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.

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....

And what goes around... (on depression and stress, too)

As they say.

Ebb and flow, yin and yang, yadda yadda. After my little meltdown Friday, things eventually lightened up. (If you've followed the blog at all, or know me, I'm sure you know this is nothing new... or maybe this isn't just me personally, but something that is a natural phenomenon of this thing called life. Maybe it's not unique to mothers, or women, or grad school, or th

ose of us who deal with depression. Maybe it is. Does it matter? Not really.)

Anyway. I posted a similar cry for help, bemoaning my situation on Facebook; basically, that the Warm One was at work, I was at the end of my rope with the girls and had no idea what happened to my patience, and the end of the weekend (the Warm One works a weekend program - Fri/Sat/Sun only, therefore leaving the girls and I to our own devices all weekend) seemed ages away. I was desperate.

And out of nowhere, a good friend came to my rescue. She invited the girls and I over, to visit, to play, to stay. It took us hours and hours to get moving and get packed, but eventually, we got there. She opened her home to us, the girls played (she has a daughter the same age as the Mini-est), and we were able to catch up. We spent Saturday together, just hanging out. Was I the most fun and exciting person to be around? No - but I hope I was a better mother and friend than I felt like I had been earlier that week. Little by little, I am crawling out of this miserable, stress-filled hole.

Before the girls and I left, I managed to pull myself up out of my funk enough to send a copy of my resume/cover letter to the physicians I work with as a labor/delivery nurse, simply to introduce the idea of adding a nurse-midwife to their practice (I've been hoping to have the 'right' moment to talk to some of them about this over the past year or so, but it just hasn't happened); I also emailed my nurse-manager to touch base. My fingers are crossed - even though my breath is far from held - that good things could grow from this tiny seed being planted.

The Warm One also came home last night and shared that another doctor, an incredibly sweet family physician working for a nearby tribal clinic, had asked where I was at with my job hunt; she mentioned that the tribal clinic had been trying to fill an open physician spot for the past year, and she was willing to bring up my name at the next physician's meeting to see what the interest there would be. Again, fingers crossed... I've worked at another nearby tribal health organization in the past, and love working with Native populations. The culture and history, combined with the deep relationships between families, make it a community I would be honored to be invited to work within. (I've requested information from the IHS about their loan repayment program, but have yet to complete the application process; it's on my radar as yet another thought...)

*And, if nothing else - this again cements to me the fact that I cannot - at least at this point in my life - function without antidepressants. I know that there are many different viewpoints on this and whether or not medication is something that is "right" or "necessary" but until I have one or two fewer things going on ... I can't let myself - and my family - go down this road. It never fails that when I manage to go without taking the pills for a short period of time - whether because I fail to get a refill in a timely manner, or because I miss one or two, and then tell myself I still feel "great!" - I find myself in a similar murky fog within a matter of days or a week. Someday, I will be able to truly dedicate the time to find other positive

lifestyle changes to experiment against this headgame, but as for now... I'm gonna take the easy way. I need to be able to accept sweet love notes from the Mini and appreciate them; I need to be able to have patience with my girls when they are being kids, instead of being over-anxious and stressed... I can't see the confusion and hurt in their eyes when they look to me for comfort, and don't get it; this parenting thing is hard. I feel like I hardly see the Mini's lately... and when I do, they're not my sweet little girls anymore! They don't listen... they're sassy... they fight. I don't know if it's a stage, or if it's related to not seeing me, or if it's how it's always been (and I'm just seeing things differently because I'm stressed), or if their actions are feeding off of me, or ...?!

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.)