Eduvacation

Well, I finally went on my first eduvacation. What’s an eduvacation you ask? Simply put, it’s a vacation…plus education! The way it typically works is you spend 4 or 5 days in a warm and/or beautiful place, listen to lectures in the morning, and have free time to sit on the beach or at the pool or for exploring in the afternoon. So, you get a little break from work and life and, at the same time, you learn some new stuff about your field.
In my case, I spent last week in Cabo, Mexico right on the tip of the Baja peninsula for an OB conference at an all inclusive resort. Lecture topics ranged from preeclampsia, to primary c section to bipolar disorder in pregnancy.

I had never been to an all inclusive resort before this trip and now, I’m not sure if I would ever go back to one. In the weeks before I went, I had fantasies about all the delicious Mexican food I would eat. I imagined strong, shirtless Mexican men delivering chips and guacamole to my palapa on the white sandy beach. I imagined genius lecturers, my Spanish skills becoming Spanish skillz. I imagined breaking hearts, learning salsa, and getting a nice, even, bring-on-the-winter suntan.

Turns out, this particular eduvacation is a way people can say they are in Mexico (your passport gets stamped, you gotta go through customs, it’s ridiculously hot) but not feel as if they are actually in Mexico. The whole time I had to keep reminding myself that I was in another country. Some days, only the pesos in my wallet and my roaming cell phone service kept me aware of this. It was sort of like I was in Florida with a lot of Mexicans walking around and all speaking English. The brochure promised Mexican food. I ate Mexican food once. The literature about the hotel boasted 6 or 8 restaurants with all different kinds of cuisines but once we got there it was clear that only one or two restaurants were open at a time and it was usually a buffet. The brochure also promised beautiful sandy beaches along the lovely Sea of Cortez. However, though I was only 20 yards from the ocean, I was never able to actually go into the water because the rip tides were too dangerous. By the middle of the first day I started thinking that an all inclusive resort is equal parts nursing home and spring break in Ft Lauderdale.

Day 1 included lectures on GDM, IUGR and hemorrhage. It was nice to be in that environment again. Learning about the latest evidence based practices, taking notes, sitting cross-legged on my chair, whispering to my friend sitting next to me, seeing just how many bottles of water we could pound down, circling all the typos in the power points. (Someone actually put “strait A student” in their presentation.) It was fun.
In the afternoon we plopped ourselves down at what was apparently the activities pool. Within seconds of sitting down, an all-pool Mexican bingo game started and, after that, tequila volleyball in the pool-I did not participate in the latter. Though I was not in a palapa on the beach, I was handed a delicious strawberry margarita and I ordered multiple glasses of agua at the swim up bar. But there were no chips and guacamole in site.
The first day also included a hotel-wide “Mexican” fiesta at night. We witnessed staff setting up the stage and multiple food booths all day and when we finally arrived at dinnertime there was an unlimited supply of tamales, tacos, grilled meat and of course, alcohol. The tamales were great. The tacos and empandadas were sub par. But the “activities” were just sad. Unlucky volunteers were brought on stage to gargle water while singing La Cucaracha. A photographer came to each table donning you with a sombrero and then selling you a framed photograph of everyone at your table wearing the hat and sticking their chests out. The same guy who ran tequila volleyball, Alberto, visited each table, pouring everyone a shot of, yes, you got it tequila, and making people scream “arriba, arriba” and “coochie coochie”. Our table gave Alberto the evil eye and we all took a walk on the beach.
Tired and still let lagged, I watched a little David Letterman on American Network TV and fell into a deep sleep.

On day 2, the lectures included PROM, stillbirth and preconception care. In the afternoon the decision was made to switch home base to the kidney shaped “adult pool”. I read, I relaxed, I snooped into the beach hut where they give massages, I had a sickeningly sweet “iced tea” and some water to wash it down. The only real unfortunate outcome of that afternoon was my sunburned left armpit, tender to the touch because I didn’t spread on my sunscreen evenly.
Before dinner, my friends and I decided to go horseback riding on the beach. I had only been once before and this experience was pretty similar to my first. Super fun. Super out of control galloping. Holding onto the reigns for dear life and screaming to the riders ahead, “Coming up fast!” each time our tour guide whipped the butt of my horse.
My sister did a lot of horseback riding when she was little. Like, jumping and winning awards and being fearless horseback riding. While I was sitting on my Mexican horse I couldn’t stop thinking of her and how, when she was a teenager and I was still in elementary school she used to let me wrap a string around her waist and walk behind her around the house as I periodically yelled out commands to her as if she was my horse and I was the jockey. I’d say, walk! And she’d leisurely walk into the living room with me trailing behind. I’d say trot! And she’d start a light jog into the foyer. I’d yell: Gallop! And she’d start skipping around the kitchen. Then I’d yell: Cantor! And she’d let out a big neigh and take off running wildly around the 1st floor with me running behind her pulling tightly on her reigns and laughing hysterically.

On day 3, we had the morning off for either sleeping in and relaxing or joining in on one of the organized trips that the conference was offering. We chose to spend the morning snorkeling. This included a drive through the city of Cabo San Lucas, a lovely boat ride full of music and dancing and helping the captain drive and, of course, snorkeling. After a 15 minute swim to the coral reef which we were instructed to head towards, I was enveloped by fish of all shapes and sizes. What seemed like thousands of tiny little minnows encircled me, long eel like fish waved along the bottom, colorful flat fish fluttered against my legs. I was surrounded by them. And then, I realized, I was also surrounded by people. Since our arrival, no less than 4 other tour boats had pulled up and let out a bunch of other snorkelers. At some point I pulled my head out of the water and saw at least 60 or 70 other white people in that dead man’s float position with their little plastic breathing tubes sticking out of the water. It was a little too much for me so I swam back to the boat. As for our promised lunch time Mexican buffet? Nope! Hot dogs and hamburgers complete with Kettle Chips and, I will admit, the most delicious dill pickles.

The afternoon lectures included controversies in elective c section, preeclampsia and poly/oligo hydramnios. There was no question that the MFM who was also a DO was the absolute best speaker of the bunch. Much of the stuff she talked about wouldn’t necessarily be things I would directly manage but it didn’t matter. It was a pleasure to listen and learn and to tell her that I thought she was great afterwards.
Before dinner, everyone in the conference was given the opportunity to release baby sea turtles into that wild ocean. These little guys had been buried in the sand until they hatched and we were supposed to simulate their “run” into the water where they would then grow up and proliferate. That is, if they weren’t eaten first. An obscene amount of them die. My little turtle, I named him “Tortuga”, was covered in sand when he was handed to me and he seemed to have some motivation problems despite my coaching. Though slow and steady might win the race I can’t help but be somewhat pessimistic about his future. He did eventually make it into the water but not until someone picked him up, placed him on the wet sand and waited for a wave to pull him away.

The last day included lectures on twin deliveries, GBS and DS screening. It was an unhappy realization that in all 4 days the one CNM speaker only talked about things like mood disorders and smoking cessation. Why can’t we, as midwives, be responsible for the more science based lectures too? Now, I will not deny that my scientific education is, well, at its best, foggy. But, that doesn’t mean we can’t become experts in ANY part of OBGYN. It doesn’t mean we always have to be seen as this weirdo touchy feely part of the OB world and I can’t help but think this way of organizing the lecture topics only serves to perpetuate the unjust hierarchy among doctors and midwives.
It was boiling hot in the afternoon but we took a sweaty walk into town, bought some shit and marveled at how many Rx meds you could buy OTC here. I almost bought a few doses of diflucan and cipro, you know, just in case, but then, I only had 20 pesos left…

So, all in all, let’s see…
• Thumbs up on the lectures, but thumbs down on the fact that CNMs always seem to be pigeon holed into talking about emotions and nutrition and not the science of obstetrics.
• Thumbs up on the American Network but thumbs down on the lack of Mexican food.
• Thumbs up on being called Sarita for a week but thumbs down on Alberto our activities director.
• Thumbs up on the DO who gave a great lecture on preeclampsia but thumbs down on the 3 female MDs who were aggressively defending primary elective section
• Thumbs up on riding horses but thumbs down on tequila volley ball
• Thumbs down: All inclusive resort?? Thumbs up: eco tourism??

