Musings of an OB Nurse in Transition

I have Followers!

2010-01-28T11:38:00.000-08:00

Been away from posting so long I hadn't even noticed! Too cool, even if there are only a few.

Now I need to give them something to follow.

Hope springs eternal...really, truly...I have more than a dozen "drafts" in the works, just can't get myself focused enough to flesh them out.

Getting right on that...ASAP.

Stay tuned.

Let's Talk Pitocin

2009-11-27T13:40:00.001-08:00

Several comments on a post by the Unnecesarean seem to indicate that more than a few mothers suspect Pitocin had been"snuck" in to their IV's during or after labor when they were unaware of it. I commented at length about it in response to these posts on the Facebook fan site for the blog, but decided to reiterate, and expand my thoughts here.

First, Pitocin is not always a bad thing. True, it is grossly overused today (I love it when a mother comes on to my unit and gives birth with nary a whiff of the stuff...and I love teasing the residents..."Look...she had a baby without Pit! Who'd a thunk it!"). But there are times when a little Pitocin can be helpful; when you've received an early epidural and things have slowed down...the longer an epidural is in place, the more likely you are to develop a fever during labor, leading to a septic work up and antibiotics for both you and baby. Of course, the way to help avoid this is either not to get an epidural at all, or to wait until labor is well established before getting one...but not all mothers want to do this...especially if they've had a long prodromal labor and desperately want some sleep. If labor has stalled, Pitocin can in all likelihood get it going again...potentially avoiding a c/section for "failure to progress". If your water has broken, and labor hasn't started after 24 hours...and you are at term, that clock, unfortunately, is ticking...loudly...and again, Pitocin can help avoid a c/section, and possibly infection from prolonged rupture of membranes. Although they are few and far between...but some mothers just don't go into labor on their own. There is rising suspicion that obesity plays a role in this, but I'm not aware of any definitive research on it yet...I imagine this could be difficult to research without placing part of the research population at some theoretical risk. For these mothers, why not try to induce before going directly to surgery? And of course, there are those mothers whose delivery, due to complications such as preeclampsia, must be expedited. Better, if there is time, to attempt to induce labor with Pitocin than to go straight to surgery.

Pitocin is the brand name for a synthetic form of the hormone oxytocin that your own body makes. That doesn't make it harmless...it's not "the same thing your body makes"...it's synthetic! Labor is a delicate balance between your hormones and the baby's, and we really don't know what truly triggers it. It may be different for each mother-baby pair, depending on the chemical balance of hormones in each. The use of Pitocin doesn't mimic the action of natural oxytocin, and I don't care how adamantly anyone insists it does. Contractions induced by Pitocin, are, by the very fact that we can control how much of it you are getting, and our goal is to get you to contract every two minutes (or at least often enough to consistently change your cervix, which will be often be "checked" as much as every two hours), usually "longer, stronger, and closer together" than what often will happen if you are laboring under the oxytocin that your body makes. Your uterus has "oxytocin receptors" on it. It is these receptors that act as the "lock" the oxytocin "key" turns to stimulate labor. Without these microscopic receptors, all the Pitocin in the world will not make your uterus contract. The number of these receptors increases during pregnancy, and during labor, when they multiply dramatically as labor progresses; thus, you become more sensitive to the action of oxytocin as your pregnancy, and then your labor, progresses; but there is a finite number of these receptors...and when they have all been used, they are saturated...and until your body makes more receptors, no amount of exogenous (outside the body) or endogenous (made inside the body) oxytocin is going to effect your uterus. There are even times when we "rest" a woman who is getting Pitocin...i.e., she has been laboring under the influence of the drug for a long time, we've steadily increased the dose, and labor has either not progressed, or is slowing down. We'll stop the Pitocin for a half hour or more, and start it up later, and at a smaller dose...and quite often, labor kicks in and takes off! Her body has had time to absorb the exogenous oxytocin, and synthesize new receptors.

Do medical personnel ever "sneak" Pitocin into a woman's IV drip? I suppose it could happen, but it would be gross malpractice. Even with Obstetrics being as egocentric as it can be, this still is something that most obstetricians would be loathe to do. In addition, on most L&D units, the drug comes pre mixed from a centralized pharmacy in a bag that is separate from any other IV fluids; that bag is clearly marked, usually with a bright red, orange, or yellow label. Kind of hard to miss, even for a preoccupied laboring woman. If you have an IV, and are in first stage labor (prior to the birth of the baby), count the number of bags that are hanging on the IV pole. If there is only one, you are not getting Pitocin. During first stage, Pitocin is always...always hung separately from a bag of "maintenance" IV fluids; and it is always run along with those fluids...it is never given alone during first stage labor; so even if the Pitocin is mixed on the unit, and not appropriately labeled (which would be a grieivous error on the part of the nurse), if there is only one bag hanging, it had better not be Pitocin!

Here's how Pitocin is commonly administered:

For first stage labor, Pitocin is always diluted in a liter (about a quart) of normal saline. The most common concentration of it is 20 milliunits to a liter of solution. The drug itself, before it is diluted, is sold in vials that contain 10 milliunits of the drug. These 10 milliunits equal a total fluid volume of 1 milliliter. To give you an idea of how tiny a volume that is, an ounce of fluid is equal to 30 milliliters so the standard concentration of Pitocin is two 1ml (milliliter) vials of 10mu (milliunits) each into a liter (1,000 milliliters) of fluid. This should also give you an idea of just how powerful a drug Pitocin is...by fluid volume, there are only 2ml active agent to 1,000 ml normal saline in the bag of fluid that will be labeled "Pitocin"...a very, very dilute concentration, but oh, so powerful.

Pitocin for labor is always run along side another bag of "maintenance" IV fluid. An IV will be started with maintenance fluid...usually Lactated Ringers or Normal Saline. The "drip rate" of that fluid will be adjusted to approximately 125 ml an hour...so, without any boluses (administration of a large amount of fluid in a short amount of time), the 1000 ml bag of maintenance fluid should take about 8 hours to fully infuse. Considering that, "normal" (not optimal, in my not-so-humble opinion) obstetric management restricts oral fluids in laboring women, this isn't an over abundance of fluid...a liter of fluid a day is the minimum amount of fluid most nutritionists recommend to promote normal healthy hydration. The caveat here is that, if you choose an epidural, you will get at least a liter of fluid in addition to this "maintenance" fluid...to help prevent or minimize the drop in blood pressure that is the most common side effect of an epidural. If the baby shows any kind of distress you will get additional boluses of fluid, to promote blood flow to, and enhance oxygenation of the placenta. Since the use of Pitocin or other induction agents can overstimulate (hyperstimulate) the uterus and contribute to, if not outright cause fetal distress, this should give you pause. Of course, if your baby is in distress, the Pitocin should immediately be shut off! Finally, a lot of hospitals hang maintenance IV fluids for healthy laboring women to "gravity", meaning that the amount of fluid being infused is not being metered through an IV pump. The thinking is that a young, healthy woman can handle a lot of fluid, so there is no need for the pump. This is not the case if any type of heart, lung, kidney or circulatory disease (including preeclampsia) is evident...in such cases, fluid will be very carefully monitored, and metered out through an IV pump; but for the average laboring woman, the rate of this "gravity" IV can change depending on her movements, and that liter of fluid can be infused much faster than intended.

Once the maintenance IV is in place, the bag of Pitocin will be placed next to the bag of maintenance fluid, and its tubing will be attached to a port on your maintenace IV tubing. This bag of fluid will be very carefully "titrated" via the use of an IV pump. A common Pitocin regimen is to run the fluid at rate of "2 milliunits per hour, increasing by 2 milliunits every 20 to 30 minutes until 'adequate labor' is achieved". Two milliunits of Pitocin per hour is equal to 6 ml...less than 1/3 of an ounce of that entire liter bag of fluid of which less than 2 hundredths of a percent is actually the drug. Now, if that amount of the infusion jump starts your labor, that's great. Most women will need more, however; and even more care providers will continue increasing that drip rate until they see contractions happening consistently every two minutes. At 20 milliunits of Pitocin you are getting the solution dripped into your vein at 60 mls, or about 2 ounces an hour, along with your maintenance fluid. This is now considered a "high dose" Pitocin regimen, and to proceed above this amount is to proceed with caution; plenty of women receive higher doses than this. At this point a wise nurse will switch her patient to a more concentrated form of Pitocin that can be run at a lower rate, to help avoid the risks of fluid overload. Personally, if there are no other contraindications, I don't mind having an intrauterine pressure catheter (IUPC) placed at this point, especially if the mother is a little "fluffy", and her contractions are challenging to palpate or see on the fetal monitor. This gives a much more clear picture of exactly how strong, long, and close together the contractions are. I know that internal monitors are invasive, and as such, they are controversial; but I can't tell you how many times I've been in a situation when a mother laboring with any dose of Pitocin, low or high, doesn't seem to be contracting much, and we place an IUPC and find that indeed she is contracting strongly, every two or three minutes. Had we continued to increase the Pit, we might have caused uterine hyperstimulation, with disasterous results; but Pitocin, in my opinion, is invasive, and a judiciously used IUPC can help to limit the adverse effects of that invasiveness. If a mother were not using Pitocin, I wouldn't suggest using an IUPC...but with high dose Pitocin in use, I think it can have some value.

High dose regimens of Pitocin increase the risk of uterine hyperstimulation, as well as the risks associated with fluid overload, including a disturbance in the electrolyte balance in your body, and "wet lungs" in both mother and baby, although, again, in healthy young women, these are rare. More often, since one of the side effects of Pitocin is vasoconstriction, a temporary "tightening" of the blood vessels (more accurately the smooth muscle lining the blood vessels), fluid leaks (is forced) out into the mother's body tissues and causes edema, or swelling. Over a few days, this swelling will leave the body, through urination and sweat, but in the mean time, it can cause some discomfort for the woman, and difficulty getting her baby to latch on to swollen breasts.

So. I've talked about Pitocin during first stage labor. A lot of women are surprised to find that even if they didn't get pitocin during first stage labor, that it is commonly run after the baby is born. Most practitioners will order the Pitocin solution to be run "wide open" (as fast as a liter or more per hour) as soon as the placenta is delivered, to help reduce the amount of bleeding after delivery. Others will order this as soon as the baby is delivered, to both expedite the delivery of the placenta and reduce the amount of bleeding. If you don't have a running IV, they will order an injection of 10mu pit into a muscle. This practice stems from the "Active Management of Labor" protocols that were developed in the United Kingdom in the 1980s. Of course, in the United States, we've adapted that protocol to our own agenda, but what else is news? Once the Pit is wide open, again, a wise nurse will turn off the maintenance fluid.

If you didn't want a lot of interventions in the first place, this is where things get tricky after the fact. Much of the time that bag or little shot of pitocin is up or in before the mother even knows what has happened..."We're going to give you a little shot to help with the bleeding", or "We're going to give you some Pitocin in your IV to keep the bleeding down"...and boom...there it is; but if you know ahead of time, and you decide you don't want it, keep your wits about you. First, if you had much in the way of intervention at all...any type of inducing agents, amniotomy (breaking the "bag of water"), frequent vaginal exams, internal monitors, a long pushing stage, "purple pushing" on your back, you might want to consider just letting them run the Pit...the more interventions you've had, the more likely you are to bleed heavily. If you had a long, exhausting labor, your uterus is tired too...and you should consider letting them run the pit...a tired uterus can't contract down effectively over the blood vessels that were opened when the placenta separated from the wall of the uterus. Second, if you are certain that you are no more at risk for postpartum hemorrhage than a mother who has given birth at home with no interventions, and you really, truly do not want the prophylactic (preventative) Pitocin after delivery, then keep your eyes open. We hang it so routinely, even with mothers who have a birth plan, and even with mothers who expressly request in their birth plan not to have it, that it's easy to forget and just hang/inject the stuff. I know it's a lot to ask if you are in the middle of recovering from labor, possibly experiencing a repair to a tear in your perineum, and bonding with your baby, but I've said it before, as it was said so wisely before me by Navelgazing Midwife, and it bears repeating "If you buy the hospital ticket, you take the hospital ride"...and part of the hospital ride is that, if you want to reduce routine medical interventions, you have to negotiate, negotiate, negotiate.

If you are adamant that you don't want Pit given to you after the fact, be aware that, for most caregivers, you are going to be asking them to step way outside of their comfort zone. If you've ever seen a postpartum hemorrhage, you'd understand...they can happen fast, with very little warning, they can get out of control even faster, and they can be devastating. Yes, I know, without many of the interventions a hemorrhage is much less likely, but consider that one of the most common reasons home births transfer to the hospital is postpartum hemorrhage. Sometimes I think we need to pick our battles. We know that induction in the absence of an absolute medical indication creates a certain amount of risk to both mother an baby. We certainly know cesarean section does; but what do we know about second stage/postpartum Pitocin? If its running full open through an IV, fluid overload is a concern; but in the absence of any other pathology, it is a small concern; it, for the most part is a temporary, reversible concern; and as soon as say, a quarter to half of the bag has run through, if your bleeding is at an acceptable level, you can request that your nurse turn the rate down to a slow drip, helping to avoid the possibility of edema. If your provider has, up to this point been truly trying to comply with your wishes (No IV, no internals, intermittent monitoring, self-selected pushing positions and techniques, immediate skin to skin with your baby), might it not be worth it, in the name of good will, to allow him or her this? There may be a few out there who are comfortable with not giving that Pit after delivery...but by few, I mean truly a few. Most are just really uncomfortable without that perceived "safety net" for their patient. In this case, it usually isn't a "control", "You patient, me Doctor" issue...and since the labor is over, it's not a "speed" issue. It truly is, even if misguided some might believe, a "standard of care" issue. If everything else has gone according to your wishes, you may want to consider...in the grand scope of things...how important is this to me?

I haven't listed the contraindications to the use of Pitocin, and I haven't listed all the potential side effects of it...just the ones most likely to be experienced. If anyone would like me to write more on the topic, I will...but there is a lot of good information out there that can give you this information...Henci Goer's "The Thinking Woman's Guide to a Better Childbirth" comes to mind. It's a good idea to keep an open mind to the use of Pitocin...but also to know your options; and you are the one who ultimately gets to decide if, and when it is going to be used. True, you may need to repeat yourself over and over, and to carefully watch the behavior of the medical staff...it's not always easy...and it's also not always advisable...because as I've said, there can be good reasons for the judicious use of Pitocin; but even if your care provider tries to convince you otherwise, the choice is yours.

