Okay, fine. I'm a midwife.

I had my scariest birth yet yesterday. Though I did my multip mantra before arriving at the hospital, the only two patients that were handed off to me were P0s. At this point it comes as no surprise that all I get are primips. I’m starting to feel like it’s a special higher plan that the universe has prepared for me. No matter how much I want ‘easy’, it gives me something else. No matter how much I want to glide through each call day seeing only category 1 FHTs and P2s who slide their babies out after a 10 minute second stage…the universe is powering back with something a little more challenging. And only now am I on the verge of toying with the idea of trying to stop fighting it. You want to give me a P0? Go for it. You want to throw me a completely dismantled perineum that won’t stop bleeding? Fine, I’ll just deal with it. You want to give me a nurse that doesn’t trust me and who makes me not trust myself? Good. I need the experience of building confidence and being in charge. Yesterday’s scare, though it left me with shaking hands for over an hour, taught me that, when you need help…it does come running.

My patient (a primip) was 9 cm when I got to the hospital. The baby was only at +1 and she was sitting up in bed, epiduralized of course, and generally, pretty happy and unaware that she was in labor. She was fully within the hour and had a BBOW so I AROMed her and let her labor down for another hour. I’ve gotten in trouble for laboring down for more than an hour at my practice so, even with the baby at +1, we had to start pushing around noon. And when we did, it was immediately clear that, left to her own devices, I’m really not sure if my patient would have been able to push her baby out. We had her in a sort of modified squatting position on the bed because if her head was low, she complained that she couldn’t breathe. And personally, I hate it when women are lying with the head of the bed all the way back and down and trying to push. It just seems so…hard. So the pt is upright, foot of the bed lowered and c/o a spontaneous urge to push. But each time she would get a contraction she would freak out at how much pressure she was feeling and shy away from pushing. She would windshield wiper her knees back and forth, almost clamping her pelvis closed. Her head was on the pillow and just lolling around and she was yelling and sighing and swearing but definitely NOT pushing. The nurse and I thought she was having some sort of episode. “What’s going on?” we asked her, “You need to use your words and tell us what you are feeling, what you need. Are you pushing? Are you having a contraction?” The patient could barely speak. Between each contraction we tried to do some teaching in order to anticipate the next one. “Push against the pressure you’re feeling.” We said. “Try not to be afraid of that pressure, try to use it as a guide.” We said. “If you can, keep your knees open wide, this will help to keep your pelvis open.” We said. But each time, a contraction would come she would pull her knees together and throw her head back and do a little grunting and not push. I gave her pressure in her vagina, I asked her what she needed in order to push powerfully. Nothing worked. Until I looked her in the eye, said her name sternly and literally told her to take a deep breath in, let it out, take a deep breath in again and push for 1, 2, 3, 4, 5. Let it out, take a deep breath in, let it out. Take another deep breath in and push for 1, 2, 3, 4, 5. And I was doing it with her, so if she was blocking out my words for whatever reason, she could see me and just mirror what I was doing. I hate hate hate counting with pushing but it was literally they only thing that would work for her. And there was no way that she could push longer than 5 seconds. Sometimes she would only make it through one round of this and then give up. But it was working. She was moving the baby down.

And after an hour and half of pushing like this, she delivered the head. Unfortunately, she also delivered a loop of cord and the posterior hand and the very top of the posterior shoulder. My first though was, what the hell is going on here? Do I deal with that cord? Do I try to get the rest of that nuchal hand to come out? Do I just deliver as usual and go for the anterior shoulder? No matter what I tried though, nothing worked. The baby was lodged. I tried for the anterior shoulder, not even close to coming. I tried to deliver the posterior arm by grabbing the baby’s hand but it wouldn’t budge. I hooked my finger under the posterior armpit and pulled…nothing. I went back to the anterior shoulder. And each time I tried the perineum bucked and pulled and stretched and would not give. The pt had now climbed as far back on the bed as she could without having much use of her legs. It’s as if she was trying to pull her upper body away from the experience her lower half was going through. I looked at the nurse.

