Houston, we have a shoulder

Does anyone out there actually LIKE nights? Please, if you do, tell me your secret. I spend the day of my night shift worried and down, trying to take it easy and attempting a nap in the afternoon which never seems to work. My emotions are even more sensitive at 3 in the morning. My ability to multitask is compromised. When you’re the “only one on the board” I feel like I could be the only midwife in the hospital. And if I am in the least bit busy and the beeper goes off I want to crumble. And the next day I sleep fitfully, at best, with my brow furrowed. But what can I do? It’s how I gets the moneys.

I worked a night last night. When I got to the hospital there were two women there, both at 4cm, and thinking back on it now, I realize, maybe these two patients were attempting a birthing race of some sort. Though there is no reason to believe that their labor curves should mimic each other, they went for it. Room 15 and room 17 poised…well, poised on their backs anyway, to have their baby first. They were both technically active but one was having pit started, the other just falling asleep s/p epidural placement. The doc I was on with only had one post partum person on the floor who needed a bunch of labs drawn and evaluated so she appropriately (and sweetly) said to me that she was around and to let her know what she could do for me at any time all night.

Pt#1 was Japanese speaking only. Supposedly we have translator services but no one in-house for Japanese. So. If you need a translator (I got this information from the CNM leaving for the night) you have to have the secretary page translator services, wait for someone to come up from translator services, that person will bring a special phone with them and dial a special number on the special phone and then put the phone up to the pt’s ear when a Japanese translator is on the line. Um. Is anyone thinking what I’m thinking? Downsizing! (That is supposed to be sung in the key of a doorbell ringing) Can we even just leave the special magic phone on the labor and deliver floor? Nope. Well, that process not only seemed too convoluted to me, it also seemed like when I started pushing with the multip, there would barely be time enough for me to page the secretary to call the service. So, I talked slowly, I used the FOB for translation and I ultimately explained a lot less to her than I would normally do.

Pt#2, a primip with a perfect pregnant body and a FOB that all the nurses were swooning over had made good change in 2 hours. She was 6/100/-1 when I checked her. Comfortable and nothing but a few annoying variables on her FHT. (Didn’t I say everyone had variables??)

Enter pt #3. A Grand Multip. A 38 yo G7P4015 to be exact. Her body looked tired. Her legs looked heavy. Her cervix was 5. Epidural please? (My epidural rate by the way is 100%. And just a quick aside about that. I do really believe it is about giving patient’s informed choice, not about whether or not they do what I think is “right”. I think if an epidural makes someone look back on their birth experience as something beautiful or exciting instead of something traumatic I think it’s a good thing. If an epidural can give a woman some much needed sleep after hours and hours of labor, I think that’s fine too. But I don’t even feel like there is time to do the education component around this. I think women come in to the hospital demanding the epidural. They ask about it at 20 weeks. And I think midwives are so easily looked down upon for educating women on the r/b of epidurals because it can easily be misconstrued as “keeping the epidural from the patient”. In terms of my personal learning curve with labor management, with repairs…I’m admittedly happy that so many, ahem all, of my patients get an epidural. But if I look at the big picture here, there is no question that there is an epidemic among us. Women, people in general, husbands, partners, nurses, doctors…wanting to be cut off from the intensity, the pain, the emotion, of the birth experience. Just like everything else, let’s put the TV on, watch law and order while the fucking miracle of life is happening under the sheets. It’s cool, as soon as the little guy is out we’ll come around. We’ll breastfeed, or at least try, we’ll start to really feel like parents then. And if we need a break, we’ll just put the baby in the nursery for a bit.)

Pt #3 was delivered before 11pm. It was exactly what I needed. An anesthetized multip who pushed her baby out in 10 minutes with not a laceration to speak of. And it wasn’t just what I needed because it was easy. It was what I needed to be able to stop being preoccupied by my fear of suturing in order to laugh with the patient and her family. To have a steady hand when I delivered her placenta. To actually look at and appreciate the newborn breastfeeding on her mom’s chest. Everyone in the room was mellow. Me, because it was a smooth birth where I felt like I knew what I was doing and her, because well, it’s her 6^th child for god’s sake.