For S....

2009-11-27T09:07:00.000-08:00

You and your husband were sleeping when I left this morning...you in the bed you gave birth in a few hours ago, sweat- dampened hair askew on the pillow, your arm thrown over your face in a posture of total exhaustion...your sweet husband curled up on the hard vinyl couch of the birthing room, tightly bound in a thin white hospital blanket...as if attempting to comfort and protect himself from the pain the both of you hand just endured...and have yet to endure.

Your beautiful little boy lies wrapped in the too large gown (the closest one we had to his size), and a hand-knit cap and blanket, and placed as respectfully as we can place him in such an inadequate situation, in the clinical refrigerator on the unit, to preserve his tiny body until you ask to hold him again, perhaps for the last time, in your aching, tear-streaked arms.

I wanted so much to say goodbye to you, but I dared not wake you from your hard won sleep. I wanted so much to hug you, to tell you how strong you are, to reassure you, once again, that you will come through this...not without scars, and certainly not without seemingly unbearable sorrow for a time; but that you will survive this; that your son's life, all 26 precious minutes of it, had tremendous value; that that value will increase over time in ways that you cannot even imagine now; that this perfect, tiny, precious, all too short life will have an impact on you and those around you that will forever make you a better person, and this world a better place to be.

The night before he was born, while you still clung desperately to the "one percent" chance that a well meaning physician held out for his survival, while at the same time you grieved in anticipation of his all but inevitable death, I told you this...that your son, no matter how long or short his life, has a reason to be here; that God did not make this happen, but if it had to happen, then He would see to it that this child, this Beloved of His, would achieve his purpose on this earth, regardless of the time in which he had to accomplish it; that I believed this with all my heart. This so loved, so wanted child did live his purpose in those 26 minutes, and as time relentlessly pulls you forward, turning this painful memory into one hopefully more sweet than bitter, as your body and spirit slowly heal, you will begin to realize what that purpose was.

But I can already tell you something that together, you, your son, and your son's father accomplished...and perhaps that can be part of your son's legacy, as it is certainly yours. You helped me to believe in myself again. You reminded me that I have a purpose too...that I am where I am supposed to be; that I am strong and resilient; and that no cold administrative rule, no heartless management agenda can ever, will ever change that. In a time when my department seems to be being systematically redefined by management that gives lip-service to "customer service", but whose actions seem to placing the very lives of those we "serve" in potential jeopardy born of cost-cutting attempts and the tyrannical pressure of overzealous, under researched regulation, you all reminded me that it's worth it to stick it out; to bloom where I'm planted; to let the roots that have grown deep within this rocky soil hold me firm in the winds that are trying so hard to uproot me and my coworkers in the name of...what??? Making an example out of us? Reminding all of us nurses...the ones who really keep this place going, the ones who really protect you, advocate for you, keep you as safe as possible...that we are expendable, not important, replaceable? WRONG!

Because of you, S., and other women like you, I have a purpose in this life; part of that purpose is my work, my employment, my vocation that is also my avocation; that purpose fulfills me and brings me joy (even the painful bittersweet joy of caring for you and your sisters in such sorrow), even when the world around my workplace is in such turmoil; even when that turmoil threatens to destroy my soul, the souls of my sister (and yes, brother) nurses.

We won't succumb to the threat. We'll above this useless struggle. Those who pride themselves on being in a position to decide will soon learn that their decisions that nearly brought disaster to this place, brought about instead, their own downfall; and while I do not wish them that downfall, if it protects those I am called to serve, I will not object to it.

S., I am blessed to have served you and your sisters. I am humbled by the opportunity to be so blessed. I am without adequate words to thank you for your gift.

My prayer for you is that you will, over time, experience the same gift of perspective that I had all but lost, but that you returned to me. I will be forever grateful; and I will forever hold you and your family in my heart.

Recession Babies???

2009-10-14T12:37:00.000-07:00

The busy time for most L&D units is summer time..."prime time"...those crisp cool autumn, and long, cold winter nights come to fruition, and we are slammed for the months of June through August...and this year it's been worse than most.

This year though, we kept getting slammed right on through September into October. Things seem to have settled down a bit, but we are still doing more deliveries than we did a year ago...which prompted a discussion between the nurses and residents last night...

Are these Recession Babies?

The timing seems about right...if indeed the recession that we are now told is resolving, peaked in late 2008 to early 2009.

Think about it. You've been laid off...or your partner has been laid off. No money to go out, you can't pound the pavement every minute of every weekday, so what's a person to do...

Have Sex!!!!! Why not? You're not exhausted from a busy work week, but you are stressed out from not being employed; or maybe you are stressed from the fear of losing your job.

I don't know about y'all, but I think sex is a pretty good stress reliever. Of course, I, in my advancing years, am not as likely to conceive as others...Thank God!

So, I put this question out to all of my other L&D nurse blogger friends out there...

Have you seen an increase in births that don't seem attributable to the usual summertime surge in deliveries?

Inquiring minds want to know...

Have We Been Conned??? (or, Midwives and Doulas and Prosecuters Oh My! Redux))

2009-10-14T10:02:00.000-07:00

So the big TLC event arrived...Anna Duggar gave birth to her first baby, a little girl, at home, and it was filmed by the crew and publicised for all to witness.

Good thing, right? After all, the Duggars have a big following...more ammunition in the "birth is not a medical event, homebirth is safe" arsenal.

Wrong.

When Josh and Anna "decide at the last minute" (I don't believe that for a minute...I suspect that this entire thing was planned) that they want to have their baby at home because their doctor is not in town, they call their Bradley teacher to ask her if she would still be their "doula" for their birth. Of course, she would.

Of course.

Except that the "doula", as it seems to appear on the show, was the only birth professional in the home at the time of birth. Interestingly enough, this "doula", seems to carry an awful lot of equipment that, during my training as a doula by DONA (Doulas of North America), I was specifically taught it was out of my scope of practice to provide to a family.

If indeed what we saw on this program is what actually happened, I think we've been conned by the Duggars, and their "doula".

Don't get me wrong. I think the Duggars are a pretty remarkable family. I don't agree with their "baby a year" lifestyle, but they seem to be self supporting, hard working people who unapologetically live according to their beliefs; but they've had the opportunity, thanks to TLC's penchant for pandering to the public's (and of course I've allowed myself to sink to this level) voyeuristic tendencies, to subtly or not so subtly use their show as a platform for those beliefs.

Now, we're all entitled to our beliefs...after all, it's a free country...but let's at least be honest about them, especially if we have the opportunity to display them in a platform that allows for millions of viewers to be exposed to them. If you believe in a concept, then say so; be willing to stand behind your beliefs...don't just sneak them in under the guise of something else, and, as a result, put that "something else" at risk to serve your own purposes...which is exactly what I think this family did.

The concept of a doula is difficult enough to promote in this culture of medicalised birth. When they appear to be attending home births as the primary birth attendant, a role for which they are specifically, if they are trained properly, taught is not in their scope of practice, their function is further undermined; as such, their role, along with the wonderful, needed, often vital service that they provide to both their clients, and yes, beleaguered nurses who support non-interventive birth practices, is subject to even more misunderstanding. This puts the entire profession (and it is a skilled profession), at risk...as well as the health of the clients they serve. It also puts the profession of midwifery at risk...allowing the public to think that anyone with training as a doula or a childbirth educator can hang out a shingle and call themselves a midwife.

Was it truly a "doula" that served as the attending professional at Josh and Anna's birth? Or was it a midwife flying under the radar, as it seems the one tending to the family in my most recent post was? To her credit, the woman who assisted Anna allowed herself to be filmed, and, if I recall correctly, her full name to be used when her Bradley Childbirth class was filmed; so if she indeed was a midwife posing as a doula, why not just say so? I don't know what the laws are in Arkansas regarding what professionals may serve as the primary attendant at a home birth; but with the recent press regarding homebirth being so negative, and with ACOG using every opportunity to bully the public into avoiding the practice, this episode of the show can only jeopardize the cause of those who are working so hard to establish a woman's right to give birth at home with a properly trained and skilled attendant.

With a properly trained and skilled attendant.

That is the key concept here.

There will always be those who choose to give birth unassisted. I don't agree with them.

Since the dawn of time, women have, by nature, sought out experienced women to assist them during their time of giving birth. Birth, while it is, given the right circumstances, i.e. a healthy mother, carrying a healthy baby, laboring in a clean, comfortable well-equipped environment, is safe, it is still unpredictable. The unexpected can happen, and things can go downhill fast. One of the biggest hindrances to homebirth in the United States (after the ignorance of the public, the sensationalism of the media, and the machinations of ACOG, the AMA, and now the ACNM, that is), is that we don't have the infrastructure that other countries that have such good homebirth statistics (and as a result, good overall birth statistics) have. We don't have a system where a family can prepare, with the full support of the medical community, for a homebirth. We don't have a system where the local emergency management system is made aware that a woman is laboring at home in the community, and resources are made available (i.e., an ambulance) should they be needed; and we're never going to get those things if the public, and the government remains ignorant of the safety of homebirth...with a properly trained and skilled attendant.

Families who chose to birth unassisted have the right, I suppose, to put their laboring mother and unborn children at the risk of the unexpected. If your "rugged individualism" means that you are willing to accept that risk (to say nothing of your unborn child, who doesn't get a say in your "choice"), then so be it; but don't attempt to con the rest of the world into thinking that you are doing it with an skilled birth attendant when you are not. Conversely, if you have a skilled birth attendant, then say so. Either way, be consistent. Don't allow your own selfish need to get what you want to confuse the issue for an already confused public, by default allowing the powers that be to use your "example" as a tool in their arsenal to damage what little progress homebirth and midwifery advocates have made.

There is homebirth, attended by a properly trained, skilled midwife; and then there is unassisted birth. The first is unquestionably safer than the second; and while it may be your right (ethically at least...because legal rights are being continually reinterpreted concerning reproduction), to give birth unassisted, it is not your right to do so at the expense of those who are working within the system, for their own right to give birth at home, with a midwife.

Where was the midwife at the Duggars birth? Who was the midwife? Was there a midwife?

ACOG is gonna love this.

Thanks, Duggars.

Midwives or Doulas and Prosecuters, Oh My!

2009-09-29T18:30:00.000-07:00

There's a family in the midwest that is in a terrible predicament...one that is grossly unfair, and my heart goes out to them. The information on their website is that, after giving birth to a healthy child at home, with the assistance of a midwife "they made the decision"...(a few hours later)..." to call 911 just to be safe" because they were "a bit concerned about the mom". In the jurisdiction in which they placed the call, since a child was involved, the police were required to respond as well. The EMS personnel insisted that the baby "needed immediate medical attention", so mother and baby were transferred to the local hospital, both were found to be well and healthy, and after a few hours were released. The police took statements from both the midwife, and the woman's husband.

Two months later however, the family was served with a summons to appear in court having had the charges of child endangerment levied against them. At their most recent hearing, they were offered a plea bargain for the charge of "disorderly conduct", which the family chose not to accept because they feel that they "are not guilty of anything", that "a guilty plea would validate the charges against" them, and that a "guilty plea would give the impression that homebirth is wrong, and possibly open the door for other families to be prosecuted". All noble arguments, but not exactly in their best interests. In fact, despite this family's earnest sincerity (and I do believe they are sincere), I'm not particularly certain that their arguments are even in the best interests of the homebirth community at large.

I agree that this family did nothing wrong. I support their right to give birth in the place of their choosing, with an appropriately trained, skilled, experienced attendant of their choosing; but despite my compassion for this family, and my desire to help them, and my fervent prayer that the charges will be dropped, I have concerns. There must be more important issues for the authorities to be addressing than a homebirth where the outcome was healthy and safe.

Or is there?

Whenever I see "calls for support" go out over the web for midwives or families that are being pursued by the legal system for whatever charges that can be trumped up regarding a homebirth (practicing medicine or nursing without a license, child endangerment, etc.), it is in my nature to question both the reasoning of the local authorities, and the actual story of those who are being charged. More than once I've heeded the call to a "persecuted" midwife only to find out that there may actually have been some questionable management of the situation. It's a sad reality in our culture that, due to the tenuous legal standing of midwives in general, and homebirth and Direct Entry midwives in particular, that the care the family received must be beyond reproach. That is difficult enough to prove, even in the best circumstances, when we've got the machinations of the AMA, ACOG, and sensationalist reporting such as the "Perils of Midwifery" piece recently aired by the Today show swirling around us. It becomes even more difficult to prove when those who are being prosecuted are not being forthright with every minute detail of the situation.

So, quick to my trusty Iphone I went, dialed my beloved friend C., childbirth educator and doula extraordinaire, who also happens to be in regular communication with our local CPMs. It seems that indeed, a small piece of information has been overlooked in the most recent reports of the incident. In initial media reports, the midwife, when giving her statement to the police, identified herself as the family's "doula".

Whaaaat? Now, when a midwife transfers her clients to a hospital, she certainly does cease to become the primary care giver, and steps instead into the role of doula. However, during the incident about which she was giving her statement, she was acting as the primary care provider. That role, as such, places her in a position of responsibility regarding the outcome of the situation. By identifying herself as a doula, this midwife exposed her client to suspicion that they were attempting to give birth unassisted, and I said as much when I questioned the family and their supporters on the informational website.

What I did not point out at the time was that I was not questioning the family's right to give birth any way they chose (I wasn't...although I won't mislead anyone here and say that I am in favor of giving birth without a skilled care provider in attendance, be that physician or midwife...but that is for another post). I was simply pointing out two things that could have a very important impact on the outcome of their case. 1). Those who were telling the story, be they supporters or the family themselves were not being forthcoming with all the pertinent information, and 2). A midwife who identifies herself as a doula, is going to be perceived as someone with something to hide...and so will her clients.

Well, immediately I was accosted by both supporters of (of whom I still consider myself to be among...I just want more information), and members of the family, including the much beleaguered mother. Was I actually insinuating that this family did not have the "right" to an unassisted birth if they chose?; that the charges were valid if there wasn't a midwife present? From there the arguments became not about how best to support and provide for the best possible legal outcome for the family, but a heated discussion, mostly directed at me, about the family's "right" to choose to birth in whatever manner they saw fit. Try as I might, until one post late in the day, I could not convince those who saw red the moment they read my words, that this was not about the family's "rights"...it was about getting all the information in their defense out on the table where it could be considered...and perhaps improve their legal standing. Ironically, that post was from a mother who chose to have several of her children unassisted. She simply pointed out the dominant cultural biases against homebirth, and how being seen as potentially giving birth unassisted were not going to work in the family's legal favor, despite their philosophical "right" to do so.

