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...

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...

The Abyss

I waver between two different realities. One, I stand on the edge of a total, all-encompassing darkness. My bare skin is chilled - goosebumped - but invigorated. Behind me is all I know, everything familiar, the things that have always been. In front of me is... what? Nothing? The steep, sudden chasm at my toes should frighten me, yet I feel nothing but an overwhelming sense of calm now; that fear - fear that should envelope my entire self - has vanished along with the light from this space. I know that to step off could end everything - but it could also be the beginning of everything. With the slightest step into the unknown I will open my wings and fly to the place of my dreams, or simply land where I'm meant to be: a pillow of soft clouds, the waiting arms of a One who created me, or the place of my family's future. A soft wind's push, a strong legged-leap, a quick stumble... any of these things would move me on, and yet - I pause at the edge of the question marks beyond.

Then there's the second place; the place where the Fear lurks. Down a constricted, narrow earthen tube - barely wide enough to descend, long enough to make the late afternoon light little more than a tarnished penny above - lies the insignificant yet crucial room. Constructed of thick steel, lined in double layers of thick and splintering wood, barely larger than a bathroom stall (and certainly less than five feet tall)... it smothers, it suffocates, it shrieks. Time stands still at the same moments that it races by; in the silence of the box, the deafening darkness threatens me with insanity. I stand at this fissure, knowing the only way to complete this journey - to pass this test - is to descend the long ladder downward, to endure my time inside with my Fear, and fight my way back up and through the long, tight passage back... and I struggle, I fight. I know I can do it, and I know I should do it - go down, do my time, and emerge victoriously, proud of my dirt and raw, rubbed skin; I know the struggle is the true origin of my Fear.

~*~*~*~*~*~

And yet - I still stand here, at the edges. Aquiver.

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....

Just Pickin' Em Up & Puttin' Em Down...

Yep, I think that's what I'll do. Every day, if that's what I need to reduce my focus to, I can do it - one step at at time. Simple, easy, as little stress as can be. Starting with lifting each foot, and then putting it down again a little bit further ahead than it started. I have a keychain that is engraved "Learn in Baby Steps" --- one of my new mottos, I believe.

Sounds easy enough, right?! I can do this - and I know I will. Patience is a virtue... but it's sooooo hard! The end of this road still seems far off, though I can tell it is getting closer. This week has been challenging; Dee has been out of the office for a much-needed vacation - although you can't really call it that since she is still functioning in a nurse-practitioner role, only volunteering her time (though she is at least enjoying herself I think) - and so I am working with some of her backup doc's and *trying* to make a good impression on them so they will agree that expanding her practice and adding a second CNM --- that is, moi --- is a splendid idea.

From my perspective, it's been great; I've been enjoying seeing things from the MD point of view and also observing visits that aren't typical nurse-midwife cases. However, on Tuesday I was hit by the WORST migraine I've had in a long, long time; the timing could not have been worse. How do you make a good impression, when you go from meeting someone and being eager to soak up all their knowledge to begging to go home with an "invisible" affliction in a matter of minutes-to-hours? It was awful; the worst part was, one of Dee's patients (who I've met several times in the office, as well as in the L&D setting) ended up presenting to L&D that day in labor, and the MD I was meeting that afternoon had offered to let me work with her during her labor. Prior to the onset of my killer headache, I was pumped to be able to follow her through, especially since Dee wouldn't be able to... until, that is, the hot flashes, nausea, and vomiting started while I was still seeing patients in the clinic. By the time I made it home that evening (after pitifully and ashamedly declining to accompany the doctor to see this particular laboring mama), I was miserable; the migraine didn't pass until later the next day, after 14.5 hours of solid sleep in my dark, window-less bedroom, with constant ice packs/hot rice bags, multiple doses of vicodin, and several doses of maxalt. Two words: it SUCKED. And, I was not impressed with myself.

(I've had migraines since I was five. They are something that are just there, and for the most part, I recognize that I have to live with them. A year or two ago, I started taking topamax and was thrilled at how well it seemed to 'calm' them; I also found that maxalt was actually reliable for knocking them out if I could take it when I first started getting an aura... these were the first meds that actually worked for me, after 20+ years of trying to find something. Now, in the past few months, they are steadily creeping back. To have two in the past two weeks, however, to the point that they disrupted my functioning - at clinicals no less - is NOT acceptable for me.... so I guess I will be in touch with my care provider.... *sigh*)

On a happier note --- things have been interesting with the MD preceptors. Again, I've seen several types of client cases that I might not normally see as a CNM: complex chronic health problems, many, many well child visits, and ---- wait for it... --- MEN! I haven't dealt with penises longer than a pinky-joint since I was a nursing student. Crazy, huh?

