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.

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...

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 

 

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...

Will work for Food...

Seriously, I will... I certainly have a bit of a love affair with food. Especially this time of year, with the county fair in town: cream puffs, beer-battered cheese curds, funnel cakes.... Oh, my poor achin' arteries.

And summer. I love summer too. (Can it seriously be Labor Day already?! I want to cry! I do *not* do well with winter... sigh...) Anyway.... this blog has clearly been neglected for the past month or so. Oops.

I've been a little busy, to be fair. Since the last time we met, I scratched off each and every last clinical hour and visit I needed to meet the requirements of my program, as well as having a "declaration of safety" submitted by Dee (signifying that she feels I am a safe, beginning-level practitioner); one of my biggest feats was taking - and passing - the first of the last 3 big tests standing between myself and midwifery. I'm engaged, descended, and flexed - now on to finishing the rest of these cardinal movements, little by little...

(was that too corny?!)

From a personal standpoint, things have also been busy. Family life has been hectic as always, with ups and downs. My bigger-Mini started Kindergarten (!) last week, which seems incredible; I still remember the moment she was laid in my arms and the immense feelings of wonder and

awe I felt to be a mother to such a wondrous little being; my Mini-er is beginning preschool this week (and memories of her labor, and birth, are even more vivid; the moments in the shower, visualizing her path down to birth, and the moment when the Warm One proclaimed her as a "little girl"... so clear!). Harder to work through these past weeks have been the continuing struggles with my brother and his own battles (battles which he alone can fight, but that as a family we have been trying to find ways to support him in...), the diagnosis of Lyme's disease in my father, and acute, aggressive leukemia in my grandfather. It's painful and exhausting to see the toll, both physical and emotional, that's accumulated across the family lines in the past weeks and months; through hopes, prayers, and support (and communication), I'm waiting for a strengthening of the bonds that hold us together.

But, back to the "Work" thought that started this whole rambling... I'm starting to think more seriously about jobs again. (It's getting to be time, I suppose. I have one more "school" test - the competency/completion exam, after which I am officially a graduate nurse-midwife, and the final step is the national certification exam). I've realized, after doing a phone interview or two over the past few months - mind you I haven't interviewed in years! - that I need to brush up on my interviewing skills. I thought maybe I'd toss out a few random, jarbled thoughts on here, if nothing else, to help myself sort out a little more about myself (you know how they - "they" being interviewers, of course - always ask about your strengths/weaknesses, what you would like to improve on, etc...)

About Me...

* I'm not there yet, but I'll be there soon!

* I don't drink coffee... but I anticipate that I will start to do so soon...

* I run habitually late (not much, but just enough to be a few minutes late...)

* But - see above - I'm reliably late those few minutes!

* I learn by doing, not by reading/listening

* I'm quiet - but only for so long. I will open up (you may be sorry....)

* I do have a sarcastic streak... and a good sense of humor!

* I may hold back a bit at first - let my confidence build, and I will shine.

* I trust women, their bodies, their intuition, and their abilities.

* I am a very dedicated, motivated employee.

* I can't even come up with enough to write here! Man, I better hire myself out to a farm or

something instead....

Things I've Learned This Week...

* Suturing actual, living tissue is much more difficult than practicing on, say, cow-tongue or a chicken breast. (Or, for that matter, a foam dummy) You've got a mom who can often feel at least some of what you're doing, there's labia and tissue to hold back, and blood seeps into the viewing field (dab... dab... dab...). On top of this, you're wearing sterile gloves which are almost always tacky with blood by this point. And - I'll be honest here, even though I know how 'forgiving' the perineal tissues are and how well they heal - you want it to look nice. (For anyone who hasn't seen the vaginal/labial/perineal tissues of a woman right after delivery - picture a gooshy, glistening mass of ... I don't even know what. I'm only now, finally, I think getting the hang of what goes where. On that note --- any volunteers so I can practice?!)

* There is a huge range of philosophies/practice among midwives - and that's okay. The things I learned with the Midwife and want to remember/use, I can. The ones that I didn't feel comfortable with at all, I can drop in favor of something that reaches the same goal but feels "right" to me. For example, the amount of traction needed to help the placenta separate and deliver, or the choice to leave a mom's perineum and labia alone as the baby crowns (while still reserving the right to support both, and maybe help stretch on occasion, if needed, rather than for every birth).