The mother says that she stands beside her midwife 100 percent.

But is her midwife standing beside her 100 percent, when she identifies herself, not as a midwife, but as a doula, whose role by definition, is anything but midwifery?

The mother goes on to say that "It shouldn't matter that the authorities see homebirthers as irresponsible. They are supposed to enforce laws, not their opinions".

She's right, it shouldn't matter.

But, unfortunately, it does matter. It matters very much in our as yet unenlightened medico/legal culture. Is this family willing to martyr themselves to a cause that their trusted midwife does not appear to be willing to herself? After all, if indeed she is a midwife, she placed herself in the role of "authority"; and now when another type of authority is attempting to insinuate itself (apparently, tragically, and unfairly) into the situation, she recoils from that role? That is abandonment of her client...and that is irresponsible. What would we do if a doctor in similar circumstances said something to the effect of "Hey, don't look at me...I'm just the gardener!". I know I oversimplify...but truly...are we holding midwives to the same standards that we hold other care providers? Or are we, because we are so passionate to advance the cause, allowing them to assume less responsibility for outcomes we would not choose?

If the local authorities believe that a family is behaving irresponsibly, they are going to try to find a law to, if for nothing else, make an example of the family, if for no other reason than to further discourage other families from making a similar decision. In the process, the family in question is placed under great stress, both emotional and financial, at what should be one of the happiest times of their lives.

As often happens, the support discussions concerning this family have evolved, for those who rally around them, more in support of the philosophy of birthing rights than the support of the family (although there is much to commend supporters on regarding the level of financial and other support being planned and given). Of course we have the "right" to give birth in any way we see fit; but legal "rights" are, unfortunately, variable, based on how a judge and/or jury interpret the law. How we present our argument to them is going to have a definite impact on their decision making process, and the outcome of the case.

The mother writes that a part of the charges say that she "gave birth in an unsanitary place and did not seek immediate medical treatment for the baby". Since they (the charges) did not address the presence (or absence of) an attendant, she does not feel that the midwife identifying herself would have changed anything.

But of course it would!

If, indeed, the woman who identified herself as a doula was actually a skilled, experienced midwife, and had identified herself as such, then the defense could point to the safety of midwife attended births in study after study, and it's acceptable practice in nearly half of the United States (let alone many other industrialized countries with much better maternal/infant, and dare I say it, economic outcomes than our own), thereby at least placing a chink in the prosecutions argument; but this would place the midwife in a precarious legal predicament, since the state in which the incident occurred is not one of the more "enlightened" states that provide a legal basis for the practice of midwifery for families giving birth at home.

So now the question becomes...on whose shoulders does the responsibility for the safe health care outcome of this situation rest?

On the Midwife's!...or at least as much as the family's!

Of course a birthing family is responsible for choosing the best possible care for their pregnant mother and unborn child. If they choose themselves as such, then they are responsible for the outcome...and liable should the outcome be not as expected. If they choose a midwife for that care, then the midwife, by the act of attending them, assuming the role of primary care provider prior to transport (if a transport is called for), and in accepting compensation for that role in whatever form deemed appropriate (money, barter, etc.), should accept responsibility for the outcome. Here it seems, only the family is being subject to prosecution, and I want to know,

Where is the Midwife?

Is the family protecting the midwife? Is the midwife going to publicly step up in the family's defense? Of course, if she does so, she assumes the risk that she will be prosecuted as well...but didn't she assume this risk when she chose to be a home birth attendant?

I'll be brutally honest here. I would have loved to trained as a midwife and provided care to mothers giving birth at home; but at the time, I was a single mother with two young children to support. I needed a steady paycheck, and I couldn't afford to risk being arrested and convicted of practicing nursing or medicine without a license, lest I lose custody of my sons. Does this make me unwilling to "put my money where my mouth is"? I guess it does. I decided get a bachelor's degree in nursing instead, and attend mothers giving birth in hospital. That does not mean I think that the hospital is the best place for a healthy, low-risk mother carrying a healthy baby to give birth. I don't; and every shift I work, I struggle with the dichotomy of my belief system while trying to give the best, most compassionate, physiologically appropriate care to my patients that I can. It helps (sometimes), that I work on a unit that accepts many complicated transfers of care, and that the majority of my patients are those who a qualified midwife would risk out anyway; but when a healthy mother in normal labor comes under my care, I struggle. That is my lot in life. I chose it, I live with the spiritual and emotional consequences. I don't have to live with the potential legal consequences that a Direct Entry Midwife has to, but that was my choice. Does that make me a less-valid supporter of a woman's "right" to choose her birthing situation? I still place myself in the position of risking my license if I would harm a patient with a medication or practice error, or by not advocating for her properly should I feel that her medical care provider not be practicing appropriately; and ironically, for all my work to avoid loss of income by choosing a more culturally accepted way to provide care, I've found myself in situations occasionally when providing that advocacy did, in fact, jeopardize my employment. It's not easy being a pro-birth choice nurse in a culture that sees technology and the practice of medicine as the preferable way to give birth; and it's not easy being a homebirth and midwifery supporter who works in the dominant health care system!

This family's freedom, as well as, should she choose to come forward, their midwife's is of paramount importance in this situation; but we need to be careful about how we couch our arguments in the current culture. The reality is that if we're to advance a woman's right to give birth in an environment of her own choosing, we are, again, going to have to hold ourselves to the highest of standards, both of care, and of how we present the appearance of that care to the "authorities". I don't see that happening here.

Again, I have only compassion for this family. I deeply want to see the charges dropped. I'm furious at the waste of taxpayer money being used to harass and traumatize them, for no good legal reason; but I think there is a missing piece of information that someone, somewhere, is unwilling to, for whatever reason, address that could help them.

And I think that information has to come from the midwife.

Trying...My Best...

2009-07-23T18:01:00.000-07:00

To get back to posting. Navelgazing Midwife made a comment on Facebook recently that it seemed so much easier to post there than on her blog. I know the feeling...with Facebook we get nearly immediate response to our posts...it's more interactive than the solitary blog...and much more seductive when you have limited time.

I spend entirely too much time on Facebook. I could (and probably will at some point) write an entire entry on the media and how it affects communication between me and many of my peers. It can be a boon...lots of access to information that I might miss but that other nurses and midwives have come across...and even more access to public opinion (or lack of awareness of) that information.

But my original intent in starting this blog was to write about my experiences in, and transitions into various areas of women's health and maternity care; to hone my writing skills; and to increase my critical thinking/writing skills with the feedback of those who may still be checking in on my posts. The time I spend on Facebook has given me yet another way to avoid writing. Time to address that.

On a positive note...I truly am back...or at least rebounding nicely from...my recent health scare. Pulmonary Rehab has done wonders. I'll soon complete the program and return to work full time (I'm already back part-time). I'm exercising regularly, my sats are back to near-normal, and I've lost 24 lbs (to date)! In that department I have a long way to go...but it's been a great start...one that I plan to continue...

...just like this blog.....

In Praise of Level One Hospitals

2009-06-03T15:02:00.000-07:00

Recently I received a comment from Ruralnrs, extolling the benefits of her workplace, a small, rural hospital. In her comments, she spoke of the low rates of intervention that occur to mothers giving birth at her facility, as well as the level of personalized care that would be difficult to match in a large metropolitan hospital. She spoke of the benefits of fewer "personalities" that (and here I paraphrase liberally), contribute to the multiple interpretations of policies that can "get in the way" of a mother's attempt to achieve a non-interventive birth in hospital. She also pointed out that the success of her unit in achieving a high level of non-intervention, as well as patient satisfaction, lies in the fact that, since the unit is not equipped to (routinely) handle high risk labors and births, they do not want to risk making a labor high risk by engaging in the administration of interventions thay may actually produce the risk! Oh, the exquisiteness of common sense!

Ruralnurs's comments were timely ones. Recently in a community not far from the large metropolitan area where I work, a tragedy occurred to two women, within 24 hours of each other, at the same small L&D unit of a small Level One hospital. Both women received epidural analgesia. Both delivered healthy babies; and both women, the day after giving birth, began experiencing complications that were first attributed to the epidural but which became progressively worse. Each woman was soon transferred... first to that hospital's ICU, and shortly thereafter to another large hospital in the city in which I practice. One of these women subsequently died. Of course an investigation is underway, the public has been "assured" that the cause of the illness, bacterial meningitis, is not communicable, and that everything possible is being done to both determine the cause of the tragedy, and to prevent it from occurring in the future.

Thanks to the "gag" order that has almost certainly been issued by attorneys to the grieving families, pending the inevitable malpractice investigation, we may never know the final outcome of the research into the incidents; of course, in the birthing community, suspicion immediately turned to the administration process during which each woman received her epidural.

Regardless of the cause, a woman has died, a family has been denied a loved one's continued presence in their lives, a child is motherless, and another family's anticipation of one the happiest times of their lives has changed from joy to horror as they gather to support the surviving mother in her journey back to health; and while I can't...could not possibly trump the tragedy being experienced by these two families, incidents like this place all of us in peril in a way, because they feed the usually incorrect perception that care at a smaller, usually rural, Level One hospital is "not as good" as care given in large metropolitan hospitals. Indeed, the continuing survival of this hospital, and many others like it, could be considered at risk due to this type of thinking, and unfortunately, when tragedies like this happen, that risk increases.

Don't quote me here...because I haven't taken the time to gather the research to bolster my words... but I've heard statistics that upwards of 50 percent...in some states, 80 percent...of babies are born in Level One hospitals. A Level One hospital is likely to be located in a rural area or a small town. If it does provide care to birthing women, often the services provided take place in small L & D units...two to four labor rooms as opposed to the dozen-plus common in metropolitan hospitals. There may be only one surgical suite, no Neonatal Intensive Care Unit (NICU), and only a handful of practitioners...Obstetricians and Midwives, usually Nurse Midwives. Access to anesthesia is often readily available only during daytime hours, and on an "on call" basis at night. In some Level One hospitals, access to surgical services...even emergency surgeries...depends on an "on call" staff that has to come in from home should a patient require unscheduled surgery during the night...hence ACOG's prohibitive stance on VBAC (Vaginal Birth After Cesarean) birth in Level One hospitals; they don't believe it is "safe" for a woman to labor on a scarred uterus in an institution of this size and limitation.

I beg to differ, both with the perceived public view in general, and with ACOG's stance in particular. These hospitals serve a huge portion of the population of the United States, and as such, are a critically important part of our country's health care system. To deny low risk pregnant women served by these hospitals access to the full spectrum of birth-related services endangers not only those women, but the overall health of our country, as well as our national economy.

Although I currently work in a large university medical center, I live about 30 minutes from my previous employer, a Level One hospital. It too has a small L&D unit, and it too has seen it's share of tragedies; but poor outcomes happen everywhere...the size of an institution is not indicative of the skill of its' practitioners. Indeed, the physicians at a Level One hospital need to be particularly skilled, in that in time of crisis, they are the point of access to care for the individual(s) involved, unlike in a larger hospital where there may be several (or many). These folks need to "know their stuff"... have exceptional critical thinking skills, and the confidence to put put those skills into action quickly; not that these attributes aren't necessary in a larger institution where there are more practitioners...of course they are...but in a smaller hospital, fewer hands can mean more responsibility on those hands. I can only speak for this one particular hospital...but if a woman I loved were to need care, I would have total confidence if she were admitted there. The skill and care given to women at this particular institution rivals that given where I work any day. No, they don't have a special care unit for infants; but the nurses were well trained to support even tiny preemies until transport from the nearest NICU could arrive. During my employment at that particular hospital I saw hemorrhages, fetal demises, preterm labors and births, even one uterine rupture...all handled expertly by the well-trained and skilled nursing and medical staff, and all with the healthy survival of both mother and infant. Until ACOG's edict limiting VBACs to basically only large tertiary care centers, that unit also saw it's share of successful VBACs.

Health care dollars being limited, resources are going to have to be distributed where they are likely to be used the most; hence Level One hospitals, particularly those few that remain independent of larger healthcare "systems" such as Humana, will rarely be the ones to have the newest and latest of the technology; JCAHO standards should provide that a reasonable standard of care in terms of technological resources will be available at any hospital. Should a patient require more, resources for adequate support should be available until a transfer can be arranged; but for initial access to care, particularly for low risk situations such as normal labor, a community based hospital is the most cost-effective and appropriate level of entry to care (actually, I really believe that home is the most appropriate level of entry to care for laboring women, but my topic being levels of medical care for laboring women, and our culture being what it is, that statement will have to suffice...for this post at least).

I think level of entry and access are the core issues here. A healthy woman experiencing a normal labor does not need all the "bells and whistles" of a unit like the one I work on; she needs care that is accessible...in her community. One of most ridiculous misuse of resources I've ever seen occurred, ironically, in the same community as the hospital that I just praised so highly. The health department in this community contracted its prenatal care to the residency staff of a larger city hospital over 35 miles away! When the women cared for at the public clinic went into labor, they were expected to travel into the city. Not all of them had the resources to get there however. Those that did not have transportation to get from their homes in the town ended up...of course...at the local Level One hospital, where the only access we had to their prenatal information was via fax...and that was if we could track the information down, and if we had time to get the information faxed to us before the mother gave birth. It made absolutely no sense, when right there in the woman's home town a perfectly good medicaid eligible clinic was available to her, within the very hospital that she would ultimately give birth in...attended by physicians she was familiar with.

It can be difficult enough to get access to health care in our country. Even in the city where I work, there are more than a few mothers who get little or no prenatal care because they cannot manage the bus fare to get to clinic; or they do not live near public transportation. How much more of a burden do we place on women in sub-suburban communities we close down the L&D unit in the local community hospital, forcing them to travel, if they have the means, to the next town or city over? Often the woman cannot meet that burden, and she goes without prenatal care, possibly setting off a sequela of events that turn a healthy, low-risk pregnancy into a high-risk situation...and a high cost situation ensues, should that mother and or her infant end up requiring a level of care that may have been avoidable had she had access to good prenatal care. How much of a burden do we place on a woman when we prevent her access to VBAC based on the perceived level of care at a hospital that may have a proven record of successful VBAC births, forcing her instead to travel out of her community, adding yet another expense on top of the considerable (and avoidable) expense ( as well as the increased risks and discomfort) of a scheduled cesarean? Neither situation can be considered a good outcome for either mother and infant...and it can't bode well for a health care system that is already crumbling under the weight of not enough financial resources to provide access to all of its citizens. Prenatal care is, more often than not, preventative care...head the high risk situations (those that we can) off, and prevent the huge expense (and increased potential for morbidity and mortality) of an unnecessary surgical delivery...or of a mother or infant in intensive care.