So, I think I would actually go on an eduvacation again. I’m just not sure I’d go to this particular all inclusive resort. Prior to going, I couldn’t stop talking about the idea of never-ending amounts of etoh but once I got there, I remembered, I’m not much of a drinker. In fact, I was more excited about the oversized bottle of water they left in our room each afternoon than the bottomless cup of Bacardi being offered 24 hours a day.

When I got back to the states, I called my father to let him know that I had arrived home safely. “Well,” he said half listening, “Back to the grind, huh?” Perhaps it was an overreaction but I took offense at his cynicism. Maybe I was still jet lagged, maybe I was even a little sad that I had to go back to work the very next day. But I’m hoping that even these few days away, regardless of how many thumbs up or thumbs down I gave the trip, will serve to soften the edges of my reality at least for a while. And when it wears off, I’ll just have to start planning for another.

Hunger

Today is Yom Kippur. The Day of Atonement. Or, if you prefer At-One-Ment. As a child, I remember being dragged to temple multiple times during the year for various holidays without any real understanding of why. I remember the smell of that place, the way the voices echoed in the lobby and the back of the sanctuary. I resented having to sit and be quiet for what felt like hours. I still remember almost all of the songs, but more, the revoltingly operatic voice in which the cantor would sing them. I remember, even then, at 5 or 6 or 7 years old thinking how poorly decorated the temple was. Walls made out of different colored rugs, multicolored stained glass… Not understanding any of the Hebrew, my eyes would always wander to the walls and the ceiling and the cantor's horse-like teeth and I would think, “Why, why?”

Growing up, I never fasted for Yom Kippur. And neither did my father. My mother did but as I later found out, she made a lot of allowances for herself:

“Well, I have to have a cup of coffee in the morning. But just the one. With cream. No sugar. I have to or else I’ll get a headache! And I need gum. Just the gum though, no food. Throughout the day. Or I’ll get sick. I get so nauseas when I don’t eat! And water. I let myself have water. Just to, you know, keep my mouth from getting dry when the gum wears out. Does that count?”

As an adult, I do try to fast every year. Unfortunately, I forgot to ask for the day off today so I had a full panel of patients waiting to see me in office. So, I semi fasted, allowing myself some miso soup and a mini container of hummus so that I was not mean to my patients all day. And, I confess, midway through the day when the office manager came around handing out homemade gingerbread whoopee pies made by one of the other midwives in the office I guiltily stuffed one in my mouth right before I started my initial OB visit with yet another pregnant teen. Does that count?

So, yes, a little sustenance was needed as I welcomed 3 more teens into the world of pregnancy this week. And each story seems worse than the last.

Teen #1 has on dark eye make-up and a purple leopard skin bustier. She, like most of the teens I “take care of”, gives me one word answers to all my questions. She seems indifferent at best about…everything. She has a significant personal and family history of substance abuse and mental illness. Her parents don’t know. She doesn’t have a job. The FOB is currently incarcerated for what sounds like violent acts against the patient. She has a restraining order against him. Her neck is covered in hickies.

Teen #2 is living at home with her mother and father and is not worried that they will throw her out when she tells them that she is pregnant this afternoon. The FOB is aware of the pregnancy. He is in college but the patient does not know the name of the college or where it is.
“You don’t know where your boyfriend is right now? Like, the state or the city? You have no idea?”
“Um, I guess not.”

Teen #3 has come with her mother. The two of them are sitting in the room when I enter, the mother on a chair, the teen, slumped way over on the exam table. I shake both of their hands, ask a few initial questions and then say, “So, this pregnancy was unplanned?” and the mother says to her daughter, “Excuse me??!! You’re pregnant??!!”
“Let’s back up here.” I said. “You are here for your initial OB appt right?” I look at the pt and her mother, waiting. The mother apologizes, “I’m sorry, I’m just so sorry. It’s just that I’m in so much shock these days, with her being pregnant. My daughter, contributing to the cycle of poverty. Her grandmother was a social worker and she would be so disappointed that her granddaughter went and opened her legs like that.” She turns to her daughter. “Why would you do that? Why would you go and open your legs like that?” Her daughter shrugs and rolls her eyes. “And that ring you have on your finger? Probably out of a candy machine. Cost a nickel or a quarter. Do you even have a boyfriend? Do you even know his last name? Probably not. He’s probably with some other girl already.” Her eyes were closed and she was swaying back and forth and her hand was on her forehead.
I took a breath. I was angry. Angry at the mother, angry at the daughter. Angry for the daughter. But, I held myself back and asked the pt if she would like her mother to stay in the room. I said it was clear that everyone had a lot of emotions around the issue. I advised the mother that she might want to consider seeing a therapist herself. She didn’t respond. Just sat with her head in her hands.
“So, your last menstrual period was when?” I asked the pt.
“April I think.”
“April? It says here you told the medical assistant it was in July. Our visit here today will be very different if your last period was in April. Have you had any bleeding since April?”
“Yeah.”
“Okay, like, bleeding like a period?”
“Yeah.”
“Every month?”
“Yeah, I think.”
“Okay, when was the last time you had bleeding like a period?”
“August 21st.”
“I’m confused. So, you may not have missed your period at all?”
“I don’t know.”
“Let me understand something. What did you expect to get out of this visit today?”
“To confirm pregnancy.” She said. It was the longest sentence she had offered.
“Why do you think you might be pregnant if you’ve had bleeding every month?”
“I’m having pregnancy symptoms.”
“What symptoms?” I asked. And then, as if she had read it from the internet-
“Increased appetite. Breast tenderness. Back pain.” She paused. “And baby kicks.”
“Baby kicks? I’d be surprised.” I said. “You’d have to be pretty far along to feel your baby moving. Did you take a home pregnancy test?”
“Well, no, it was at my friends house, not at home.”
“Okay, that counts. A home pregnancy test does not mean you have to do it at your own home. Was it positive?”
“Yes.”
I stepped out of the room to run the pt’s urine through our office pregnancy test which is essentially the exact same thing as a home pregnancy test but it allowed me some time to escape the space and for some reason both the pt and her mom wanted to know what our test said. Positive of course.
We finished up the talking portion of the visit with minimal interruptions from the mother and thankfully, the pt asked her mother to leave the room for the exam. When she left, the pt and I spoke briefly about her choice to keep the pregnancy.
“I just couldn’t deal with it emotionally, y’know, having an abortion.”
“Do you think you are emotionally prepared to be a mother?” I couldn’t help but think of the shitty role model she had.
“Yeah.” She sad. I resisted the temptation to scold her. To try to change her mind. To tell her that she was wrong. To give her all of the reasons why, in fact, she was not ready for motherhood. But I told myself it wasn’t my place. Instead I promised that I would take good care of her if she promised to be honest with me, to ask questions, to let me know if she was having problems with her mom, and to take care of herself.
She lay down on the exam table and it was clear that no matter how much I had tried to convince her, it wouldn’t have mattered. This girl was very very pregnant. Her belly was huge. I hadn’t noticed it because she was so slumped over and because the gown was so baggy on her.
“You’re very pregnant, aren’t you?” I asked
She nodded.
“Let me go get my doppler.” By measurements she was 25 weeks. She certainly had been feeling baby kicks. And as soon as I put my Doppler on her belly a rushing fetal heartbeat filled the room. She looked at the ceiling.
Her chart said she had had a previous termination at 17 weeks last year. And that her mother had called the school prior to that saying that she had tried to kill herself. There was the possibility that she had been abused by a friend of the family. She is currently positive for Chlamydia. The list goes on and on and on.

And when I try to find a social worker to be involved with these patients’ care, I am again reminded that our resources are minimal. Our social worker can send me a packet of information to give to them but she can not always call them and she can never meet with them in person. Rumor has it that there is some sort of “alert list” I can get these girls’ names on so that someone will come see them in the hospital and tell them in person about the organizations that may be able to provide them with some support. They can assess their home situation, make sure it is safe for the baby and the new mom herself…But it is not enough. If I give any of these patients a packet of information about WIC and Jewish Family Services it will instantly become a coaster when they get home. They won’t make the phone calls, they won’t fill out the forms.

So even after I came home from work and broke my Yom Kippur fast with more food than was good for my shrunken belly, I was still angry and still hungry. I feel constantly torn between wanting to provide these teens with non judgmental care and wanting to convince all of them to terminate so that they don’t have to be a mother before they are even an adult. Singlehandedly, I can’t keep them from getting pregnant. I can’t keep them from wanting to have a baby. That’s of course their choice and not mine. So I’m left with this wrenched feeling in my stomach, this frustration that there isn’t even better care for these girls since they need so much more attention and education than others. I come home every day and think about how hard my job is, how difficult it is to see these girls especially, with their growing bellies and their one word answers, how I am left with this sense of hunger for easier days, more time, better resources…

But then, I think, they’ve got to be way more hungry than me.

