I have been blessed...

I started to write this post last week, and never got around to finishing it. The title was different, and the whole tone of it - it was a little more playful, with an undercurrent theme that mirrored Tigger's theme from the classic Pooh cartoons (for those of you familiar with Pooh's adventures... and aren't we all??) - was meant to be a light-hearted-yet-deep reflection of the wonderful thing about blessings in life.

And I have. Truly, in so many ways, my life and my family, are lucky. As I (finally) sit down to type this, though, I just don't quite have the same levity as I did a week or so ago when I started composing this in my head. I was going to recite the list of changes that have happened over the past two months (comps, graduation, etc, etc...). Instead, I'm quiet; the Warm One is battling a fierce cold, the Littles are runny-nosed and cranky, and I've passed my boards exam. I am, officially and with no holds barred, a certified nurse-midwife.

The colds will clear up, and the Kleenexes and textbooks (and highlighters and scattered notepages) that have overtaken our home will eventually be cleared away as well. Some will be recycled, or tossed; others may be stored in the office "just in case" - who knows if I'll need that text again, or maybe I'll decide to 'recycle' it to an incoming student?

The other blessings in my life are just as clear: my family, who have been so close and willing to step in whenever needed during this journey. The Midwife, even when things became rocky, was a blessing in disguise; I learned things, personally and as a midwife, that I needed to know, from her. From D, and from all of the women and families along the way. From so many close, wonderful friends - some nearby, and some far away... women who I may never have met in person, and yet who I can (and have) shared so many of my deepest fears and funniest moments; these are my sisters and peers, both fellow students and mothers.

And, of course, the Warm One and the Littles (one of my proudest moments so far? When the Bigger Little 'corrected' the younger, who had thought that "Dimbo's" - Dumbo - mommy was being 'naughty' in the movie. The elder of my daughters explained that Dumbo's mother was upset that the other elephants were being mean to the baby elephant and making fun and picking on him because of his ears; that sometimes mommies had to stand up for their babies. It was a touching conversation for a mother to overhear between a 5 and a 3...)

*~*~*~*~*~*

Some blessings are a little harder to understand... in the months since my last post, my family has been stretched apart, and pulled together in an even stronger way. My grandfather, the "boss" of the family, was diagnosed with an aggressive leukemia just before Labor Day, underwent one round of chemotherapy, and has become progressively weaker since then. After a bout with a massive infection and complications due to the infection and its treatment, hospice - and the care that goes along with it - nurses are a daily reminder of the change. It's so hard to see the difference between the strong, capable man that taught me how to bait a fish hook and tossed hay bales into a barn loft, and the saddened man that cancer has made my grandpa. The thought of saying goodbye - along with the pain of seeing my grandfather this way, as well as how it hurts my grandmother - is only soothed by the idea that the time we are gifted by this allows for storytelling, memories, "I love you's".... my family has been together much more in these past few weeks than in the past years (we've always been close), although I don't know if this outweighs the pain that my grandparents are feeling. At this point, all we can do is "Let go and Let God..."

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.

dreams...

As I was on the very, very verge of waking up this morning, I dreamt I was walking into the Midwife's office. We sat down, and faced each other one last time. She looked older, and nervous; almost on the edge of tears, shaky, scared. In fact, much as I felt as I dropped off the thank-you cards and gifts at the office yesterday (I just gave them to the receptionist - I didn't see either the Midwife or her MA, thank goodness... my facebook friends might have seen my status about "so this is what a panic attack feels like" - that was the emotional/physical storm I found myself in as I approached the elevator). But, anyway, even in my dream state - these changes surprised me. Why was she so anxious? It touched me. The dream was short... but the message clear. She stumbled through the single statement she made to me, asking me, "Is there anything, any pressure, that you think is going to hold you back from being successful in your next area of practice?"

My dream self just sat, thinking carefully of the best way to answer. There was none of the anxiety or self-doubt that filled my last days before, simply a feeling of wanting to give the clearest answer that I knew was my right answer. I don't know if I answered in my dream, or if it was as I was waking up, but it has lingered with me all day: The heaviest pressures that I have dealt with, are the ones I have placed upon myself.

~*~*~*~*~

(later)

I know this is true - and I accept this. Doing so, I promise to myself to let this go, and let myself grow.

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.

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.

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?!

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.