newest to all...

If you've met the eye of the wise, scared, strong mama,
and seen the deep wisdom in her new babe's gaze...

... then you have had a delicious delivery.

This is one of my *favorite* birth images... I don't know if it has an actual name, but is attributed to Ina May Gaskin and (I believe) the book Spiritual Midwifery. (Which reminds me, I am soooo overdue to do some good, non-work-related reading...!) Someday, sadly enough for the Warm One, this will end up permanently inked somewhere on my skin. The question is, where...???

Winner, winner...

... Chicken dinner?!

Sorry to post late, but I promise I really did determine the lucky pendant winner on 2/28 as promised. And, according to the roll of the lucky pinkish-red die (it was a nice, small pool of commenters & "likers", so this worked out perfectly!), I'm looking forward to packaging up something pretty and sending it to ...

(( drumroll please ... ))


Reply #1 (it truly is the 1 spot on the die, despite the awful pic making it possible to see --- congrats Rixa!!

But wait!! Since everyone posted such lovely comments & I need an excuse to avoid laundry (shhhh --- don't tell the Warm One!) any of you all who posted a reply or commented/shared on FB about or since the initial "birthy beauty" post will receive a little something with my thanks!

To do so, though, I could use a bit of direction... So email me your mailing address at hebamme82@gmail.com within the next 7 days. I promise I won't stalk your home, spam your email, or otherwise abuse this info :)

tomorrow, tomorrow...

... it's only a day, aaaawaaay!

(and do you remember that tomorrow --- pending any full-moon-babies! --- i'll send a lovely pendant to someone, just for fun?  really, just because i LOVE sending packages, and because i bought these pendants months ago with the intent of sharing TheMandalaJourney's gorgeous birthy art... and they still mostly sit unseen.  Not cool!)

If you want to be in on the fun, post below - or on any of the posts in the last week or so - and we'll go from there.  (see the "Birthy Beauty" post from Feb 19th  - http://www.onedeliciousdelivery.blogspot.com/search?updated-max=2013-02-24T19:53:00-08:00&max-results=2 -  for the nitty gritty on this, but it's pretty simple, really, and it's looking like a small pool to play in!)

'round & 'round (the circle we're in)

Yesterday the bigger Mini scrawled a whole page full of 8's, and over and over we discussed each one, deciding which was our favorite, our least loved, the most aethetically pleasing, that sort of thing... exactly the way you like to spend time with a girl of about that age.  At one point or another, I spun the dry erase board a bit and rambled on to her about the magic of the infinity symbol and loosely tied the concept into our conversations throughout the rest of the day.  (It's important to remember here, in case it hasn't been mentioned before, I am not a math geek ...  my knowledge of the infinity symbol and the whole "no beginning, no end" idea is mostly gained from jewelry commercials, that sort of thing... but it was still very cool when the Mini caught on to the idea and tied it onto the fact that circles also have no beginning, no end.)

Like health. Like parenting, or life itself, really (when you think about it, can you pinpoint a moment when your life began? What about when it ends?) ... one way or another, for better or for worse, beautifully or morosely, all of these things will blend seamlessly into each other like the sands of the desert for most of us. We can mourn the changes and losses as they happen, fear the uncertainty that lies ahead, or embrace the moment we have.

(Wow. Lying awake at midnight, post-migraine meds, makes me wax philosophical!)

Wait! There was an actual midwifery tie to this post, I promise. Before I veered off into the hazy lands of half-sleepytime dream talk (oops, there I go again), I meant to talk about the beautiful, uncertain, chaotic orb of life. So much of everything seems to revolve in such a cyclical pattern (I'm trying to avoid breaking into "circle of life" a la Disney and The Lion King here...); whether you call it karma, fate, luck, gas, whatever --- what goes around does seem to come around. Pregnancy is no exception; countless cultures celebrate feminine goddesses, ripe with child, as evidence of rebirth - from death, to birth again. The gravid abdomen, round and splendid, is exalted and rejoiced.