* You gotta use a heck of a lot of traction to help resolve a shoulder dystocia.... I always fear that I am going to injure the baby when using excessive traction, but when looked at it from a different, more sombering perspective --- a baby with a broken clavicle or even nerve injury, is better than a baby that never is.

* I got this.

Thank God for Midwives

(And mama's, and babies, and supportive dads/aunties/grandmas/friends, and doulas...)

But, at least for me and at least for this week --- thank God for Midwives! If you've followed along at all, you might remember how intense (is that a good word??) things became at my last clinical site. I won't go into all of the details again - because frankly, it makes me feel pretty lousy and I also start to feel a little badly for the women who really want a midwife and don't realize (until it might be too late) when they've actually found a medwife - but it was rough.

Rough on me a student, as a person, and even as an OB nurse. That site caused me to question a lot of things both about myself and the way I have been prepared to practice as a CNM; the Midwife was motivated, she was popular, and she was good. But - she was also (either by choice or by necessity) very much a medwife. As a learning experience, it was good; the four months I spent with her allowed me to begin the hands-on learning I needed to grow as a new midwife, and the last few weeks (along with many, many weeks thereafter) gave me pause to reflect on ways that I myself need to grow my personality to better perform in that role, as well as on the pieces of the Midwife's practice that I did and did not want to take with me into my own practice.

It wasn't until today, though, that I realized how deeply I felt wronged in my previous site. My faculty advisor has been working hard to help me find a new clinical site; this process, which originally seemed as though it would be fairly quick (I had another preceptor in mind, who was happy to work with me) ended taking 2 and a half months. Obstacles with policy, administration changes, and just enough little roadblocks to keep things from progressing have kept my hands from officially (as a student nurse-midwife, that is) welcoming a baby into the world since March 1st. (And it has been kiiillllllllling me!) As things continued to stall, my advisor suggested I come to a site that has welcomed several of my classmates in the past; while at first I was hesitant (as this site is a 3.5 hr drive from home) eventually it got to the point where any site was perfect, and I jumped at the chance. The midwifery group agreed to work with me, the paperwork was approved, and plans were made for my arrival early this week.

And, it has been amazing. Amazing for the births I have attended - 9 so far since Tuesday (and I missed several others one day when I finally had to admit that my body and mind needed rest), including two glorious waterbirths, two VBAC's, and a handful of other triumphant displays of mama-power. Amazing in the fact that the midwives and nurses have welcomed me with open arms, eager to help me blossom as I work my way towards becoming a beginning-level midwife. I've had "scary" moments - a decel that wouldn't come up (while my precepting CNM and the OB on-call were in the midst of a c-section and completely unavailable), a shoulder dystocia that didn't resolve easily with McRobert's maneuver and suprapubic pressure - but made it through them. I've been allowed to be more independent in four days, with four different midwives, than I was in four long months with the Midwife: when our dystocia baby's shoulders didn't ease out shortly after his head, the CNM I was working with that day didn't push me aside to take over... instead, she stayed back (as hard as it must have been) and allowed me to identify the situation as a shoulder dystocia and to work to resolve it. When my efforts weren't quite doing it, and I looked to her for help - she was there. The trust that I've found from these midwives - each of whom I have met for the first time the morning that the call shift begins - literally brought me to tears as I finally took some time today to reflect on this first week. It takes a momentous amount of trust to stand back and allow a student to be in control of a situation - especially one that is as intense as a shoulder dystocia or prolonged decel. I can't even begin to fathom how difficult it is to stay back and just "be", while a student works to resolve something that can so quickly develop into disaster. And yet - the true mark of a good teacher is to understand that without allowing a student to take the next step towards independence, the student will ultimately never succeed, and both teacher and pupil end as failures. In labor and delivery, with the life and well-being of a longed-for baby on the line (as well as the mother's safety), the amount of trust and courage in takes to do this is multiplied ten-fold... with the rewards equally as impressive.

I'm not there yet - a part of me froze up in those tense situations, and it took longer than it should have for the little voice in me to say, "this is what you do... remember?". But the gift of being allowed to wake that little voice up, to do my best, and to know that I had a supportive preceptor right behind me --- rather than pushing me to the side immediately --- was worth more than anything else. Then, the bonus of constructive feedback and open communication - rather than quiet, tired frustration - after each incident: What should I have done? What might have been a better way to do that? And - what did I do right?

