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.