Anniversary

Last Tuesday marked my one year anniversary at my current midwifery practice. One year later I certainly feel more competent on many days. I don’t cry as much. I get slightly less panicked the day before a call shift. I know which nurses I have to sweet talk and which ones I don’t in order to feel respected. I speak up more at meetings. I started a newsletter and have precepted medical and nursing students. My leadership skills have definitely been recognized by others in my group and I am almost always nominated to head up creative endeavors and any community organizing that needs to be done. The director of a local advanced nursing program has invited me to teach an elective class to her students on literature and medicine. I guess when you write it all down like that, there’s lots to be proud of.
But to be honest, there is still something missing. And I can’t quite put my finger on it. As always, I’m not sure how to tease out the dissatisfied feelings that are coming from my life in general and which are coming directly from my job. I do think, on many days, that I would be happier if only my practice started less inductions, if less women demanded (sobbing and decompensating and pounding their fists into the mattress) epidurals in early labor, and if I was not as responsible for what feels like medical issues that are often outside of my scope of practice. On other days, I am certain I could live with a little more philosophical compromising if I felt the group of midwives I worked with was more cohesive or if my boss was more supportive. And some days I feel like none of this would make any difference at all. That I was not meant to have a full time back breaking job that demanded all of my emotional attention and where sometimes my intuition is rewarded and sometimes it is resented. I think, on those days, maybe I’m supposed to find a way to be a full time artist or videographer or dinner party holder. But then, I know myself better. And I know I am very very willing to give a lot of time and energy and emotion to work that feels right and satisfying. Plus, you’d have to do so much clean up if you were a full time dinner party holder, right? And I hate washing dishes…

I haven’t written for a while and I’ve been thinking a lot about why that might be. I certainly don’t feel nearly as compelled to come home from a call shift or a day at the office and “get it all down” as quickly as possible. Maybe it’s because, as I move further and further into the day to day experience of being a midwife the ability to break up each day into these little vignettes or anecdotes is more challenging. I mean, I still think the stories are unbelievable-I’ve had 3, yes 3, IUFDs, an inverted uterus that came all the way out of the vagina and into my hands and I was lucky enough to catch the baby of one of my best friends and watch her labor and push and make the sounds a woman is supposed to make when she is having a baby-but as time goes on, as I see more patients and deliver more babies, the stories do run together as a whole lived experience; As, my life, really. And writing it all down in a few paragraphs feels like I am compartmentalizing or trivializing it. At the start of my career (and believe me, I still think I am at the start) writing down everything that happened, telling stories, holding someone’s attention and making them laugh…It worked as such a great coping mechanism for all the emotions and hardships one has to deal with in this field. And now, I don’t know. Sometimes, writing about my day feels more like I am giving it away than doing a cathartic sharing.

It reminds me of one of the last monologues in the John Guare play Six Degrees of Separation that Stockard Channing delivers so well as she is sitting at a lunch party with her husband recounting to the other diners the last segment of the story of a homeless man who both lies to and befriends her. It dawns on her that this story she was telling was more than that, more than an anecdote. It’s her life. And as I sit down to write about pregnant teens or self-righteous nurses or unhelpful doctors I can’t help but relate.

Her character says, “…And we turn him into an anecdote, to dine out on, like we're doing right now. But it was an experience. I will not turn him into an anecdote. How do we keep what happens to us? How do we fit it into life without turning it into an anecdote, with no teeth, and a punch line you'll mouth over and over, years to come: "Oh, that reminds me of the time that impostor came into our lives. Oh, tell the one about that boy." And we become these human jukeboxes, spilling out these anecdotes. But it was an experience. How do we keep the experience?”

I’m trying to figure that out.

Babies Having Babies

I can’t remember if I have already written about just how many teens I see in the office. Our practice doesn’t really serve a ton of teens in general but I do think because during my interviews I expressed an interest in them and on my “bio card” that is at our front desk it says under professional interests: “Adolescent health and prenatal care”, they just send’em all my way. 17? Unplanned pregnancy? No secure housing? More afraid of an abortion than of a baby? I got the perfect midwife for you!

And taking care of these teenagers can be very rewarding. Seeing them through their pregnancy, trying to educate and empower them, watching them become mothers and women…But when the majority of the pregnant women you see are these young girls, your ideas get skewed. And I, admittedly, get resentful and angry. These girls probably need me more than most but I often walk into their exam room with a healthy bias, thinking that they have no fucking clue what they are doing. Sometimes I am wrong, and pleasantly surprised. But sometimes, I’m dead on.

I walked into room 17 last Thursday to meet my latest soon-to-be teen mom. Crowded in the small room were three people, no one over 18. The girl I presumed was my pt was sitting hunched on the exam table, her scabbed legs dangling. The boy I predicted was the FOB was sitting on the only chair in the room and another hefty girl was sitting on the stool that I usually use during the exam. I introduced myself to my pt, her boyfriend and then to the girl in my seat.

“Hi” she said. “I’m the Godmother.” I shook her hand and wondered if she was the godmother of the pt or of the unborn. I chose not to ask because I was immediately distracted by trying to figure out if anyone was going to give up their chair for me or if I would hover over everyone the whole time. “You probably need this chair, right?” The Godmother said.

“Yes, thanks.” I said. “I do usually use that one.” The Godmother got up, moved past me and planted herself on the exam room floor, cross-legged, in the corner.

I asked my usual questions about the patient’s last menstrual period, went over her dates, asked her if the pregnancy was planned (it wasn’t) and attempted to have a conversation with her about the responsibilities of parenthood:

“So, was this pregnancy planned?”

“Um, no…”

“And you guys are certain that you are going to keep the pregnancy?”

“Yes.”

“Do you have support?”

“Kind of.”

“Do your parents know?”

“Well, my mom doesn’t know” My patient said. “But I think my dad does, I think my sister might have told him. I’m not sure.”

“How about your parents.” I looked at the FOB.

“Um, no. Not yet.”

“So you both plan on telling your parents?”

“Well…at some point I guess…”

“Are you concerned you won’t have their support if they know you are having a baby?”

“Yes. My mom told me I couldn’t live there if I was pregnant.”

“Do you think that’s just your fear or you really know that to be true?”

“Oh no, it’s definitely true. She wouldn’t want to see me.”

“So, you’re living at home right now?”

“Yes.”

“What about you? Where are you living?” I looked at the FOB again.

“With her.”

“So, you’re both living with your mom.” I look at my patient. “And at some point you think you’ll have to move out. Do you have a plan for that?”

“Oh yeah. We’re gonna get an apartment.”

“So, you have a job?”

“No.”

“So how are you going to pay for the apartment?”

“Well, I’m gonna try to get a job and plus he works for a carpentry company…”

At this point the Godmother, who had been texting up a storm and who has not lifted her head the entire time (here’s hoping she pays more attention when the baby is actually born…) stands up and politely excuses herself to make a phone call. I think she actually said something like, “um, sorry to interrupt. Is it okay if I step outside to make a brief phone call?” As if she’s taken time off from her busy CEO position downtown. Sure, sure I said. Take as long as you need. Really.

The conversation looks pretty much the same each time. Sometimes the dad isn’t involved. Sometimes the pt works at Subway. Sometimes, luckily, there is no Godmother present. But in general, it’s tough to feel hopeful for the lives of everyone involved. Myself included. There’s always a lot of nervous laughter during the exam. My patient on Thursday kept blowing kisses to the FOB while I did her pap. It was…uncomfortable.

We finished up. I gave them the emergency numbers and asked if they had any final questions.

“No.” said the patient.

“Nope.” said the FOB.

“I got one question actually.” Said the Godmother as she was hoisting herself up from the floor. (She had returned to the room just in time to text during the entire PE)

“Sure,” I said. “What’s up?”

“Um, I’m wondering if she can, like, go to 6 flags this summer.”

* * *

Another recent memorable moment with teen parents was while I was on call last Friday. There was a 17 yo in labor and she had her mom and grandmother and aunt with her. Their support was amazing. Holding her legs, wiping her down, encouraging her, telling her how strong she was, sharing their own birth stories…And then there was the FOB. He was 21 and only moderately present throughout the labor and birth. He did take many pictures of my patient’s privates while the baby’s head was making its way through but I think it was more in order to find a place to hide than genuine curiosity and awe.