As I wrote what was supposed to be a quick update to my advisor, letting her know how incredible of a learning experience this has been so far, I found myself reflecting back to the days with the Midwife and comparing the feelings I had at the end of that rotation (inadequacy, doubt, fear, shame) and the ones that have emerged in just a few days here (confidence, readiness, calmness). Sitting on the back porch of the midwife who so graciously invited me into her home, smelling the lilacs with songbirds for a soundtrack, tears rolled down my cheeks as I typed on and on. Where my hands were rarely able to catch without the Midwife's covering them before, they now have eased 9 new lives into the world with very little guidance; when I reluctantly began to perform certain skills in the way that I had been taught from the Midwife (but had never been comfortable with), I was reassured that there was another way, and that the way I learned was not necessarily the best practice; what had been frustrating in the past (lack of expectations, absence of any real rapport) was nowhere to be found among these midwives.

So, thank God for midwives... the midwives I've worked with this week, who took my hesitant, injured confidence and allowed it to begin to heal; the midwife who opened her home to me, with its peaceful quietness (no television, no cell phone reception) and country beauty; the midwife (my advisor) who spent so much time working with me to find this happy place again. And even the Midwife, who started me on this journey and puts this all into perspective.

My own dystocia...

Dys *to * cia : noun

DYSTOCIA: slow or difficult labor or delivery. (From Greek dystokia)

I'm stuck. Like a wayward fetus or a uterus that doesn't quite have it going on yet --- something just ain't right. At times, I feel like I get in my groove and things start moving along; my rhythm is a-rockin'. And then... something happens to knock me right back down.

This makes me wonder, right from the start, how far back I'm going to have to go to "fix" things. Midwifery is supposed to - and I love this - "high touch, low tech". Me, on the other hand... I'm more of a "high tech, low touch" kind of girl... I've never been a hugger, and I'd much rather text or email than talk directly to someone. (Is it just me, or is it a generational thing?) With all of this stuff--- I can't think of a better term for it --- going on with the Midwife in the past couple of weeks, so many friends have been in touch, saying "Call me", "give me a call", "let's talk!", etc, etc... And it sounds sooo good, and promising... but I can't. I just can't. Instead, I send out a pathetic little email or text, promising to call later, or assuring them that everything is "better" now, or that it's figured out...

(If you are one of those who's been in touch --- I love you, you're awesome... please, please don't take it personally. It's definitely one of my flaws, and - like so many other things I have going on - I don't know how to fix it. Keep reading for more on this...)

The Midwife is picking up on this, at least somewhat. "I don't know how to communicate with you." She says. "I don't know if you're coming or going; you have to tell me." My RCC may have noticed; we have only talked on the phone once or twice, very, very briefly. As much as that one phone call reassured me (she called me after catching on from one of my self-evals that I needed to talk) - I still can't bring myself to call her. I know that I need to be the one reaching out, and yet... I can't. It's difficult to explain.

I know that it is holding up my labor, though; after all I have gone through this far, it is stalling my progress.

This week was, again, tumultuous. The Midwife and I just are not in sync. I can't figure out what she wants from me; we are both getting frustrated. I am trying, so hard, to be there early and to try to do what she expects from me, before she asks or prompts me - but instead, I do the "wrong" thing. My self-confidence is crumbling, and my exhaustion and sense of being overwhelmed is growing by the day. As with Murphy's (or is it Murray's?) Law, the three births that we had this week were all "abnormal" - a shoulder dystocia, a cord that abruptly broke from the placenta (which subsequently required a manual removal), and a postpartum hemorrhage following an OP babe. How much of these outcomes had to do with my management (Too much traction on the cord? Did I let the placenta sit a moment too long at the introitus, letting clots build in the lower segment?), and how much was sheer dumb coincidence, is of course impossible to say. (I know the traction was, if anything, light... and the placenta was *just* at the introitus... but I also believe in the whole positive/negative vibes kind of stuff --- and I have not been riding a positive wave lately, believe me!).

