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.

blogging for happiness

For some reason, though I’ve had more than my fair share of scary, challenging, and memorable experiences in the past few weeks, I just haven’t been as compelled to write. Maybe I don’t need the catharsis right now. Maybe I’m sick of writing about my incompetence and insecurity. Maybe I’m just distracted by all the planning I’ve been doing for my recent Passover Seder. But I heard a story on NPR about blogging and it basically said people who blog are generally happier than those who don’t, even when they are talking about the most boring and mundane things. I’m not sure I actually believe that. But if the biggest side effect of writing this blog is boring all of the people (you) who are reading these entries, I figure it’s worth a try. So even when it feels like there is nothing to write about…I’m gonna put pen to page, or, ahem, fingers to keyboard, and get something down. So, today I have for you some choice parts of a conversation I had with one of my patients in the office today: (let it be known that this was the end of a very very very long day. And this pt was very very very late.)

CNM: So what brings you in today?

Pt: To be tested.

CNM: to be tested for anything in particular?

Pt: No. I guess not, just…everything?

CNM: So…would you like me to test you for strep throat?

Pt: um

CNM: …

Pt: I guess?

CNM: Are you here for STD testing?

Pt: Yeah, that. I want that.

CNM: Are you having any particular symptoms? Or do you think you’ve been exposed to an STD?

Pt: Yeah.

CNM: Which?

Pt: I sort of have something weird coming from down there.

CNM: From where?

Pt: From, you know, my hole.

CNM: Which hole? There are 3 of them.

Pt: Oh, I guess my…

CNM: Your vagina?

Pt: uh, yeah.

Later in the conversation:

CNM: Any other recent changes or problems with other systems of your body? Respiratory issues? Burning with urination? GI changes like constipation or diarrhea?

Pt: Well actually, now that you mention it, I have had some diarrhea for the past couple of days and I’m not sure why unless it’s the extra shot of hazelnut I’ve been getting in my coffee…

I couldn’t help myself. I laughed. Very, very loudy. And I have to admit, writing it down now is making me smile.

Women's Health Conference

For some reason, I was only scheduled for one call day last week as opposed to my usual two. I noticed the extra blank space in my appointment book a couple of weeks ago and got this relief/ecstatic/criminal feeling in my body and my mind kept jumping back and forth between thoughts of, “Should I tell someone about the mistake?” to “Yes yes yes. There is no way I am not getting away with this extra day of escape from the hospital.” But then, I got an email announcing that some administrative person from my organization was going to be manning a table at a women’s health conference and she would just love it if someone else could be there with her to represent our women’s health services. In all honesty, I have to say, I was genuinely interested in this. It was a conference as opposed to a day “on” so, though I would be glad-handing a bit, I wouldn’t be responsible for anyone’s life, plus there might actually be some good info to glean about women’s health AND, most importantly (see my last entry) there would be free breakfast and lunch and coffee all day (stated clearly in the conference program that was sent along electronically with the administrator’s email.) Long story short: I said I’d do it and started thinking about what professional-casual outfit I might wear for the day…

I arrived at the conference a little late. The woman from my organization who was in charge of the table said her plan was to get there (I mean, there and ready to go and work and talk to people and be normal) at 7am. Now, when I read that, I thought, does there really need to be 2 of us putting little pamphlets and pens out on the table at 7am? Why not bring in fresh legs at around 8 or so? She never really told me when I should get there. Just mentioned what her own plans were going to be. I rolled into the hotel function room a little before 8, and let me state for the record, I decided to take the bus and it ended up either picking up or dropping off someone at every single stop. Plus, the driver gave me bad information about where to get off downtown and I ended up having to back track on foot (in a pretty mighty wind!) to get to my destination. So, I probably would have gotten there earlier if it hadn’t been for all those…situations.

Thankfully, I didn’t stop for coffee cause when I finally did arrive there was an enormous spread of starbucks coffee and pastries and bagels and all sorts of fresh juices in glass bottles stuck into buckets of ice. Had there been some lox there to go with my toasted bagel, well, the day may have turned out better.

