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.