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?)

Mama Needs a Time-Out

Seriously.

Whatever happened to TGIF?! So much for Friday, I guess... whatever optimism and good vibes I had going into the earlier part of this week somehow dissipated as the week rolled on. In the wee hours of Wednesday morning, while I was gearing up for the clinical week - I usually do clinicals with Dee Weds/Thurs/Fri - I woke up with a killer migraine. (I've had migraines since I was four or five ... nothing new there. They've probably been in the best control of my life for the past year or two, actually; I've found a daily preventative med that seems to help, and for the first time ever, I've found an abortive that seems to actually knock them down when they do kick in. Score. But - that being said - I do still get the occasional nasty f*@!er, but never, or rarely, has one ever woken me in the middle of the night before... so this one sucked!) I did my best to get through the day Wednesday with Dee, but even after taking my abortive, and all my usual knocker-outers, I had nothing and had to leave early ---- which I hated doing. After a few hours of solid rest and a combination of narcotic, another abortive, heat/ice, and some topical cream to my neck/shoulders/etc (which by the way was not a good idea - more on that later), I was somewhat coherent again.

Unfortunately, the arthritis cream that I picked up to rub onto my neck/shoulders/temple (similar to what I usually use, but a different brand... I can't even think of what I picked up that day) was awful. Whether it was the intended effect or not, it caused my skin to feel as though it was on fire - my palms, my shoulders, and my neck raged at me the entire afternoon, evening, and next day, even after scrubbing in an attempt to relieve the sensation. And, of course, smart cookie that I am, I slipped my contacts out (and then tried to replace them the next morning) with residue apparently still remaining. Good gracious golly. Not only was I living in the migraine hangover, I was also fairly certain I was close to blind...

Then, when I got out to my car --- I found it egged. What. The. ... Seriously. Of course, as usual, I didn't have any spare time (why would I?! Any of you who know me, know that I don't generally run with spare time...) to rinse the gook off, much less for a real car wash. Okay, so it was only one egg (or maybe two) on the driver's side door and window, but for the love of mud --- why?! I really, really was NOT in the mood and, as I'm sure you can imagine, would have had some not-so-pleasant things to say to whoever thought sharing their breakfast fare with my vehicle was a good idea.

The rest of the week has pretty much continued as such. Though I am sooooo close to the end of my necessary clinical hours - T-minus 66 and counting - I've hardly knocked any off this week, thanks to the lovely migraine and having to cut out of clinicals early yesterday (Thursday) as I was scheduled to work in Babyland.

So it's been a non-productive, miserable-feeling, blah kind of week. Oh, and that "other" position that I was excited about? I had a phone interview Wednesday evening, post-migraine... I thought it went all right, even though it didn't sound like my "dream" position by any means; while I didn't expect to get hired as they disclosed on the phone that they were doing a second interview for a previous applicant the next day, it still stung today when I received an email telling me that my "career goals didn't appear to be a fit" for the position, and thanking me anyway. Ouch. I guess it just is a downer, all around, even though I had more or less decided that I wasn't all that interested... *sigh*

To top it off, I'm finally home, getting to spend some time with my family --- and my lovely young ladies are not listening to me, I'm incredibly crabby and cranky with them, and I just don't have any patience for them, for myself, or for anything. I don't like how I feel, how I'm reacting to them, or anything at all. In desperation, after too much hollering after too much whining, I sent them to separate rooms for extended time-outs --- but really, deep down, I'm the one who needs the time-out.

Just keep swimming, just keep swimming...

It's seriously 99 degrees outside, with a heat index (whatever that is) another 10-15 degrees hotter. Wooooohooo. Swimming sounds amazing, no!?