“Will you be cutting the cord?” I asked him while we were pushing and he was sitting on the couch looking through the pictures he had just taken of his girlfriend’s crotch.

“Yeah.”

“I’ll be cutting it too.” My patient’s mom said looking at him out of the corner of her eye.

“What?” the FOB said. “I’m the father!” he said and pointed his thumb towards his chest.

“Well,” The pt’s mom said still not looking at him, “I’m the other father. So we’re both cutting the cord.”

After the delivery the FOB was thoroughly disgusted by the placenta and verbally convinced us of that by pointing and groaning and talking about it as “that thing”.

I cleaned up, completed all my paperwork and gave a final hug to the new mom. I spotted her boyfriend holding his new son in his arms, just staring into the eyes of the newborn. He was transfixed. I motioned for the pt to look at him so she could witness how much that new little boy was holding his attention. She rolled her eyes.

“Well,” I said, “One last thing I forgot to ask you. Are you planning on having your baby circumcised?”

“What?” The FOB shouted as he stared into his son’s eyes, “Hell yeah we’re having him cut. He not walkin’ around with no elephant trunk. Uh un. Not my kid.”

And just like that, whatever respect or hope I had gained, had vanished. I pulled out a piece of paper from my pocket and wrote down exactly what he had said because, well, it was just too fucking good to not remember forever.

And as I drove home that night and thought about my young patients I heard a song by our dearly deceased Michael Jackson whose music is now being played 24-7 on most every radio station. He sings: If you can’t feed your baby (yeah, yeah), Then don’t have a baby (yeah, yeah), And don’t think maybe (yeah, yeah), If you can’t feel your baby (yeah, yeah)

He may have been a weirdo but he sure did get that right. Hear that kids? If you can’t feed your baby? Then don’t have a baby. Got it?

Today at the office a nurse pulled me aside to tell me she just got off the phone with someone who wants to get prenatal care with our practice.

“I think she’s perfect for you.” The RN said. “She’s 16.”

Falling Into My Lap

There are more than a handful of nursing schools in the city where I live. And it just so happens that the director of one of these schools is also a graduate and the president of the alumni board at the nursing school I graduated from. I was invited there to participate in a panel discussion not too long ago where some of us recent grads talked and answered the questions of the students who were about to graduate and make the transition from student to professional. This director/president was the facilitator of the panel discussion and at the end of the event she handed me her card and said simply, “Come teach for us.” I was initially sort of shocked and honored that she would think to say that to someone she had never met before that night and someone who only threw out a couple ideas and pieces of advice for the graduating students. I shoved the card into my purse and assumed she had most likely given her card to everyone at that panel. “So what?” said a friend. “You’re making excuses.” Said my therapist. “Whatever.” I said. But then, a few weeks ago, I thought, Why not? So, I dug out her card and emailed her, reminding her of who I was and basically said I was interested in teaching because my best days on the job were the ones I got to spend with students. I said it’s tough being a new professional. I said that I am always trying to expand my community of people who understand the emotional and physical and intellectual challenges of direct care. I asked if I could pick her brain sometime about how someone with a master’s degree in nursing might head in the direction of teaching. She wrote me back within the hour and proposed we have a conversation over dinner.

Two weeks later we sat a local thai food restaurant, her drinking wine and me drinking beer, discussing some alumni issues at our alma mater. I mentioned that I felt that one of the communities I found a home in during grad school was the fairly established humanities and medicine culture and that I haven’t quite been able to find the same sense of home here. I told her about the writing workshops I’d been a part of, the writing award ceremonies I’d attended and, more importantly, how the worlds of art and science felt like they were continuously feeding each other while I was in school.

“Why don’t you teach an elective class in literature and medicine for my students?” She said. “Like a 1 credit class where you’d meet like 4 or 6 times over the course of the semester…we’d pay you of course, and there’s some paper work you need to complete with your objectives and a syllabus, things like that…Every student has to take at least 4 credits of electives and there are not that many offered…”

“Are you kidding?”

“Um, no?”

“I’d do it even if you didn’t pay me. I’ll do it for sure. That would be so amazing.”

“That’s ridiculous. Of course we’d pay. It’s work, right? I’ll send you all the paper work when I get home so you can get started. I think the students will love it.”

I took a swing of beer. Why was this so so so easy? We kept talking about nursing, teaching, how she got to where she is today…and I asked her how I could start to teach actual clinical skills to students.

“Well,” she said, “You send me your CV, I forward it on to the people who do OB placements for our school and you start to precept.”

Again , shocked. So. Easy.

“Why are you being so nice to me?” I said. Yes, I said that. I actually asked her why she was being nice to me. But, in all honesty, I really could not understand why this was all going so smoothly. When every other part of my life feels like a struggle, why was this just…happening?

“Well,” she said, “We’re both alums of the same school, you’re smart and you really want to do this. Why not?”

“You are so great.” I said. Again, I’m not sure how this kind of dialogue fits in with professional interviewing strategies but hey, it was genuine, right?

“Well I think you’re so great. I wasn’t planning on coming here to recruit new teachers and I didn’t know how much of a passion you had for this. So, I think we both win.”

She walked me most of the way to my house and then she continued on to her own home. We made a plan for me to send her a description of what the class might look like, she told me to say hi to a few of the L and D nurses at my hospital that came through her program and she asked me to send her my resume.

And that was that. The process is underway. A new little path is starting to come into view, one that actually makes me excited for, not fearful of, the future. One that makes me feel totally calm about taking risks, about being wholly responsible for something and completely, completely accepting of the fact that I will certainly make mistakes. It’s true that I’ve only been a participant, not a facilitator, of a humanities and medicine class but this just feels right. Maybe all things are supposed to feel this easy. And, even if not, it’s really nice when something comes along that is.

not so good week

There have been so many upsetting things that have gone down this week. I don’t think I have ever wanted more, someone to come home to, someone to talk to or cry to, than in these past 7-10 days. It was a week that the universe not so subtly reminded me how hard it is to constantly be the recipient of someone else’s pain. It also reminded me that there is a finite pool of strategies to use to make yourself feel better in these situations. Alcohol, TV, long walks, talking with someone who gets it. But really, even when I have the option of all of these things, the hurt is still there. These “strategies” are just temporary emotional distractions. When I get home from my walk, when the ETOH wears off, when 2 episodes of The Wire are over, when I can’t seem to get a hold of anyone who may have been through the same thing…all the emotion comes rushing back in. At some point you just have to stop moving and sit with it. And I really hate those moments.

I won’t go into too much detail here but two of my prenatal patients had very bad outcomes this week. One, PPROMed at 35 weeks, was induced, there were deep variables with and without pit, she got sectioned and the baby showed no respiratory effort at birth. It was immediately intubated, and still is. He was found to have some sort of neuromuscular disease. I spoke with the pediatric attending who was taking care of the baby in the NICU and she said the baby would never live a normal life, it would never be able to breathe off of the vent…and this kind of situation would of course be devastating for anyone and every single woman deserves to have their baby be healthy but I just can’t help but think that this patent needed this baby to be perfect. She needed something to work out, she needed a miracle. And she did not get it. “My baby doesn’t cry.” She said to me, crying herself. “He just lays there. He’s so beautiful but he is so still. He just doesn’t move.” That was Tuesday.

Another pt I have been taking care of came for her routine OB appt on Thursday at 25.3 wks. She was S She went downtown for a f/u US where they have better equipment and actual OB ultrasonographers. The MD downtown called me an hour later confirming that the pt had severe oligo due to something she was calling renal tubular dysgenesis. The lungs would most likely never mature and the baby would never be able to take his first breath. Even more devastating is the fact that in my state (in most states actually) the pt is too far advanced in her pregnancy to terminate. So what are her options? Taking a trip to Kansas, carrying the baby until it dies in utero or until she aborts spontaneously. Did I mention she had a previous loss at 24 weeks? I called the pt the next day to let her know I had set up an appt for her with our high risk doc and to see how she was doing. She didn’t have any questions. She’d been through this before. She knew what this meant. Note to self: if I ever marry my first cousin, don’t have sex.