By 2 am both of my other pt’s were fully and +2. I had to call the doctor, who up until this point had been sleeping all night. I let her know the situation, that both pts were ready to push, that my primip had now spiked a fever and was having deep variables. She told me to start pushing with the multip, she’d hang out with the primip and I could take her place when I finished up with the other patient. It turns out, the primip pushed her baby out in three contractions with a 1^st degree tear. “One of the most beautiful births” the doctor said. I, on the other hand, was “pushing” with the multip who squeezed her legs closed every time she pushed. It was virtually impossible to communicate with her. Impossible to help her push, impossible to explain that certain positions will keep the pelvis more open than others, impossible to tell her to bear down like she was pooping. Her baby’s head eeked along. One breathy push after another. Well, the slow progress was keeping her perineum intact at least and she felt to me as if she had tons of room in her pelvis. “Do you want some castille soap?” the nurse asked. “No, thanks. She’s moving along.” I said. “How about some jelly?” She tried again. “No.” I smiled. “You’re not into that stuff, huh?” The nurse seemed disappointed that I didn’t want to manipulate the process more. But whatever, she crowned. And crowned and crowned. And finally, the head came out. And restituted. And then pulled back in. I put my hands on the baby’s head, tried my standard maneuvers and nothing budged. No shoulder, not anteriorly or posteriorly. “Should I call it?” The nurse asked. I could already feel her anxiety. I reached my fingers under the pt’s pubic bone to see if I could dislodge something. Nothing. “Ok.” I said. “I have to call it.” And then, all of a sudden, the nurse literally drops the pt’s leg, runs out of the room and into the hallway and yells as loud as she can, “We have a shoulder! We have a shoulder!!” And then at least 7 people run into the room to “help”. Is it me or do things seem to get worse in an emergency situation when someone decides to scream at the top of their lungs? Maybe I’m crazy but I don’t think that strategy helped anyone involved. After the nurse came back to the bedside and before the stampede arrived and after McRoberts and suprapubic pressure, the shoulder was delivered along with the rest of the 9lb 6oz baby girl. Oh and did I say that the pt’s 6 year old child was “asleep’ on the chair in the room the entire time too? He was. And very annoyed (and I’m sure confused) at all the commotion. Rumor has it, they had no child care.

Her vagina looked terrible. I grabbed the doctor to help me piece things together. I started the repair with her looking over my shoulder but upon closer inspection we, well, she, discovered that this was a 3^rd degree tear. So, the doc stepped in and took over. “So, I’m gonna do some plastics right now.” She said. She was talking about muscles and capsules and sphincters and lots and lots of things that I knew nothing about. Holes were closed, tags of flesh were magically pushed back and hidden, her vagina was intact again instead of gaping. I felt incompetent of course and afraid to let her know but, in the end she agreed it was a nasty and very jagged laceration. When I asked her if a year or two from now, that repair was something I should be able to do as a midwife she basically said, I could do it but it would probably look bad. I told her that we never learned how to stage a perineal tear, that we were never taught how to find the hymenal ring. “I don’t get it.” She said What did you learn?” Note to self, keep lying about what you know so as not to feel dumb in front of people you want to have a respectful professional relationship with. She also told me it was completely fine to tell all the docs I was on with that I really want to get good at repairs and that I should just ask them to be in their with me if I can. This job is so humbling.

Oh lord. When will this be easier? I’m exhausted. Off to bed.

A Mother's Burden

My mom has this fantasy she told me about a few years ago. I’m not sure if it came to her in a dream or if her mind just created a story while she was listening to the radio in the car but, in this fantasy, she is a choir teacher for a high school and one of her students is a rebellious teenage girl who happens to have a fantastic singing voice. For the “end of the year show” my mom has decided to have the choir perform the Bette Midler song “From a Distance” and in the hopes of stirring up self confidence in this young girl and creating for her some investment in the choir and the school, my mom has picked her to have the lead part in the song. But on the day of the performance, the rebel girl is no where to be found. There is no choice but for the show to go on without her. But, as my mom tells the story, she feels that this young girl won’t let her down. She assures the rest of the students that they will sing the song as best as they can and things will be ok. So, they head out on stage and start the song. As the rebel girl’s part gets closer and closer you can feel the nervousness on stage. But then, just at the last moment, the back doors to the auditorium fly open and she comes in, unable to stay away because of her belief in herself, the group and, I don’t know, the power of song?, she comes down the aisle singing her part perfectly and everyone is relieved and happy and smiling. Believe it or not, my mom actually worked this fantasy out in her head and shared it with me years ago. I often say to her when she is convinced of a downright unrealistic miracle: Mom, this is your From a Distance fantasy. This is not real. For instance, I’ll say to her, “I hate tests. The tests are too hard. I don’t know how to study. And they aren’t a good measure of my knowledge anyway.” My mom’s response would be something like: “Sarah, you just keep pushing and studying and being honest. You’ll see. In one year’s time you will be the best test taker anywhere and people will be coming to YOU for help.”