Tomorrow finishes off my week with the docs... fingers crossed that if nothing else, they think having an extra pair of hands could be good for something or other...

~*~*~*~*~

This can be a glass half-empty/half-full kind of pondering.... I think I posted last week that I had sent out an email to the doctors that I work with - as an OB nurse - just to sort of "feel them out"regarding how they might feel about hiring a CNM into their practice (as there are no nurse-midwives other than Dee delivering within 60-75 miles of our area). I received this response from the 'head' of this OB group today, and took it to be a good sign; it's of course impossible to read, but the gist of it is that most of the MD's in the group think that nurse-midwifery care may be a plausible option, but there are questions that would need to be discussed; it does not give any indication that they are not supportive of CNM care, and that they are willing to entertain the idea... the logistics of it may need to be explored, but it "could be interesting". (Again --- this email certainly could be read with optimism or pessimism, since it doesn't go strongly either way... but tiny seeds, no?)

Our Strength

I've been thinking about strength today. Mainly, because I am feeling wiped out - emotionally, physically, mentally, financially... you name it. And yet - a part of me truly believes that I just need to give in and accept that this is truly part of the process. I'm all right with this; it's just kind of, well, a drag.

Plus side: I started at my new site, officially, today. LOVE it. Everyone, so far, is amazing. Very welcoming. My new preceptor, "Dee", is introducing me to everyone (docs, nursing staff, random folks walking through the hallway...) as "the student midwife who we're trying to convince to stay here with us as a second midwife with our doctors & I". I so want to be that midwife, and am trying not to get my hopes up, but if there was a wishing well in front of me right now, and I had a penny to toss in, do you think you could guess what my wish would be?? (I won't tell, of course... but if you guessed, well, anyway...)

Not so plus side: I'm exhausted. I think I already alluded to that above. I started trying to type this post almost an hour ago, and keep getting distracted. Like, for example, I wanted a cute little pic to post with this (because honestly, doesn't a sweet picture make everything easier to read??) -- that took forever. Stupid picnik.com and it's stupidness. Also, we stayed overnight at this hunting cabin my grandparents have (I actually love it - it's very remote, quiet, and peaceful --- and a *tad* closer to my new clinical site as well --- but, there's always a but, right?) I got NO sleep. Like, very, very little sleep. A combination of woodtick paranoia (if you live anywhere that ticks are prevalent, you know what I'm talking about - nasty little creepy crawly vampire things - I had the heebie-jeebies ALL NIGHT LONG thinking they were stuck on me), not having the migraine-preventative med that I usually take at bedtime (which has a convenient side effect of zonking me out nicely), a less-than comfy air mattress, and first-day jitters (will my alarm go off? will I make it in on time? etc), all added up for a loooong night and weird dreams. I dreamt that I was living in a strange apartment building --- I think it was early 20th century, yet there was an odd open-air elevator to get up to the upper floors; very odd, in fact, in that you wrapped yourself around what was basically a fireman's pole and held on for dear life as you shot up it. If you let go ---- not good. I was doing okay until, all of a sudden, I was almost at the top and realized my arms were very tired, slippery, and I just didn't think I could hold on; plus, I realized I also had another "tier" to go (apparently, somehow, to get to my "level" I had to switch poles?! Very ... odd...). So that was one unsettling dream. Another involved the cottage we were at; we were apparently taking turns sleeping (in the dream) and someone - my older brother, I think, looked out the door all of a sudden and someone had jumped in one of our vehicles and taken off out of the blue. (There was much more to this dream, when I woke up --- at the time, it was very vivid and I meant to share it with the Warm One... but being that it was 0530, I decided to let him sleep, and know the details have faded. Anyway, it was another disturbingly vivid dream, I guess.)

I think, what this all boils down to, is that I need a good night's sleep. But,instead of going to bed at a reasonable hour (10 p.m. or so) as I had planned, it's almost midnight and I'm just deciding to call this blog post a night. It's nowhere near what I had planned to write (is there anything about nurse-midwifery, really?? Not much!!), but it's good enough. Suffice it to say - I feel stressed; I need to work more so that I can pay my bills, yet I need to get through clinicals so I can graduate. I also need to study more so I feel less anxiety about upcoming boards, comps, etc. I also need to work on family stuff - or maybe let it go; a close family member is dealing with heavy stuff (addiction) and I don't know how to help him. And yet.... I think it's all going to be okay....