On a slightly lighter note if you don’t think about it too too hard, I had another medical school student with me this past week during a call shift. Let me just say this again. I freaking love teaching. And it kills me to watch these med students who are barely with us for 2 weeks, who have never seen a baby be born, who have never heard of a BPP, who can’t read a FHT to save their lives, I can’t stand to see them sit in our office, trying to keep themselves busy by randomly looking at things on Up to Date when the MDs have no one in labor. Do the docs discuss cases with them? No. Do they ask them what their goals are for the day? No. Do they take the time to go over some basics with these kids so they don’t waste a full 12 hours doing absolutely nothing? No, sir. Enter New CNM. I pull out strips, I quiz them, I let them write notes, I ask them if they know what something is and if the answer is no, I have them look it up and teach back to me what they’ve learned. I’m not trying to brag here but I don’t think I’ve had one med student spend the day with me who did not pull me aside afterward to say how much they appreciated my teaching. In a sea of discontent and disillusionment with my job and obstetrics in general, it feels damn good to hear that.

Anyway, I had a med student with me last week and, well, I was underwhelmed by his performance. These med students have a pretty high baseline. They are ALL self motivated. They are ALL very very curious and ask a ton of appropriate questions. They ALL seem to be fairly quick learners. But they vary in terms of their ability to create and maintain patient relationships. The particular med student I was with could not have been more than 24yo. I mean, he looked way younger but if you work out college and maybe even a post doc program and then 2 years of med school he’s probably not that much younger than 25 right? Anyway, he was just awkward. It was clear that he didn’t want to make any mistakes, that he wanted to be liked, that he wanted to do everything right. And all of those things are understandable. I think he was just a little to “right on!” for me. Like, for instance, before I’d even gotten all of my words out to critique his soap note he’d be over my shoulder saying: “Of course! Thanks! Super! Yes!” I’m like, shut up kid. We’re gonna be together for 12 hours and if you are that overzealous about everything today I may have to anesthetize you.

In short, the main things I think he’s going to need to work on are 1) his inability to just do nothing. He wanted to fix the gown and get everyone water and change the sheets on the bed when it got wet, wipe the floor dry, get me extra gloves… it was never ending. Helpful but just way too much. And my sense of things (and I like to think I have a pretty good sense of things) was that he was unconsciously attempting to avoid what was actually going on. The pain of labor, the noises of labor, the idea that sometimes you just sit and watch and encourage but mostly just let the laboring woman do her thing. And 2) when we reached second stage and the woman started pushing the only thing this kid could think to say was “beautiful”. So, you’ve got the woman, sitting on the bed, spread eagle, her husband and the nurse holding her legs back and my little male medical student watching her vagina bulge and saying “beautiful” over and over again. It was just plain gross. Unfortunately, I had to race out of there at the end of my shift and since the patient was still pushing the student stayed and I didn’t get a chance to give him this “constructive criticism”. It will definitely go into his written review…

Lastly, I was again harassed for not calling my patient a “rim” when she was actually fully dilated in order to “buy her more time”. I can’t even go into the rage I was feeling when the “team” coming on had an issue with my decision to start pushing with an unepiduralized woman who was at +1 with a spontaneous urge to push. What would they have done? Told her to breathe through another hour of contractions so the head could get to +2? Please. Our protocols say we need an MD to write a note if a laboring woman has been pushing for 2 hours. And what good would “buying her more time” have been when she has been pushing for 2 solid hours with little to know progress? I mean, maybe a doc should be involved at that point. And maybe giving her another hour only increases her risk for chorio (for instance. Not to mention wedging the baby even further into the pelvis making a possible section even harder) because, most likely, she ain’t going much further. But what do I know?

My Trip to Russia

When my sister lived in New York, we used to try to go to the 10^th Street baths whenever I came to visit her. Wednesdays were women’s days. You’d go in, give your 25 bucks to a man behind the counter who had a big belly and a hairy chest. He’d hand you a key for your locker and you’d walk past a sort of “deli” with a paltry offering of unidentifiable meats and canned juices, a TV hitched to a corner of the ceiling playing sports or Russian news and into the locker room. Inside your locker there was a an oversized robe that would only fit a man weighing at least 300 lbs and some flip flops and you’d exchange those for your clothes and head downstairs to the baths. As a teenager, this experience pretty much blew my mind. There were women of all shapes and sizes getting beaten with branches, walking around with mud on their faces and grinding kosher salt into every part of their bodies. But I was with my sister and it felt safe and cool and I always slept like a baby the night after he day I’d been there.

I figured, living in an urban area now, there must be something similar in my town. A quick google search a few years ago uncovered a little known Russian bath house not too far from my neighborhood. Women’s day at this bath house is on Mondays only from 4pm to 9pm. Every other hour of every other day is men only. It’s unfair but that is the subject of another blog entirely so I won’t go into my thoughts on that now. But, I do think when there are only 5 hours every week that something is available to you, it is so much more special when you actually take advantage of it. As luck would have it, I am in clinic on Mondays and there is nothing that calls for a few hours in a sauna like a day of vaginitis and complaints of sciatica.

Yesterday was an unusually slow day at clinic. I finished each chart before I saw the next patient. Everyone’s complaints were pretty straightforward and there were very few add-ons (which I was responsible for that day). The sheer boredom made me panicky though and I raced to the bath house as soon as I got into my car.

This Russian bath house is small. You come in, walk down a long hallway and into a locker room/check in area/tv room. Everything is open and public. And very very very laid back. There’s one bathroom for everyone, the woman taking money at the counter is always calling you honey and leaning on her elbows and talking to the women sitting in the TV room who are taking a break from their steams. There is a card table set up that always seems to have pastries or egg salad sandwiches set out for people to eat, though I’m still not sure who this food is for. More investigating will have to be done…

Anyway, the place is disgustingly cheap. For 26 dollars I got a towel, plastic sandals, unlimited time (well until 9pm that is) in the sauna and steam room, a platza treatment and a bottle of spring water. I stripped down, put all my clothes in the locker they assigned me, and turned off my brain. Well, tried too. The thing about this place is that it’s a community. These woman (anywhere from 20 to 70 years old) are regulars here. They know each other from the baths, from work, from growing up. And they have A LOT to talk about. The sauna is far from a meditative place to be when you just need some peace and quiet. It’s more of a really warm gossip session. This is a slice of real life. Everyone has thick accents and drooping bodies. And last night was not the first time I overheard some of the women talking about their recent plastic surgeries:

“I just got my eyes done.” One older woman said.

“You did? I can’t tell. Lemme see. What did you have done?”

“I know. It’s still a little swollen. I had all of this pulled back.” She points to the sides of her face by her eyes. “My doctor said it might take 4 months for the swelling to go down though.”

“Hm. Nice. I’m thinking about having something done too. But, were you black and blue?”

“Nope. For 2 weeks before the surgery I ate lots and lots of pineapple.”

“Really.”

“Tons. It make you less likely to bruise. But the doctor I go to, Richardson something or other, he does’em Thursday and Friday night so everyone goes back to work, no problem on Monday morning. I had mine done on Thursday late afternoon and let me tell you something, I was at Neiman Marcus on Friday morning. I got home Thursday night from the surgery and my friend had left me a message on my voice mail. All she said was: Neiman Marcus, 20% off sale. And I was there.”

“I’m just not sure. I mean, what if I don’t like what it looks like afterwards?”

“You know what you do? If you want to see what it’s gonna look like, you lie down on your back and look at your face in a mirror. When you lie back like that gravity pulls everything away. That’s exactly what you’ll look like.”

The woman who had just gotten the surgery was very obese. And, I just couldn’t help but think, Why did you choose your eyes?

Last night was my first time getting a platza treatment. Basically what that is, if you’ve never had one or seen it done, is me, lying naked on the top bench of wooden bleachers in the sauna while receiving an “invigorating” rub down with a branch from an oak tree (supposedly hand made by one of the men that works there every other day of the week) and periodically being doused with buckets of freezing cold water to “promote circulation” by a woman wearing a bikini. The platza was good, though, I couldn’t really see any evidence of things being cleaned at all between treatments. Not that I minded all that much. The whole place sort of makes it feel like you are in a garage or an unfinished, I mean really unfinished, basement. But the truth is, if the woman who got her rub down before me had crabs, I definitely have them now too. And let me tell you something else. When I got home and took a shower in my own bathroom, I found oak leaves in body parts I didn’t even know I had.