Or

“No one likes me. I feel like I don’t have any friends and people don’t want to talk about the things I’m interested in.” My mom’s response might be: “Just stick to being yourself, do you hear me? You’ll see. You will have so many friends at this time next year you won’t know what to do with them. People will love you. They are just are too intimidated right now to actually come out and say so. You just wait. You will be the most popular person anywhere.”

So, when I mention to my mom why I feel like such a failure at perineal repairs, she gets on top of her soap box and begins: You just wait. People will be coming to YOU for help with suturing. People will pull you out of other deliveries, of other rooms where you are with patients to ask for your help. They will be saying to patients, ‘you know what? I could do this but Sarah Kleinman, the nurse midwife is right next door and this is her specialty. Why doesn’t she come in and repair this?’ You will be the very best in the practice.”

It is an almost constant conversation I have with my mom where I think I suck and she thinks I am the most amazing thing in the world. And, she insists, it is not because she is my mom but because she just knows. It’s the burden of unconditional love. It’s just a little delusional sometimes.

It was a fairly quiet day in the hospital yesterday. I got hit with the snow storm that came through so many cities and it certainly helped to keep pregnant women home and out of triage. I said to a midwife from the hospital based practice while we were watching 5 consecutive episodes of Cash Cab in the L and D lounge, while I was shaking my pager in the air which had not gone off all day long, “You see?” I said. “It just goes to show you. Women are never really in labor when they call. They just get paranoid or scared or feel alone…Now suddenly when it’s snowing they just stop being in labor? I don’t think so.”

I had one woman in labor when I got to the hospital. She was a primip (of course) with a history longer than my arm. Metformin until 12 weeks. A choley at 14 weeks. Colpo in pregnancy with CIN. GBS+. Rh Neg. An EFW putting the baby in the 90^th%. Nothing that would greatly change my management, just another experience that pushes me into believing that normal healthy pregnancies just do not exist.

The baby had been having some variables throughout labor but at this point I can’t remember the last time I was managing a labor and there were no variables. Regardless, the nurses want to page you every time they see something that veers just slightly away from normal so I was in and out of the room a number of times to look at the strip, nod my head, thank the RN for asking me to evaluate, reassuring the pt and the FOB, writing a note and basically saying “I’m fine with this strip. Let me know if it changes significantly.”

There was a 3^rd year med student there all day and I felt bad for him because the day was so slow and my patient, the only one my practice had in house, did not want a student at her labor or birth. But I let the med student know that there was still room for learning. Every time I was called in to assess the strip or every time I went in to check the pt’s progress I made sure to have a conversation with the med student about what I saw, what I did, what our options were at certain points in her labor etc etc. And man, I have to say, talking to this guy made me feel so much better about myself. No offense to any med people out there but third year med students really don’t know much of anything. Partly because they get three weeks on L and D and that’s it. OK. I get that their exposure is very, very limited but I mean labor and birth 101, man. Tell me what the different kinds of decelerations are and what they are indicative of. He didn’t know. Tell me what latent, early and active labor are. He fumbles. Ok, tell me what the definition of labor is…unsure. Let it be known that I did not make him feel bad. I did not rub in his face the fact that, well, he needs to start studying up. In fact, I told him that while he was with me there were no wrong answers, it was okay to say I don’t know. I told him that much of what we would talk about would be a conversation and oftentimes there would be many right answers to a problem. And I embraced, I mean really, got happy with the reality that I kind of know what’s up a lot more than this kid. And I felt good that he might look back on his training and say that a midwife taught him something. He had a lengthy homework list when he left that day. Hopefully, he’ll be on again Monday night.

My patient was fully dilated and ready to push at 12:30pm. But not before my finger ruptured her BBOW when I went to do a SVE an hour before. And of course not before she spiked a fever and the baby got tachy and I had to give her the dx of chorio. And not before her husband, at one point, watched his wife’s face and watched his baby crown and then looked at me and was breathing heavily, his eyes wide and just said: It’s a miracle. It’s a miracle. “Are you okay?” The nurse and I said virtually at the same time. “Are you being moved by the emotion or the sight of the baby’s head?” I asked. “The emotion I think.” He said, but I hadn’t seen him blink in almost a minute. “You know what?” I said to him, “You need to sit down. Sit down on that chair until the next contraction, ok?” “Ok.” He said sitting back slowly. “Ok. But, it is such a miracle.” It’ll be a miracle if this baby comes out with no problems and I can suture your vagina by myself, I thought. A fucking Christmas miracle.