Our culture has collectively "forgotten" that there is an entire world of medical care independent of the big, dramatic city hospital we see on primetime television with it's depiction of exotic diseases and traumatic occurences that seem to happen every day and require the highest and most expensive level of technology to treat. We forget that when we use resources appropriately to maintain our health, that this level of drama and expense is the exception, not the norm. Of course the tragedy that occurred in the Level One L&D that I depicted in the beginning of this post was just that...a tragedy (and likely a very avoidable tragedy); but with appropriate investigation into the cause, and corrective intervention taken (albeit after the fact), the hospital involved can reduce dramatically the likelihood of a reoccurrence. It would be an even larger tragedy to close the unit, and reduce access to the pregnant women of the community served by the hospital.

I love what I do...I love where I work...but my family continues to utilize the same health care providers that we did when I worked for my previous employer. I've found, both as a patient and as an employee that the care is both cost, and health effective. Level One care can be, and often is the very best care.

STAY TUNED.....

2009-05-30T22:03:00.000-07:00

I've had the misfortune of experiencing the evolution of a simple upper respiratory infection into a major exacerbation of long asyptomatic asthma. As such, I've had little time or energy for much more than multiple physician's visits interspersed with frustrated, boring days at home with the occasional tentative (and frequently abortive, due to shortness of breath and a general inability to tolerate much in the way of activity) foray to the grocery store or the bookstore.

And so, the blog has suffered my absence.

My husband though, I think has suffered the most, bless his heart. He, in addition to running his own small consulting firm, has been keeping up with (well, as much as any non-homemaker can) the housework, laundry and cooking, dealing with the misadventures of raising two impetuous, impertinent, impulsive, sometimes rebellious, usually know-it-all, but always endearing and beloved teenage boys, and a wife who is one minute crabby and whiny, and the next remorseful and grateful. God bless that man!

I miss work. I haven't been there for nearly two months! After multiple trips to my family physician and pulmonologist, one trip to the ER (I tried to go back to work...wasn't gonna happen, my body immediately let me know), and even one trip to an urgent care center two days before Memorial day (sure...let's just add double otitis media to the mix...I can handle it...not), I found myself in the care of an amazing Nurse Practitioner who works in my pulmonologist's office. What a stroke of luck! My appointment with this wonderful woman came only after multiple phone calls trying to get another appointment with the pulmonologist ("No, July 25th will not work, I'm consistently satting 90 percent at rest, I've got to be able to get well enough to get back to work, and I can't wait two months to find a way to get this fixed!".) Finally I called my case manager in a weight loss-program I am now involved in and told her my plight...I was afraid to exercise unsupervised until I got this respiratory thing under control, but I couldn't get an appointment to get the advice of my physician. She, bless her, brought up the idea of pulmonary rehab. Really? Did I really need something that drastic?

Turns out I did. I made one call to the coordinator of the pulmonary rehab department, who promptly got me an appointment with the NP. That wonderful woman (the NP, although the director of the rehab department is wonderful as well) did more for me in one 30 minute appointment than the ER, and three physicians had done in six weeks! In the past week I've undergone a slew of pulmonary tests, I've been x-rayed and CT scanned, scheduled for allergy testing and a sleep study, been exercise tested (managed to gasp my way through), and admitted to the pulmonary rehab program.

All indications are that I should be able to return to work with in a month's time, probably part-time first, gradually increasing back to full time.

I knew being an L&D nurse was a big part of my identity, but this experience has really pushed home just how true that is. Maybe that's not a good thing. Maybe I need to get moving on some of those "transitions" I talked about when I began this blog. I've certainly had time to think about them enough.

It's also hard to "watch" via Facebook, my friends working their backsides off, knowing that my absence is contributing to a lack of staff during the busiest time of year on our unit. When coming off of a shift, they will comment to each other how busy things, are, how tired they are, and here I sit...in front of the computer, inhaler at my side, just wanting to be there to lighten their load a little. I love my family. They are my first priority; but I get a lot out of my job (in addition to the frustrations), and I respect the work that my coworkers do.

C'est La Vie. What is, is. For now, I'm slowly improving, looking forward to getting stronger and learning more about how to control this disease through rehab, and I've even managed to start losing some of this extra weight ( "...the journey of a thousand miles begins with a single step..."). With my husband's help, and my "expert" directions, I'm starting to get caught up on all the long-neglected organizational tasks that I've put off in favor of sleep when I wasn't working, and I'm hoping that will clear a path to beginning some of those "transitions" (I'm the kind of person that needs to be organized in order to have a mind clear enough to concentrate effectively...at least at home...at work, I've learned to with the flow...the crazy, ridiculous flow...it's called survival!). Truth be known, I think this has been coming for some time. I wasn't taking care of myself well enough. The last few weeks at work I could barely make it to the car, so exhausted would I be at the end of a shift. My body finally revolted and forced me to take a good long look at how I've been not caring for it, and here I am; but I think (hope, pray) that I've dodged a few serious bullets in the past few weeks, and am now on the road to a full recovery, with a wiser appreciation of just how important it is to not let myself get run down.

In the meantime, the writing bug is hitting me again (a person can only knit so many preemie outfits and blankets, watch so much TV, read so many books, or vegitate on the internet...did I mention I'm spending money I don't have on things I don't need on EBAY?...for so long), and just in the nick of time I got a (coincidence...I think not) response to my last post that gave me the idea for my next one.

Stay tuned!

On Childbirth Education

2009-04-02T06:06:00.000-07:00

More than once in my work I've met a couple who brought with them the expectation that what they learned in childbirth class is what they would experience in the hospital. Simple, right?

Unfortunately, no.

I know a few childbirth educators. Most of them are excellent (My beloved friend C., well, she's just the absolute best of the best). Others, not so much. At least one of them is not particularly supportive of her clients who are planning to birth in a hospital (read that...she can barely contain her disgust), and therefore, not helpful at all...a total waste of her clients' time and money. Others are just plain not giving their students accurate information - for example their couples come in asking for oral vitamin k instead of injected vitamin k for their baby (we don't have it); they ask to be monitored via doppler or fetoscope (we don't have a fetoscope, and we don't have the staffing to use doppler monitoring...aside from which, no hospital is going to risk not having a paper tracing of a labor; they ask that the newborn nursery not bathe their baby, but simply massage the vernix into his or her skin (fat chance!); or, they ask to be allowed to eat during labor (good luck), or my personal favorite, not to be administered an enema or shave prep (we haven't done this in over twenty years, so I'm wondering why these particular educators are not checking to see if their information is realistic, accurate, or current). I'm not saying any of this is right, it's just what is, albeit at best unfortunate. Finally, several educators, whose classes I've not had a chance to observe, or who I don't have an opportunity to converse with often, are, well, I'm just not certain what kind of information they are giving (or not giving) to their students.

Case in point: I once cared for a sweet couple having their first baby, who were genuinely shocked that their very aggressive obstetrician was just that...extremely agressive. This couple came in, and Mom was 4 centimeters dilated, with bulging membranes. She was laboring beautifully, and I told her physician as much. As if he didn't hear a word I said, he ordered "(have a resident) Rupture her membranes, put in internals, and start 4 by 4 Pit (twice the amount of Pitocin that is normally used)". Truth be known, it was the day of "The Big Game" in our town, and Mr. MD wanted this delivery over before "all the traffic started up". Baloney...he didn't want to risk being called away from his toasty box seats, but what do I know...I've only watched this ass leave several dozen labor rooms looking like the aftermath of a suicide bombing, always in such a hurry to be done that he can't bother to leave a perineum intact, put instruments back on the table instead of dropping them on the floor, or even put his bloody gown in the biohazard can instead of tossing it aside for the nurse to pick up. This is one of those guys that make me wonder why in the hell I keep doing this.

Why indeed...because I want those who choose to give birth in a hospital to know that they have options...options that far too many physicians and nurses don't let them know they have. No, I can't monitor you with a doppler...and I can't find oral Vitamin K for your baby, but, damnit, if I don't think you need Pitocin (yet), I'll tell you...and If you want to wait until your membranes rupture on their own, and you and your baby are doing well, I'll remind you that you don't have to consent to that. If I can't "effectively facilitate communication" between physician and patient (some physicians are not interested in two-way communication), I'll advocate for my patient.

This couple stood their ground though. they gently, but firmly asked the resident who was itching to carry out their physicians orders why this was necessary. They asked for more time to make a decision. Finally, after being cajoled and hassled for hours, they gave in. They consented to having the water broken.

But we have a happy ending...for this couple at least...miracle of miracles, before the resident could finish a delivery in another room, I saw a look..."that look" come over the mother's face, and my heart nearly leapt for joy as "that look" turned into an unmistakable grimace, followed by a surprisingly loud grunt from such a petite woman, and a splash of fluid from beneath her gown spilled onto the floor, over the shoes of her startled husband, and flowed into the towel I quickly flung onto the floor to catch it. At my urging she climbed into bed just in time for her little boy to squirm his own way into the world, without Pitocin, without internal monitors, without artificial rupture of membranes, heck, without even a doctor in the room! Baby in the Bed! I loved it. Take THAT Dr. Ass (as if he cared...as if he even realized it was possible).

But for those situations that are not the recipients of such Grace, what are the Childbirth Educators in question telling their students? I wish I knew. This poor couple, when I told them what their OB wanted me to do, were absolutely stunned...who wouldn't be? They had learned in their childbirth class to stay home as long as possible, that they could avoid pitocin if the labor was progressing well, that internal monitors were an uncessary intervention if the baby was doing well and easy to trace (as was the case here), and that they should avoid having the membranes artificially ruptured if possible.

All good information; but were they encouraged the to speak with their care provider about this information? This wasn't the first couple that had come under my care with these same or similar expectations, only to be blindsided by the basic hospital "business as usuall" delivery system. All of these couples seemed genuinely confused that their physicians would order care that was so different from that they were taught to avoid.

Perhaps the educators did encourage these couples to speak with their care providers, and the couples did just that, only to be brushed off or outright lied to. Perhaps the couples, as expectant couples are sometimes apt to do, just assumed that their care provider would practice as their childbirth educator taught, so they sort of "zoned out" when the educator was advising them to speak with their provider...like so many couples do when the topic of cesarean section is brought up...they assume it won't happen to them, so they don't really listen. Or maybe, just maybe the ecucators themselves are simply teaching a philosophy...without reminding their students that theirs is not the only philosophy out there...and that, if they can, they need to learn the philosphy of both the hospital, and of the provider they are trusting to care for them during the most important moments of their lives...or at least be prepared for the possibility that they may have some significant "negotiating" ahead of them, and be given suggestions (doula anyone?) to help navigate those negotiations.

Moms, Dads, what do you think? What has been your experience? Educators, do you ever hear from your students after they give birth? What do they tell you?

Enlighten this frustrated Labor Nurse, please.

The Ultimate Transition

2009-03-04T04:46:00.000-08:00

She was only fourteen. Fourteen. A tiny wisp of a girl, a pale, sweet, freckled face encircled by ringlets of short red hair. And she was going to become a mother. She had gone into labor the night before, things had stalled, and her labor was to be augmented with pitocin. When she went to her local hospital, her blood pressure had shot up, so she was transferred to our unit. She labored in the haze of a magnesium-induced fog, an attempt to prevent the seizures for which she was at risk because of her blood pressure.

The father of her baby was nowhere to be found. "He's too young for that" his parents had explained to her. I'm thinking...hmmm...well, he wasn't to young to make the baby...and she doesn't get to say "I'm too young for this". Instead, she prepared to raise, with the help of her family, the little boy that she carried.

She had wonderful support though. Her sisters were there...all four of them, all with the same fair skin and curly copper-colored hair. They ranged in age from mid-thirties to late teens. It seems our little mother had been a surprise baby herself, conceived during a rebound relationship of her mother's shortly after her sister's (half-sisters, but sisters, just the same) father's death. It was not lost on her that she was the offspring of yet another absentee father.

Her mother wasn't there. I didn't know why, but many telephone calls were going out to friends and family who seemed to be in close contact with the soon-to-be grandmother. Perhaps there wasn't transportation, or enough money for her to get the several hundred miles from her home to her daughter's bedside. That happens a lot on my unit...we transfer mothers in from hundreds of miles, covering three states. A lot of the families of the mothers we care for are desperately poor...too poor to follow the ambulance or Medivac helicopter to our hospital.

I felt sad for her. A woman needs her mother when she is about to give birth...especially such a young girl-woman; but this precious young woman was surprisingly, yet precariously stoic...the kind of stoic that made me caution myself to choose my words...even the inflection of my words carefully...lest I cause her to burst into tears.

Her sisters were lovingly, literally at her beside. When they weren't hovering near the telephone, they hovered over their laboring sister, rubbing, massaging, loving, wiping away the occasional tear. When she balked at the idea of getting an epidural, they encouraged her...gently...to reconsider. "So much pain", they murmured, more to each other than to her..."why take more?"..."especially when there's a choice".

She chose the epidural. While we usually allow only one support person bedside during epidural administration, I broke policy and let them all stay, because I couldn't bear to tear them away from their little sister who seemed to depend on them so. She suffered no untoward side-effects from her epidural, so I placed her foley, tucked her in, and stepped out of the room.

I felt a tap on my shoulder. When I turned around, I faced the oldest sister, who was wiping a tear from her cheek.

"I wanted you to know...we're not purposely being rude to you"...rude??? They had been anything but rude. I thought they had been perfectly lovely, and I told her as much. "Well", she said, "Thanks...but there's so much going on...I just wanted to let you know; She doesn't know...and we're all having a difficult time keeping it from her. Our mother is dying. Literally. Probably tonight. She has breast cancer".

Now, how many times does a nurse hear something like that? Not often, I would imagine, even on a unit prone to as much melodrama as ours. But, indeed, this was the situation, and here we all were: A fourteen year old girl about to give birth to her first child; her four older sisters to whom would soon fall the responsibility for them both; a still fairly young woman, their mother, hundreds of miles away, slowly slipping into that pre-death coma from which she would never wake up; and me, not quite certain how to respond to the sad uniqueness of it all. Instinct took over and I wrapped my arms around the now sobbing sister, as I held back my own tears.