At least in a symbolic sense (or a Finding Nemo sense), that's what I'm doing. I'm not sinking, I'm not thrashing wildly trying to get through these last few weeks of clinicals, and I'm doing more - at least, I think so - than just treading water. The end is in sight! I've just crossed the 600 hr mark (out of 675 required hours) of clinical experience; most of my numbers are met or very close. "Dee" keeps throwing this hope-rope to me about submitting a proposal to her administrators to add another midwife to her practice; several of her doctors are on board and supportive. I am so comfortable working with Dee, and with the women she sees - I think we are both praying that things work out and they (administration, that is) agree that expanding her midwifery practice would be beneficial all around. I also just had a phone interview - or at least, a short chat - with a midwife from another midwifery practice about an hour and a half from my home... it was encouraging and again gave me hope for a job opportunity in the near future.

So, while I'm trying desperately not to get too excited about any of these possibilities - and trust me, I really want to get excited... how great would it be to stay within an hour or so of our families?? - it does allow me to drift into the occasional daydream. House hunting... comparing elementary schools... thinking about future vacations and scheduling considerations... and, oh yeah, maybe a paycheck! (This whole "9 months of clinicals and little working" thing has really, really hurt our finances... I think anyone who's been in this spot can commiserate!)

Two more weeks - give or take - of clinicals; one more assignment (a client journal that I should have had done long ago, but had to start all over after the abrupt change in clinical sites); several uber-important tests. It's not that much, especially considering how far I've come this far - but when I look at it that way, it can easily overwhelm me. So, instead --- I'll just keep swimming.

(And, on a side-note, I'll keep looking forward to the end of September, when I will hopefully be an official nurse-midwife, and celebrating in Punta Cana...)

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...

The Power of a Mother

“We have a secret in our culture, and it’s not that birth is painful. It’s that women are strong.” – Laura Stavoe Harm

~ * ~ * ~ * ~ * ~ * ~

In the past weeks, I've had the opportunity to see a beautiful display of the strength the we, as mothers, hold within ourselves. I have seen two first-time mothers carry twins to term and birth them vaginally (a rarity in today's obstetric world), and I've been blessed to be a part of several beautiful water births. I've supported women as they shed the pain and negativity of their prior births - whether vacuum-assisted, episiotomied, or cesarean - and worked their way to fulfilling, heartwarming experiences this time around. I've coached women through difficult labors, instructing them to push - or not push - at the hardest times, when it was the thing they most didn't want to do (but needed to, for the sake of their baby - whether due to a stuck shoulder, nuchal cord, or other concerning issue). I have seen mothers labor and push for hours, with no analgesia; I've seen mothers who plan to get "everything [they] can get" - but still have intense discomfort... regardless, the strength, and the determination to make it through, is amazing. I've visited women in the hours and days after their births and been awed at the love that's obvious as they snuggle their newborns; the way they hold their nurslings to their chest, cooing and adoring, proudly showing off their babes to older siblings, grandmas and nurses.

*~*~*

Strong thunderstorms and tornados moved through this region - and much of the country - last weekend. The similarity between Mother Nature's power and that of a laboring mother is not lost on me. Surveying the damage of what has officially been deemed a tornado - which moved right alongside of the

hospital - brings to mind the rapid internal changes that occur with labor... Mama feels as though her insides are being ripped apart, ravished by the incredibly intense waves of contractions moving through her. Until labor began, she may not have even realized the strength within herself; and yet, like the buildings and trees damaged from this storm, her body will begin working its way back to normal within hours after baby's birth. (And, in fact, just as a beautiful, brilliant, calm sunset emerged from the storm - mama will almost always emerge from birth with a tired but peaceful sense of wonder as well, with the most beautiful prize to be had.)

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.

Birth photography...

... is something that I've always loved the idea of. As an OB nurse and now student nurse-midwife, I always find my mind taking these mental snapshots during labor, birth, and those first few days of each new family. I find myself saddened by the intimate moments lost, the sweet "firsts" that are missed, and the beauty of a partner's touch or a newborn's soft skin slipping by unnoticed. "Where is your camera?!" I scream, noiselessly, to the new parents, or the grandparents, or anyone else nearby. "Don't you realize how precious these moments are? You'll never get them back..."