In addition, yesterday was the second straight week I witnessed a woman in the sauna openly shaving every part of her body. I mean, not just the places you usually shave either. She was going all out. Arms, feet, neck…and from what I could tell, she didn’t have any excess hair to begin with. She used a bucket of water sitting next to her to shake her razor out and then, when she was done, just dumped it on the floor, all the water and the little hairs trying to make their way to the drain. I looked away.

So, all in all, the baths are great. I’m sure some of my readers out there will disagree with me after my description but I’ve always been attracted to those places, physically and emotionally, that make people turn their heads and cringe. Why do you think I’m a midwife? Labor and birth is full of scary, dirty, smelly things. Panic, poop, blood and total exposure. I love being a part of experiences where there is absolutely no room for pretense. Things are real with a capital R and there is nowhere to hide from it. And I like that part of my job, a big part, is about normalizing those sometimes uncomfortable experiences for others. So, thankfully, the Russain baths did not include any blood or poop (that I saw anyway) but I think it’s another place where you can let it all hang out. You can sit there and sweat and talk shit and pull leaves out of your butt and no one will think twice.

Last night was the last session of the season. The baths reopen in September. And I have a feeling I’ll be going there a lot after work come fall.

Kids these days...

There was a knock on the exam room door in the middle of one of my routine OB visits. I gave my patient a confused and frustrated look as I got up to answer the door.

“This never happens,” I said. Though it has already happened more than a handful of times. “Sorry.”

When I opened the door, one of the medical assistants was standing there apologizing but letting me know that a pediatrician from downstairs asked that I be interrupted in order to consult with her over the phone regarding a 16 yo pt she had “on the table.” I excused myself and headed toward the phone thinking, Why would a pediatrician be asking for me? Like, she wants me? Me, me? Or just a clinician? My MA didn’t know. She just handed me the phone.

“Hello?”

“Hi, thanks so much for taking my call.” The female voice on the other end said.

“Well, I was told you wanted me to be interrupted.”

“Yes, yes, thanks so much. I hate to bother you during your busy day but I have a pt here, like on the exam table, and I’m not exactly sure what to do with her.”

“Okay, well, I can try to help.”

“Well, the patient is saying that during sex last night she had a “gush of blood” and now she is also having some pelvic pain. I’m just not sure what to do. You see, I’m just a floater here…”

I couldn’t help but think of her swimming in the toilet even after a flush or two…

“Well, is she bleeding now?” I asked.

“No, not really. I don’t think so.”

“Well, I’d do a pregnancy test, and I would definitely take a look inside.”

“Ok, well, but, as I said before, I am just a floater here. I’m not even sure I can do that here.”

“You mean you don’t have speculums down there?”

“No, no, of course we have speculums; it’s just that, I was hoping you could see her?”

Long story short, after being interrupted for a 2^nd time by this same “floater”, the patient was sent upstairs to see me.

It turns out, she did have a gush of blood while she was having sex. A “gush” that she describes as “filling the cup of her hand”. Then the bleeding almost immediately tapered. She reported only having brown spotting today. She had no pain before or during the episode of bleeding but now she has diffuse pain in her lower abdomen. She’s been sexually active for 2 years. She’s on the pill and has not forgotten to take her pill, ever. Her last period was normal. Her pregnancy test today is negative. This has never happened before.

I tell her that I have to take a look inside. She understands though is squirming and uncomfortable with the idea. The pt has minimal problems/discomfort with the insertion of the speculum. I can immediately see blood in the vagina and as I look around and use the speculum to push away vaginal mucosa, it’s clear that the bleeding is no longer brown but bright red. Not tremendous amounts but there is no question that something is actively bleeding. There was blood on the cervix but it wasn’t clear that the bleeding was actually coming from the cervix. I pulled my light around even more to get a better look at the sidewalls. And then I saw it. The right side of her vagina was completely intact and I could visualize the entire thing from introitus to cervix. But the left side was not right. There was a fairly large laceration that was running down the length of her insides.

“You aren’t in any pain in here?” I asked as I dabbed the gash with a q tip.

“No. I can’t feel that.” She said.

It’s true that there are less nerve endings inside the vagina. If the wound had been on the outside or up near her cervix I am certain she would have been in more pain, but presently, she was generally comfortable. Just embarrassed and anxious.

“Was there anything in your vagina besides a penis?” I asked.

“No.”

“Like, no toys? No fingers?”

“No, nothing.”

“Well you have a pretty significant cut in here.”

“I do?”

“Yes, you do. I can’t see it very well but I’m pretty sure that is where your bleeding is coming from.”

“That is so gross.”

“Well, it happens, I guess.” I had never seen this before. “But I definitely do not want you to have anything in your vagina for a while. Until this heals. And I’m going to let the doctor know what I found and see what she wants to do.”

I grabbed one of the docs who was in the office that day and let her know what was going on. We got a pelvic US to r/o any kind of hematoma (which not surprisingly was normal) and the doc told me to pack the vagina for today, give the patient good warning signs for increased bleeding and pain and to have her come back tomorrow to see if it has healed. Initially I was a little frustrated that the doctor didn’t want to see (confirm) my “diagnosis”. I mean, if she saw the extent of the laceration, maybe her plan would be different. Plus, I just didn’t trust myself. Maybe it wasn’t a gash. Maybe the blood was coming from somewhere else and I just didn’t see where…But after I packed the pt’s vagina and made her an appt for the next morning to see another clinician I checked in with the doctor.

“So, you think that packing will be enough for tonight?”

“I hope so. It might just be enough to tamponade the area. I’d like to avoid suturing the vagina of such a young girl if we can just use expectant management. And tomorrow when she comes in, I can help assess and if she’s still bleeding we’ll just have to suture her.”

That made sense to me. And since the patient’s bleeding was well under control, her CBC was normal and I could bet any amount of money she wouldn’t sticking anything inside of her for a long time, I felt better.

It turns out, she was one of the patients I thought about all night and well into my next day on call. Around noon (I knew the pt’s follow up appt was at 11am) I called the office and spoke with the midwife who saw her. It was definitely a laceration just where I had thought it was. It was still bleeding when the packing was pulled and the doc and CNM advised the patient that she would need to have the wound stitched. And she refused. She just refused. She wanted to just let it heal and bleed and not have anyone else touch her. Which, is absolutely her prerogative. I just couldn’t help but think it was the wrong decision. And I couldn’t help but think it was only embarrassment and fear that made her refuse. And I definitely couldn’t help but think that I would most likely be seeing her again. I’ll have to remember to do better education on lubricating agents the next time she makes an appointment…

Deja Vu

Well friends, it happened again. Just like I told you. I was covering for my friend and fellow midwife yesterday at the hospital from 1pm until 7:30pm. She was moving to a new apartment, I was free for the afternoon and I needed some hours so I thought I would do her a favor. When I got to the hospital there was literally no one on the floor. I finished some charts from the office, chatted with another midwife friend of mine who works with another practice, hung out in jeans and open toed shoes for what seemed like hours. And then 5pm hit. Three, yes three, patients came in all at once. 1 woman at 41.3 wks who was sent in from the office for induction for an IUGR baby, not to mention post dates. Another woman who had been contracting irregularly since the morning, had a non reactive NST in the office but an 8/8 BPP who was now c/o very painful and regular contractions and the last was my own patient from the office who was a 38 yo G2P1 being induced at 41.5 wks. They ALL got to triage at the same time. Got there, in fact while I was upstairs on the postpartum floor seeing a patient that the CNM pp rounder didn’t have a chance to evaluate. One moment it was chill, the next moment it was crazy.

The IUGR induction pt got directly admitted. She was 2/75/-2, soft, midposition. She was started on pit and sat in the rocking chair while her husband knelt on a carpet and prayed over and over and over again.

The woman in spontaneous labor, yes, that’s right, I said spontaneous, was only 3cm (50% and -3) but had three elevated BPs into the 140s over 90s so we kept her. Ran labs, got her a room…her labs were normal, she had no headaches or protein in her urine, basically, she was just hypertensive. She wanted an epidural an hour later when she was 4cm/100/-2. An hour after that, she ruptured on her own to clear fluid.