(and, big cheers to my CKC'ers --- one just got married, one just passed comps, and one is on her way to CB!! Jaeger all around!!)

Hey! Can It Be?

Can I actually be back in the clinical saddle again? The wild ride continues, apparently... a month after my short stint on the western side of the state (only catching babies - no clinic), and almost four months after parting ways with the Midwife, it looks like I might finally be "good to go" with "Dee" (hopefully a psuedonym I'll remember!), my new preceptor. The wait to start at this site has been such a long, drawn-out struggle... even though everything seems to be ready and in place for me to start this last leg of my clinical journey on Wednesday, I'm still hesitant to really believe it. There have been so many false starts: way back in March, it looked like I would be able to start building up hours with Dee in early April, after she returned from a short medical leave; after weeks and weeks with no communication, it turned out that somehow my paperwork had been lost among the administration team, pushing the process back further. Then, gradually it was May... and now June...

Luckily, the short voyage across the state last month did much to re-energize me and to remind me why I'm doing this all in the first place (although I feel like my clinical skills and knowledge are going to be awfully cobwebby once I finally break my way back into the clinic); my daughters tossing off comments without a second thought - "Mama, when you were a little girl you were like us, but then you grew up and started to catch babies all the time!" - like it's always been this way, only cements that feeling even more.

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

Which, of course, leads to the next step in the journey. If (when) I ever get through this step - clinicals, that is - and if (when) I manage to pass both comps and boards (an overwhelmingly terrifying prospect) ... then what?! The job market for a CNM in my area is bleak. As in - none. Zip. Zilch. Nada. I've been following several CNM search engines --- GetMidwifeJobs.com; the job listings on ACNM's website, the listings on my school's forums, etc. I've sent resumes, cover letters, and CV's to anyone and everyone, to every job that looked remotely interesting; to Alaska, New York, and AZ. With no calls, no emails, nothing. Kind of depressing, to be honest... but I haven't been very aggressive myself - you know? I still have 170 clinical hours, and up until this week, no idea when I would get those hours going.

Out of the blue, though, I got a call this week from a physician in Maryland; we had a nice, 20 minute chat (after I hung up on him initially - oops, the drags of living in the rural Midwest) and I was left with a bit of hope and interest in what could come from the talk. Could I do Maryland? Pro's - Adventure, ocean nearby, change of pace... a job. Con's - Moving across the country, no family anywhere (some days that might be a slight pro... slightly), higher cost of living... and apparently it's a very 'un-rural' area. Not so good, since I have a feeling I might get kind of antsy surrounded by city/urban folk... maybe. (Although living around here in a cardboard box, with loan papers coming in the mail on a daily basis, might making me kind of antsy too - especially when the snow starts flying...)

I hate to even post this here, since a tiny part of me (okay, a good-sized part of me) is superstitious - but when I met with Dee last week, she also gave me a glimmer of hope for a potential position at her site. (This site is about 45 miles from my current home; it's within the same healthcare system I currently work for, and while it would have its own set of pro's/con's to consider, staying within the area would be a huge "pro". ) So, after talking more with her this week, maybe - hopefully - I'll be able to expand on this more...

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 Town

My town is (relatively) rural, "under-served", and ... beautiful. There are days that I find myself awestruck at the innocence of the people here, the young families working so hard to bring about the change that we need, the grandparents so active in the younger generations, and the community programs that are so involved in so many areas of our growth. Two Native American reservations adjoin the region, sharing a wealth of rich tradition and cultural diversity.

Even after nearly thirty years of living within thirty miles of the same spot, I still have moments of wonder at the physical world around me as well. My home is a mixture of fertile, strong farmland - capable of bearing grains most months of the year - and rolling hills and thick, tall stands of trees. Rusty tractors and beat-up cars dot the highways and country roads; anything shiny and speedy is less likely to be seen. Deer are everywhere (driving home from my mother's today, I had to hit the brakes twice to avoid last fall's scrawny doe-fawns), with wild turkeys just as present and pesky. A bear loping across a country road is a much more sacred experience; bald eagles are a daily, humbling, occurrence.