Let me set the scene for you. This is a day-long women’s health conference with various speakers and MCs throughout the day. Women (and 1 or 2 men) have signed up for this conference, paid a fee to register, received a bag full of goodies like coupons for health clubs and travel first-aid kits and are set free to roam in a moderately sized function room with about 20 tables, each advertising a specific sleep aid or cholesterol lowering drug or boasting the attributes of a near-by mammogram screening facility etc etc. Our table had a bunch of info on our own services, specifically women’s health and midwifery related materials. The woman I was working with seemed indifferent about my being there. She barely said hello to me and definitely did not give me any directions as to what she wanted me to tell these women, the plan for the day, etc…So, I grabbed a bagel and coffee and started smiling at passersby.

The first woman I spoke with was something called a “Well Coach”. And I quickly learned that this is currently a VERY popular profession. As I kept talking with people it became clear that probably a third of the participants here were these “well coaches”. Stationed at medical centers, health clubs, resorts, or working privately they seem to be a nutritionist, a trainer and a psychologist all rolled into one. Which sort of sounds good…on paper. But it was kind of like all those people in customer service jobs who are just mean, bad communicators that make you hang up the phone and think, “Now why would that person ever want a job where they had to “service” people when they so obviously hate the species??” Similarly, many of the “well coaches” I spoke with seemed distrustful and invasive. One of them kept pushing me on some sort of wellness system she had created and that she was trying to sell to various organizations so that they could promote it to their patients. I didn’t really get what it was, plus her services aren’t covered by insurance so I can’t see that many of my patients would be interested in her “system” anyway. But I tried to give her some kind of lead.

“Well, I hear we actually just hired a wellness coach at our facilities (I overheard the admin person I was with saying this to someone else). Maybe you should speak with her about getting the word out.”

“Actually,” the Well coach said, “That is the last person I should speak with. She’d probably just take a look at the system I’ve created and say something like, ‘Wow this is great, wish I’d thought of it. I don’t know what to tell you.’ So, I don’t think that’s a great idea.”

Her response stunned me into passing her off to my right hand woman from administration. Bitch. I thought. And took another bite of my bagel. Moving on…

The participants roamed the hallway of tables until a hotel staff member (I kid you not) comes around banging on a soft but clear sounding xylophone alerting everyone that the lectures were about to begin. Everyone slowly leaves the room and takes a seat at the larger but still windowless assembly hall for 3-4 hours of power point presentations. And this was when things started to pick up downhill speed.
It is amazing how easily a women’s health conference can become a trite collection of analogies about “being present” and finding a way, in this 21^st century world, to happily balance life and kids and husband and work and pleasure. I immediately got the feeling that the population the speakers were targeting were the 50-something women who were concerned about heart health and titillated by this new funky idea of “being present”. From the outset, sitting in the very back of the room I could see an ocean of bleached, permed heads aggressively nodding in agreement with the speaker as she talked about watching her golden retriever chase birds on the beach for 45 minutes straight without tiring because he was totally and completely “in the present”. I hoped there was a barf bag in that collection of goodies all these women got when they registered cause I think I might need them all.

Someone spoke about aging gracefully, someone spoke about heart disease, someone spoke about sexual assault (after which I overheard a participant say “That was boring. I had to get out of there and come back to the tables”).

It was disappointing but I have to say, I agreed with her. I had to take a breather back at the tables a few times. I filled up my coffee cup, I drank some water, a visited the ladies room for a change of scenery. I even called my father to say hi. Any way to escape. My father, who has been an insurance salesman for over 30 years has been to a bunch of conferences about, selling life insurance I guess, in his career and his response when I told him where I was, went something like this. “Oh god. I hate those things. I used to go at the beginning of my career, thought I’d learn something, had a lot of energy to get out there, meet people. They were always so boring. I felt like I was in prison. It was hell. There was nothing worse-”

“Okay, dad-Thanks. I got it from here. Already feeling bad about being here. Thanks for the empathy, though.”