My own patient from the office was a different story. She had arrived at the hospital for cervical ripening at 7:30 in the morning. But because the hospital was so busy, she got bumped till the afternoon. She had a quick NST, went home, came back a few hours later and still had to wait until 5 to get into triage to be evaluated. When I finally saw her, she looked tired, disenchanted. She’s the kind of person who was cheerful 99% of the time I saw her in the office. Today, she looked heavy. And I could see that she was trying to stay light and stay smiling but her eyes were already glassy like she was just waiting for an opportunity to let go. She was c/o irregular tightening but other than that, no real change from when I saw her in the office the day before. And her cervix hadn’t changed much either. She was a tight 2 cm, posterior and only about 25% effaced. Her last baby was an induction as well and she reported having a really hard time with the “tablet” they gave her. She remembered being sent home and starting to have frequent and painful contractions almost immediately. She was scared and in pain, and didn’t know when to come back to the hospital.

She’d been here all day, I thought. And she does need some ripening. But I didn’t want her to panic more than was necessary or relive an obviously traumatic experience. So, I went with gel. Gel, yes, gel. It’s got a reputation for not working so well. Or at all. One of my preceptors from school used to joke that she thought the gel formulation of ripening agents was just KY jelly disguised in a medical looking syringe.

“I’m gonna give her gel.” I said to another midwife who asked me what I was going to do with my patient.

“Might as well not give her anything at all.” She said back to me.

The thing was, giving this woman gel solved some problems. For one, the patient was less anxious about the ripening process and also, I was able to honestly tell her that this was a way less aggressive form of ripening agent. I was able to look her in the eyes and say, this may not do anything to you at all. You my feel crampy but it’s unlikely that you will have the same experience as you had with the cytotec.

“What if we just didn’t do the gel and we came back tomorrow for the pitocin?” She asked.

“Well,” I said, “If you just come back tomorrow and your cervix is the same, you may have to get a dose of this anyway.”

“Okay,” she said, “Let’s just do it.”

The gel went in and we started the two hours of monitoring you need on this agent at our hospital before a patient can go home. Within 5-10 minutes my patient was contracting every 3 minutes. And then she was contracting every 1 ½ minutes. And they were painful. After an hour and a half of monitoring she was shaking and asking for an epidural. This is the report I got from the triage nurse and I immediately felt disbelief and guilt. Was it really the gel making her contract so wildly? Was it my exam prior to the gel placement? Was the patient mad at me? Was she thinking I lied to her? Did I lie to her? I could barely go back into that room to confront the answers to these questions and to witness her pain. And usually, when it comes to labor pains, I’m kind of a tough guy.

“These contractions hurt!” Patients will say.

“That’s great!” I’ll say. “They are supposed to hurt. Labor is hard work. You’re doing great.”

But with this woman, I couldn’t put on the act. I wanted to immediately take away her pain. I wanted to see her smile again. I wanted to make her comfortable. I did not want her to think badly of me. I relayed her story to the oncoming midwife, who had arrived for her shift at this point.

“You know,” she said, “when you have a personal relationship with someone, when it’s someone you have seen almost every week for the past 2 or 3 months, it’s much harder to watch them be in pain.”

“I know. I know.” I said, “But these contractions…they’re like every 2 minutes…”

“So, the gel is working.” She said.

And yeah, I guess the gel was working as it was supposed to, I just didn’t care. In my head I’m thinking can we give her narcotics in triage? Turb? How can we make this go away. My head was in such a different place. The other CNM and I made a plan to admit her, get her an epidural and pit her as soon as we were able if there was no cervical change at her next exam. Armed with that plan, I was finally able to walk into her triage room. She was drenched with sweat, crying, and looked up at me with eyes that had lost every ounce of her reserves. I put my hands on her shoulders.

“Listen, I’m not going to make you go home.”

“Please, please please don’t. I can’t go home.” She said.

“I promise. You’re going to stay here. We’re going to get you a room and get you some pain relief. And I’m not going to leave until you are comfortable.”

And then the nurse told me it would be at least a half hour until she even got a room. And I bailed on her again. I just couldn’t go back in there and give her what I thought would be horrible news.

“Guess what? I know I just told you you were going to get a room and an epidural but you’re going to have to wait longer, a half hour at the very least longer, before any of that happens. I know you’re having contractions every minute but you’re doing great! Keep it up!”

I just couldn’t have that conversation with her. So the nurse went in, started her IV, drew labs, gave her fluids, basically distracted her, made her feel like things were happening before they actually were. She did get a room. And finally the anesthesiologist came in, took forever to fill out all the paper work because, I’m pretty sure, she was very new. My patient assumed the placement position with her legs dangling off the bed while her “team leader” talked her through every step of the placement. At one point my patient opened her eyes and looked at me hiding behind the curtain that separated the room from the rest of the labor floor. She just stared at me. And I couldn’t read her at all. Mad? Sad? Scared? I kept hiding.

But little by little, she started to feel relief. And her face brightened. And her shoulders softened. And she opened her eyes and looked at me again.

“You’re a saint.” She said. “Thank you so so much.” She was so sweet to say that and it made me feel so relieved. But I was also so embarrassed. A saint for what? For being a coward? For not being able to be a midwife who could sit in a room with a laboring woman who was in pain? Which part made me a saint? I wasn’t sure. But I was happy that she was comfortable. And I was happy that her husband looked like he was having a reprieve from his own stress. We all took a deep breath, they showed me photos of their first child who was 19 months old, and we joked that this labor thing would be so much more fair if the length of it could be determined by how much pain you felt.

“Well, you know what?” I said, “When you have your third child-”

“Um, no.” She said, cutting me off. “This is it. The last one. Snip Snip.” She made a scissors motion with her hand.

I wasn’t sure if she was talking about surgery for her or her husband but I looked at him and he seemed unaware. So, avoiding any more uncomfortable topics for the evening, I kissed her on the check, gave him a hug and finally left the hospital around 10pm.

I stopped in to see her today on the post partum floor. She had an 8lb 6oz baby boy at 5:46am and she was definitely NOT mad at me or disappointed in her care at all. She loved the midwife who took care of her in labor, she was happy she only pushed 3 times and she knew, without a doubt, that the gel was a much better experience than the cytotec.

She lifted her baby up from her lap so he could see me. “Look honey!” She said to him. “Is that your midwife? Who took care of you while you were inside me? Huh? Is that her?”

He just kind of stared at me with unfocused eyes and a trembling chin.

“Yeah,” I said to him as I grabbed his tiny red foot. “It’s me. Here I am. I’m your midwife.”

My Cycle

Here is the cycle I go through basically every time I’m on call. I start out in a minor panic as I get report, trying to keep everyone straight in my head, and resist speaking up when I disagree with the reasons someone is being induced (for example). My shift starts and things slowly but surely get under control. On many days, not all but many, things are fairly slow, or at least manageable. I have someone “in labor” who isn’t really in labor and I baby sit her while she gets ripened or gets low dose pit and sits on a birth ball changing her cervix from 1-2 to 2-3 in 12 hours. But then, lo and behold, almost without exception around 5pm things start to pick up at a sometimes alarming pace. More triage patients come in because the office is now closed and patients are making a bee line to the hospital, someone ruptures in the lobby, a nullip calls three times freaking out that her ctx are painful and coming frequently, a patient on the pp floor can’t pee…So, after a completely in-control day, I get bombarded and things start to unravel. Suddenly it’s 7:15pm, the oncoming midwife is on her way upstairs, paper work is only half way done, there are loose ends blowing all over the place and I start to panic (ah we’ve come full circle here) that it will look like I’m just a lazy, disorganized fool who waited until the last minute to do anything. And, the woman who usually takes over for me when I work a Wednesday or a Friday shift (often the two days of the week I am in the hospital) is so hard to read. She almost never laughs at my jokes, she takes report from me without sharing eye contact, barely asks questions, just stays silent, wishes me a good night and head’s out to the floor to, I’m sure, change management plans and do her own thing.

Now, I know that one of the things I need to work on as a new practitioner (and in my life) is to chip away my stellar ability to assume that everyone else’s plan or management decision is way, way, way better than my own. I’m so good at channeling insecurity. Too good on most days. And I am constantly working on finding a balance between confidence and humility. And it is hard, hard work. Trusting yourself, sticking with your choices, knowing, and I mean really knowing, that each decision I make doesn’t directly relate to my worth as a midwife or even as a human being. Why can’t my reflex be to think that that midwife is tired, or weird, or has bad people skills. Instead I think she hates me. Yep, that’s what’s going on here. She resents that I am new, resents that I would not have done things the way she would have and now feels like she has to “clean up” my mess.