In our modern times, we still go 'round and 'round. With all the cutting edge technology, evidence-based medicine (in theory), and "best case" scenarios --- we still meander our way through the same beautiful, uncertain, chaotic orb. We can do all of the testing available (nuchal screening, quad serum testing, even amniocentesis) and expect a baby who will have major chromosomal abnormalities -- and at birth meet a sweet babe with only the very mildest form of Down's Syndrome... or conversely after all of the testing, anticipate a chromosomally healthy baby at birth, only to have a baby born with significant (undetected) other congenital anomalies. Sometimes babies die, or mamas; too many times there is absolutely no good explanation why (or none that can be explained or prevented). Sometimes, on the other hand, babies live and grow and thrive - hormone levels that don't seem to be rising well at all, or ultrasounds that don't seem to show much of anything reassuring, suddenly have an entirely different story just a few short days later. (What an amazing sound that fast heartbeat can be!)

My belief (and I'm quite certain that I adapted this idea, if not stole it outright, from another source somewhere... I would love to cite that source if I remembered where I originally read it...) is that our babies never leave us.  Sometimes, though, it's not the right time - for us or for them - and so they leave us for a bit, until it truly is the right time. Eventually --- even if it's an abortion as a 15 yr old, three miscarriages, and an adoption as a 35 yr old later --- I believe that they always find us. (Maybe even as grandparents.... or neighbors... or anywhere else along the line....)

I'm pretty sure we do just keep going 'round and 'round, and it's all in our own hands, no matter what.

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

Addendum: 

Also, I feel as though I left out a few important details to the "fine print" post. (Mostly, because I usually start writing these blog posts when I'm falling asleep, and then by the time I actually DO write them, they look quite a bit different. Funny how that works!)

Anyway.

My biggest disclaimer? Queen of bad analogies. Like, "pushing is like blowing up a balloon". Right? Because at first you know how blowing up a balloon sucks -- you have to stretch it out with your fingers all crazy (pull it this with and that), then puff and blow and your cheeks get all red and you kind of feel like you could just pass out; you get sort of a headache... then all of a sudden, woosh! there it goes! Isn't that how pushing is?!   (I totally might've stolen that from somewhere too...I probably did...)

Or, how about this one (I think) I just came up with: it's the sunburn-vs-healthy-immune-system analogy. So, if you're healthy, you've got a good diet, decent coping mechanisms for stress, don't smoke or stress your body out with drugs/etc, have good support, things like that --- it's pretty equivalent to wearing a high SPF and probably like a sunhat, maybe even long-sleeve, light-colored shirt at the beach on a super-hot, sunny day. You might feel hot, a little sweaty, but you're fine. If you're stressing your body already (with drugs/smoking, existing health problems you're ignoring, etc), you're maybe sporting some low SPF at the beginning of the day but otherwise nada. If you're dealing with some health issues, overall are NOT healthy anyway --- stressing your body with uber-stress from drugs/AODA stuff, no social support, not putting healthy things in (diet/exercise, mentally), you're sitting there in the hot, glaring sun in a g-string and no sunscreen and frying -- you will suffer every single ray, and an awful lot longer than either of the first two.  (This is my tentative awful analogy for why some people deal with colds/viruses/vaginitis/etc more frequently/longer, etc, than others...)

Oh! And for inductions? (Which, I have probably blabbed on and on about, of course.... another topic... another day, but...) Awful analogy --- Prostaglandins to "preheat" the oven; most likely won't kickstart labor in the same way that an oven at 250 won't bake cookies, but... you never know!

*sigh*

(Don't worry, I've always had such eloquence with words... My hands aren't "cold as ice"...they're "cold as popsicles"...  and such similar oddities...)

The fine print...

I feel like I owe my potential clients a sort of disclaimer, or a caveat emptor of sorts, before they really jump into care with me. Making a commitment to join together - whether for continued primary care or prenatal care - seems like kind of a big deal.  Maybe not quite as significant as, say, a marriage or civil union, but important none the less. The health care relationship needs to be built on a good foundation of trust, openness, and understanding from both partners, and I definitely don't want to lure patients in with a false idea of who I am as a provider (or a person).