I went back into the lecture hall as the presenter was sharing stories about her family’s yearly windsurfing vacation. She was telling us how one of the most fun things to do is get on her board, catch the wind, straighten her legs and lean way back. This, apparently, makes her and her husband and her three beautiful children fly through the ocean at top speed. And it is very fun. But, there was one day when the waters were rougher than expected. And, try as she might, she just could not get her legs to straighten without losing her balance and toppling over. Again and again and again. She spoke with her husband (who is an excellent windsurfer”) about her struggles and he said this:

“When you’re riding in the chop, you have to bend your knees.” Make it stop. I wanted to say. Make her stop. But she would not. She continued.

“I looked at my husband and thought, my god, what an amazing analogy for life. When life is hard (ie when you are riding in the chop) you have to stay flexible, bend your knees, ride the waves, and you won’t get thrown off balance.” I grabbed my own goodie bag and looked for anything to regurgitate my lunch into. (Which really would have been a shame because lunch was actually the one shining moment of the day. A lovely sit down meal with fresh rolls and grilled chicken and some sort of cheesy risotto situation.) I stepped out of the room to catch my breath, went to the bathroom, and tried to concoct a way to leave early…

I made it until 2pm which I think was admirable since the thing only went until 3:30. I was sitting, “listening” to a presenter with my elbows on my knees, head in my hands, thinking of my father who thought these “educational” conferences were like jail (probably the best analogy anyone made all day) when the woman at the podium leans towards us and says into the microphone in a determined voice just over a whisper:

“Listen, the truth is, no one can start over, but you can start today and make a new ending…” Applause erupted from the audience. So, so true, I thought. I can make a new ending. Starting today, never agree to volunteer at a women’s health conference, regardless of how good the menu is …

I turned to the admin women: “How would you feel if I left now?” I asked.

“That’s fine.” She said indifferently. “You can leave whenever.”

I packed my bags, took the escalator to the ground floor and walked out into the sun. A free woman.

Drug Reps

I have very few political morals at this point in my career when it comes to free dinners sponsored by drug reps that want me to prescribe their product. I like to think I have the ability to make unbiased choices regardless of how much roasted chicken and smooth tasting red wine someone else is paying for me to eat and drink. So, I rarely give up a chance to sit and listen to someone talk about the benefits of Yaz on PMDD if I can relax, eat buttery garlic mashed potatoes and flourless chocolate cake without ever having to open my wallet. It’s just, something I am okay with right now. In fact, I’m more than okay with it to be perfectly honest with you. I freaking love it. I love free food. I love free things. I am not embarrassed to say that I spent a good two years of my life gathering bread of all kinds from dumpsters and storing them in my freezer for toast, sandwiches, dinner parties…(It was because of a guy basically. Long story which I will not go into now but, just to reiterate, I am not a stranger to good deals.) So when a fellow midwife told me that there were some drug reps inviting any and all OBGYN providers to a spa last night in order to hear about the latest in HPV screening guidelines in exchange for a FREE treatment of my choice, well, I was not about to turn them down.

I arrived at the day spa around 7, was immediately served a glass of wine and multiple appetizers and had a lovely woman tell me all about the 2008 screening recommendations for HPV. She was sweet, not too overbearing, and wasn’t talking for long when it was time for my facial!

A heavyset Jamaican woman led me through a hallway to a dimly lit room that smelled like eucalyptus and had a massage table placed diagonally in the middle. She sat at the head of the bed and I wasn’t sure if I was supposed to undress in front of her, or undress at all.

“Should I take my shirt off or…” I started.

“No, honey” she said to me opening some of the bottles on the metal cart beside the table. “You’re getting the mini. You can just lie down.”

“Oh.” I said, a little disappointed that this “mini” might not provide the deep tissue massage of the neck and shoulders I was hoping for. I laid down on the table.

“So…tell me about your skin…” She said.

“I guess it’s on the drier side for the most part. Mostly right here.” I pointed to my “T zone” and might have even said “T zone” to her in the hopes that it would sound like I knew something about skin care.

“Any products?” She asked.