So, she got abx in addition to the PCN she had already gotten d/t her GBS status and pushed her baby out in 19 minutes. No dystocia, no problems. Just a 2^nd degree laceration and a big crooked gash down the side of her R labia. And I really had to think. What happens with my hands when that baby comes out? I was really doing a good job of supporting the perineum, making sure the baby’s head was well flexed, that the woman was controlling her pushes…but then, after the head comes out and I want to deal with delivering the shoulders…do I neglect the perineum at that point? Is that when the tear happens? Because I didn’t feel anything give before then…It makes me think my hands could be working better. They could be positioned better, could be delivering the shoulders and protecting the woman’s tissue at the same time.

In the end, I had to call the doc in. I could not make heads or tails of the labia. But I had no shame. And the doc that came in was sweet and casual and let me stay in the suturing driver’s seat the whole time.

After all my paper work had been done, after the circ was scheduled and the baby was cooed at, I found the doctor and apologized for being so dependent for suturing help. He was confused. “Why do you feel bad?” he asked. “I just feel like we never learned how to suture really, really well in school. And learning on raw chicken is never going to be like practicing on real bleeding human tissue.”

“Well,” he said “You’ll get a lot of practice here.” He didn’t say, y’know, you’re right. Your program should add in more opportunities. He didn’t say, yeah, your skills are sub par. He didn’t say, next time you should just push yourself to do it on your own. He said you’ll get a lot of practice here. Which, for me, basically translates to, you’re in the right place. Be patient. You’ll be better soon. And right now, everything is as it should be.

Today was ok

Things are getting bad, and not even related to my job. I’ve started talking to my car (i.e. Listen, Carlos, I’m gonna leave you in the hospital garage overnight, ok, cause there’s gonna be a snowstorm? So, don’t be surprised…) and my food (i.e. How we doing in there, Cous?) and I have given birth to a week-long pain in my knee that is now being evaluated for lyme and arthritis and other autoimmune origins. I got onto the elevator at work this morning, running late, annoyed at the pain in my knee and my inability to walk fast, climb stairs etc and at the 2^nd floor a man gets on. An obscenely large man. How large you say? Like, I mean, check-the-elevator-capacity-real-quick-with-your-eyes-to-make-sure-you’re-safe big. Y’know? And anyway, he was getting off at the 2^nd floor!!! He was going up 1 FLOOR! Wanted to scream. Would it have killed him to take the stairs? Well, maybe…

I had one of my first ok days at work today. A full schedule quickly turned into a few no shows and one cancellation and a fair amount of time hanging out with the MAs. But the patients I saw got good care. And they got thorough notes written in their charts. And my A neg pt who was demanding rhogam for no reason at her IOB even though she hadn’t had any bleeding and was pissed when I told her that she couldn’t have the shot just to “make her feel better” was actually bleeding (!) when I did her GYN exam so…she got what she wanted! “Isn’t it funny how the universe provides like that?” I said to her. I tried to focus on her success in acquiring the injection instead of the fact that there was a possibility that she could be having a SAB. And my 18 yo G2P0 who comes in virtually every week for abdominal pain or decreased fetal movement and who has had trich for weeks because she’s too busy to pick up her meds came in today for what basically came down to right-sided butt pain. It turns out she got her rx for the trich and has been taking the pills! And she came to the office without her mom today! And she was satisfied with non-pharmacologic comfort measures!

I think days like today are not only good ones because the patients get good care and because I feel a little less shitty about myself when I crawl into bed at night but I think more accurately because there are no awful reminders of how my skills and my limited knowledge fail the patients I am supposed to be helping. One of the stories we read for my lit and medicine class describes this perfectly I think. The author has been the doctor to a patient with depression who continues to come to the clinic over and over again for various somatic issues. She writes:

“I am not suffering. I am actually the complainer. I’m the one who can’t face this patient without immediately rolling my eyes and turning off my compassion. The reality is that I am profoundly discomfited by my inability to treat Mrs. Uddin, and she is simply the thorn that continually reminds me how limited my skills can be.”

(From the story “Torment” by Danielle Ofri)

And then, indirectly related I guess, I was listening to NPR at work and just before I shut off my computer to go home I heard a story called "After the forgetting". It was about this guy and his relationship with his 91 year old mother as she was descending into the depths of dementia. He says at the end: I can’t imagine my relationship with my mother being any better than it is now. What an amazing feeling it must be to feel that way. And what would it be like to be able to say that about your relationship with your father? Or your work? Or yourself? And why why why would you want to settle for anything less if that feeling is possible? (http://www.npr.org/templates/story/story.php?storyId=98450439)

The morning after

Night call has left me exhausted and oversensitive. I was on call with a spunky young doc who, though she commonly thinks everyone who has any kind of abnormal tracing or labor curve is “getting cut”, she is extremely approachable and normal. Even better, she was up all night with two of her own patients so I never worried about waking her up or not being able to find her. The labor floor was scarily quiet. Only three patients on the east side of the unit which has about 25 rooms.

