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.

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...

Well, here we go...

... the blogging wagon is rolling, and I guess I'd better jump on it. Sh*t, or get off the pot, right? Speak now, or forever hold my peace? (Any other corny cliches you guys can come up with?!)

Seriously, though, everyone is blogging these days. I've been meaning to, forever... maybe since I began my MSN program almost two years ago. Or, at least since I began the "fun" part of it (read: clinical portion) two and a half months ago. Or, at least when the new year - 2011, holy crap! - began a couple of days ago. And yet... it's like pulling freakin' teeth to get this going. What the hell?! So many (valid) excuses - I can't think of a good name, I don't know what to say, who cares what I'm thinking about, am I going to be violating those darned privacy laws, I doubt I'll keep up with it anyway, blah blah, blah, yadda yadda, etc, etc...

So, in honor of the new year - or, to be more honest (one of my new resolutions), to avoid dealing with the Mini's who are fighting bedtime - I'm going to hit these *very* valid reasons head on, if for no better reason than to have a list of arguments for my own little mind, next week, when I'm ready to call this thing quits. Here goes...

All the catchy names are taken. Well, this is 110% true, I'm just plain S.O.L. on this regard. "At Your Cervix", "Speculative Speculum", etc.... taken. (And awesome, by the way --- check them out!) So, with that in mind, I am going to bow gracefully out on the name front. Maybe I'll get into my chosen title another time. Actually, I'm sure I will. But, that's another topic, for another post, on another day. (As a teaser, though, I will promise that I don't - usually - nibble on the newborns. That's all I'm giving you right now.)

I've got nothing anyone cares to read. Oh well! Even if no one reads this blog, maybe it will give me something to do. (Again, see the paragraph above. My Mini's, ages 2 1/2 and 4 1/2, have this silly little habit at about 7-8 p.m., where they need to go to bed, but they get very stubborn and naughty about it. If I'm doing "homework" - which to me, this blogging seems to legitimately be - I can feel better about sharing this duty with my darling spouse, yes? Yes.) Also, to be honest, while I might not be catching the "pearls of midwifery" wisdom that were touted here and there throughout my education thus far, I am definitely picking up some very intriguing facts every single day in clinicals. (Did you know, for instance, that women - many women - can have long hairs growing on their breasts? And that it is INCREDIBLY embarrassing to be doing a breast exam, see one of these said stray, long hairs, and then - as a student nurse midwife who may frequently 'shed' similar long stray hairs - assume that it is mortifyingly your own hair, fallen on the exposed breast, until you grab it gingerly between two fingers and yank, only to realize... Again, maybe not a *pearl* of midwifery wisdom, but I would call it, oh, I don't know, maybe - some sort of nice-looking glass bead, not quite swarovski, but not bad).

And that nasty old HIPAA... The lovely blogger-friend over at "At Your Cervix" has a wonderful outlook on privacy, which I am going to paraphrase (without, unfortunately, giving her proper APA credit - sadly this is too tricky to do with the anonymity of the 'Net. I hope she doesn't mind.) Anyway, if you're reading this and think I'm posting about you, your mama, your sister, or your baby, or your baby-mama - I'm not. See my "About Me" - in my 20-odd, or 30-odd, or however many years I've had in my days**, I've been a...

* Mother, * Daughter, * Sister, * Nurse, * Student Nurse-Midwife, *Nursing Assistant (Nursing Homes, Hospital, and Clinic), * Table games worker, * Waitress, * Cashier, * Babysitter, * Tutor, * Friend... and who knows what all else I've forgotten. I have around 350 'friends' on Facebook and have attended more conferences regarding labor/delivery, prenatal care, obstetric emergencies, and various midwifery topics, than I could care to try to count. I have a terrible memory, which means that even if I try to remember or describe a specific situation - which, having been schooled on the HIPAA regulations many, many times, I wouldn't - I would have no chance. Instead, scenarios tend to be from my own history, stories relayed to me by family members or friends, etc. No patient data is ever shared. All right, enough about that drivel.

You know I'm not going to keep up with this, though... Honestly, we'll see about this one. Maybe I will - who knows! I have some stories I do want to share (a couple of takes on the 'delicious delivery' thing --- a bowl of tortellini alfredo, which I will never be able to eat again --- as well as maybe some other things) and imagine that some other things might just come up.

On that note, I just thought of the tortellini, which is really killing my vibe... *that* story might have to start out the next post... :X

(** does anyone question that I really, really have to think to figure out my age?! Because I do, no joke.)