So this is where we are at. As we were leaving yesterday - literally, over the course of about five minutes - the Midwife just barely started to talk to me. She asked if I had any questions, and then said she would "email me" again; then started to sigh a bit. It was good, to the point that at least we had some honest, face-to-face communication. It was not so good, of course, for the reasons above; face-to-face communication is not my strong suit. Between the exhaustion, the migraine that was kicking in, and just everything finally catching up - I started tearing up and was soon blubbering like an idiot --- very embarrassing but, on the other hand, I think a very honest reaction. It, unfortunately, made it hard to communicate any of my thoughts/concerns back to the Midwife, and ultimately made it a very one-sided (short) discussion.

Her concerns (think of them as a bit of Pitocin, if you will - hopefully, they will stimulate me to get moving and back on track): I need to keep her updated with what I'm doing, and I need to be more prompt. (I know these things... somehow, the one-hour commute has gotten worse and worse; staying somewhere during the week and only doing clinicals - and then driving home for the weekend - is starting to sound much, much better... As I described in a response email to the Midwife, my children are like sweet little eels, and they hang on me literally as I'm walking out the door most mornings.) I don't seem interested, and I just seem tired. (I don't even know where to go with this. I am exhausted, and I'm overwhelmed. This ain't gonna change, any time soon...) I'm going backwards. (Again, I feel like I'm going backwards in some areas...?!?!)

So, here we are. I've emailed her back; I need to be in touch with my RCC, but at this moment in time, I just can't bring myself to do it. The Mini-est and I are just vegging for now (I'm thinking a late lunch - delivery?), and that's how I want to keep it for a few hours anyway. I've se

nt out a couple "feelers" to try to find another clinical site for another perspective. I've also sent out a couple of resumes for CNM openings around the state - although I'm not especially hopeful about them (my being "ready" by June came up in the brief conversation the Midwife & I had as well...), it did give me something to do - and managed to shower and get myself and the Mini dressed.

I'll keep you posted. One way or the other, things do keep moving forward... I don't think there's an option of a cesarean in this situation (although, maybe being "taken out" of this site and heading to

a different one could being symbolically viewed that way.... I'm not even going to go there...) If you are the kind of person that does anything like this, I could use some kind of confidence/stress-busting/calming vibes... I know that this is the kind of thing that I make ten times worse myself, and I need to knock that crap off and get back on track.

Speaking of, I need to bring the Bears back out... http://onedeliciousdelivery.blogspot.com/2011/

01/im-scared-to-death.html

but on the OTHER hand...

Today is another day. A new day, a brighter day. If you read yesterday's post, I'll update you to say that both (a) and (b) have been resolved, which might have a lot to do with the brightness of the day... or maybe, it just has to do with the support of some great friends, a good night's sleep (even though, to be honest, there were a handful of moments where

I woke up thinking, "oh, @*$#, now what?!"...), and a belief in something out there that will just let things be as they will be).

The conclusions I've come to -

I am not brand-spankin' new to this - I am not a new nurse, not a new OB/L&D nurse, and not a new student nurse-midwife. I know how to check a cervix, I know how to deal with and support women in the throes of labor, and I know how to assess their well-being.

There are parts of this game that I need help with - that's the point of learning. That doesn't mean, though, that I have to let myself and my confidence in my own abilities be funneled down... whether I'm doing that to myself, or letting the nurses, the Midwife, or the families I work with to do this (and please understand, this is not to say that they are or are not doing it intentionally - so many of these issues I am certain are happening in my own mind).

This is the point where, like the mamas meeting the burning at crowning, I have a choice to make... I need to push through, and birth the midwife within, rather than fighting the same pressures and pains I have had for so long.

~*~*~*~*~

At work recently, one of my patients delivered precipitously... the weather was worse than it seemed, and the doctor's drive in took just long enough that she walked in as the head was delivering. Thinking that her drive would be the "normal" length, I had my mama start pushing and worked with her as I have become accustomed to more as a SNM than an RN; everything was going perfectly and - had the doctor arrived as expected - the babe's head would have been merely a few pushes from delivering. Instead, I caught --- as it was my patient and the ER doctor was unable to make it --- and everything went smoothly, to the patient and doctor's happiness. The entire process was calm, and reinforces my belief that I can do this --- it is in me. In this experience, when I should have been anxious/nervous/antsy/fill-in-the-blank... it was blissful. Even though this wasn't my patient... wasn't supposed to be "my" delivery... and I didn't have my preceptor's watchful eye... (not to mention the niggling thought of getting in trouble, though I certainly hadn't planned to deliver)... it was beautiful, perfect, and right. My hands did exactly what they needed, my mind didn't falter, and any coaching that needed to be done was there.