A woman who had been seen earlier in the day for decreased fetal movement, a reactive nst, a 6/8 bpp and an EFW of 9.13 called back around 11pm c/o ctx q 7 minutes. She was (surprise!) a nullip and extremely happy so I had her stay at home and call me back in 2 hours to check in. She initially called me back in about 15 minutes to tell me that she was still having contractions, still feeling the baby move but now she was having this weird blood on the toilet paper when she wiped and thought I should know. At this point it was pretty clear it was going to be a long night. I reassured her about bloody show and tried to get a couple hours of sleep. I got a call from the answering service around 1am “Guess who called back?” The telecom operator “tom” said to me annoyed when I called him back after getting the page.

She was now c/o ctx q 4-5 and they were stronger. But she literally seemed giddy while she was on the phone with me. “Well,” I said, “maybe you’re just a really happy person.”

“I am.” She said breathing hard. “I’m really, really happy. That’s exactly how I am.” After barfing in my mouth a little I invited her in because, though I think she could have stayed home, she lived an hour away and she was 3cm in the office two days ago.

She was 5cm when she got to triage and because no one wants to budge my 100% epidural rate, she got her placement and assumed the left side lying position. She was tachy, I bolused her. She got some lates, I turned her and, amazingly, they went away! I checked her at 6am and she was 7/100/-2. “You think this baby is coming out vaginally?” My nurse said. I never know how to respond to that question. How should I know? She’s 7! And yes the baby is high, and supposedly big but why is everyone so quick to be distrustful of the ability of the pelvis??

The next time I checked on her she was sound asleep. So, I passed her off to the next CNM on call and am now checking my work email incessantly to find out what happened to her. Did the baby come down? Did the lates come back? Did she in fact deliver vaginally?

The midwife who discharged the pt that I delivered on Friday did a perineum check this morning and called me to let me know that the repair was completely lopsided. As you recall, this was the repair the chief resident did for me. The partial 3rd that somehow became a 2^nd midway through her repair.

The doctor was called in to see it, a note was written about it and sent to her primary care providers in the office. It was stated again in her discharge note that the resident’s hands, not mine, were the ones responsible for the mishap. But I can’t help but think what kind of a job I could have done if I had just pushed myself to try to repair it on my own…

I’ve been flaked on by two people tonight. And I specifically made plans on my post call night to give me a reason to get out of the house. Annoyed and feeling …annoyed. Tomorrow evening my literature and medicine class meets. And I was chosen as the lead part in this staged reading we are doing of a William Carlos Williams play. Maybe I’ll rehearse…

I hate the perineum

I feel like, as a midwife there is this assumption that I am supposed to love the vagina. I’m supposed to think birth is beautiful and normal and perfect and happy. But, I just got home from call and am certain that I hate the perineum. I wait while a woman labors in constant fear of her pushing on a nulliparous perineum. I have such suture phobia that I would gladly give up all of my births to only manage labor if I just never had to repair anyone’s vagina. And now that I am finally home, out of my scrubs that were covered in blood and amniotic fluid, showered and making dinner I am still getting whiffs, from I don’t know where, of placenta and blood and vernix. It’s in my nostrils and my hair and, currently, I cannot think of a worse smell than labor and birth.

I had two patients today, both of which I was certain would not deliver on my shift.

Pt #1:

She came to triage from the office where she was seen by the CNM for her routine ob exam. She was 39 wks. But when the CNM examined her, she ruptured. Even though she was GBS neg, the head was high enough to make the CNM nervous and so she got sent in to me. She was 2cm when I checked her in triage. And writhing in pain. She got a room, took a shower and then, 2 hours later got an epidural. (2 hours because when I initially walked into her room, she was lying in bed, one fluorescent light on, not on the monitor and, no IV, no IV pole despite the fact that it was very clear she wanted an epidural. The nurse was no where to be found. When I finally did find her I have to say she was the slowest most turtle-like nurse I have ever seen in my life. Her walk was slow, her talk was slow and I would not be surprised if her brain was slow as well.) Her tracing was yet to be reactive. Good variability, no decels but no real accelerations and no scalp stim. I let her get comfy s/p her epidural, the med student wrote a note for me, which was so weirdly incomplete. There were so many things she just didn’t remark on. Decelerations, plan for reassessment, length of contractions…(I even told her to comment on these things after I read the note over and she never completely described the strip and, under UC, when I put “x” after her “q 2-3 min” she put “6 hours” instead of something like “45-60 seconds”. It was clear I should have explained better…)