I showed the sister our family consult room...the little room near the back of our unit that is used for physicians to talk to family members when things aren't going as planned with the birthing women they are supporting. It holds an institutional wood and vinyl couch, and two chairs, along with a lamp and a selection of out of date magazines; not much in way of comfort, but at least it's private...and it has a telephone.

The sisters each took turns going into the consult room to check in with the family that was caring for their mother. She was "in and out" they said. She seemed to be aware of what was happening to her "baby" daughter. Through a haze of pain killers, she had been repeatedly asking to speak her, but the family wanted to spare the laboring girl the pain of knowing her mother's death was imminent.

Our little mother slept through most of her labor until she abruptly sat up in bed and called out for her mother. "He's coming now! When will she be here?" I checked her, and indeed, her baby was nearly crowning (pretty rare for a first-time mother). I called out for a "doctor for delivery", and instantly the dark womb of the room became once again a bright, too-noisy hospital room. The sisters took their place around the bed, I "broke the bed down", the resident took her place at its end and began exhorting the girl to push.

She refused. "I won't!" she wailed..."Not until she get's here!" We all stopped and looked around at each other. By now, anyone who was involved in her care new what was happening. Eventually this baby would be born no matter if his mother pushed or not...but as often happens, his heart was slowing with each contraction as her body moved him ever closer to his birth. Most babies do fine, even with this...but it can be unnerving if the birth isn't imminent...if the mother isn't helping things along by pushing...at least a little.

The youngest of the four sisters finally broke rank from the Circle of Women around the bed and picked up her cell phone...you know, that piece of equipment that you're not supposed to use in the hospital because it might interfere with the other machinery? Too bad...she was on a mission, and I wasn't about to stop her. She punched a speed dial number, spoke quickly into the phone and placed it next to her laboring sister's ear.

"I will. I promise. I know. I love you tooooo.....", and her little body twisted up off of the pillow with a powerful involuntary push, and as her sister lifted the cell phone high in the air, a tiny, five-and-a-half pound little girl wailed her way into the world amidst the sobs of joy, surprise, and heartbreak of her mother and aunts (so much for the accuracy of late-term ultrasound). Time of birth...4:01 A.M. Grandma was listening.

After promising into the cell phone that she would call back soon, the youngest sister snapped it shut and began to attend, along with her older sisters, to her little sister and niece. As a group they dried the baby off, and placed her against her mother's body. The older sisters, mothers themselves, gently encouraged the new mother to hold her daughter close, showing her how to feed her, pointing out every precious, miraculous, infinitesimal little finger, toe, and wisp of downy, copper-colored hair. The baby never cried, not once after her entrance announcement...but curled into her mother's warm body, turned little her head sideways, and watched her aunts smiling down at her.

I moved around the room as inconspicuously as I could, clearing away the delivery paraphernalia, charting, and tidying up between checking on the new mother and baby. Once satisfied that all was in order, I left to give the new family their privacy. A few minutes later, the oldest sister walked up to our reception desk and asked for me. When I approached her, she asked me..."What time was she born?" A tear rolled down her cheek with my answer.

"Our mother died at 4:05".

Now I was crying...and not just a dainty little sympathetic tear or two to streak down a cheek...no, I had to be sniffling with the red nose and blood shot eyes of someone who has had entirely too little sleep...it wasn't pretty...but it was heartfelt, and the sister knew it. She asked that no one say anything to her little sister until she had had a chance to get a few hours sleep, after which they would tell her, and of course we all agreed...but it wasn't easy to stifle those tears and act cheerful while I helped the new mother into a wheelchair and tucked her baby into her arms for their trip to her postpartum room.

As often happens, I never saw this patient or any of her family again. I wonder how she reacted when she learned of her mother's departure so soon after her daughter's arrival. Two souls had literally crossed in the night. Did they reach out to and greet each other along the way? Did that precious little baby feel the warmth of her Grandmother's kiss on her cheek? Will she carry a tiny, almost imperceptible memory of it with her? She will most certainly experience her love through the love of her very young but very special mother and her very special Aunts. She is part of a very special Circle of Women indeed...one that reaches down from heaven, flows through her family, and wraps itself around her.

A bittersweet story...but a very fortunate little girl.

Transitioning Back

2009-03-04T04:05:00.000-08:00

Four and a half months????? How can that be? How could I get so sidetracked with the holidays, the boys, the relationship, the job, the house, my workouts, meal planning, (slowly) shrinking profile, and all the other things I use to distract myself from climbing the stairs to my little study and writing?

Of course my family are not distractions...they are priorities...but the other things? Well, I've got to find a way to motivate myself to get back here more often.

I'm so impressed with At Your Cervix...despite all of her obligations, and now graduate school, she manages to keep up her blog. Me, well, I'm wondering if I just don't particularly like always being so far away from my family when I'm writing. I love my little study. It has all my books, my favorite photographs and art projects, my professional journals and texts, along with piles of yarn, fabrics, and other needlework supplies stashed in the closet. Maybe I need a studio too, someday...when the 19 year old finally decides to move out of the bonus room over the garage that I had targeted for it. But back to my study...I've decorated it in my favorite colors. I love the huge old rolltop desk (my husband calls it my womb), overstuffed chair and ottoman, and bookshelves I've managed to squeeze into the tiny space. It's mine...it says me, and me alone to anyone who walks into it. There are times I just want to shut the door on the testosterone chaos (even the pets are male) in my house, pour a cup of tea, wrap up in one of my throws, and read, knit, write, journal, listen to music, and sometimes even drowse off in that wonderful chair...but not always; and with the amount of ideas for writing rolling around in my brain, all of the experiences I want to process, I could spend days...weeks up here getting it all out in text. I've tried sneaking in to my husband's office to write while I'm down in the thick of family life...but invariably he needs to get on the computer or I become an unwilling partner in his engineering business, taking calls, filling, or chasing receivables...shudder!

So what's a reticent writer/blogger to do?

I may try to work some extra shifts and get a laptop...something I could keep downstairs, in the middle of all the family mayhem, and use when the spirit strikes me. I could keep my recipes and meal plans on it; I could keep my food and exercise logs on it; I could fiddle with my fledgling photography hobby on it; plan my grocery trips while perusing all the coupon sites...fritter away time on Facebook...well, ok, I'll need to try to curb the temptation to do that...not easy when just about everyone I work with...nurses, techs, attendings and residents alike...use it to unload on each other after shift upon shift of craziness ( I guess if we can't debrief at work, we can do it online).

So; until that laptop shows up, I've got to find a way to spend more time, at least every few days, back at this computer.

Here's to good intentions!

C-Sections are Births Too!

2008-10-14T07:18:00.000-07:00

After writing my last post, a "block" seemed to have been moved; story after story of amazing births I've been privileged to attend just seem to tumble from my memory; I sat down at my computer to start writing about them, and then I thought about E.

E. gave birth to her third child, a precious little girl, several weeks ago. It was E.'s third C-section, her second attempt at VBAC, her third attempt at a vaginal birth. With both of her previous birth experiences, the argument could be (powerfully) made, that mismanagement of her labor led to each C-section. With her third birth, only God knows why events unfolded as they did, and led to a third surgical birth, this one an emergency situation, that occurred with E. under general anesthesia.

E. had tried so hard to "do the right thing". She takes excellent care of herself. She's well educated, seeks out the right support for herself, does everything she can to have a safe, healthy birthing for her children and herself. For her first birth, she chose to be attended by very well-known Certified Professional Midwives; for her second, she chose to attempt VBAC with a physician who works very hard to be "hands off" and encourage her patients to give birth on their own terms; for this third birth, E. was fortunate enough to live in a city in which a prominent (it could be argued the national expert) physician-researcher (responsible for probably the most comprehensive study on VBAC ever published) practices. She chose this physician to attend her for her third pregnancy and birth, and together, this patient/physician team worked very hard to secure a healthy pregnancy and safe birth. In the end, that is exactly what they did...although with a significant "hitch" that both of them would rather not have experienced.

After an uneventful pregnancy and smooth first few hours of labor, no pain meds, no epidural, with an attentive husband and doula at her side, E. had progressed smoothly to nearly transition labor. I was so pleased for her! Having popped my head into her labor room to welcome and encourage her, and a share a quick hug with her doula, a close friend of mine, I picked up my bag and clocked out for the day (she had arrived near the end of my shift, and I would not have the good fortune to be her nurse). There was a celebratory mood in the room, and I was nearly floating on air out of happiness for her.

On my way off the unit, a barrage of nurses, residents, and the prominent attending physician suddenly came barreling out of the nurses station, clamoring towards E.'s labor room. The flurry of activity, calls for help and surgical preparations (anesthesia! OR!) that were occurring made it clear that something had gone wrong. The amazing emergency "machine" of our unit had mobilized. When a true emergency occurs, this is a thing to behold. The nurses, techs, clerks, anesthetists and physicians on the unit truly become a single entity, each individual a cog in a wheel that is rotating furiously, each performing nearly automatically, and almost always expertly, their own function, with the goal of getting the mother into surgery, and keeping her and her baby safe. While I admit that the "adrenaline addict" in me gets a bit of a "high" from situations like this, and while my main goal is to avoid having any of our mothers go to the OR, times like this make me feel grateful, and humbled to be able to call myself a part of this amazing team.

Already out of my scrubs, and off the clock, I felt helpless and powerless as I watched in dismay the "machine" thunder down the hall towards the OR with E., hunched over in "knee-chest" position in her bed, her doula and her husband running behind as they pulled on the white, zip-front "bunny suits", caps and masks they would need to accompany E. in the OR. I knew she would be OK. I knew the baby would survive...because I know that machine; but I ached that she seemed to be losing her last chance to have the vaginal birth she had always dreamed of having.

After the commotion had settled, the baby was out, and both she and her mother were deemed safe, I learned that E. had experienced a uterine rupture! This blew my mind. Why her??? She had worked so hard! She was well nourished, it had been several years since her last birth, plenty of time for good tissue healing, and from her previous op reports, she had had a strong, "double layer" repair after her second C-section. She had labored naturally, without the aid of Pitocin, and had (gratefully, in retrospect), had no pain medication or epidural to mask the symptoms of uterine rupture. She had labored to almost complete dilation. The odds were so in her favor for a vaginal birth that this occurrence was a true stunner.

Fortunately, the tear in E.'s uterine wall was repairable, and with the skill of what I am convinced is the best surgeon and surgical team in the country, E. was safe, her baby is healthy, and I know she will heal well.

Physically, at least.

But emotionally?

E. knows that what happened to her was a random, unlikely occurrence. She is grateful and happy to be alive, and to have a healthy daughter to love and raise; but still she grieves for her lost opportunities to experience birth as she had always expected she would; to give birth the way she was designed to. To give birth the way most mothers take for granted. To feel her baby emerge from her body as she worked and pushed to bring her forth under her own incredible power.

Everything had happened so fast. It must have taken quite a bit for it all to sink in, for E. and her husband. This is a couple that has always wanted a big family. Even as they counted their blessings from this averted tragedy, I heard that E.,s husband had asked their doula if they would ever be able to have more children. "Maybe...but only if you schedule a C-section at 39 weeks", she had replied...and this coming from a woman one of whose main missions in life is to help get our country's C-section rate down from it's current outrageous high of 33 percent. For a while I worried that E. just was not coping with her loss...that she was so focused on having a vaginal birth that she was letting the first precious weeks with her new daughter slip away ruminating about her lost opportunities and planning for a future VBAC. While most would feel that decision would be unsafe (and I even include myself in that number), there are midwives (who's judgement I reject) out there who might accommodate such a request. Indeed, well meaning posters on our local birth-support email lists tried to encourage E. by questioning whether she experienced a "true" rupture (she did) rather than "just a dehiscence", by questioning the decision to perform the surgery (!!??), by questioning her memory of the events, and by encouraging her to look forward to a VBA3C in the future. After a couple of unreturned telephone messages to her, and several emails without response, my worries increased...for a while.

My worries were unfounded. As much as I know she cares, I think right now I'm a reminder to E. of her lost dream of a vaginal birth. I understand that, and I won't pursue contact that she might be uncomfortable with, even though I mean only to support and care. Through the community of women who support birthing women in my city, I've learned that E. is doing well. From time to time I will see a post from her on our local ICAN (International Cesarean Awareness Network) email list, and I can tell that she is working through her grief in her own way. One post in particular that she made, was an impassioned plea to the leaders of ICAN in our community to provide more support for "those of us who will never have a vaginal birth".

My heart goes out to her. She is correct to make such a plea. While I support the work that ICAN does both nationally and locally, I've been concerned for a while that the focus on avoiding C-section, and the focus on VBAC neglects those women who may never experience another pregnancy after their C-section; that those whose C-sections were truly life saving or health-preserving might doubt their caregivers, or more importantly, their acceptance of their care-giver's decision. What aggravated me most in this particular situation, was how quick E.'s "supporters" were to second guess both her trust of her medical team, after she had put so much time and effort in choosing it, and in that team's decision, particularly when those supporters were so far removed from the situation. Hindsight is not always 20/20, and I did not consider that support.

I don't think this is or was intentional; but I think some of the printed materials, and particularly those mothers who were able to achieve a successful VBAC after a truly unnecessary c-section can inadvertently give off the "vibe" that ICAN is only for those mothers who are recovering from, or avoiding abuses of the medical system. Knowing that it will be a fine line to toe, I would like to see the group, while avoiding the risk of "normalizing" the procedure, provide more overt support to mothers who, as E. has so passionately phrased it, will never have a vaginal birth.

C-Sections are Births, too. No one would deny that, but I think in our zeal to reduce the c-section rate, to avoid that first c-section, and to promote VBAC, we have inadvertently minimized that. We in the medical community, in our rush to protect the safety of a mother and baby needing an emergency or emergent c-section, or to keep a busy, even over-loaded maternity unit running efficiently, are guilty of the same. That "machine" I spoke of, the one that I so admire and am so proud to be part of most of the time, continues to, on a calmer level, run much the same, even when the surgery is planned. It's what we do; it's our culture; it's what we are accustomed to; it's our turf!