Self-doubt

Today, as I was driving home from clinicals, I cried on and off. It sucked. This is the email that I was composing in my head, trying to sound appreciative, and not needy but ---- what's the word?? (Not desperate, but close...)

"thanks for your patience this week (and in general), this week in particular just was not impressive and i'm not sure why. the areas that i'm not 'getting' are frustrating to me - as an OB nurse not to mention as a SNM - and it is getting to that point that i feel like i'm losing ground. i know i need more confidence and to be more assertive, etc - but am not sure how to get there from here, if that makes sense. not being able to palpate fetal body parts/find FHT's, determine what a cervical exam is/isn't, how to tell if the anterior shoulder has delivered or not (is that just feel or is there another obvious sign -- does the anterior shoulder become slightly visible before you switch to the posterior?), etc.

i know that these are women and families that you have been working with for a long time and i appreciate that you are giving me the opportunity to learn with them; i also recognize that your reputation and license are ultimately on the line as well and i am grateful to you for that reason and for the advice/criticism/info that you share, because i need whatever i can get to keep going forward.

also, just as an FYI - i know we talked a little about it when A was here - i have been trying to work out another site to get another perspective for at least part of my remaining hours... if/when that happens, i will let you know (i don't know if it would be just for a month or so, or longer/shorter term, etc... do you have an opinion on that?)

thanks again, have a great weekend... ~m"

(Maybe I'll jump in here and say that all of this may be exaggerated by the fact that (a) I'm probably a bit hormonal... I think AF is going to rear her lovely head *any* day now... and/or (b) I've been outta my little happy pills for days and days - so hopefully for us all, the Warm One has picked some up for me and life can cheer up soon...)

Anyway. Back to the post.

And I've been tearing up randomly ever since getting home. I've blogged before about self-doubt and having low self-confidence, I think. I don't think this is a great thing, but may not be that uncommon, either, for a student going into this sort of field... in fact, part of me thinks that being less-than-100% confident may be a good thing. (Isn't some bit of humility, some sort of willingness to admit that one might not know everything, probably good for everyone?) Anyway, I keep getting off-track here.

Earlier this week, I had a rough night with The Midwife. (My own fault) We had an induction, and another labor patient had come in as well; at around 12:30 a.m. the Midwife called me to let me know that the induction was going to be AROM'ed due to some concerns with the baby's heart rate (rather than "slept" and induced in the morning, as was the original plan...). I unfortunately was out like a light when the Midwife called and talked a lot of mumbo-jumbo, making little to no sense about needing a floor to sleep in if I came in and some sort of lighthouse or something --- totally looneyness, until my brain caught up with my mouth. Eventually, I made it in --- I live about an hour from the hospital --- checked in on both moms and caught up on their labors, and then laid down. Suddenly, it was four hours later when the nurses called to let me know that Mom A was about to deliver. Fast forward a bit, Mom A delivers, all ends up well, blah blah blah.... but it just wasn't my best delivery. At all. Mom A froze during pushing, head delivered, and I froze as well; baby was of course delivered and did wonderfully, but Mom A did get a tear and needed stitches, and the question comes up as to how much of her tear might have been avoided. Mom B delivers later, all is well... yadda yadda...

But, the crux of that night/morning was the Midwife's comment (at the nurse's station) that I need "a lot" of work in L&D. That stung... "a lot". Like many things, of course, that sting, it was important and necessary to hear. I do need a lot of work in L&D.

Of course, now, as the week has progressed, those words have been eating at me more and more. I've been walking on eggshells, slightly anxious about doing or saying the wrong thing... and a teensy bit scared to death about going back to L&D with the Midwife. (The irony is that what I was afraid of happened at work - away from clinicals - and went perfectly, without a hitch, in the meantime...) Not so, though, at clinicals... Our next go-round with L&D was tense again; my cervical checks seemed to be off (I don't get how I'm feeling a rim of cervix all around, and the Midwife can only feel an anterior lip when she checks right after me... I swear I have been checking cervices for years. I can, I can!) The delivery - same thing. Head delivers - mom tenses, fights pushing; I have a hard time "catching" when the anterior shoulder delivers... has it? Hasn't it? Time to go for the posterior shoulder now, or keep with the down and out pressure? I can tell the Midwife is not happy with my indecision (easily) but I JUST DON'T KNOW.