At 5pm I stepped out of another labor room (see below) to check in on her. The tracing looked crummy. She now had light mec, had progressed to 5/100/-2 but her variability was minimal, no accels and these repetitive lates that I was NEVER called about. I asked the doc to come assess, (You’re gonna hate me, I said to start my report on her) and went back into my other labor room because my pt was crowning (see below). Within minutes the pt I had asked the doc to assess was rushed back to the OR for a STAT c section. Apgars 6/9. Done and done.

Pt #2:

32 yo P0 at 39.5 wks. She was being induced for mild preeclampsia which…she didn’t have. She got one dose of gel yesterday and arrived today reporting ctx all night. She was 3/80/-2 in triage which was an amazing change from the day before. We started pit and almost immediately she asked for an epidural. The next time I checked her, she was 6. And a couple hours later, I was paged to come assess her tracing. She was having variables with almost every contraction down to 90 (the notorious dipsy doodle!) so we shut off the pit (well, actually the nurse did before I could ask her to) and I checked her. Fully and +2. Meanwhile, the doctor on with me was deciding whether or not to take a morbidly obese woman back to the OR who was having lates vs variables and who hadn’t made change in over an hour with adequate ctx. He decided to wait on her and I got the go ahead to push. And for the most part her pushing was very controlled. The med student was there, with “sterile” gloves on for some reason. But she kept putting her hands on the pt’s knees and feet while she was pushing. Oh well. The head was crowning, the tissue was stretching, the FHR was reassuring, ahem, category 1. And I have to say a little midwifery thought went through my head. There is no reason to rush this, I said to myself. The nurse trusts me, I thought. The med student is watching a clinician be patient with the process of crowning and pushing and not needing the actual delivery to happen before it wants to. I imagined the ghosts of some my friends in the room proud of my confidence, my lack of fear, my ability to coach my patient, appease the nurse and teach the student all at the same time…And of course I’m thinking stay intact, stay intact, stay intact. Please. And then the heart rate went down. And stayed down. And my plan changed.

“Ok, so guess what, you are going to have a baby with your next contraction!” I said to my patient.

And she did. The baby shot out in one push. Head, shoulders, knees and toes, just slid out half on the bed, half on my arm and a liter of amniotic fluid was all at once on the bed and my thigh and in my shoe. Nuchal cord x 1 reduced and mom and dad were the first to see that they had had a baby boy. But while I was waiting for her placenta to be delivered…I got a good look at the perineum and I started to sweat. It was just a sad gaping mess of red. And there was a purple bulge on the right side and the apex of the tear was so far beyond what I was able to see…I panicked. The doc poked his head in: “Everything ok in here? Great. I’m goingback with your other pt. Stat section.”

“Oh, sure everything’s great! Sure!” I said and I have no idea why I couldn’t ask for help. I started to be angry with myself for being scared. I started to be angry with my midwifery professors for never really teaching us how to determine if someone had a 2^nd degree vs a 3^rd degree tear. My back up docs were the residents now. And I have no relationship with them at all. But they were called to help me piece this woman together. When the clipped and efficient chief resident arrived she determined initially that it was a “partial 3^rd” which made me feel somewhat validated. But then, as she basically just took over the reins she kept calling it a 2^nd and I’m like what happened to partial 3^rd? Can we please call this a partial 3^rd? Just so I don’t have to feel bad about myself? Please? “You’re ok with repairing the 2^nd right?” She asked me. “Yup. I’m good.” I said. “Well, I’ll just do it.” She said for reasons I seriously do not know. “It’ll take me 10 minutes and you’ll be all set.” I know I should have pushed her out of the way, and I have to admit I was annoyed that she just took over my suturing seat but another part of me was relieved. Another part of me didn’t want to ask her to have to come BACK in if she left. Another part of me recognizes how hard it is for me to even ask for help in the first place. How humbling it is to say, I’m new, can you help me?

I simply just have suture phobia and I hate perineums.