(Now, of course - don't get me wrong. There are so many areas that could be improved on; there's the same old political drama as any other area - the community is older than the average town, with a very conservative tilt - as well as tension from a so-called "religious cult" that has had ongoing legal claims against the city government over the past five years or so. Racism/ethnicism between "whites" and Native Americans (as well as members of the religious group mentioned above) does exist in the area despite commitment by many organizations to work towards common goals of unity. Business is always business: our small, not-for-profit, community-run hospital recently "merged" with a larger health care system, and competition continues with other clinic systems in town and with the "bigger, better, newer" facilities located slightly further away. My town may not be perfect - but it may be perfect for me, anyway.)

And yet, with all our imperfections, all our arguments and all our petty squabbles - we really do have it good. On our small, four LDRP obsetretics unit - in which each room has banged up doors, peeling wallpaper, and so many aesthetic no-no's that it's becoming painful to give tours during my childbirth classes - we've celebrated the birth of not one, but two sets of vaginally birth twins in the past few months. In the years that I've been a part of 'my' team, we have had several more sets, both to primiparous and multiparous mamas. (I have not be lucky enough to be present at any of these births yet --- can you tell I'm a bit peeved?! --- but am still so excited/proud/any-number-of-adjectives-fits-here that the diagnosis of "twin pregnancy" hasn't automatically equaled "cesarean section" for our mama's; generally, as long as Twin A is vertex and the pregnancy is otherwise healthy without factors contraindicating vaginal birth, trial of labor has been offered/attempted, and as far as I know - all have been successful with wonderful outcomes.)

As a nurse, I've had the joy of holding patients' hands, helping them breathe through contractions and ease their way to the births of their sweetest creations; I've been blessed enough to have to catch babies (when the doctor didn't quite make it to the room, or even to the hospital in time), and instead of being reprimanded or frowned upon, I've been thank

ed and even praised because of how well things were handled. One mama had a vacuum assisted delivery with her first babe, and a massive laceration with repair; she was terrified of pushing and delivery. With the doctor down the hall, ready for the call, she tried her first push - and with just a little encouragement, gentle support, and the right words... she delivered her beautiful daughter by herself, into my hands, before the doctor could make it down the hall to us. No lacerations, no need for any assistance - only her own strength.

Much of this truly comes down to my own inner calmness. As a new nurse - starting directly into OB/L&D nursing, I was terrified of having a mama "precip" on me. And, of course, two of my first handful of mamas did just that. (At that time, I was new enough that I still had a precepting nurse with me, and I basically froze, leaving her to jump in and catch.) From that point, I had such o

f phobia of having that happen again that I became hyper-vigilant of when a mom might suddenly progress to delivery rapidly - and so I began calling the doctors to come in very, very early in second stage. (Now, if they were midwives they would probably already be there... but that's another story...) La la la da.... fast forward a couple years, I became more relaxed and understanding, intuitive, and comfortable with idea of catching if need be - and, I was entering midwifery school, so the idea of catching was a little more addictive at this point! - I had no precips, because I had finally gotten it down pat of when to call the MD's in so they would get there *just* in time. (Drats!) But, finally, I realized, if and when a baby delivers - I'm all right with that. I no longer frantically instruct a mother to "Stop pushing!" or "Pant! Breathe through this one!" ... if she is going to push because the baby is right there, I am not going to stop her. I don't plan to catch any babies in babyland - but, if they come to my mamas and there's no one else around to catch 'em ... mama and I are going to do it!

I live in a town without high rise buildings, with no Starbucks or malls to call my own; "my" unit has only four labor beds, with peeling wallpaper and drab furnishings, and no OB/GYN's to be found. My countryside is, well, just that - fields, tractors, and farms. To be blunt, summertime smells like cow-shit... but also the sweet smell of lilacs, alfalfa, and fresh-cut grass.

And - I like it this way.

Drinking, Resting, and Breathing.

That's all I'm going to do for a while, on the advice of someone I consider to be a friend and a kind of spiritual advisor (she's a pastor, but for some reason, that title seems awkward to me...?). Anyway, her wise words: "Drink lots of water, get lots of rest, and just breathe."

It seems like a good strategy, and the kind words - said at the perfect time, by someone whom I have only had a handful of actual face-to-face conversations with - touched me. Like all of the supportive comments to my blog posts, all of the "likes" and thoughts (both heartfelt and sassy) on my Facebook statuses, all of the texts, emails, and walls posts from friends reaching out to me - it was enough to bring tears to my eyes and warm fuzzies through the rest of me. I'm not someone who has ever had a lot of close friends; usually, I have one or two very close friends that I confide everything to, and then a handful of acquaintances. To have so many people that I feel like are there for me, is an overwhelmingly touching feeling.