Well, it may be so, but it's also the birth of a human being. A woman becomes a mother, a couple becomes a family, or a family grows by one (or two, or more ;-}). I've read about calm, quiet, lowly-lit (for the emergence the baby) surgical births where the baby is delivered slowly, in full view of the mother and her support person(s), sometimes even to be placed on her upper chest before being whisked over to a warmer to be dried off, examined and bundled up by nurses or pediatricians; of babies who have even breastfed while the mother was being sutured post-delivery. Even in my own experience on a unit made sometimes over-conservative as a result of being a referral center for high risk pregnancies, I know of at least one physician, one who is conservative himself, who is frustrated at the business-as-usual way in which our cesarean deliveries are usually carried out. I suspect he would balk at the slow, dimly lit delivery with a newly born, wet baby being placed immediately on the mother, or of baby nursing during surgery (I can also envision the hysterics of our very conservative chief anesthesiologist, LOL), but I know he would prefer that we keep baby with the mother and her support people during recovery, and get breastfeeding initiated, rather than whisk baby away to the nursery after a few moments in Dad's (or whoever the mother has chosen for her support) arms, while he (or she) sat next to the mother. On a busy unit such as ours that can be a challenge...particularly because our recovery room has limited space and no infant warmers...but we have done it from time to time, for those assertive mothers who have requested it. It can be done. I'd like to see it done more often.

Likewise, I'd like to see members of ICAN be more conscious (although I know they already try to be) of the feelings of mothers who have given and will continue to give birth surgically. I understand the triumph of a woman who has "beaten the system" to have a VBAC; but that is not reason enough to, even unintentionally, and even sympathetically, view a woman who has had a c-section as a woman who has had a negative birth experience...who has not researched all of her options...who has "given in" to the system.

No, we don't want to risk normalizing surgical birth; but we certainly could benefit from humanizing it much more...both those who perform surgical births, and those whose (admirable) goal is to avoid it.

A Beautiful Birth

2008-10-06T07:20:00.000-07:00

It's been four days since my last shift, and I'm still trying to find the words to describe one of loveliest births I've had the privilege of attending as a labor nurse. This kind of birth is so rare in the hospital environment; but the experience has reaffirmed my belief that if a woman truly educates herself, has trust in her body and the Natural Design of birth, and surrounds herself with the appropriate support, a minimally interventive birth can be achieved in the hospital. With the permission of the lovely couple and their doula, I am honored to be able to tell their story here.

The mother is a 32 year old woman G., who was laboring with her first baby. She was accompanied by her husband C., and her doula, S., a lovely woman who stayed by the side of her client nearly every moment of a long, long labor. I came on shift at 7:oo P.M., and the couple had been there since the late hours of the previous night shift. The report I received was that G.'s water had broken at 2:30 in in the morning (so we are now well over 12 hours) and that she, C., and S. had walked for hours trying to get labor started, until finally she consented to have her labor augmented with Pitocin.

When I entered the room, G. was in the throes of full, hard labor. The room was dark and soft music played from their ipod dock on the side table. The labor bed was bent into a "chair" position, with the top of the bed straight up, and the bottom of the bed lowered to support her feet. This was a woman who had determined that her labor would be accomplished on her own terms. She wore her own clothing, a tank top and a short "skirt"...it looked like it might have been a "Binsi" skirt (www.birthbinsi.com). She sat upright on the "chair"bed, bare feet planted firmly on the foot rest. S, a slender (thirtysomething?) woman with short blonde hair perched just behind her, one arm about her waist, the other on her shoulder. In front of her, C. knealt on the foot of the bed, while she rested her forehead on his chest, his hands placed around her shoulders in a soft embrace. Back and forth they all rocked, a single, loving, hard working entity, to the tempo set by G. as she groaned a low, throaty labor song with each contraction. As each contraction slowed, she would exhale and lean back into the S.'s arms, to accept a sip of water or a cool cloth on her face and neck. As another contraction would well up, she would again lean in towards C., S. would take her place behind her, and they would resume the rythm of their labor "dance". Occasionally G. would move from the bed to a birth ball beside the bed, and C. or S. would massage her lower back or perform a "hip squeeze" to help aleviate back labor. As time moved on, G. began standing beside the bed, bending over with each contraction, placing her hands on the bed and rotating her hips through each one. As each contraction would peak, her labor song would progress from a long low moan to nearly a growl...a "she bear", working to bring her baby into the world.

During each contraction (which S. would refer to as "surges"...appropriate, I think), G. seemed to move completely into her own world. As each surge came to an end, she would look up and brightly smile at one of her companions, crack a wry joke about her "situation", or, if I was in the room, ask a question or ask to be checked. What I loved about these times was that she would be completely calm and happily "present", as if the considerable pain she was experiencing during the surges had never happened at all.

One of the things I hear over and over again, from nurses, physicians, anesthesiologists, and from many women is why, with the epidural, women would want to experience the pain of labor. As a nurse, I struggle with complying with the wish of some mothers not to offer them pain relief until they ask for it. We're trained to treat pain. It's difficult to stand by and let it happen. My doula friend C. has helped me by reminding me that the pain of labor does not always mean "suffering". That has helped me when working with mother's who fully understand and want to work with their labor; but so many women equate labor pain with just that...suffering. I've listened to women who've arrived at the hospital with no time before delivery to get an epidural and heard their panicky pleas for "something, anything" to save them from their pain. They truly felt they were suffering. Sometimes I've been able talk them through their contractions, either with my voice alone, or with a visualization, and they realize that yes, they can do this...and they seem to cope better. Other times, no matter how hard I try, the woman is so tightly gripped by her fear of the pain, and of the process, that nothing I do seems to help. This is when I feel the most helpless.

I wonder if some physicians and nurses roll their eyes at a woman who has arrived at the hospital with a birthplan, or a doula, or both, because they are not accustomed to the woman being the one who is "in charge". We're used to setting the pace for labor, of determining in what manner the "outcome" will be achieved. When a woman and her support team call the shots, and call them appropriately, there is very little for us to do. Waiting and watching, listening and supporting, while it is the major role of a midwife, is not something that labor nurses get a chance to do much of; and it's not something that physicians are trained to do. I tend to make myself scarce during this type of labor; I figure the woman knows her support team and each knows what to expect of the other. Particularly when a good doula accompanies the woman, there is very little I can offer in the way of education and support. With G.,s labor, as much as I truly supported and admired the way she was accomplishing it, I felt like an intruder when I needed to replace the blood pressure cuff, or readjust the fetal monitoring system. She was very gracious though, and before long I began to feel welcome as a part of her "team".

Several moments stand out for me in my memory of this labor. The first is a "picture" I will forever hold in my heart. While G., C., and S. rocked back and fourth in their labor dance, there was a moment when C. laid his head against his wife's breast. G., her eyes closed, leaned back against S., face turned upwards, and S., as she rocked with G. in her arms, placed her cheek softly against G.'s hair, her eyes also closed, with a look of pure love on her face. My words do little to describe the sweetness of that moment. I so wished I had a camera to capture it for them. Later on in labor I was able to borrow C.'s camera and take a few photos as G. pushed, lying on her side, while S. and C. supported her, and the Nurse Midwife squatted at the end of the bed, smiling at the progress G. was making with her powerful, grunty pushes (no "hold your breath and count to 10" nonsense here...and she pushed for only 45 minutes. I wanted to pull every nurse and resident on the floor into that room and say "See, you can push a baby out without holding your breath !!!!! Of course I didn't, but I made sure to get the word around afterwards). At one point just a short while before G. began to push, she called me into the room and asked me to check her progress, because "I feel like I'm losing control". She wasn't though...in between those contractions she was as clear and "in control" as any one else in the room. I hope that pointing this out to her...that from my perspective she was maintaining perfect control...was something she was able to "hear" as she continued on in her labor. There were a few times when she would come out of a contraction and breathlessly exclaim "I can't do this any more"...but she was nearly complete at that point...a classic "signpost" of transition labor.

At 1:53 A.M...nearly 24 hours from the time G.'s water had broken...a beautiful little boy tumbled into the world and a family was born. He spent the next hour and a half cuddled next to his mother, nursing, snoozing, occasionally protesting. C. was ecstatic, and G., as exhausted as she might have been, instead seemed to experience a second wind. As she chatted and nursed her son, you might never have guessed that only a few moments before she was near exhaustion. S. continued her constant support of G., helping her position the baby for nursing, providing food and drink, and tidying up the room for the coming move to the postpartum room.

If only every labor could be like this; if only every woman had such a wonderful support team; if only every woman believed in herself the way G. did.

Welcome Little One. You are as fortunate to be born to your Mother and Father as they are delighted with you. I will forever be blessed for having been witness to your arrival.

And I am Thrilled...

2008-10-02T10:02:00.000-07:00

...for "AT YOUR CERVIX", as she begins a new journey in her life, the road to becoming a Certified Nurse Midwife...and a blessing to many women in the future. Check out her blog (again, click on the link in my "favorite blogs" section), and enjoy following it as she no doubt provides many wonderful, moving, hilarious, and educational stories of her journey...and be sure to leave a great big

CONGRATULATIONS!!!!!

in her comments section

I Am Humbled...

2008-10-02T09:57:00.000-07:00

To know that women can communicate so eloquently and respectfully about a topic as important as a woman's decision to continue or terminate a pregnancy and all the issues surrounding it.

Please go to Navelgazing Midwife's blog (see my "favorite blogs" section and click on the link), and read her September 29 post, and particularly the comments. You will be richer for it.

For K

2008-08-19T11:13:00.000-07:00

(Note...for those who, for whatever reason may be reading this blog, and think that I'm in a mass "catch up" mode because it's been waaaay too long since I've made any entries...you would be correct ;-) ).

A couple of weeks ago I was going through my email and opened a notice from a national list that I belong to. In one entry, the poster left a url to her Utube documentary of moments during her pregnancy and birthing. Lo and behold, when one picture captioned "My midwife" came across the screen, I actually clapped and cheered (a little...I mean, I was sitting alone at a keyboard in front of a computer monitor...didn't want to look like I was...emotionally challenged).

The picture was of a very special woman...a midwife who I met nearly 10 years ago when I was a brand new L&D nurse, and she was a "vet" nurse, having been on L&D for over 20 years.

That job was one of the most miserable jobs I have ever had. I had just put in my obligatory year of med/surge nursing where I had been very very successful, fresh out of college, when I transferred to where I had planned to be all along, labor and delivery.

First day out of the gate, I went into a total state of shock.

This was the late Nineties...I had "come of age" in the Seventies, in the era of "Our Bodies Ourselves", Ina May Gaskin, fighting for our rights in the hospital to have our partners at our side, to birth our babies naturally, without the fog of Scopalamine or Demerol, of immedate bonding and breastfeeding, of Bradley, Lamaze, and VBAC. Although I didn't give birth myself until nearly fifteen years later, I totally absorbed that mind set. I had pretty much gotten what I wanted when I gave birth for the first time in the late Eighties. I had no idea how much things had changed (read that regressed) in the "Self Empowerment in Birthing" school of thought. I was stunned at all the planned inductions, the "epidural as norm" attitude, and the relative ease with which the decision to perform a Cesarean Section was made. Honest to God, I even remember a physician sitting on the edge of the bed of a newly admitted, beautifully laboring multip, with a history of two vaginal births , then a c/section, and finally a successful VBAC, trying with all her might to convince the mother that it was too dangerous to "attempt" another VBAC, and that she should immediately prepare for surgery! She didn't, thank God, despite what was essentially a temper tantrum by her physician...the same physician who had attended her VBAC!!!!!

Needless to say, things didn't go well for me. I was simply aghast that mother's seemed to just accept drivel like this, few if any took childbirth preparation classes, or if they did, they managed to squeeze them in during an 8-hour marathon Saturday class, and that most of them wanted to "stop being pregnant" by 39 weeks, so they gladly scheduled their inductions, and the first question out of their mouths upon arrival was not "How soon can I breastfeed my baby", but "How soon can I get my epidural"? My sense of shock must have come across loud and clear, because I was not a favorite of the Assistant Nurse Manager or the Nurse Trainers on that floor. We butted heads over and over again. The Nurse Manager and I got along well...she knew where I was coming from. She was a woman who truly cared about both the patients on her unit, as well as her staff, but even she was struggling. Turns out that Ms. Assistant Nurse Manager had applied for the job, but had not gotten it because she didn't have the required Master's degree. The Trainers were her "homies" from years and years of working together. Together, they had as their mission in life to make the Nurse Manager's life miserable. Did I say I hated that Job? I hated, hated, hated it!

Three months into the job (I don't know how I even lasted that long) I was diagnosed with a serious surgical problem, and took a long (about another three months) sick leave post op. Somehow I managed to drag myself back to the unit after my leave, only to learn that, in my absence, the Nurse Manager had left for a position in the hospital I now work in, and Psycho Assistant Nurse Manager had inherited the job because no one else was willing to even apply for it!.

Crap. No, make that Shit! Shit, Shit, Shit! Sometimes, there's only one word that fits, and this is the one!

It took about three days before I was a complete basket case. PNM (Psycho Nurse Manager) decided that I needed to be "reoriented", since I had barely finished my orientation to the unit before I became sick. In other words, she wasn't going to let one of her predecessor's allies stay on her unit if she could help it. At the same time, she was making life miserable for her other "targets", many of whom decided to resign, and with each new space that opened, she brought in one of her "homies" from her former employer, a decrepit unit downtown that still practiced like they were in the dark ages. It was becoming a unit of battleaxes.

I don't know why I kept fighting. I'm very stubborn. I keep thinking that if I just try one more thing I'll be ableto "fix" whatever is going on that is not working. I have an uncanny way of making myself (and anyone close to me) nuts that way. Stupid, I know.

Enter K...othewise known as, "She Who Introduced Me to the Sanity of Hope and Knowing Myself".

One long, late, dark night on the unit I was working in the newborn nursery all alone (for of course, all mothers were encouraged to "rest" by leaving their newborns to cry it out in the nursery all night). I had just managed, as a new L&D nurse, to get the entire nursery (that night about a dozen babies) bathed, vaccinated, fed, tucked in and charted for the night (I came to find out later that this was both unheard of and discouraged for nurses of my level of inexperience, but PNM was working very hard to get me to dig myself into a hole, and she didn't care if she put any or all of the infants on the unit at risk to do it). As I stood looking out over the parking lot from the (now quiet) nursery's window, K. walked up beside me, put her hand on my shoulder and said "nice job...you're going to be good at this...if you can stand it much longer".

I almost (almost...I'm too stubborn to otherwise) cried.

