My mom has this fantasy she told me about a few years ago. I’m not sure if it came to her in a dream or if her mind just created a story while she was listening to the radio in the car but, in this fantasy, she is a choir teacher for a high school and one of her students is a rebellious teenage girl who happens to have a fantastic singing voice. For the “end of the year show” my mom has decided to have the choir perform the Bette Midler song “From a Distance” and in the hopes of stirring up self confidence in this young girl and creating for her some investment in the choir and the school, my mom has picked her to have the lead part in the song. But on the day of the performance, the rebel girl is no where to be found. There is no choice but for the show to go on without her. But, as my mom tells the story, she feels that this young girl won’t let her down. She assures the rest of the students that they will sing the song as best as they can and things will be ok. So, they head out on stage and start the song. As the rebel girl’s part gets closer and closer you can feel the nervousness on stage. But then, just at the last moment, the back doors to the auditorium fly open and she comes in, unable to stay away because of her belief in herself, the group and, I don’t know, the power of song?, she comes down the aisle singing her part perfectly and everyone is relieved and happy and smiling. Believe it or not, my mom actually worked this fantasy out in her head and shared it with me years ago. I often say to her when she is convinced of a downright unrealistic miracle: Mom, this is your From a Distance fantasy. This is not real. For instance, I’ll say to her, “I hate tests. The tests are too hard. I don’t know how to study. And they aren’t a good measure of my knowledge anyway.” My mom’s response would be something like: “Sarah, you just keep pushing and studying and being honest. You’ll see. In one year’s time you will be the best test taker anywhere and people will be coming to YOU for help.”
Or
“No one likes me. I feel like I don’t have any friends and people don’t want to talk about the things I’m interested in.” My mom’s response might be: “Just stick to being yourself, do you hear me? You’ll see. You will have so many friends at this time next year you won’t know what to do with them. People will love you. They are just are too intimidated right now to actually come out and say so. You just wait. You will be the most popular person anywhere.”
So, when I mention to my mom why I feel like such a failure at perineal repairs, she gets on top of her soap box and begins: You just wait. People will be coming to YOU for help with suturing. People will pull you out of other deliveries, of other rooms where you are with patients to ask for your help. They will be saying to patients, ‘you know what? I could do this but Sarah Kleinman, the nurse midwife is right next door and this is her specialty. Why doesn’t she come in and repair this?’ You will be the very best in the practice.”
It is an almost constant conversation I have with my mom where I think I suck and she thinks I am the most amazing thing in the world. And, she insists, it is not because she is my mom but because she just knows. It’s the burden of unconditional love. It’s just a little delusional sometimes.
It was a fairly quiet day in the hospital yesterday. I got hit with the snow storm that came through so many cities and it certainly helped to keep pregnant women home and out of triage. I said to a midwife from the hospital based practice while we were watching 5 consecutive episodes of Cash Cab in the L and D lounge, while I was shaking my pager in the air which had not gone off all day long, “You see?” I said. “It just goes to show you. Women are never really in labor when they call. They just get paranoid or scared or feel alone…Now suddenly when it’s snowing they just stop being in labor? I don’t think so.”
I had one woman in labor when I got to the hospital. She was a primip (of course) with a history longer than my arm. Metformin until 12 weeks. A choley at 14 weeks. Colpo in pregnancy with CIN. GBS+. Rh Neg. An EFW putting the baby in the 90th%. Nothing that would greatly change my management, just another experience that pushes me into believing that normal healthy pregnancies just do not exist.
The baby had been having some variables throughout labor but at this point I can’t remember the last time I was managing a labor and there were no variables. Regardless, the nurses want to page you every time they see something that veers just slightly away from normal so I was in and out of the room a number of times to look at the strip, nod my head, thank the RN for asking me to evaluate, reassuring the pt and the FOB, writing a note and basically saying “I’m fine with this strip. Let me know if it changes significantly.”
There was a 3rd year med student there all day and I felt bad for him because the day was so slow and my patient, the only one my practice had in house, did not want a student at her labor or birth. But I let the med student know that there was still room for learning. Every time I was called in to assess the strip or every time I went in to check the pt’s progress I made sure to have a conversation with the med student about what I saw, what I did, what our options were at certain points in her labor etc etc. And man, I have to say, talking to this guy made me feel so much better about myself. No offense to any med people out there but third year med students really don’t know much of anything. Partly because they get three weeks on L and D and that’s it. OK. I get that their exposure is very, very limited but I mean labor and birth 101, man. Tell me what the different kinds of decelerations are and what they are indicative of. He didn’t know. Tell me what latent, early and active labor are. He fumbles. Ok, tell me what the definition of labor is…unsure. Let it be known that I did not make him feel bad. I did not rub in his face the fact that, well, he needs to start studying up. In fact, I told him that while he was with me there were no wrong answers, it was okay to say I don’t know. I told him that much of what we would talk about would be a conversation and oftentimes there would be many right answers to a problem. And I embraced, I mean really, got happy with the reality that I kind of know what’s up a lot more than this kid. And I felt good that he might look back on his training and say that a midwife taught him something. He had a lengthy homework list when he left that day. Hopefully, he’ll be on again Monday night.
My patient was fully dilated and ready to push at 12:30pm. But not before my finger ruptured her BBOW when I went to do a SVE an hour before. And of course not before she spiked a fever and the baby got tachy and I had to give her the dx of chorio. And not before her husband, at one point, watched his wife’s face and watched his baby crown and then looked at me and was breathing heavily, his eyes wide and just said: It’s a miracle. It’s a miracle. “Are you okay?” The nurse and I said virtually at the same time. “Are you being moved by the emotion or the sight of the baby’s head?” I asked. “The emotion I think.” He said, but I hadn’t seen him blink in almost a minute. “You know what?” I said to him, “You need to sit down. Sit down on that chair until the next contraction, ok?” “Ok.” He said sitting back slowly. “Ok. But, it is such a miracle.” It’ll be a miracle if this baby comes out with no problems and I can suture your vagina by myself, I thought. A fucking Christmas miracle.
So, she got abx in addition to the PCN she had already gotten d/t her GBS status and pushed her baby out in 19 minutes. No dystocia, no problems. Just a 2nd degree laceration and a big crooked gash down the side of her R labia. And I really had to think. What happens with my hands when that baby comes out? I was really doing a good job of supporting the perineum, making sure the baby’s head was well flexed, that the woman was controlling her pushes…but then, after the head comes out and I want to deal with delivering the shoulders…do I neglect the perineum at that point? Is that when the tear happens? Because I didn’t feel anything give before then…It makes me think my hands could be working better. They could be positioned better, could be delivering the shoulders and protecting the woman’s tissue at the same time.
In the end, I had to call the doc in. I could not make heads or tails of the labia. But I had no shame. And the doc that came in was sweet and casual and let me stay in the suturing driver’s seat the whole time.
After all my paper work had been done, after the circ was scheduled and the baby was cooed at, I found the doctor and apologized for being so dependent for suturing help. He was confused. “Why do you feel bad?” he asked. “I just feel like we never learned how to suture really, really well in school. And learning on raw chicken is never going to be like practicing on real bleeding human tissue.”
“Well,” he said “You’ll get a lot of practice here.” He didn’t say, y’know, you’re right. Your program should add in more opportunities. He didn’t say, yeah, your skills are sub par. He didn’t say, next time you should just push yourself to do it on your own. He said you’ll get a lot of practice here. Which, for me, basically translates to, you’re in the right place. Be patient. You’ll be better soon. And right now, everything is as it should be.
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