Today was officially my last day with the Midwife. As expected, it was bittersweet; now that I am home, starting to unwind and draw closer to my bed, I am becoming more at ease and even relieved. It was time. The Midwife and I finally had a good - not great, but at least a better - talk as I was saying goodbye. We did not, by far, clear up many of our miscommunications - but I think maybe, just maybe, things were at least left on a fair note.

As a student nurse-midwife, I feel like it was a good time to leave this site. The last birth that I attended was beautiful; the couple was strong, dedicated, and so in tune to the birth process and their baby, through the many curve-balls that labor and birth through their way. They were "my" type of client: they chose the Midwife because they wanted a Midwife-attended, natural, low-intervention birth. It was a joy to be with them as they became a family of three and welcomed their sweet daughter into the world, exhausted yet exhilarated. They gifted me with another blessing as I said goodbye, with kind words towards me as a SNM as well as words from another past client.

I wish the Midwife the best; I know that she is dealing with stresses in her life, and I hope that peace and calm descends to her.

For me - it's going to be a lot of just drinking, resting, and breathing.

And ... the Paper.

So This Is It... (Or, "The Medwife")

This is my last week with the Midwife. This is bittersweet; of course, there is some relief - the last few weeks have been incredibly stressful and long. But, I will also miss the many beautiful clients I have grown relationships with, as well as several of the nurses and other staff members I have met along the way.

In the end, there is no way around it. The Midwife and I are just too different. You could say she's more XBOX and I'm more Atari... In some ways, I hope that some day I gain some of the Midwife's qualities - she is prompt, she can answer any patient questions without a stumble, and she is assertive. On the other hand, I need to be true to myself and the true heart of midwifery. I will never be an "aggressive" person, nor an aggressive midwife; I will continue to look tired for a few years yet, at least through I adjust to this midwifery gig and my kids catch on to letting me sleep at night (seriously, Mini's --- you're 2.5 and 4.5... get it?!). I will never be someone who appears at events, and the office, an hour before I need to be there. I try to do too much with my time, end up misjudging the clock and how fast I can get to point A from point B, and wind up running a few minutes behind. These are things I have accepted and will continue to work on - but can't change overnight.

The Midwife is, in essence, a "Medwife". She practices with a group of OB-GYN's, she has never practiced outside of a high-risk setting, and she views birth as an occurrence that is one step away from disaster. While I recognize and respect that even in the most normal, low-key labor and birth, something can always go wrong; (I think) I have a healthy dose of the "what if's", especially for those labors that are going smoothly... I am afraid to be lulled. I don't think either perspective is right or wrong, just different.

Will I offer elective induction to my patients at 39 weeks? Probably not. Do I see where the Midwife is coming from, when she gives that option to her patients? Sure. Does it work for her, and for the majority of her patients? Yes, it seems to. Do I agree with her statements after some of these births, that "It's a good thing we induced now rather than waiting because..."? Not always, but that's not my place to argue. If mom and baby are happy and healthy, and were given the choice to make the decision - with full informed consent - I can't, as a student, jump in and point out potential flaws to that logic. As a "green" CNM, fresh-eyed and optimistic - with my views on birth and outcomes unblemished by malpractice insurance, peer reviews, and "bad" babies (or a history in high-risk OB), I still lean more towards the hopes that by giving good care, thorough information and honest explanation of risks and benefits - rather than practicing "defensive medwifery" - the relationships I cultivate with my clients will be close and trusting. (Do I think some of these perspectives will change - probably within the very first year or even months that I am practicing? You bet. The Midwife does what she does, for a reason. But... maybe not. Another good reason that another site, a different site, seeing a different population - might be helpful.)

Because with labor and birth, honestly --- who knows? The most wonderful looking baby on the EFM can come out floppy and blue, needing a full resuscitation, while the baby who looked miserable for the longest time, with a short and scrawny cord comes out wailing and pink. The 9-pound chunker of a primip delivers easily, without a scratch - while the G2P1's barely-seven-pounder gets hung up on the shoulders (unlike the larger older sibling a few years before). A common disclaimer in obstetrics: "We just don't know": a simple way to explain that so often babies are doing their own things, and our bodies - which are made to carry and nurture those babies - will instinctively protect those babies... but also a smooth segueway into a conversation encouraging (with different levels of "encouragement") various interventions that may or may not be truly necessary.

