My Trip to Russia

When my sister lived in New York, we used to try to go to the 10^th Street baths whenever I came to visit her. Wednesdays were women’s days. You’d go in, give your 25 bucks to a man behind the counter who had a big belly and a hairy chest. He’d hand you a key for your locker and you’d walk past a sort of “deli” with a paltry offering of unidentifiable meats and canned juices, a TV hitched to a corner of the ceiling playing sports or Russian news and into the locker room. Inside your locker there was a an oversized robe that would only fit a man weighing at least 300 lbs and some flip flops and you’d exchange those for your clothes and head downstairs to the baths. As a teenager, this experience pretty much blew my mind. There were women of all shapes and sizes getting beaten with branches, walking around with mud on their faces and grinding kosher salt into every part of their bodies. But I was with my sister and it felt safe and cool and I always slept like a baby the night after he day I’d been there.

I figured, living in an urban area now, there must be something similar in my town. A quick google search a few years ago uncovered a little known Russian bath house not too far from my neighborhood. Women’s day at this bath house is on Mondays only from 4pm to 9pm. Every other hour of every other day is men only. It’s unfair but that is the subject of another blog entirely so I won’t go into my thoughts on that now. But, I do think when there are only 5 hours every week that something is available to you, it is so much more special when you actually take advantage of it. As luck would have it, I am in clinic on Mondays and there is nothing that calls for a few hours in a sauna like a day of vaginitis and complaints of sciatica.

Yesterday was an unusually slow day at clinic. I finished each chart before I saw the next patient. Everyone’s complaints were pretty straightforward and there were very few add-ons (which I was responsible for that day). The sheer boredom made me panicky though and I raced to the bath house as soon as I got into my car.

This Russian bath house is small. You come in, walk down a long hallway and into a locker room/check in area/tv room. Everything is open and public. And very very very laid back. There’s one bathroom for everyone, the woman taking money at the counter is always calling you honey and leaning on her elbows and talking to the women sitting in the TV room who are taking a break from their steams. There is a card table set up that always seems to have pastries or egg salad sandwiches set out for people to eat, though I’m still not sure who this food is for. More investigating will have to be done…

Anyway, the place is disgustingly cheap. For 26 dollars I got a towel, plastic sandals, unlimited time (well until 9pm that is) in the sauna and steam room, a platza treatment and a bottle of spring water. I stripped down, put all my clothes in the locker they assigned me, and turned off my brain. Well, tried too. The thing about this place is that it’s a community. These woman (anywhere from 20 to 70 years old) are regulars here. They know each other from the baths, from work, from growing up. And they have A LOT to talk about. The sauna is far from a meditative place to be when you just need some peace and quiet. It’s more of a really warm gossip session. This is a slice of real life. Everyone has thick accents and drooping bodies. And last night was not the first time I overheard some of the women talking about their recent plastic surgeries:

“I just got my eyes done.” One older woman said.

“You did? I can’t tell. Lemme see. What did you have done?”

“I know. It’s still a little swollen. I had all of this pulled back.” She points to the sides of her face by her eyes. “My doctor said it might take 4 months for the swelling to go down though.”

“Hm. Nice. I’m thinking about having something done too. But, were you black and blue?”

“Nope. For 2 weeks before the surgery I ate lots and lots of pineapple.”

“Really.”

“Tons. It make you less likely to bruise. But the doctor I go to, Richardson something or other, he does’em Thursday and Friday night so everyone goes back to work, no problem on Monday morning. I had mine done on Thursday late afternoon and let me tell you something, I was at Neiman Marcus on Friday morning. I got home Thursday night from the surgery and my friend had left me a message on my voice mail. All she said was: Neiman Marcus, 20% off sale. And I was there.”

“I’m just not sure. I mean, what if I don’t like what it looks like afterwards?”

“You know what you do? If you want to see what it’s gonna look like, you lie down on your back and look at your face in a mirror. When you lie back like that gravity pulls everything away. That’s exactly what you’ll look like.”

The woman who had just gotten the surgery was very obese. And, I just couldn’t help but think, Why did you choose your eyes?

Last night was my first time getting a platza treatment. Basically what that is, if you’ve never had one or seen it done, is me, lying naked on the top bench of wooden bleachers in the sauna while receiving an “invigorating” rub down with a branch from an oak tree (supposedly hand made by one of the men that works there every other day of the week) and periodically being doused with buckets of freezing cold water to “promote circulation” by a woman wearing a bikini. The platza was good, though, I couldn’t really see any evidence of things being cleaned at all between treatments. Not that I minded all that much. The whole place sort of makes it feel like you are in a garage or an unfinished, I mean really unfinished, basement. But the truth is, if the woman who got her rub down before me had crabs, I definitely have them now too. And let me tell you something else. When I got home and took a shower in my own bathroom, I found oak leaves in body parts I didn’t even know I had.