Part of this melancholy stems back to Mini #2. As I was preparing to host the luncheon for her baptismal party, I was throwing together a photo album/scrapbook of her first days. (Of course, this happened to be only a day or two before the party... but that's another story.) It was only then that I realized - I only had a few pictures that were taken during labor and delivery. But... what about... I don't remember... How come....

Suddenly, it wasn't about the photo album (Heaven knows we had plenty of pictures for that), but the fact that I wanted to remember more. Now, granted, I feel like I remember our labor very, very vividly; my water "sprung a leak at home", I knew it was definitely my water (because, first of all, as an OB nurse, you just know amniotic fluid... and second of all, I had somehow accidentally managed to procure an amnioswab...), went in to the hospital and was deemed to not be ruptured - but still given IV antibiotics "just in case" since I was GBS +... continued to labor, eventually beginning to have "real" contractions and delivering within a matter of about four hours. I remember reading No Country For Old Men early on, I remember the Warm One laying out on the cot next to me and snoring away through much of my labor, I remember my boss coming in about two hours into labor to visit for a few minutes; I remember realizing in amazement that I was using a focal point (a focal point! something I have always discussed in Childbirth Classes, but never actually thought of using myself...) on the chest of drawers, and I remember visualizing my cervix melting away as I waited, and waited, and waited, in the shower. Anyway --- the point of this post wasn't to share my birth story (that's another day) but to mourn the lack of pictures.

But, now the Warm One came in and ruined my train of thought. I'll leave you, instead, with an invitation to visit these friendly blogs that I've come across - gorgeous examples of a touching, sweet birth story, told in pictures:

http://www.jackspratphotography.com/category/birth/

http://capturingdayone.com/gallery?pid=173 (click through the 16 images)

http://creativelookimagery.com/blog/?p=2441&cpage=1#comment-207 (my favorite - make sure you view the full-screen version, with your sound on...)

http://imaginatephotography.com/blog/2010/03/19/baby-ms-birth-illinois-birth-photographer/ (another video)

Enjoy!

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.

OK...

... now I'm just getting pissed.

When my 2 yr old is looking at me, telling me "I don't want you to be sad!" and running out of the room because she's upset that I'm upset... and I'm sitting here (again) blubbering like an idiot, with no one to talk to... I just get mad.

The Midwife just emailed me back. I fully accept that part of this whole thing is my issue; I am not a perfect person, and certainly not a perfect student. But. But. I feel like I have been trying very, very hard to reach out and figure out what she wants from me, to make this clinical experience work. When we were early in the experience, "daily evals" were necessary; I begged her for constructive criticism, and rarely got anything from her that I could work on besides "you're learning, you're doing fine." She told me often that if I needed to change my schedule because of work or family obligations, it was "fine", just to let her know - which I did, if it happened.

I don't know when any of this changed.

The Midwife has "worked with many students in the past and something just does not feel right". Ouch. Does it matter that I have worked with many, many instructors and preceptors in the past? I have never been told that I was "not right" before... no one has ever "fired" me as a student or preceptee.

First impressions are important... the Midwife, in her reply, seems to be saying that something has been "off" all along, and its noticeable not just to her, but the entire staff. She doesn't feel she's unapproachable or distant... so it must be me.

Well, doesn't this all suck.

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?!

Whichever way the wind blows...

... may be the path that I will take.

I haven't blogged in a while. Almost two weeks, in fact. (Crazy!) Not that much has happened in those two weeks, to tell you the truth. Looking back, what exactly have I been doing that has kept me away from blogger.com??