As we continued to talk, I learned that K. was as unhappy with what she was doing as I was...I remember breathing a huge sigh of relief hearing her say she hated seeing women being "treated like cattle" - finally someone acknowledged how I felt!. When I asked her why she was still there, she told me she was apprenticing as a Direct Entry Midwife, and wouldn't be there much longer. She had thought about going back to school for a CNM, but she knew that she would be forced, in that capacity, to work within this system, and the system stunk. She was willing to give up her nursing license to do it.

That morning when I got home, I did my usual "tears on the pillow" dance with my husband, who had finally had enough. He demanded that I quit the job. When I said we couldn't afford it, he pretty much threw a temper tantrum. "God Damn it, I just got the rest of your life handed back to me back on a surgeon's knife, and I'm not going spend it with you miserable. You should have learned by now that life is too short, and not to put up with crap like this. Quit! We'll manage!"

I quit the next day. Took a letter into human resources regarding the situation, and got them to agree to let me use my vacation in lieu of notice (heard later that PNM got nailed for some of the behaviors I described in my letter...I was also congratulated on a "very professional" resignation letter - I had included rebuttals to demands that had been made of me regarding standard of care, and backed them up with references to research articles, quotes from the State Board of Nursing, etc...typical for me, couldn't just write a simple, one-page resignation letter...had to write a tome...but it worked for me). When I went back to my unit to collect my things from my locker, not one head lifted from whatever they were doing...the experienced nurses because so many of them were the complicit cronies of PNM; the new nurses because they knew not to piss off PNM by seeming to sympathize with me; certainly I got no acknowledgment from my new (or old) Preceptors, or the unit Trainers, and absolutely not from PNM; but I did get a warm, tearaful hug from K. "I'm happy for you, honey. You've made the right decision. You'll be a great labor nurse when you find the right fit. Keep the faith. Go be happy."

That soft, warm hug kept me buoyed for weeks until I landed my next job...which was wonderful, and which led me to my current job. I did keep the faith, because K. had faith. No, things have not been easy...I "live and learn" every day. PNM isn't the first "Nurse Ratched With an Agenda" that I've had to deal with...and she won't be the last...but each time I come up against one, I recognize them earlier, and quickly beat them at their own game. I now practice on my own terms, those that are supported by good research and established Standard of Care.

K. is now a practicing Certified Professional Midwife. The state board of nursing has made a few underhanded threats about taking her nursing license from her for "practicing medicine without a license", until finally she gave up that license...something she had worked very hard for...something she was rightly proud of...and that was valuable to her...so that she could not be challenged by them any longer.

Unfortunately, K. and so many other midwives like her have more to fear than the state board of nursing...but they keep the faith. They support my faith. K. supports my faith. I have the opportunity now, to run in to her from time to time when she transfers a client, or when we attend the same event. It is always wonderful to go get my next "hug" from her.

Thank you, K. You are a blessing among blessings,

Speaking of Communication...

2008-08-19T10:12:00.000-07:00

Some people are just more skilled at (or creative about) it than others.

I am a very concrete thinker, and that comes across, sometimes too bluntly, in my communication style. Tact is not one of my finer skills...and that gets me in to hot water when I'm working with friends and families of laboring mothers.

We have a "three visitor" rule where I work...by policy, we allow only three people in the room during labor and birth. We're a major high risk referral unit...that floor is absolutely hoppin most of the time, and with a lot of our patients, it means we have to move fast at times...and there are a lot of us in the room doing it...so we can't exactly have everyone from Great Grandpa, down to big sis's latest newborn progeny in the room...either someone's gonna get trampled, or precious minutes are going to be lost that can mean the difference between a good or poor outcome. BIRTH IS NOT A SPECTATOR SPORT. For those whose hackles I raise when I say this, let me tell you that, at nearly every labor I have attended where a huge conglomeration of family and friends hung around during labor, most, if not all of the crowd were gone...vamoosed...as soon as Junior or Juniorette made his or her way past Mom's perineum...seriously...most people seem to just want to get a goggle at the emergence of this little alien from the mother's body, and then the show's over...they are out of the room before Mom is even out of stirrups (yes, they use them where I work, I hate it, but it's just how they do it), leaving her and her partner (if there is one...I have often see a family leave a mother totally alone) still dazed about what has happened to them. So, I don't think I'm being unreasonable when make that statement...because, more often than not, that's exactly how the onlookers are treating the situation.

It's also difficult to enforce this policy when Mom is sick. For example...when Mom has preeclampsia. The high blood pressures that a mother can experience with this illness can deprive her brain and nervous system of oxygen...when we treat a mother for preeclampsia, we're only buying time until we can effect a cure the only way that it can be effected...by ending the pregnancy (more specifically delivering the placenta, which is where current thought leads us to believe the problem originates, and of course, if the placenta is coming out, so is baby). In the mean time, Mom is at risk for seizures; so we keep the lights and noise down in the room, so as not to add to the problem of an already overstimulated nervous system. It doesn't help things when there are half-a-dozen or more family members, some of them with cranky toddlers in tow, coming in and out of the room, talking and laughing, eating, schmoozing, switching on the lights and television, and in general, acting like they are at a social event.

Over and over again I've explained to families, as gently as I can, why we need to keep the room clear of debris and extra bodies, so that, if need be, we can move fast...or so that we can keep Mom calm and resting. Things will quiet down for a while, and then, little by little, people tend to drift back in, and the noise level drifts back up. What gives? How many times can I explain things? How many signs do we have to post? Do they not believe that the risks I am pointing out to them exist? Maybe it's one of those "for other people not us" frames of mind. I can only guess. Anyone have any suggestions for Nurse Ratched here? I think I'm being nice when I explain. I try to be!

But those are my complaints. Patients and their families have legitimate complaints as well (doh). Sometimes they just aren't "meshing" with their nurse...or worse, the nurse is being a "b*&%$"...it's been known to happen...we all have our bad days (nights), and some of us seem to just hate our job, pure and simple (why these people stay in the job, I'll never be able to understand...I mean, nurses are among the most employable workers I know...there has to be something out there that they would rather do). There have been times on our floor when a Mother or family will ask (pleasantly or not so pleasantly) for another nurse; and we try to accommodate them...but it's not always easy...and sometimes we, probably because we've been asked in a way that we've allowed to get our defenses up, will allow ourselves to believe, and attempt to convince the family that, this just isn't possible (due to staffing, etc).

C. to the rescue...some people are just gifted in this way. Her advice to her Doula clients when a personality conflict (or worse) comes up...send someone out to the nurses station, ask to see the charge nurse, and with a smile and complicit sort of tone, say "I'm sorry to have to ask this, I know you are busy...but...this is so awkward...our nurse looks exactly like (my ex wife or, my abusive mother-in-law, etc.)

Of course, while C. is suggesting this, everyone in the room is roaring with laughter...but how could it not work? I'd move Heaven and Hell to relieve my laboring mother of her current nurse if I thought this was the situation.

Like I've said...some people (unfortunately, not me...I'm still [hopefully] evolving...are just plain gifted.

If only we could all be.

Communicate, Communicate, Communicate...

2008-08-19T09:40:00.000-07:00

But do it well...do it honestly...and allow for the inevitable misunderstandings.

This I learned (or relearned, as I will forever continue to), a few days ago when I had the opportunity to attend a meeting of our local ICAN (International Cesarean Awareness Network) group. The group met in a room at the offices of the midwives I referred to in my last (and much too distant) post. I had the opportunity to spend time with one of the midwives.

My friend C. was with me. Ever the diplomat, C., after the meeting was over and we had a few moments to gab after the meeting ended, was able to gently approach the topic with the midwife. Interestingly enough, the news was just that...news to them. Even more "interesting" was her comment that the physician who they had been collaborating with was continuing to do so, long after the partners had decided that they no longer supported the collaboration.

So what is the solution? I'm not sure there is one that will make everyone happy. I'm more than a little frustrated that the collaborating physician doesn't seem to be more up front with his partners...a little passive aggressive perhaps? Who knows? Not an unheard of trait in the All-American-Male. The midwife feels that she and her partners have been as diplomatic as possible when transferring care...and I believe her...I've trusted her judgement and skills for years, and nothing has changed that for me; but a mother in labor and her family are not always in the most reasonable state of mind during a transfer...they don't always hear what is being said..and they are not always able to respond completely rationally...labor takes us out of the corporeal world and places us somewhere between earthly ground and some other plane; and perhaps that is where the misunderstandings began to originate...again, who knows?.

What I do know is this; that there are so many underlying prejudices, memories of past experiences, and motivations that lead us to understand or respond to a situation in whatever way we do, that trying to predict how any particular exchange of communication is going to turn out is, well, unpredictable. The only thing we can do is try very, very hard to listen when someone is speaking to us, and not let our own agenda ("I must have a vaginal [natural, unmedicated, monitor-free, {whatever}] birth", or, "If they wear scrubs, I'm not sure I can trust them") get in the way of what is being said. On the other hand, we can't let it (that agenda...and we all have one, to some extent) color what we are saying ("This is my decision, I'll do/say what I think is appropriate" - [despite the fact that life doesn't always cooperate with our plans]).

Do I think that this is what ultimately conspired? To some extent, yes; to just how much of an extent I can't know...I wasn't there, and I don't know all of the participants well. I'm glad though, that because of C.'s amazingly effective way of getting her point across without triggering the defenses of the person she is speaking to, that the midwives, their clients, and the physician in question just might be a little closer to forming a collaboration that can continue.

I know I said this once before...but, I can hope, can't I?

A Letter To My Beloved Midwife Friends

2008-07-26T05:07:00.000-07:00

My Dears K, N, A, and T....

I love you guys...you know I do. I can't thank you enough for being there when I get saturated with medically managed, high risk births, and you spend entire afternoons with me reminding me "how it's done" when things are blissfully normal, helping me regain my perspective; but sadly, things are not always normal, even during some of the births you attend, and you have to transfer.

I was so pleased that you had found an M.D. to back you up....not an easy (heck, pretty much impossible) thing to do in this overly conservative area; but now that backup is being taken away.

And why?

Now, I'm getting this information second hand (it might even be third hand), but I trust the source I got it from implicitly, although I'm allowing for a margin of error in the sending vs. receiving of the communication that it took to trickle down to me; but it seems that Dr. H.'s partners are frustrated that their decisions were being second guessed when you would arrive the hospital with your client, and they were on call instead of him. An example that was given to me went something like this; when the Docs expected continuous monitoring, they got comments like "But Dr. H. says we don't have to have that"...and similar stories.

Oh my treasured friends! You know better than this! As incredibly knowledgeable and skilled as you are, once you and your client decide to transfer, you are no longer on your own turf. By definition, the pregnancy of the woman you are caring for has now become high (well, at least higher) risk, which takes you out of the care provider position, and places you into the support position. I know I'm not telling you anything new; but perhaps because Dr.H. has been so easy going and laid back when you came in, you assumed that his partners would be as well.

Not so. In my albeit distant and limited experience with all three of these physicians, they each have their own style of managing their patients. As with any practice, if a woman in labor comes in and her own physician is not the one on call, some compromises are going to have to be made if the other physician has not been consulted on the birth plans. At the very least there is going to have to be, if there is the time for it, some gentle discussion of whether or not she is comfortable providing care the way you assumed Dr. H. would. Keep in mind that you can't really be certain what decision's Dr. H. might have made...depending on the reason for your transfer, he might have insisted on continuous monitoring as well.

I can't speak for any of these physicians, any more than I can speak for any of you; and although I am well aware that our area is full of intervention-happy Docs who would just as soon have you prosecuted as look at you, I don't believe that every doctor out there is out to deny a pregnant or laboring woman her right to make well-informed decisions about her own body, her own baby, and her own birthing; but I do believe that every doctor has a right to practice in a way in which he or she is most comfortable...in a way that does not compromise their values, and that protects them from a lawsuit that could jeopardize their license, their practice, their family, and their employees and their families.

This is only fair.

If we want the medical community to respect us as collaborators, then we have to collaborate. We would not want them coming into a client's home and insisting on lithotomy position for the birth, or forbidding any food or drink in labor; in kind, we should not be insisting that they practice in a way that compromises their comfort level when a client is transferred into their care. Some compromises are going to have to be made, and the client needs to be made aware of this.

I know that, once a client is transferred, you feel very protective of her...that you want to advocate for her; but in truth, the legalities in this situation are that only a client (or her family) can advocate for herself. The fact that a transfer has taken place, in and of itself, is a clear indication that the client's hopes and expectations for her birth are not going to be completely met. It's a sad reality that we can't always have what we want, no matter how hard we try. Remember that old adage...how do you make God (the Universe, etc.) laugh? Plan something.

Life is unpredictable; the beginning life, as you all have experienced over and over, is equally unpredictable. Given the love and support of her treasured midwives, a client encountering a disappointment in her birth experience can be helped to feel the joy and beauty of her baby's birth, no matter how that birth is accomplished. True, the personnel of the hospital you transfer to may not be as supportive as we would like them to be; but that comes as no surprise to any of us; we know what kind of environment you are likely to encounter once the decision to transfer is made. Of course things could be done better than they are currently being done...but we aren't going to be able to achieve change with the one birth that is currently in question. It will take dozens and dozens of delicately handled transfers for the medical community at large to even begin to trust, respect, and cooperate with you. It's just the unfortunate reality that we have to accept right now.

Maybe it's not too late. This was a wonderful opportunity for collaboration; given Dr. H.'s respect in the community at large, once it became known that he was willing to back you up, maybe others would be willing to open their minds to the possibility (although I remember the situation with Dr.S. from years ago, and my hope is diminished somewhat). Maybe a well-written letter of apology and compromise, along with a request to meet and discuss the situation might change things for the better.

I can hope, can't I?

Blessings and Love,

K.

And Now for a Word from Our Sponsor...

2008-07-22T11:17:00.000-07:00

From reading other blogs of L&D nurses, I’ve begun to realize that things are pretty much the same all over the country. So, instead of attempting to rewrite what has already so elegantly been done, I now turn this blog over to my online friend at At Your Cervix… L&D nurse extraordinaire, future midwife, and all around “Good-ole-girl”. These are her words…I could only hope to be able to so clearly depict the realities of this “Love it, but Hate it” job

“Which leads me to some of my gripes and concerns about coming to L&D triage.