In addition, yesterday was the second straight week I witnessed a woman in the sauna openly shaving every part of her body. I mean, not just the places you usually shave either. She was going all out. Arms, feet, neck…and from what I could tell, she didn’t have any excess hair to begin with. She used a bucket of water sitting next to her to shake her razor out and then, when she was done, just dumped it on the floor, all the water and the little hairs trying to make their way to the drain. I looked away.

So, all in all, the baths are great. I’m sure some of my readers out there will disagree with me after my description but I’ve always been attracted to those places, physically and emotionally, that make people turn their heads and cringe. Why do you think I’m a midwife? Labor and birth is full of scary, dirty, smelly things. Panic, poop, blood and total exposure. I love being a part of experiences where there is absolutely no room for pretense. Things are real with a capital R and there is nowhere to hide from it. And I like that part of my job, a big part, is about normalizing those sometimes uncomfortable experiences for others. So, thankfully, the Russain baths did not include any blood or poop (that I saw anyway) but I think it’s another place where you can let it all hang out. You can sit there and sweat and talk shit and pull leaves out of your butt and no one will think twice.

Last night was the last session of the season. The baths reopen in September. And I have a feeling I’ll be going there a lot after work come fall.

Kids these days...

There was a knock on the exam room door in the middle of one of my routine OB visits. I gave my patient a confused and frustrated look as I got up to answer the door.

“This never happens,” I said. Though it has already happened more than a handful of times. “Sorry.”

When I opened the door, one of the medical assistants was standing there apologizing but letting me know that a pediatrician from downstairs asked that I be interrupted in order to consult with her over the phone regarding a 16 yo pt she had “on the table.” I excused myself and headed toward the phone thinking, Why would a pediatrician be asking for me? Like, she wants me? Me, me? Or just a clinician? My MA didn’t know. She just handed me the phone.

“Hello?”

“Hi, thanks so much for taking my call.” The female voice on the other end said.

“Well, I was told you wanted me to be interrupted.”

“Yes, yes, thanks so much. I hate to bother you during your busy day but I have a pt here, like on the exam table, and I’m not exactly sure what to do with her.”

“Okay, well, I can try to help.”

“Well, the patient is saying that during sex last night she had a “gush of blood” and now she is also having some pelvic pain. I’m just not sure what to do. You see, I’m just a floater here…”

I couldn’t help but think of her swimming in the toilet even after a flush or two…

“Well, is she bleeding now?” I asked.

“No, not really. I don’t think so.”

“Well, I’d do a pregnancy test, and I would definitely take a look inside.”

“Ok, well, but, as I said before, I am just a floater here. I’m not even sure I can do that here.”

“You mean you don’t have speculums down there?”

“No, no, of course we have speculums; it’s just that, I was hoping you could see her?”

Long story short, after being interrupted for a 2^nd time by this same “floater”, the patient was sent upstairs to see me.

It turns out, she did have a gush of blood while she was having sex. A “gush” that she describes as “filling the cup of her hand”. Then the bleeding almost immediately tapered. She reported only having brown spotting today. She had no pain before or during the episode of bleeding but now she has diffuse pain in her lower abdomen. She’s been sexually active for 2 years. She’s on the pill and has not forgotten to take her pill, ever. Her last period was normal. Her pregnancy test today is negative. This has never happened before.

I tell her that I have to take a look inside. She understands though is squirming and uncomfortable with the idea. The pt has minimal problems/discomfort with the insertion of the speculum. I can immediately see blood in the vagina and as I look around and use the speculum to push away vaginal mucosa, it’s clear that the bleeding is no longer brown but bright red. Not tremendous amounts but there is no question that something is actively bleeding. There was blood on the cervix but it wasn’t clear that the bleeding was actually coming from the cervix. I pulled my light around even more to get a better look at the sidewalls. And then I saw it. The right side of her vagina was completely intact and I could visualize the entire thing from introitus to cervix. But the left side was not right. There was a fairly large laceration that was running down the length of her insides.

“You aren’t in any pain in here?” I asked as I dabbed the gash with a q tip.

“No. I can’t feel that.” She said.