Again, baby delivers, all is well in the end... but the vibe, again, is not so hot. I want to talk with the Midwife before leaving, but it's 5 p.m., Friday, my babysitters at home wanted to leave by 5 (and I still have an hour drive...), and the Midwife is at the desk yet. I change, stop to say something on my way out, and she mentions that she will email me with "a few things"...

Can my preceptor dump me via email?!

I'll get you, my pretty... and your sneaky little cervix, too!

For those of you who aren't in the Midwifery/Nurse Practitioner/Medical-kind of fields, I'm going to lay this out there straight - cervixes (cervices? cervix-i? your cervix, and mine, and many others...?!) are tricky little buggers. Oh, sure, sure, sometimes they can be sweet and innocent and just pop right out at whoever may be doing your annual pap-n-pelvic ("BAM!" says your little cervical os... "Nice to meet you, take what you need!"). But, on other occasions - not so much.

Especially, I'm sure - as is Murphy's Law (or possibly Murray's law?) - when the one wielding the speculum is just a wee bit less confident than an NP or MD - or CNM - who may have been searching high and low for the small orbs for years and years. For example, a student nurse-midwife, early in her clinical hours (or, an FNP student, or even a SANE examiner, etc, etc).

Now, as a "good girl" - read that as, "guideline-fearing woman who gets a reminder letter in the mail and promptly grins and bears it"- I have had my share of annual gynecological exams. Honestly, girls... I know, they aren't fun, but really - I've had two kids now, so, I can't complain so much about a silly little plastic (or metal? Is it funny that I can't honestly say what my provider uses? I think it is, a little!) thingamabobber being inserted to allow for one spatula and one brush to gather a few simple cells from my cervix. You live, you learn - and you get scraped. Right?

That being said, I don't necessarily enjoy it when women know that I'm coming at them - as a student nurse midwife (gasp) - with a big, scary metal doodad. (That is, a "speculum"... go ahead, try it! And to tell the truth, the metal ones have really grown on me --- they are nice and warm, they don't 'click' -- eww, right? no one likes the 'click' -- and they don't snag or pinch like the plastic. Anyway, a different topic, for a different day. Back on track...) I know that I don't have the same finesse as the Midwife, and of course so do they. I am immensely grateful to each and every woman who has accepted me for this (by the way, for the few who I have visited with during their exams and mentioned they are nursing/NP students --- my offer still stands and my vagina/cervix are yours for pap/pelvic practice as needed), and I promise that my skills will become gentler and softer as time passes. Wait, wait! Back to the cervix.

(See?! Even NOW, when I'm simply trying to blog about the darn thing, it's avoiding me... what a knack it has!)

I've always thought of the cervix as a nice, perfectly smooth circle; the opening to the uterus. In labor, I know, it gradually opens to eventually - or at least hopefully, and in most cases - allow the baby to birth. It also dilates a slight amount each month around the time of the menses to allow for the shedding of the uterine lining.

All right. Got that. In my mind, when I imagined a cervix - prior to really beginning my SNM clinicals (and the whole tortellini alfredo scene, mind you) - I pictured a perfect, cherry-red LifeSaver. (Minus the "Life-Saver" imprint, I suppose - although that would add a certain comic charm to the whole thing...) The one or two cervices - there we go with that word again, darn plural terms - that I had peeked at throughout my time as an L&D nurse (every now and again we would be expected to do a speculum exam to check for pooled fluid around the cervix, or to do a swab near it to check for leaking amniotic fluid, etc, etc) seemed to cement that image. And, I got no real argument from the DVDs I popped in during childbirth prep classes that I taught, so.... everything seemed right in my little world!

Until, that is, I started with the Midwife.