“Just a mild cleanser once a day, and a light moisturizer.”

“How about exfoliation?”

“Yes, I do that too. Like 2 times a month maybe.”

“Mmmmm.”

“Is that okay?” I asked.

“Well, it could be 2 times a week…Close your eyes.”

Light comes over my head and, even though my eyes are closed I can sense the woman’s face coming closer and closer to mine, examining my skin with her enormous magnifying glass.

“Hmmmm.” She says. “Hmmmm. Uh-huh. Not bad. Not bad.”

“Is everything okay?” I ask.

“Mmmmm. Well, dehydration seems to be your main issue. Lots of dehydration. You need to hydrate yourself. Dehydration causes lines. And you don’t want lines.”

I was immediately reminded of one of my midwifery school professors who interrupted me during an exam to let me know that she was distracted by how much I furrow my brow. “Well,” I said to her, disconcerted by the fact that I was still mid-exam. “I like to think that my face is just expressive.” I put my head back down but she continued to talk to me. “You know, another one of the midwives here does that. She’s been doing it all her life. And look at her now…You definitely don’t want to keep squinting like that.”

“Okay, well, thanks.” I said and kept working.

The dehydration blow was somewhat easier to digest. And, to her credit, the woman was right. I don’t drink nearly enough water. I settled in to the lotions and scrubs and hot towels laid over my face, wished there was about an hour more of the very brief neck rub and emerged from the “mini” feeling somewhat relaxed and inordinately sticky. Nonetheless, everyone still hearing about HPV screening and eating cheese said I looked like I was glowing. In addition, all of us who came to the event went home with a goodie bag including a few travel moisturizers.

So, another drug rep success. A free facial, a new HPV algorithm, party favors??!! I think I made out nicely. Listen, I voted for Obama. My politics are just fine.

No Patience for my Patients

Me: Was this pregnancy planned?

Pt: Well, I was tryin’, and then I just wasn’t getting pregnant. It just wasn’t happening. And then I missed my period and I was like What is this?? And I went to the dollar store near my house (laugh) and I bought one of those test things and it was positive and I called you guys and said the test was positive and the nurse, I forget her name, but I was talkin’ to her and she was like you better come in and I was like But does it matter where you get the test like what if I got it at the dollar store or something? (laugh) and she was like, No it doesn’t matter where you got the test so I guess that was it.

Me: It says here you have no drug allergies. Is that right?

Pt: Yup. No allergies, well except lidocaine. And epinephrine.

Me: Do you have good sources of iron in your diet?

Pt: I can’t eat bananas. I just don’t like them.

Me: I wasn’t going to recommend bananas for iron.

Pt: No, you don’t understand. I just can’t eat bananas! (laugh). I just hate them. Even thinking about them, ug! I just cannot eat any bananas for the rest of my life.

Me: Listen to me. You don’t have to eat bananas. What about red meat? Do you eat red meat?

Pt: Not really. I mean, if my grandma makes something at her house and I go over there I might have some, but I don’t eat pork or anything.

Me: Pork isn’t red meat.

Pt: I eat chicken and fish but no pork. I just do not like pork.

Me…

Me: I see in your problem list that you have a history of seizures. When was the last time you had a seizure?

Pt: Oh like a long time ago, it’s not even really a problem any more. Like 2 or 3 years ago. I was hospitalized that time. I think should have my records for that. But it was like a big deal because I was like unconscious and that’s when they found out I was allergic to epinephrine.

Me: I see in your problem list that you have a history of herpes. Is that type 1 or 2?

Pt: What? I ain’t never had any kind of herpes or anything like that. We’ve been together for over 3 years now and I haven’t had anything. I had Chlamydia. Maybe that’s why my chart says that about herpes or whatever.

Me: Chlamydia and herpes are two very separate things. And you may have never had an outbreak. We just don’t want you to have an outbreak during pregnancy-when you are in labor. We wouldn’t want the baby to be exposed to a herpes lesion.

Pt: I have no idea why my chart says that. I have never had any kind of anything anywhere. I definitely don’t have herpes. That must be wrong.