The mystery, and beauty, of birth is that every baby writes his or her own story; as midwives (and nurses, and doctors, and doulas, and mamas and daddies), we are just along for the ride, wild as it may be.

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

Snow Day

A snow day is EXACTLY what I needed today. Fate, or karma, or G*d, or my daughter's school district (seriously - the 2011 calendar they sent home in December had today listed as a snow day'...?! Wooooooah. Crazy, man, crazy... ), or Ma Nature, or all of the above, agreed; my driveway is covered in drifts of snow ranging from 2-3 feet deep. Since the Warm One conveniently blew a belt on the snowblower this morning trying to dig us out, I couldn't leave the house if I tried.

Shucks.

Such good memories of being a kid, sitting by the radio in jammies and waiting in suspense - sleep still crusting up our eyes - as the DJ's worked their way down the list of schools that were called off on account of the weather. My teachers (and maybe my mom or grandma) will take all the credit for teaching me to read, but I will swear to this --- I learned alphabetical order by hearing the names of neighboring school districts on the radio: "Abbotsford... Bonduel... Bowler... Clintonville... Coloma... Edgar..." Believe you me, when you are a kid and the glimmer of hope for a snow day is there, you learn really quickly how the name of your school fits in with the long list of other districts. And you will listen religiously to that same listing, over and over. And over. And over. (Because eventually, even as the bus is pulling into the school's parking lot, the school may just catch on that the roads are impassable. They might.)

A two-hour delay was acceptable... but a cancellation was golden. The whole day off, for... what? Some days, we kids would just lounge around and watch cartoons (or soap operas and court shows... hey, we were rural and relatively poor - no cable on the farm!). Or, maybe we'd suit up and head outside for as much of the blustery snow as we could handle... because realistically, most of the time by the time the schools were called off, the weather ended up being perfect for snowball fights, sledding, and snow angels. Eventually, we hit the Nintendo stage; then there was books, toys, chores, and all of that fun stuff, too... the important thing was simply that it was an unexpected free day. (Why I never chose to just sleep ALL DAY I don't know. What kind of child was I?! Dear heavens.)

~*~*~*~

Anyway.

I really, really did need a "snow day" today. Last night, when the bigger Mini-Me saw all the snow coming down, she asked me if I had to go to work (i.e. clinicals) today; I mumbled something about that I would probably have to, but it might depend on the weather. She then proceeded to remind me that she was having a snow day, and that she hoped I would, too. (Awwww!) And how she wanted to have three days in a row with me home... and to have "Dad" home, too... (he works a 'weekend' program, so it's rare that all four of us are home for a full day together). That planted a teeny seed in my head, which blossomed overnight - watered by the inches and inches of snow outside - into the pretty firm idea that a day of R&R would really be good for my mental health. I had pretty much decided, then, that I would just stay home and work on homework instead of driving the hour to clinicals (for a short 3-hr stretch of office, anyway), when the morning's news of nasty roads and crazy drifts and winds starting rolling in. Then, of course, the snowblower sealed the deal.

(Well, actually, what sealed the deal was the email response from the Midwife to my email from this weekend... which, of course, brought me down for a while. Whether they were tears of frustration, relief, anger, fear, or something else - I'm not sure. At one point during her email response, she noted something to the effect of "I'm just having a hard time communicating with you" -- and I think this is the crux of our difficulty. Whereas the Warm One and I have two very distinct personalities and they mesh well together, or some of my close friends and I are complete, complementary opposites --- this does not work so smoothly for the Midwife and I. There is no existing history, no extensive trust, no equal sense of giving... or at least this is how it seems to feel. I'm sure for the Midwife, it seems as though there is so much more at stake: these are her patients, this is her practice, and her reputation and her income. And I certainly do have my own large faults at the heart of this matter. Anyway, this post wasn't meant to revolve around the email... I don't think. I'm wandering... maybe another post later, or tomorrow, or something... )

So, all of these things in the end convinced me to stay home, jammies on, and french toast a la Warm One served up. Now, it's the Heffalump movie and job-searching online ( <--- read: avoiding the Birth Center paper).

And, did I mention that I am doing a phone-screen for a CNM position, right down the road, within the next couple of days? (Which may or may not be related to the fact that I called that facility to inquire about possibly doing some clinical hours with the midwives there - who I didn't know even existed - in the upcoming months, for a change of perspective...) ...

When snow falls, nature listens. ~Antoinette van Kleeff

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?!