Clearly, these topics are just fodder for my weekly therapy sessions. But, in the meantime, I have 2 mantras to recite: my multip mantra as I head into the hospital and now mantra #2 which I will start to meditate on as I leave the hospital in order to quiet the judging voices in my head. I’ll take deep breaths, appreciate the fact that, if nothing else, I am walking out of the hospital and into the now soft spring air. I’ll acknowledge my insecurities but remind myself that it’s okay to be new and that patience, for my development as a midwife, is an essential virtue. And a strong gin and tonic usually helps too.

Follow Your Gut

I spent the night trying to get a woman into labor who, on paper, had been augmented for post dates but who, in reality, was a TOLAC (her first was a c-section and then she had a successful VBAC a few years ago) who had started prenatal care at 19 wks and was only seen in the office 5 times since then. So, it’s been worse, right? And we actually got her GBS status (negative) somewhere in those 5 visits. Anyway, she was 41 wks by that 19 wk US and decidedly not in labor when I got to L and D.

She was reported to me as “favorable” at 2/50/-3 which I wouldn’t call supremely ripe as I gave her a bishop’s score of 5. She was “contracting” but her ctx were almost undetectable by the patient. But hey, she was on the floor, pit had been started, she was a multip and I had already prepared to be up all night. She finally changed to 3 and proceeded to an epidural. And like so many of my patients, had some rest and 4 hours later she was 8 and 100 with a BBOW.

I also ended up admitting a multip (a G6P2022 to be exact) who called me around 4am c/o irregular contractions since 3am. No bleeding, no LOF, no HA, +FM… I’m like: Call me back when the contractions are regular, like every 5-10 minutes for an hour. “Really?” She says. “But I really think I’m in labor!”

“I think you might be in labor too! That’s great. Call me back.”

I barely finished my telephone note on her when I get a phone call from our answering service. It was the same pt. Calling back less than 15 minutes later reporting 2 painful contractions since we had spoken last.

I mean, is this me? Is it my practice? Is it just people? What the fuck is up with that?

I call her back. “You didn’t make it the full hour, huh?” I said trying to mask my annoyance.

“No.”

“So, tell me what’s going on.”

“Well, it’s just these contractions! They keep coming and coming! I just keep having them! And man they hurt so much!”

I checked the number against her chart. Yep, same woman who has supposedly had 2 other children vaginally.

“Well, you’re in labor, honey.” I said a little softer. “You’re supposed to have contractions. And it’s supposed to hurt.”

“But I’m nauseous and getting all hot and these contractions keep coming!”

“All normal. You’re doing great.”

“But…”

“Are you saying you would like to come in and be evaluated?”

“Yes!”

“Okay, come on in.”

I just don’t get it. When someone has been in labor before, not once but twice (!), why do they always seem so surprised with the pain of contractions, or, actually, with just simply the contractions themselves?? What are people preparing for during those 40 weeks? No seriously, tell me! I am at a loss here. I probably get at least one report like this every night I’m on call. I understand the fear. I understand the sense of feeling out of control. I even understand the somewhat misguided feeling that the hospital is a better place for women to be than their own homes when they are in labor. But surprise? Complete and utter surprise than contractions just, well, happen? (I smell a bumper sticker here…) I do not get that. So, she got to triage, she was 5/100 and high. I admitted her and she decided she wanted an epidural before I had a chance to say anesthesia.

And then it was 7am. Glorious oh glorious 7am. This is the time I start to write my last notes, do my rounds on my patients, say goodbye, let them know who the next midwife will be…it gives me a sense that morning has broken and my own warm bed is in the very near future.

I gave report on these two patients and the CNM who was on call for the day told me she had three inductions scheduled in addition to these two patients I just left her. “Well,” I said, “I do think these two will probably go. Both are in pretty good labor now.”

“You never know.” She said back to me. “You just never know. You think these multips will go and then you are surprised. They stall or something happens…You just never know.”

“Yeah, I guess you’re right.” I said “But, I don’t know. They might.”

“You just never know.”

The on call midwife and the pp rounder started chatting as I was getting my coat on. They were talking about 2 recent IUFDs we had in our practice. Both 3^rd trimester. In one situation the MD wanted the patient to come in for a f/u NST after 1 episode of decreased fetal movement for which she had been evaluated and it was found to be benign. The doc just wanted to run another strip.

“Just because she ‘had that feeling’” The midwife said.

“Oh yes.” The other midwife said “That ‘feeling’. You have to follow your gut. You have to follow your intuition. That thing that keeps you up at night. You have to listen to it.”

Now hold on. I thought I just had a good feeling about these 2 multips headed into some nice active labor and possibly second stage. And I got shot down. I got the “you never know” response. But why sometimes, usually in hindsight I might add, do you get the “you just have to follow your gut” response. There are so many problems I have with this. Besides the glaring hypocrisy here, I think sometimes your “gut” is so wrapped up in feeling scared that it is difficult to “know” what the truth is. I also do not believe you can ever tell what the future holds. I also do not believe that because that doctor wanted the patient to have that NST and the pt refused and the baby was without a heartbeat the following week, that that doctor somehow had a 6^th sense about the fetus’ wellbeing. Or maybe it’s just that I don’t feel that I have that intuition (yet?) so I don’t even want it to exist.

But here is something I do know: I left the hospital, walked into the parking garage and just 3 cars away from mine was a blue station wagon with the license plate “BELLY”. I rolled my eyes, might have uttered a tiny “ew” as I passed and knew in an instant that that must be the car of a fellow midwife. I mean look, she followed her gut, right? And look where it got her.

Sweet 16

I like to think I can relate to my teen patients. Yes I have 15 years on them, and yes, my skin isn’t as taught as theirs, and maybe I am not quite as computer literate as they are but I do like to think that I’m still sort of hip, I can still remember what it’s like to be young and not trusted and clueless about so many things. So I really make determined efforts, when young women come in for birth control or their first annual or an unwanted pregnancy, to make them feel safe and at home and like they can be honest about themselves and their situation. But sometimes, the adult in me comes out. And it surprises and actually upsets me when the adult/caretaker head rears itself at unpredictable times. I can’t tell if it’s actual caring that’s happening or just frustration and anger with the bad mistakes I see being made by some of these girls.

Yesterday I had a 16 year old girl on my panel who was coming in for her annual exam and her depo shot. Just seconds after I walked into the exam room it became clear that I would not have a huge amount of patience for this patient and that my “adult” head was starting to grow and grow and grow. She hadn’t filled out her intake form that each patient is asked to complete prior to their visit. She “lost” it. So, we filled it out together. She is a sexually active 16 year old female with NKDA currently not in a relationship but using depo for contraception who feels safe at home. She has been using depo for just about a year now but doesn’t like the “irregular” bleeding, which for her is spotting q 2 months. She’s interested in another form of birth control but can’t remember to take the pill and thinks the nuva ring is “confusing”. Her medical history is benign. She has a significant family history of alcoholism and a cancer that she does not remember the name of. She smokes ½ a pack a day but denies drug use. She uses ETOH 1-2 times a month.

She does not perform monthly self breast exams. She does not wear her seatbelt.

“You never wear it?” I ask.

“Nah…I don’t like to.”

“Why not?”

“Well, I wear it when I think I’m in a dangerous situation.”

“You should really wear your seatbelt all the time.”

“Well, I’m really good at knowing when the situation is dangerous. And basically when I’m in the car I just put my feet up on the dashboard so that would brace me if there was a crash or something.”

“Your legs would break if you were in a head on collision.”

“Well…better my legs than my head, right?”

“You should wear your seatbelt.”

“My friends and I were in a car accident and one guy got hurt pretty badly.”

“That’s too bad.”

“I saved his life.”

“uh huh”

“I did. I saved his life. There were four of us sitting in the back and I just laid right across everyone. If I hadn’t bee there he would have gotten hurt so much more. Human seatbelt!”

“…”

“So, I think about wearing my seatbelt more I guess.”

“I hope one of your friends doesn’t have to die before you start to wear your seatbelt all the time.” My “education” was devolving into scare tactics. It was terrible.

“No, I really saved his life.”

“Listen, I know when you walk out of this room you are going to do whatever you want to do. But as your care provider I have to encourage, no advise, you to wear your seatbelt.” And then it got worse. “I’m sure you and your friends are incredibly safe people and drivers.” I said. “It’s the other drivers on the road I’m concerned about. That’s where the unpredictability is.”

She didn’t buy it. She just smiled her sweet 16 smile. And started texting someone.