I...

dealtwithtwosickkidsandonesickhusband*hadasitevisitwithmyRCC*boughtfartoomuchgasandtookmanytripsbackandforthtomyclinicalsite

*workedalittlebitandgotpaidforwhatseemedlikeevenless*wastedtoomuchtime*caughtthreebabiestwogirlsandoneboyIthinkorwasittwoboysandonegirl*hadanawfuldayatclinicalandfeltaboutaninchandfiveeighthstallwhenIreceivedsomehardtohearbutprobablynecessarycriticismfromtheMidwife*pretendedthatmyeyeswerejustredandwateryandthatIwasn'tbawlingatclinicalsforthatsamereason*foundapossiblysuspicousbutmostlikelybenignbreastlumporcystwhiledoinganannualexam*amwaitingsomewhatimpatientlyformyownmissingmensesalthoughitcan'tbetoofarremovedasmyBCis99.8%effective*hadsomelongnightsoflittlesleepduetothelittlerMiniwhodoesn'tseemtoenjoysleepinginherownbed*beenstrugglingwiththedilemmaofwhetherto"holdback"theolderMinianextrayearin4Keventhoughsheisacadmicallyperfectjustincrediblyteensyandabitshy*madeitthroughValentine'sDay*passedthehalfwaypointofmyclinicalhourstally*droppedofftaxeswiththeaccountantsinceIhaveNOideahowtodothemmyself*caughtanunofficialbabyatwork(hey,hey,hewasLOA!)*attendedagrantwritingclassandtossedaroundtheideaofstartingajointCNM/CPMbirthcentersomemore*splurgedonanewAndroidcellphonesinceminestartedhavingseizures*taughtchildbirthclass*managedtogotobedonenightat8p.m.andsleepuntil10a.m.mostlyuninterrupted(thankyouWarmOne!!)*hadalovelymassage&scheduledahaircut,highlight,andbrowwaxwhichIWILLkeep*gotthegoodnewsthatagoodfriendhadasuccessfulVBACofa~gorgeous~babyboy*senthappythoughtstootherfriendswhoneedthem*avoidedhomeworkbutmadeateensybitofprogressonmy"big"paper*mayhavelosta$20billsomewherebutI'msuresomeonewhoreallyneededitfoundit*hadlunchwithanawesomefriend*hadsomeveryvividdreamsandwonderedwhattheymeant*learnedmoreaboutmygreatgreatgreatgrandma...didIevertellyouthatshewasamidwifeinthe"old"country(Germany"??)*learnedthatILOVEpecanbarsfromthisrestaurant/bakerynearmyclinicalsite...heaven!*justrealizedhowtiredisuddenlyam...

Does this count as flight of ideas?

"The answer, my friend, is blowin' in the wind, the answer is blowin' in the wind." ~Bob Dylan

Hurts

"Never ruin an apology with an excuse." ~Kimberly Johnson

~ * ~ * ~ * ~ * ~

My heart hurts. My brain hurts. My ego hurts. My body hurts. My checkbook hurts. From my eyeballs down to my left big toe (specifically) I hurt. This nurse-midwifery thing is trying - but I have so much faith that it will b

e worth it.

Where to start?! I'll try going from the top and go down... on a light note (looking back now), I had the embarrassment of walking in on the husband of one of my mama's as he was, um, using the bathroom facilities. I had peeked in her bathroom to see if there were pads and lovely mesh undies set out for her, and - seeing that there were none - headed to her closet to grab some. This apparently took a few minutes longer than I expected, because in the very brief time that I thought it took me to turn around and head back to the bathroom... he snuck in. Surprise!!

(Well, that's what she gets for coming in at 4:00 a.m... right? These people should know I'm no good before 10 a.m.!! Ha, let's see how far that excuse ever gets me!)

So, that was the first bruising of my ego in recent memory. I'm sure there has been others, and there will be many more. Patients who do not like me, or prefer not to have a student working with them; personality conflicts, and, of course, staff/physician/etc conflicts.

Moving on. My checkbook. Oh. My. Heavens. I'm not going to go into details here, since I think my very last post spent a little time talking about this --- but it's not pretty. Thoughts of LAC ("life after clinicals") are really becoming time-consuming, including some pretty in-depth fantasies of where I can find or create a CNM position in the local area. More on that topic soon, I think.