Now, I don't quite think I need to explain to them that I am the queen of running five minutes late (no matter how I try, I can't quite to make it anywhere when I need to be there... I can leave fifteen minutes early, and still hit roadblock after roadblock), or that I crave naps more than anything else in the world. But I do want to pass on other tidbits; I want women to know where on I stand on their care what I have to offer them. I want the women I care for to know that I value them, I acknowledge their pain and their history, that I'm willing to work with them.

But.

I also want them to know - regardless of whether this is perceived as negative or positive - that in caring for them, I'm investing in them. (Side note: I'm not very financially literate - I can manage to sign the right forms with my work-related retirement and, um, usually get my taxes filed on time, those kinds of things, but stocks and bonds are waaaaay out of my sphere - yet even I recognize that when you invest in something, financially/emotionally/otherwise ... you want to see it grow and be well.) I want to see my patients be well; I want to see them improve their health, their families, their relationships. I won't prescribe narcotics or any medications that are known to be abusable to a client that is new to me, and I'm very, very slow prescribe them to anyone in general. I encourage, prod, preach, discuss, promote, celebrate exercise and meditation and the "right" diet and good sleep habits and physical therapy, massage, chiropractor, acupressure, so many other complementary therapies. I empathize with chronic disease, mental illness, family struggles, but also emphasize the importance of working to address problems from a multifaceted approach rather than simply a pharmaceutical one.

As a midwife caring for women during the prenatal and intrapartum period, I specifically want the expectant and new mothers I meet to know that I will be with them every step of the way.* I am honored to walk with them, step by step, as they journey through the path of creation, and ready to meet any obstacle along the way together. We will embrace the normal and address the rest, but together. I won't prescribe Vicodin for low back pain, I won't induce at 39 wks "just because" ... but I will be there.

*(I feel like, maybe, I should also warn many of my prenatal women that, at one point or another during labor and delivery, they will all likely hate me... does that seem fair??)

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

Medicines are not meat to live by.  ~German Proverb

Birthy beauty...

... is always more fun than some of these downer things that have been weighing on my mind.  And since I've been wondering if anyone out there ever actually reads this, or if this blog is just a wonderfully cathartic yet unseen release for me, I'm thinking about doing a little something fun.

So, since I've fallen in love with the gorgeous artwork at The Mandala Journey (themandalajourney.com) and may have a bit of a shopping habit there on occasion, I would be ecstatic to give away a sweet pendant. I haven't put enough time or thought into this to actually post a picture of the pendant, but I promise it will be both lovely and meaningful.I will post a picture of the actual necklace soon!

To enter, post a comment below about why you would (or wouldn't!) follow a "birthy" blog... and if you have any posts you've found especially profound; if you "like" OneDeliciousDelivery on Facebook, twitter (@hebammema), and/or share this on Facebook, you can receive an extra entry for each.  Winner will be drawn 2/28.

{{ if, really, anyone is reading --- comments, criticism, suggestion would be lovely. we are not alone! :) }}

His name was Gary...

... and he believed in Santa.He was SO excited for the big red guy to come that night, it was all we heard the entire shift - "Santa? Santa Claus?!" - and thrilled murmurs about presents to come.  Between the palpable joy in his voice and his garbled speech, it was tricky to even understand this much sometimes --- but once you figured it out (or if you knew Gary*), there was no question.

He was pumped.  It was Christmas Eve, and as soon as he went to sleep that night, you-know-who would be slipping in to drop off something special.  It didn't matter to Gary that he was stuck in a hospital bed, miles away from his home, or that there was no Christmas tree, chimney, or fireplace near which his stocking could be hung with care; there was snow out the window and he knew. 

Gary could've been any other six-year old that Christmas, except for the IV taped to his arm and the feeding tube inserted into his stomach. 

Also, Gary was in his late forties. 