And realized that cervices (cervixes? cervixi?) come in 103 different sizes, shapes, consistences, and colors. AND they hide. They love to play hide and seek! Who knew?! Up and around, underneath, way over to that corner there.... so many places, and such little area to maneuver the speculum. (And it didn't help that I was focused on looking for that little red Lifesaver for the first two weeks.) Flopsy, firm, red, white, pink, big, little, deep and shallow, innies and outies - I've seen 'em all, and I've barely just begun! I've seen cute, petite little cervices and some that I could care to forget, to tell you the truth. (Not really, I made that last part up --- a cervix really is just a cervix. Do you think a person would really "like" or dislike a cervix? Come on, now!) Sometimes, I've learned, I can play a little game of my own... when the little tricksters are hiding, they leave a little trail of blood and this can be followed; busted!

Now, the Midwife and I are still working on this, of course. We have a ways to go, but I think I'm getting there. I'm 3 for 3 on my last batch of exams, which if nothing else gets me excited. I've caught on to lower the stool right away. I finally figured out how to maneuver the spec with my left hand (not easy for me, at all!) and collect my swabs with my right. My brain and my hands are still playing a little quasi-queasy about how to make the motions that the Midwife explains and demonstrates on scooping and "flipping" the cervix into place. But - I think I'm getting there.

Be --- Aggressive... Be, Aggressive...

(First and foremost, "aggressive" is probably the last word anyone would think to use to describe me. And personally, when I think of midwifery, it's one of the words that seems the least appealing... who wants an aggressive midwife?!)

But. I'm 1/3rd of the way through my clinical hours, and halfway through the births required for my program (woot, woot!). I'm thrilled about that, but still don't feel like I'm "there" if that makes sense. I still feel like a beginner. A pussyfoot. A lightweight. Dumber than a box of rocks. A little slow. Wet behind the ears. Scared. Mumbly, fumbly, and bumbly.

I can't be sure, but I think I lack confidence. A lot of it.

See, I've always just figured I was quiet, reserved; calm, cool, and relaxed. (And, to be fair - I think this is mostly still true; ".....they call me mellllllow-yelllllow....") On the other hand, my preceptor (we'll call her simply "the Midwife") is full of energy, and has been doing this a loooong time. She's got tons of experience under her belt - as an OB nurse (forever), then as a nurse practitioner, and as a CNM for the past decade. She's understanding - but she's driven. She can easily see 16-20 patients a day, plus manage a labor and have a surgery in the morning before her office hours. Knowledge and good judgment spilleth over her cup, if you get my drift; the woman is wonderful at what she does, and her clients love her. She is a wonderful teacher, but I think it's been tricky for us to work out the dynamics of our partnership; the first couple of months have been awkward and have left me feeling somewhat anxious... I'm two-left-feet-and-balding Barney, who was paired with the gorgeous and talented Ginger-Rogers-esque at the local singles dance class. I so want to learn everything from the Midwife (and to possibly build a lasting relationship, or at least a quality reference), but feel as though I just keep fumbling around at her feet.

I need to remind myself to speak up, breathe deeply, and trust in myself. No more light taps on doors - the Midwife tells me, "knock like you mean it!". No more mumbly little explanations - I need to enunciate, and project, when I speak.

(I don't think these are necessarily "aggressive" things, but rather "assertive". Unfortunately, there is no catchy "Be. Assertive. Be-e-e assertive..." cheerleading cheer, so --- aggressive is what will have to work in my little head, from my little midwife-on-my-shoulder cheerleader)

My RCC - regional clinical coordinator - is coming to visit my site in a few weeks. I just learned this today, from the Midwife. I am petrified, for the above reasons. (See also "Scared to Death"). What are the odds that there will be an impassable avalanche that day, or every single patient will cancel? Dang. A girl can hope (and will keep hoping).

This post, I'm afraid, isn't very exciting or enlightening. I'm sorry for anyone who just started reading --- what a way to join! I promise, there may be better things buried beneath... or to come.

Things To Remember: (Not-quite-pearls)

~ the bag of waters really won't break when it's just touched with an amnihook (usually)...

those buggars are tough!

~ the Midwife LOVES her some goo (so I am starting to love me some too)

~ bulb syringes get very slippery when you have gloves covered in goo

~ bulb syringes bounce (and are no longer clean)

~ Pull those legs back and try to give that cervix a little gentle help...

~ Sit on the bed for delivery - not on my foot...

~ Lower the seat of my stool before starting a spec exam

~ Keep the feet off the footrest (I guess it's *not* for me!)

~ A vagina/perineum is a lot trickier to sew up than, say, a block of foam or a cow-tongue

~ I'm learning