After all the notes were written and ordered put into the computer, I found my doc. He put his hand up in the air and gave me a high five. “Why did you say I would hate you?” he asked. “Just because I kept bugging you all day.” “You were appropriately bugging me! I’d rather you over tell me than under tell me things. You were right to get me. Anyway, apgars 6 and 9, could we have waited another 15 minutes to see what happened? Maybe. Would the apgars have been worse if we did? Maybe. Who knows? I think it was the right thing to do.” “I just hate not knowing what to do so often.” “But soon you will,” he said. “Don’t worry, soon you will.”

So. Another shift gone. Another baby born by my semi-competent hands. And back on Saturday night. This job is never-ending.

Things are just bad

The problem with trying to keep the blog updated is that at the end of a busy day when I have tons to vent and gripe and ask for validation about, I just don’t have the energy to sit down and write about it. I want to come home, get into bed (before or after I have taken off my coat) and fall asleep. Remember how in Broadcast News the holly hunter character puts on such a confident, motivated, hardworking face when she is at work and then the moment she gets home, drops her bag and is by herself she sits on her bed and starts sobbing? That’s pretty much me. And I’m not doing such a good job these days of holding back the tears until I get home. Today, I closed my office door twice in the middle of the day to take a deep breath, hold back tears and tell myself it was going to be ok. My work life sucks. My personal life sucks. And it’s all I can do to hold out until I come home, sit on the couch, put my face in my hands and let go.

I feel like I never see anyone normal at work. In the past two days I saw 1 person who had no problems. And I am realizing now that I should never have blabbed about how excited I was to see teens and pts with multiple social issues. Why did I do that? I feel like the entire day I am listening to people’s shitty lives and have no way to solve their problems. In the past two days I’ve seen a teenager who just realized she was pregnant at 25 weeks and whose mom is so overbearing I want to scream. She has extensive back issues that I have no idea how to evaluate and she just got out of the hospital for pyelo which she didn’t know she had because she is so used to back pain she just shrugged off the ache in her flank for 2 weeks and popped Tylenol. I saw my return OB pt who is also a teenager and who is also 25 weeks and who has already had a total of something like 15 visits either to the hospital or office. Abdominal pain that subsides when she gets to the office, decreased FM that she starts to feel once she gets put on the monitor…she has had Chlamydia this pregnancy and trich twice in 10 weeks but assures me she has not been sexually active since she found out she was pregnant. She had trich in her urine weeks ago and she still has not been treated. The first time it was because she and her mother were “afraid” that the medicine was unsafe in pregnancy so she just didn’t take it. “Why didn’t you call me to ask?” I said. “We were busy.” She responded. I saw her yesterday and she still was untreated. Why? Because they went to the pharmacy and there was no script. “Why didn’t you call me?” We were busy, they said. “It’s really really important for you to treat this infection”, I said. “I understand it’s important” her mom said to me slowly. “I work in a hospital”, she said. “It’s just too much for us to handle right now but I don’t expect you to understand that”. I reordered the rx. Every time I asked the pt a question her mom answers. “So, you feeling the baby move every day?” I say to the pt “Oh, we’re feeling that baby move now. Now we know when that baby’s moving, don’t we? After I had to be in that hospital for hours last week…” she eyes her daughter. I wanted to say who the hell is pregnant here? Are you BOTH pregnant? If you’re pregnant too you really need to schedule something…

And I had a pt who had seen me for irregular periods and alopecia and fatigue and weight gain and terrible PMS whose labs all ca\me back normal and the MD said she thought she should have a more in-depth f/u and potentially an US and the pt basically said she couldn’t pay for any more visits. She’d try to call in February. And meanwhile she is suffering from “extreme moodiness and fatigue” 10 days before her period. And today I had a 39 yo with a history of IV drug use and alcohol addiction and her father killed her mother and himself when she was 13 and who has chronic hep c given to her by her ex husband who is now dead and she has abnormally elevated LFTs and wants OCPs and I am so at a loss for how to even begin to help her. The MD said she should f/u with her and believe me I agree, I just hate having to say to someone…I can’t do anything for you. You have to come back and see someone else who knows more than me. I’m sure she’s thinking, why did I even see you at all?? I should have just seen the doc to begin with. And I can’t say she’s entirely wrong. I feel like all I do is see patients and hold back tears and ask other people what I should do. I just don’t know how it gets better. I learn more? I just become familiar with the feelings of incompetence? I find more ways to distract myself? I fall in love and have that fill the hole in my belly when I come home at night? I just deal with the fact that this is an unbelievably hard job and there is no way around the emotional challenges?

It just seems to continue to get harder.