Every so often I remember that Christmas Eve shift that I spent caring for Gary; I had taken care of him a few times previously on the Medical/Surgical unit of the hospital during short stays, and was familiar with his cognitive impairments.  Confined to bed or a motorized wheelchair, Gary had severe contractures of his extremities, and cognitively functioned at the level of a toddler.  He was always pleasant, but often confused; I rarely saw visitors, though on occasion he would have an older gentleman or few women stop in, who I assumed to be older relatives. I never met a mother or father, sisters or brothers; whether there simply were no closer family members or they lived too far away to visit frequently is impossible to say. As a nursing assistant at the time, I had little background information; I assumed (and still assume) that Gary lived at one of the nearby long-term care facilities. 

Like most holidays, that particular shift was bittersweet; though it's always miserable to be away from home and family during such intimate hours, there is a certain honor to be able to sweeten those same hours for someone who might otherwise have a much less warm celebration (the trend tended to be lower census on our unit, but there was always a few patients with pneumonia, unexpected broken hips from falling on the ice, etc...).  Once I was able to get past the initial crankiness of pulling away from my family --- this was prior to the Mini's, so in retrospect it shouldn't have been so hard at all! --- I made it to the hospital to find a pretty festive mood on the Med/Surg unit. A potluck was in full swing, carols were playing quietly at the nurse's station, and staff were bedecked with twinkling pins and bright scrubs.

I worked my way through my rounds, passing ice water, dinner trays, helping patients up to the potty and down to bed. Families visited, stories were told, and smiles brightened the halls. In Gary's room, especially, the spirit of the holiday was huge. Every visitor - from housekeeping to dietary to nursing - heard about the REAL visitor Gary was anticipating, and his excitement for "pres'nts?" in the morning.

And, so, we played along. Of course Santa was coming!  "Any sign of him yet? Nope?" "Gotta go to bed early, though, Gary!" "Hope you were good this year!" Each question and every statement met with a beaming, toothy grin from Gary's stubbly face.

It was only at about 9 p.m. that we realized... Would Santa come?  Gary had had few visitors, none that seemed to be a caretaker or close relative... Gradually we recognized what this meant - Gary could awake not only to an empty, stark hospital room (bare of Christmas decorations or cards) but also devoid of any sign that Santa had dropped by. Our hearts broke thinking of the spoils of gifts awaiting us in our own homes. We set out on a search of the hospital, able to procure a few small stuffed animals, a child's book, and a bit of candy (useless to Gary and his feeding tube, but something anyway...) to leave from Santa.

Our meager pile seemed so small, but there was nothing else. I drove around for an hour after clocking out at 11:30 p.m., but in small-town USA just before midnight on Christmas Eve, even gas stations and Wal-Mart close. I considered driving home (an hour away) and driving back, but was uncertain what I could scrounge up. In the end, we left Gary his gifts, decorated with a few balloons and a note from "Santa". By my next shift, Gary had been discharged, and I never really learned how his Christmas morning ended.

~ * ~ * ~ * ~ * ~

I'm not sure why Gary's story is here; it's clearly about as far from a midwifery story as you can get, but it has been on my mind as of late. I think, on some levels, caring for Gary on Christmas Eve was the first true experience I had in falling short of what I felt I needed to do... and yet, considering the obstacles, I feel that we (my partners that night and I) pulled together to make Gary's Christmas morning so much brighter than it may otherwise have been.  

And that, I think, is the true spirit of any caregiver. We may not know it all, we may not have all the tools or resources that we need, we may encounter obstacles beyond our control -- but the heart of our profession is by pulling together as a team, then putting forth the best effort possible so that each person we serve is able to have the most positive outcome possible. (I need to remind myself of this often --- I can't "fix" everyone, prevent everything, or do it all myself  but I'm there, anyway.)

* not his true name...

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...

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 (http://www.huffingtonpost.com/2012/12/16/i-am-adam-lanzas-mother-mental-illness-conversation_n_2311009.html) 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...

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...

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

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...

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.

Oops.

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.

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 

 

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!