It’s true that there are less nerve endings inside the vagina. If the wound had been on the outside or up near her cervix I am certain she would have been in more pain, but presently, she was generally comfortable. Just embarrassed and anxious.

“Was there anything in your vagina besides a penis?” I asked.

“No.”

“Like, no toys? No fingers?”

“No, nothing.”

“Well you have a pretty significant cut in here.”

“I do?”

“Yes, you do. I can’t see it very well but I’m pretty sure that is where your bleeding is coming from.”

“That is so gross.”

“Well, it happens, I guess.” I had never seen this before. “But I definitely do not want you to have anything in your vagina for a while. Until this heals. And I’m going to let the doctor know what I found and see what she wants to do.”

I grabbed one of the docs who was in the office that day and let her know what was going on. We got a pelvic US to r/o any kind of hematoma (which not surprisingly was normal) and the doc told me to pack the vagina for today, give the patient good warning signs for increased bleeding and pain and to have her come back tomorrow to see if it has healed. Initially I was a little frustrated that the doctor didn’t want to see (confirm) my “diagnosis”. I mean, if she saw the extent of the laceration, maybe her plan would be different. Plus, I just didn’t trust myself. Maybe it wasn’t a gash. Maybe the blood was coming from somewhere else and I just didn’t see where…But after I packed the pt’s vagina and made her an appt for the next morning to see another clinician I checked in with the doctor.

“So, you think that packing will be enough for tonight?”

“I hope so. It might just be enough to tamponade the area. I’d like to avoid suturing the vagina of such a young girl if we can just use expectant management. And tomorrow when she comes in, I can help assess and if she’s still bleeding we’ll just have to suture her.”

That made sense to me. And since the patient’s bleeding was well under control, her CBC was normal and I could bet any amount of money she wouldn’t sticking anything inside of her for a long time, I felt better.

It turns out, she was one of the patients I thought about all night and well into my next day on call. Around noon (I knew the pt’s follow up appt was at 11am) I called the office and spoke with the midwife who saw her. It was definitely a laceration just where I had thought it was. It was still bleeding when the packing was pulled and the doc and CNM advised the patient that she would need to have the wound stitched. And she refused. She just refused. She wanted to just let it heal and bleed and not have anyone else touch her. Which, is absolutely her prerogative. I just couldn’t help but think it was the wrong decision. And I couldn’t help but think it was only embarrassment and fear that made her refuse. And I definitely couldn’t help but think that I would most likely be seeing her again. I’ll have to remember to do better education on lubricating agents the next time she makes an appointment…

Deja Vu

Well friends, it happened again. Just like I told you. I was covering for my friend and fellow midwife yesterday at the hospital from 1pm until 7:30pm. She was moving to a new apartment, I was free for the afternoon and I needed some hours so I thought I would do her a favor. When I got to the hospital there was literally no one on the floor. I finished some charts from the office, chatted with another midwife friend of mine who works with another practice, hung out in jeans and open toed shoes for what seemed like hours. And then 5pm hit. Three, yes three, patients came in all at once. 1 woman at 41.3 wks who was sent in from the office for induction for an IUGR baby, not to mention post dates. Another woman who had been contracting irregularly since the morning, had a non reactive NST in the office but an 8/8 BPP who was now c/o very painful and regular contractions and the last was my own patient from the office who was a 38 yo G2P1 being induced at 41.5 wks. They ALL got to triage at the same time. Got there, in fact while I was upstairs on the postpartum floor seeing a patient that the CNM pp rounder didn’t have a chance to evaluate. One moment it was chill, the next moment it was crazy.

The IUGR induction pt got directly admitted. She was 2/75/-2, soft, midposition. She was started on pit and sat in the rocking chair while her husband knelt on a carpet and prayed over and over and over again.

The woman in spontaneous labor, yes, that’s right, I said spontaneous, was only 3cm (50% and -3) but had three elevated BPs into the 140s over 90s so we kept her. Ran labs, got her a room…her labs were normal, she had no headaches or protein in her urine, basically, she was just hypertensive. She wanted an epidural an hour later when she was 4cm/100/-2. An hour after that, she ruptured on her own to clear fluid.