Me: Do you have any concerns about your caffeine intake?

Pt: Well (laugh). I like coffee a lot. In the morning I usually have like 3 cups of coffee and then in the afternoon I usually get a Turbo.

Me: What is a Turbo?

Pt: It’s at Dunkin Donuts. It’s a coffee with a shot of espresso in it.

Me…

Pt: But I love the taste! (laugh)

Pt: So, how big is the baby now?

Me: After you get dressed, come into my office and I’ll show you some pictures I have of what your baby looks like.

Pt: Oh my god (laugh)! Okay (laugh). Cool.

A Little Bit of Everything

When I'm on call, I try to take each situation and file it away in my mental filing cabinet so that I can easily recall what kind of labor management I did so, the next time I have a similar situation, I can just go back to that place in my filing cabinet and do the same thing. The problem is, every time I have a patient in labor, it feels and looks nothing like anything before it. The labor is different, my nurse is different, the entire situation is demanding new things from me. And even if there is one piece of the puzzle that looks the same as another, the rest of the story doesn’t fit. So my management decisions have to be different and my mental filing cabinet is immediately made obsolete. It's a shame actually. Because I try really hard to let one call shift inform the next. But it feels like each time, I am reminded that there are no rules, no black and white, no cookie cutter approach to labor and delivery that can get you through a non-straightforward situation. At least not yet anyway.

I had one patient in labor all day yesterday. She was a young and healthy G1P0 laboring naturally and easily, probably in more control than I had ever seen anyone. She was a role model for natural labor, and for staying on top of each contraction, asking for what she needed and staying open minded and not panicking the entire time. She had SROMed to clear fluid the night before at 10pm, labored at home until she came to the hospital at 4:30 am when she was found to be 5cm. I checked her as soon as I got to the hospital and got report in the morning and she was an anterior lip. So, she labored for another hour and I checked her again. Still an anterior lip. So I tried to reduce it. I gave her cervix a gentle push and the pt bore down at the same time. The cervix, soft and flexible, slipped back behind the baby's head. I kept my hand there and the cervix seemed to stay back. So, we started pushing. Pushing on hands and knees, pushing side-lying, pushing on the toilet. But the contractions space and the woman wasn’t feeling the spontaneous urge to push with each one. So, after 45 minutes, I checked her again. And that lip had come back.

"Well" I told her. "I can try to reduce that cervix again, but if it keeps coming back like this I have to wonder why that is. If it's not ready to stay back, it might just be trying to tell us something." Her back labor and the baby’s complete lack of descent was sort of telling me that the baby might have been in a funky position too...Either way, I did feel like her contractions just needed to be closer together and potentially stronger. But we'd already started pushing, and she originally had that ant lip, and then didn’t and now the lip was back. It just wasn’t straightforward to me. And I have to admit, when something gets "unstraighforward" I start to get “unsecure” about my decision making skills. And maybe it was completely appropriate to ask the doc what she thought at this point. But, I just started thinking, should I be doing more? Should I be more innovative? Should I know how to do sterile water papules for this woman's back labor? Would it make any difference at this point anyway? Should I seek out another practitioner who knows how to do them?

I told the pt to do nipple stim for augmenting her labor while I went to consult with the doc. I knew she needed pit but this was a pt who never got an IV, never got her initial labs drawn, had had zero interventions and minimal exams...i figured, why not let her try the least invasive option first? Plus, it bought me some consult time.

I start to page my doc to give her an update and I see another doc from my practice. "Hey," I say to her, "You have any great ideas for getting rid of a persistent cervical lip?"

"Yeah," she says, "C-section."

"Come on, really." I said

"I'm serious. C section." And she was. She was really really serious.

"Well," I said, "I don’t think her contractions have enough power."

"Well, that may be a different story." She said.

"Yeah,” I continued. “She was an anterior lip, and I reduced it so she was fully and then she pushed for a bit but now that lip is back."

"I've never heard of that." the doctor said.

"Of what?"