My brain. Oh, yes, the brain... or what's left of it. There are days when it is just a-reelin', if you will. Between the ego-beating and financial stressing just mentioned, and then the mind-trips about future career possibilities, I feel like I'm stretching myself pretty thin when it comes time to actually focus on life and clinical critical thinking. While I know I need to push all of that nonsense to the side and get down to business - that knowledge certainly fits in the "easier said than done" category. Distraction has always been a strong suit of mine, and continues to be so...

Where was I??? Oooh, how about my body next? It is sore as heck, many days. I'm loving what I'm doing, don't get me wrong. L-O-V-E. But, as they say (I think I'm hitting every cliche in the book here) --- love hurts. In this case, it's some of the twisting and maneuvering that I do - usually during births - that gives me some aches and pains. Nothing that I think is going to cause any lingering damage (it's already much better than the first few weeks of clinical, and usually is just a little bit of muscle pain for a bit after a looooong second stage); enough to mention in this somewhat-related post, but not worth changing the way I deliver. (The Midwife doesn't break down the bed; she drapes the foot of the bed, and takes her place sitting on the side of it... this is how I catch, as well, and don't think I would have it any other way... sore back be damned). But, there is al

so my bum toe - my left great toe, to be exact. I broke the S.O.B. four years or so ago tripping on my grandparent's step in my trusty flip-flops, and it's given me a fair amount of grief ever since. I'm still looking for the "right" pair of shoes for clinical/L&D; so far, everything I've been wearing (and maybe it's partially due to the nasty, cold winter weather we've been having --- and the fact that I'm getting to be one of those old fogies that blames the weather for everything) seems to aggravate this darn toe. But, cute shoes are worth the pain, right?

And here we are, at the heart of this post. Pain. My pain, really, is not an issue. I can deal with that. I like to think that I can handle pain, as much as I need to. When "my" mama's are in pain, I help them through it as best as I am able and as best to the plan that they had wanted to follow - whether than means using medications, a shower, or screaming obscenities at passersby. (Well, maybe less-violent forms of vocalization are encouraged, depending on the situation... anyway...)

What kills me, though, is pain that I can't "fix". A mama who has desperately lost sight of what's going on, or feels as though her birth experience is being taken away from her. A baby, who may have suffered an injury during a birth. I have felt these types of aching moments as a nurse, and am beginning to see them now as a student nurse-midwife; fellow students are also sharing their experiences in the same way. A rapid second stage; quick birth of a head with massive cheeks - and then apparent progression of the shoulders. Mama's legs repositioned to open the pelvis further, strong encouragment to PUSH! along with gentle traction as the anterior shoulder finally delivers... and a soft but clear pop is heard/felt. The rest of the baby delivers easily, stunned for a moment, then recovers beautifully and transitions to life on mama's chest.

As a student, this kind of scenario fills me with so many questions and so much guilt (just as a laceration has in the past) - Did I cause this? Could I have prevented it? How could this baby - not "big" by any means, and delivered over an intact perineum - be an innocent victim of trauma?

The sinking pit in my stomach, of course, is only stirred up a bit further by the babe, consistently irritable and refusing to eat; moving both arms but certainly favoring one. Though the Midwife - whose hands guided mine, whose hands guided the baby's head into this world - is reassuring that the injury was not "mine" (but rather a part of the delivery) and the prognosis of a fractured clavicle is excellent... my heart aches at the pain that little soul (and the mother) will bear. However this happened, there are no excuses and no reasons why. Little one... I'm sorry.

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

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

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

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

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

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

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

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

Until, that is, I started with the Midwife.

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

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

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

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

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

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

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

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

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

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

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

Things To Remember: (Not-quite-pearls)

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

those buggars are tough!

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

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

~ bulb syringes bounce (and are no longer clean)

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

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

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

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

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

~ I'm learning