My own patient from the office was a different story. She had arrived at the hospital for cervical ripening at 7:30 in the morning. But because the hospital was so busy, she got bumped till the afternoon. She had a quick NST, went home, came back a few hours later and still had to wait until 5 to get into triage to be evaluated. When I finally saw her, she looked tired, disenchanted. She’s the kind of person who was cheerful 99% of the time I saw her in the office. Today, she looked heavy. And I could see that she was trying to stay light and stay smiling but her eyes were already glassy like she was just waiting for an opportunity to let go. She was c/o irregular tightening but other than that, no real change from when I saw her in the office the day before. And her cervix hadn’t changed much either. She was a tight 2 cm, posterior and only about 25% effaced. Her last baby was an induction as well and she reported having a really hard time with the “tablet” they gave her. She remembered being sent home and starting to have frequent and painful contractions almost immediately. She was scared and in pain, and didn’t know when to come back to the hospital.

She’d been here all day, I thought. And she does need some ripening. But I didn’t want her to panic more than was necessary or relive an obviously traumatic experience. So, I went with gel. Gel, yes, gel. It’s got a reputation for not working so well. Or at all. One of my preceptors from school used to joke that she thought the gel formulation of ripening agents was just KY jelly disguised in a medical looking syringe.

“I’m gonna give her gel.” I said to another midwife who asked me what I was going to do with my patient.

“Might as well not give her anything at all.” She said back to me.

The thing was, giving this woman gel solved some problems. For one, the patient was less anxious about the ripening process and also, I was able to honestly tell her that this was a way less aggressive form of ripening agent. I was able to look her in the eyes and say, this may not do anything to you at all. You my feel crampy but it’s unlikely that you will have the same experience as you had with the cytotec.

“What if we just didn’t do the gel and we came back tomorrow for the pitocin?” She asked.

“Well,” I said, “If you just come back tomorrow and your cervix is the same, you may have to get a dose of this anyway.”

“Okay,” she said, “Let’s just do it.”

The gel went in and we started the two hours of monitoring you need on this agent at our hospital before a patient can go home. Within 5-10 minutes my patient was contracting every 3 minutes. And then she was contracting every 1 ½ minutes. And they were painful. After an hour and a half of monitoring she was shaking and asking for an epidural. This is the report I got from the triage nurse and I immediately felt disbelief and guilt. Was it really the gel making her contract so wildly? Was it my exam prior to the gel placement? Was the patient mad at me? Was she thinking I lied to her? Did I lie to her? I could barely go back into that room to confront the answers to these questions and to witness her pain. And usually, when it comes to labor pains, I’m kind of a tough guy.

“These contractions hurt!” Patients will say.

“That’s great!” I’ll say. “They are supposed to hurt. Labor is hard work. You’re doing great.”

But with this woman, I couldn’t put on the act. I wanted to immediately take away her pain. I wanted to see her smile again. I wanted to make her comfortable. I did not want her to think badly of me. I relayed her story to the oncoming midwife, who had arrived for her shift at this point.

“You know,” she said, “when you have a personal relationship with someone, when it’s someone you have seen almost every week for the past 2 or 3 months, it’s much harder to watch them be in pain.”

“I know. I know.” I said, “But these contractions…they’re like every 2 minutes…”

“So, the gel is working.” She said.

And yeah, I guess the gel was working as it was supposed to, I just didn’t care. In my head I’m thinking can we give her narcotics in triage? Turb? How can we make this go away. My head was in such a different place. The other CNM and I made a plan to admit her, get her an epidural and pit her as soon as we were able if there was no cervical change at her next exam. Armed with that plan, I was finally able to walk into her triage room. She was drenched with sweat, crying, and looked up at me with eyes that had lost every ounce of her reserves. I put my hands on her shoulders.

“Listen, I’m not going to make you go home.”

“Please, please please don’t. I can’t go home.” She said.

“I promise. You’re going to stay here. We’re going to get you a room and get you some pain relief. And I’m not going to leave until you are comfortable.”

And then the nurse told me it would be at least a half hour until she even got a room. And I bailed on her again. I just couldn’t go back in there and give her what I thought would be horrible news.

“Guess what? I know I just told you you were going to get a room and an epidural but you’re going to have to wait longer, a half hour at the very least longer, before any of that happens. I know you’re having contractions every minute but you’re doing great! Keep it up!”

I just couldn’t have that conversation with her. So the nurse went in, started her IV, drew labs, gave her fluids, basically distracted her, made her feel like things were happening before they actually were. She did get a room. And finally the anesthesiologist came in, took forever to fill out all the paper work because, I’m pretty sure, she was very new. My patient assumed the placement position with her legs dangling off the bed while her “team leader” talked her through every step of the placement. At one point my patient opened her eyes and looked at me hiding behind the curtain that separated the room from the rest of the labor floor. She just stared at me. And I couldn’t read her at all. Mad? Sad? Scared? I kept hiding.