1st Night

My first night of call off of orientation was Monday. Thankfully, it was a quiet night. (The Saturday before had been an almost perfect dry run. I was still on orientation but the midwife I was on with went to bed at 10 and didn’t wake up until I paged her at 7:15 the next morning. Though I felt terribly alone and though every time I sat down to close my eyes I was kept awake by anxiety that something would go wrong, I made it through. The MD and the other CNM had no idea that I had triaged, admitted and delivered the baby of a G2P1 at 2:45am. She arrived at 4 cm after having regular ctx for at least 3 hours at home, got her epidural finally (it only took two hours), and was tucked in for some rest. I spoke with the pt’s 2 friends during the placement. One friend was very annoyed that the baby would probably not be born until November 30^th since they had arrived just after 11pm on the 29^th. Why do you care so much? I asked. Well, she explained, “My ex husband’s birthday is November 30^th and my boyfriend’s ex wife’s birthday is November 30^th so…it’s just a bad day.”

I told them all to try to get some sleep, to turn out the lights and not to talk. But an hour later I was called to the room by the nurse for what she called “dipsy doodles”.

(“You should have told her that ‘dipsy doodles’ are not in the NICHD criteria” said a friend of mine. But I’m gonna choose to live with a dipsy doodle strip until I am certain of the nurses’ respect)

I will say though that when I saw these so-called dipsy doodles I was not impressed at all. There were three variable decels to the 100s. Three.

“These dipsy doodles just started so we figured either something’s wrong or she’s fully”. Said the nurse.

Right, I thought. First of all, what would be wrong with 3 dipsy doodles in 15 minutes? And secondly, she was 4 like 2 hours ago. But whatever. I checked her.

And I stood corrected. Fully and +3. She pushed her baby out in 2 contractions. I considered attempting to deliver in the caul since her water hadn’t broken yet but the nurse stuck her head between my patient’s legs when she saw membranes bulging out of the introitus, squinted her eyes and systematically handed me an amnihook. It would have probably gotten in my mouth anyway.)

So Monday, I was certain to get slammed. But I prayed to whatever god you want to believe in and they came through for me. I had two triage situations at the beginning of the night: one woman with decreased FM who had never heard of kick counts and who felt the baby move before, during and after a reactive NST and then a call from a term pt who was c/o flu like sx, afebrile, vomited x2, +FM, no bleeding…turned out when her husband came home he reported having the same sx all day. And the relatives they were both with all weekend for the holiday had been puking too. I told her to push fluids, brat diet, call back if she spiked a temp. And then, I babysat a cervadil pt all night long. She was a P0 being induced of course. For repeated episodes of decreased FM, a BPP of 6/10 and an AFI of 6. Now, none of these things on their own would necessarily be a good enough reason to induce but together they seemed to be enough evidence of…the clinician feeling uncomfortable? In any case, the pt was feeling the baby move the entire time she was in the hospital and her strip looked great from the moment she walked in the door. Her cervix was so closed I would actually call it sealed. The cervadil went in at 8:45pm and every time I came to the floor to write a note on her, I was sure to give the nurses some face time. I watched them look at each other’s pages on facebook and listened as they talked about their boyfriends’ bad habits. The rest of the time I let myself lie in bed and sleep. It was so quiet the rest of the night that I woke up with a start at least two or three times convinced the beeper was broken. I’d grab it, press the button that lights up the screen to see if the battery had died and even though a little skepticism remained I thought…I’m just not going to investigate. If they need me, they’ll find me.

I pulled the cervadil at 7am because the pt was contracting every minute and writhing around in a tremendous amount of pain with each one. Her exam was unchanged. I mean like a bishop’s score of 1, with 1 as a handicap because I felt bad for her. Like, sealed so tight that my fingertip barely, barely got in the external os. At that point though, the next midwife was coming on. If the tables had been turned and I was coming onto the floor with the same situation, I thought to myself, I’m actually not sure exactly what I would do. I asked the doc on call with me. Well, she said, you could just let her contract on her own, or you could start pit. Really? Start pit? Isn’t that just asking for a bad outcome? I thought.

The midwife coming on wanted to send her home. And the doc coming on agreed.

I checked her chart today. Turns out the patient was sent to c-section for FTP after 2cm and a maternal temp of 202 at midnight. It also looks like though her epidural was adequate enough to control the pain on her skin during the section, it was not enough to cover the pain of the surgery on her insides and she had to receive IV sedation for the 2^nd half of her surgery. She is 21. It was her first baby. And I just can’t help but wonder if the outcome of her labor could have looked different…

I’m back on Friday. I keep praying to all the same gods I prayed to before but I sort of have this feeling that I am due for a busy shift. And the anxiety will begin…now.