"Of a pt being fully and then not fully. She had a lip and then no lip an then a lip again...? That just doesn’t sound right and you’re getting into dangerous territory."

She was making it sound like I didn’t know what I was talking about. Trivializing the situation and the work we had been doing in the room to "lip, no lip, lip." She was making me second guess myself.

But, when the doctor I was on call with got back to me, she agreed that the patient could have some pit to see if that would get her into a better pattern and maybe get rid of that extra bit of cervix. So, we started pit. And though it got to 6 the patient stayed sans epidural amazingly through a wonderful contraction pattern of q 2-3 minutes. I checked her again. Ant lip. I tried to reduce it. It disapeared. But, I wanted a second opinion. The doc checked her. She felt nothing and gave us her blessing to push. So, out loud I said "Great, so maybe that lip has finally stayed back. Good news! The reduction worked! Let's push!" But inside I was crumbling and second guessing: What the hell was that that I felt?? WAS it a lip? Was it...nothing?? Was it there ever? Did I just make this woman go through tons of pit for nothing?? More second guessing.

We pushed for 2 hours. With no descent of the baby’s head. We pushed in every position we could think of, we coached and didn’t coach, and supported and did what we could but the baby just would not budge. If I could actually assess fetal position I could tell you for sure if I thought it was posterior but since I can usually only feel one fontanelle and never have much of a clue which one it is I was in the dark on that.

The doc came in and gave the "I think the best thing would be to have a section" speech and the patient agreed. She was exhausted. And though she was disappointed, she thought there was no sense in continuing.

At this point in my career, when someone disagrees with me (ie. c-section for an ant lip, if my vag exam is off from someone else's etc etc), my knee jerk response is to assume I am in the wrong. I never think, What the hell do they know? That baby was at +2 not +1! Or, A c-section for an ant lip when nothing else is concerning...??!! She is a bitch and I will get someone else's counsel. I can't wait for the day that I could care less what someone else thinks. Or, at least, keep their opinions in perspective, not let a disagreement wreak havoc on my sense of security...

So, we shut the pit off, went over the risks and benefits of section, wheeled the pt into the OR, gave her husband a set of scrubs, got her epidural placed, prepped her belly, brought her husband back to the OR to hold his wife's hand and delivered her baby. Her direct OP baby. And that whole time, before the pt got her epidural of course, she was walking and talking and not in any pain whatsoever. It was as if her labor had just stopped. As if her mind was like, Ok, well, there's no point to continuing like this so, I'm just gonna get out of the contraction mindset. And her uterus was like, Well, you know what? I'm tired anyway, and since I don’t need to help push this baby out anymore I'm just gonna take a ...little...break...zzzzzzz. The resident who was helping the doc out with the section turned to me and said "How far did she get?" "Fully and pushing." I said. "Really? She doesn’t even seem like she's in labor." "I know." I said. "As soon as she knew were going to section, things just kind of stopped."

In the end, the family was happy. I stopped by their room before I left the hospital for the night. They thanked me profusely. Though, still, I can’t put my finger on why. I was so worried the whole time that I was adding bad energy to the room by knowing deep down that there was no progress and not wanting to wait and wait and wait for hours until we were certain she couldn’t deliver vaginally and until everyone was dog tired. I know, I'm human, but I feel like I'm supposed to stay optimistic and positive and enthusiastic. And maybe it's only me that has those expectations. But clearly it's a theme for me, what can I say?

"We thought about it" the patient said, "And we're really happy about the way things turned out. We decided we definitely got our money's worth. We had all natural childbirth basically, and we also got a c-section! We had a doctor AND a midwife! We got a little of everything."

“Yeah,” her husband said. “We really wanted to be part of your “no epidural statistics” but at least the baby and my wife are healthy.”

“You’ll just have to be part of our VBAC stats!” I said. I felt a little better after talking to them but went home emotionally exhausted yet again. At some point I am hoping to quiet some of those self-doubting voices in my brain…I’m just not quite there yet…

I am on call Tuesday night with the doc who resolves anterior lips with c-sections. Already in a mini-panic.