But little by little, she started to feel relief. And her face brightened. And her shoulders softened. And she opened her eyes and looked at me again.

“You’re a saint.” She said. “Thank you so so much.” She was so sweet to say that and it made me feel so relieved. But I was also so embarrassed. A saint for what? For being a coward? For not being able to be a midwife who could sit in a room with a laboring woman who was in pain? Which part made me a saint? I wasn’t sure. But I was happy that she was comfortable. And I was happy that her husband looked like he was having a reprieve from his own stress. We all took a deep breath, they showed me photos of their first child who was 19 months old, and we joked that this labor thing would be so much more fair if the length of it could be determined by how much pain you felt.

“Well, you know what?” I said, “When you have your third child-”

“Um, no.” She said, cutting me off. “This is it. The last one. Snip Snip.” She made a scissors motion with her hand.

I wasn’t sure if she was talking about surgery for her or her husband but I looked at him and he seemed unaware. So, avoiding any more uncomfortable topics for the evening, I kissed her on the check, gave him a hug and finally left the hospital around 10pm.

I stopped in to see her today on the post partum floor. She had an 8lb 6oz baby boy at 5:46am and she was definitely NOT mad at me or disappointed in her care at all. She loved the midwife who took care of her in labor, she was happy she only pushed 3 times and she knew, without a doubt, that the gel was a much better experience than the cytotec.

She lifted her baby up from her lap so he could see me. “Look honey!” She said to him. “Is that your midwife? Who took care of you while you were inside me? Huh? Is that her?”

He just kind of stared at me with unfocused eyes and a trembling chin.

“Yeah,” I said to him as I grabbed his tiny red foot. “It’s me. Here I am. I’m your midwife.”

My Cycle

Here is the cycle I go through basically every time I’m on call. I start out in a minor panic as I get report, trying to keep everyone straight in my head, and resist speaking up when I disagree with the reasons someone is being induced (for example). My shift starts and things slowly but surely get under control. On many days, not all but many, things are fairly slow, or at least manageable. I have someone “in labor” who isn’t really in labor and I baby sit her while she gets ripened or gets low dose pit and sits on a birth ball changing her cervix from 1-2 to 2-3 in 12 hours. But then, lo and behold, almost without exception around 5pm things start to pick up at a sometimes alarming pace. More triage patients come in because the office is now closed and patients are making a bee line to the hospital, someone ruptures in the lobby, a nullip calls three times freaking out that her ctx are painful and coming frequently, a patient on the pp floor can’t pee…So, after a completely in-control day, I get bombarded and things start to unravel. Suddenly it’s 7:15pm, the oncoming midwife is on her way upstairs, paper work is only half way done, there are loose ends blowing all over the place and I start to panic (ah we’ve come full circle here) that it will look like I’m just a lazy, disorganized fool who waited until the last minute to do anything. And, the woman who usually takes over for me when I work a Wednesday or a Friday shift (often the two days of the week I am in the hospital) is so hard to read. She almost never laughs at my jokes, she takes report from me without sharing eye contact, barely asks questions, just stays silent, wishes me a good night and head’s out to the floor to, I’m sure, change management plans and do her own thing.

Now, I know that one of the things I need to work on as a new practitioner (and in my life) is to chip away my stellar ability to assume that everyone else’s plan or management decision is way, way, way better than my own. I’m so good at channeling insecurity. Too good on most days. And I am constantly working on finding a balance between confidence and humility. And it is hard, hard work. Trusting yourself, sticking with your choices, knowing, and I mean really knowing, that each decision I make doesn’t directly relate to my worth as a midwife or even as a human being. Why can’t my reflex be to think that that midwife is tired, or weird, or has bad people skills. Instead I think she hates me. Yep, that’s what’s going on here. She resents that I am new, resents that I would not have done things the way she would have and now feels like she has to “clean up” my mess.

Clearly, these topics are just fodder for my weekly therapy sessions. But, in the meantime, I have 2 mantras to recite: my multip mantra as I head into the hospital and now mantra #2 which I will start to meditate on as I leave the hospital in order to quiet the judging voices in my head. I’ll take deep breaths, appreciate the fact that, if nothing else, I am walking out of the hospital and into the now soft spring air. I’ll acknowledge my insecurities but remind myself that it’s okay to be new and that patience, for my development as a midwife, is an essential virtue. And a strong gin and tonic usually helps too.

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.