“I need help.” I said. And that was all I needed to say. No less than 7 or 8 people were in the room within seconds. I have no idea why all those people come in, by the way. I feel like at least half of them are nurses and, really, what are they there for? To observe? To be able to tell the on coming shift: Oh yeah, there was an emergency today in that room. It was crazy. I was there. I mean, what are you really doing just standing by the door?? Well, thankfully, one of the people that ran in was a doctor who threw his gloves on in half a second and stuck both of his hands into the woman’s vagina to try to dislodge the kid. I put both of my hands against the woman’s perineum as he twisted and turned and pulled the baby out and handed it to me. And then, as fast as my savior had arrived, he was gone. Disappeared and I was back in the game. Baby crying immediately, both arms waving vigorously, new dad in the corner shell shocked and me, trying to hide the fact that my hands were shaking wildly. Baby was handed to peds because there had been some light mec, I don’t know, maybe, hours ago? The placenta delivered immediately, I let the woman massage her own fundus to make her bleeding stop and very, very carefully I checked her bottom. Nothing. Okay, I take that back. She had a teeny tiny hemostatic abrasion on the inside of her R labia and a small 1^st degree vaginal tear, also hemostatic. It was amazing. I’d certainly like to think it was my stellar protection of her perineum both during the pushing and the delivery that helped to maintain an intact bottom but I really don’t think I can take credit. This was a birth made of miracles. And I’m not even talking about the baby. You ask for help, and you get it. A nullip delivers an 8lb 11oz baby with a compound presentation and she walks away without any need for a repair?…the gods were with me. They really, really were. Oh, and with her too, I guess.

Yesterday was one of the few days that I walked around the halls of L and D and thought, I’m being a good midwife. I’m making good choices, I’m busy, I’m checking in with my doctor at appropriate times, the nurse respects me, I’m doing ok. And I felt like I was being a good midwife not because I think “birth is cool”. Not because I sat in a shower with someone giving them counter pressure while they endured hours of back labor. Not because I believe that the vagina is a perfect and beautiful flower and that contractions have a beginning and an end. I felt like a midwife because even though the nurse barely said hello to me when I first walked into the room, she pulled me aside after the birth and told me that I was really good with the patient. I felt like a midwife because when I finally came out of the room to write all my notes, hands still shaking, all the nurses at the nursing station told me to take a breath and be happy that was over and I felt like they really gave a shit. I felt like a midwife because even though I hate coached pushing, the patient needed a directive singular voice to take orders from and as soon as I became that voice, she started to push her baby out. I felt like I could be myself. I could make the room laugh between pushes. I could tell the pt that she was safe and mean it. I could actually access my intuition about what my patient needed and about what I needed, what the nurse needed from me, when I needed help.

And it’s too bad that things have to get to an emergency level sometimes to really see and feel the community that I work in, but it’s the truth. In those moments of panic, every single person in the room (all, um, 12? of us) had the exact same goal in mind. And I have to say, though I was shaking and scared, it felt really good. To be on a team, to have everyone taking care of the same problem, no need for explanation.

I introduced myself to the doctor who had come in to the room to save me and thanked him. Super nice and super humble about saving the day. “It was like a puzzle.” He said “Just had to figure out how to solve it. No problem.” He offered to talk to the patients, he offered to have me include him in my note…it was…cool. So, I guess, yeah, sometimes birth is cool.

Another little perk of my week was that I was asked (with just under a week’s notice) to come back to where I attended nursing school and hand out diplomas to the graduating students who have finished their 1^st year of the program. The administration had wanted to get alumni involved and, well, they thought of me. Though it probably means very little, I am so honored to have been asked and so proud to continue to be a strong part of my school community. Just the idea of ushering new students through the three year process of an advanced practice nursing degree, being there to witness all of them pass from one phase to the next…it makes me very excited. Those transitions, those scary middle places where the past might be familiar but something you know you need to leave behind, and the future is exciting but mysterious and scary…I love that. I actually hate it when I am going through it myself, but to be the Shepard, to even just be an observer of someone else’s passage…is fantastic.

Oh, and also, the test of cure results came back for my pregnant pt with trich. Yes, that’s right. She still has it.