Don't ask for food immediately - it's not happening - think about it - you're here
because of pain, leaking fluid, vaginal bleeding, preterm labor, n/v/d, or for whatever reason. You will NOT be automatically given food upon arrival, and chances are good you won't get food while you're here on L&D. The best you can hope for is some clear liquids, unless your doctor allows you to eat. And if you can eat, chances are you don't need the level of care required on L&D. (Ed. Note…and no, we can’t provide a meal to your mother, your boyfriend, or your kids…I’m sorry they are hungry and you didn’t have time to feed them. I’m hungry because there are six more women here just like you, a dozen more sitting in the waiting room, we’re understaffed, and none of us in L&D are going to get a meal break tonight.)
Triage means: you will be evaluated, and seen according to severity. Your stomach virus is a lower priority than the preterm patient who is ruptured.
If you're not in active labor, expect to be sent home. Home is more comfortable than a small stretcher in a room with 4 other women who are also being triaged.
I'm not here to cater to your every whim. I am caring for multiple women, with multiple problems. I have to prioritize, so do not be upset if I can't get you that cup of water immediately. There is only one nurse in triage. I cannot be everywhere.
There are no TV's in triage on purpose - to discourage you from staying any longer than needed. Plus, I also need to be able to hear all 5 EFM monitors simultaneously. I cannot do that with 5 TV's blaring at full volume.
Each person may have ONE visitor with them. The triage bays are too small to accommodate your entire family.
Speaking of which, just WHY did your friend/family member drag your 1 yr old child out to the hospital at 10pm? (ed. Note…or 2:00 A.M., tired, fussy, hungry?)
I really don't care about how tired you are of being pregnant when you're 32 weeks along. You won't be admitted and induced because of this. In fact, you're here because we're trying to STOP your preterm labor. You really want a baby subjected to being in the NICU for weeks?
If you can't urinate on your own for the urine sample I need from you, I can easily use a catheter. But you don't really want that, right? Because I don't want to have to catheterize you unless I absolutely need to. It hurts too much. So please drink the fluids I've given you to help you produce urine for the specimen.
I'm glad you have signed your tubal ligation papers, but I'm not worried about that right now.
I'm going to keep my mouth shut when this is baby #4, and you're only 21. And the father of this current baby wants 10 more babies, because "they're so cute." And he doesn't work. Neither do you. Great.
I'm also going to keep my mouth shut when you presented to prenatal care only 1 week ago at 38 weeks, and you're in active labor today. Oh yeah, and you have 3 different STD's to boot. And the baby has a cardiac defect. And this was NOT your first pregnancy, so you knew better. But I will keep my mouth shut, even when I want to lecture you about good, early prenatal care.
Don't expect an epidural upon arrival - when your cervix is closed/thick/high, and your contractions are every 20 minutes. You're going home, because you're not in labor!
Please don't bring in your suitcase when you are the above patient. You're just going to have to lug it back to the car when you leave. Besides, it also takes up precious room in triage, and I need to be able to get to the fetal monitor to care for you and your baby. (Ed. Note…ditto the car seat…your not-yet-born baby’s car seat belongs, duh, IN THE CAR!!!!!!!!!!!!!!!!
Thank you for bearing with me when I've made you wait for that drink of water. I appreciate the "thank you" that you gave me when I was finally able to get it for you. I apologize for it taking so long.
Thank you for not arguing with both your doctor and then myself, when your doctor has discharged you home. Thank you for realizing that you don't need to be admitted today.
Thank you for listening intently to my discharge instructions, and asking intelligent questions to clarify any concerns. This shows that you are actively listening to my teaching.”
(Ed. Note…and thank you for looking at me with suspicion every time I make a request, perform a treatment, relay information to you from the doctor…I really am here to help you. If you distrust us so much, why are you here? We’re not the only L&D in town…
Ed. Note continued…yeah, yeah, I know, you’re gonna sue _________Hospital, because they were so stupid as to tell you that you are not in labor…guess you’re gonna have to add us to that claim, because YOU’RE NOT IN LABOR!!! Fine, drive on over to ________ Hospital, five miles further up the road…they’re going to tell you the same thing…and I just LOVE knowing my tax dollars are paying for your waste of hospital resources for absolutely nothing! By the way…don’t you have better things to be doing at 3:00 A.M. in the middle of the week than shopping for some hospital that will admit you because you are “tired of being pregnant”?...like, perhaps, SLEEP?)
Ed. Note, continued, one last time…for one of my personal favorites…

L&D RN…”When did your vaginal bleeding start?”

Answer…”About an hour ago”.

L&D RN…”Did you soak more than one menstrual pad?”

Answer...”Uhm…I didn’t use a pad…but there’s this spot on my underwear…

[L&D RN squints to see the pin-sized, pink dot on pts underwear, which patient happily whips off and holds up in the air].

L&D RN “When did you have sex last?”

Answer (giggling, looking up at snickering boyfriend…”About an hour ago”.

Here, another gem from At Your Cervix (catchy blog name, isn’t it? Wish I had thought of it, but that’s just how clever this writer is).

“Abuse of the"taxi" service

She arrived via ambulance. 18 years old, pregnant with her first baby. This was by far not her first visit with us, nor was it the first time she utilized the ambulance service to grace us with her presence.

"What brings you to L&D tonight?" I ask her, my standard opening line.

"My water broke."

Hmm, ok. I do my usual assessment and evaluation. Chief complaint of large gush of fluid x 1 at 3pm. Not wearing a pad on arrival, nor is she currently leaking any fluid. She's also smiling. Started having "contractions" while in the ambulance on the way here, now rating them 5 out of 5 on the pain scale.

(You haven't felt pain at a 5 out of 5 yet honey, I think to myself. Note that she's still smiling.)

She also mentions to me that the doctor in the clinic "broke my membranes" today. Hmm, at 9am, the time of her appointment? And she's just now coming in with c/o ruptured membranes at 3pm? I don't think so.

I try to clarify things with her a bit, "The doctor today must have stripped your membranes in the clinic, because she would have never broken your membranes on purpose in the clinic - it's just never done that way. Also, if she broke your membranes, it would have been accidentally, and she would have sent you over to us on L&D immediately for monitoring."

But no, she insists that the doc "broke my membranes" in the clinic at 9am, then then her "water broke" at 3pm. We're not talking about the highest on the genetic chain of life here, if you get my drift.

"So, why did you call an ambulance?" I question her.

Her mother answers, "well, we couldn't find anyone to drive her here. And besides, her insurance pays for the ambulance." I note "medicaid" under her insurance company in her demographics paperwork.

I try REALLY HARD to bite my tongue.

When later letting her doctor know that she's arrived, her doc even mentioned that the doc the patient saw in the clinic that day told the patient POINT BLANK - DO NOT CALL AN AMBULANCE, call for a taxi if you can't get a ride in to the hospital.

Oh yeah, and the doc stripped her membranes in the clinic that morning. For which, I wanted to verbally lash said doc, because this patient was only 37 weeks gestation.

In the end, the patient's membranes were intact, and she was sent home - without the luxury of a taxi - I mean an ambulance - to bring her home.

+++

Comments re: taxi/ambulance service abuse

Recently, in the comments section regarding use and abuse of the "taxi" aka ambulance services, there was this comment:

Thea said...

"What, no room at the inn tonight? It's sad when someone's career slowly strips them of compassion. Have you ever tried to get around without a car for any decent amount of time? Do you know what it's like, truthfully? Have you been 18 and pregnant? Do you have a clue?"

And here is my response:

"Thea - actually, I do know what it's like to be pregnant as a teen - twice. I had my first child at age 15, and my second at age 18. I wasn't bashing her for being pregnant as a teen, because I've been there myself twice. I was, however, upset - and rightfully so - that young women like herself will abuse the ambulance and hospital services like this. I had yet another ambulance abuser come in last night at work. It happens almost every single day! They don't care, because their "insurance" pays for it - well who pays for that? We do - the working class.

I have also been on state aid - for my pregnancy at age 18, only because my then husband did not have health insurance at his job. I knew the importance of prenatal care, and went to a clinic to receive it. Did we abuse services? No, absolutely not.

What really, really pisses me off, is the fact that after the ambulance brings the patient in, her entire entourage of family and friends DRIVE IN BEHIND HER! Or, like last night, the family members arrive BEFORE the ambulance does!

Add up the costs - ambulance ride: bare minimum of several hundred dollars. Eval time in triage at the hospital - minimum $750 for basic services, double that when we charge for an NST as well. That's a total of close to $2000 (including ambulance services) that the taxpayers pay. And 9 out of 10 times, the patient is sent home.

Now, multiply that by numerous instances by the same patient. Now multiply that by numerous patients who abuse the system the same exact way.

And that's just ONE hospital.

And people wonder why the health care spending and industry is out of control????"”

(Ed. Note…[but then, you knew this was coming, didn’t you?...You know, if you are pregnant in this town, and you call the squad to your house, they have to transport you…even if your husband/fiancé/boyfriend, who has a perfectly running car sitting in the driveway, didn’t want to be bothered because he just got off work, and he was too “tired” to drive you in, or your mother (who also has a decent car sitting in the driveway) was cooking dinner and wanted to finish her meal before driving you in…so there they sit, in the recliner in the living room, or at the kitchen table, watching nonchalantly as the medics load you up on a cart and take you out to the squad. I sure hope there isn’t a serious problem going on in your neighborhood right now…like some one having a heart attack, who just might die because your significant other was too tired or your mother didn’t want her Rice-A-Roni to get cold! And, since you are not in labor, and you are not truly sick, and neither is your baby, we are sending you home, and no, we aren’t going to give you a taxi pass…CALL YOUR MOTHER!)

END OF RANT (with mucho thanks to ATC)

Equal Time...

2008-07-21T10:40:00.000-07:00

...for nurses, residents, and physicians who work in obstetrics. In my last post I used a lengthy and extreme (but for all intents and purposes...had to change some facts to remain HIPPA compliant...true) example to whine about families who come to the hospital with expectations that they did not educate themselves about beforehand.

Well, now for the other (at least an other side) of the issue. It frustrates me how few nurses and physicians are vehemently anti-homebirth, (or any other kind of "alternative" birth) based on non-existent (e.i., their opinion), or poor research.

For a long time, all homebirth advocates had to rely 0n in terms of published research to back up their point of view was the "Tew" study, ( British Journal Obstet Gynaecol 1986 Jul;93(7):659-74) which is now over 20 years old. In a world where research over five years old is considered outdated, regardless of how well designed and carried out it may be, this is no longer going to cut it; nor are subsequent studies performed in the ninties. Now we have the Johnson/Daviss study ( BMJ 2005;330:1416 (18 June), doi:10.1136/bmj.330.7505.14), obviously much more recent, which, even in it's criticism of it's own limitations, makes a very good case for the safety of homebirth.

So why do so many of the people I work with not know about this study, or any of the others? Why do they think that the "homebirthers" out there are uneducated women who place more value on their experience than on the safety of their baby? Why do they make fun of women who choose to give birth in any number of ways that does not jive with the "norm" of being limited in movement by I.V.s and fetal monitoring equipment, no eating or drinking in labor (not even clear liquids, heck, not even popsicles! Does someone want to tell me what the difference between one contraband popsicle and half a dozen cups of "allowed" ice chips is?), pushing in lithotomy position while holding breath, who question the need for Pitocin if they are otherwise healthy and not post-term, etc? (Yeah, I know, it's a run-on sentence, but make some allowances for passion, OK?).

In a discussion I once overheard between several of our residents and one of our attendings regarding the "trend" of waterbirth, I heard the attending exclaim "and what if you get a shoulder dystocia while you are in the water, then you are screwed!"...(uhmm, excuse me, ever heard of theGaskinManeuver???...aside from the fact that "shoulders" are more likely to occur in lithotomy position).

Recently, a doula friend of mine told me about one of her clients who asked her physician (a woman who is an excellent diagnostician, and extremely skilled surgeon, and a favorite of many of the nurses where I work - including me - who chose her to deliver their own children) if she could push in a squatting position if she felt so inclined at the time. The physician said that she wouldn't be able to have clear access for catching the baby if mom chose to do so (hmmm...how so, when the mother would be several inches above the line of view if she pushed while squatting on the bed? I bet a lot of midwives would be surprised to hear that). This particular physician is part of a huge and popular practice, so I doubt that the loss of this one patient made much of a difference to her professionally, but I wonder if it made a difference to her personally? The mother subsequently gave birth to her baby at an outlying level-one hospital, in water, attended by a physician who is gaining in popularity because he seems willing to listen to his patients, and if nothing else, empathize with them. He managed to be able to have clear enough access to deliver this child, from the floor (I assume), and through water that, in all likelihood, became at least a little murky with the fluids of birth emerging with the baby. In the first situation, a woman denied a choice to another woman, seemingly for her own personal comfort. In the second, a physician who did not have the back up of countless residents and multiple ORs felt confident enough, and was willing to respect this mother's wishes. Professionally, this gentleman is very respected where I work. He doesn't transfer cases to us just because he would rather not deal with them, he doesn't take unnecessary risks with the cases he does transfer, and the attendings that I work with just seem to like him in general...he's a "buddy" to many of them; but there were more than a few raised eyebrows when I bragged that "hey, he's willing to do it, why aren't we?" I don't think it changed their opinion of him at all...but he's certainly not holding to the status quo, and I wonder how that is going over (unsuccessfully trying not to gloat here)?

As for waterbirth? Most of the nurses I work with think it's "gross"...I mean, you can get poop in the water (as if they don't see enough poop when the mother is up in stirrups); or, all that blood and goo in the water (what, they've never had to deal with blood and goo in this job?)! Can we get consistent here folks?

I once had a patient that didn't want pitocin routinely run in after she delivered her placenta. This was written on her (albeit, a little too long for my tastes) birthplan. When one of the nurses I work with, one who does a lot of training no less, asked "Why didn't she want Pit after she delivered?", the following conversation took place between the two of us:

"Because she didn't need it".

"She didn't need it?" (I knew I was being baited here, but I couldn't resist...)

"No. No one was yanking on her placenta, so she didn't need it".

"What do you mean?" (more baiting, my irritation and irrational need to win every
"argument" taking over),

"C'mon, C, you know better...left alone, a healthy one will come out on its own, you don't need traction, and there won't be any excess bleeding to worry about".

"I don't believe that"

"Of course you don't".

"Before we started using Pit after delivery, what was the main thing women died of
in childbirth?"

"If they were otherwise healthy? Infection"

"No it wasn't...it was hemorrhage!"

"You need to go back and reread your nursing school OB textbook".

Rolled eyes, sighs, shaking head, clucking tongue...tough having a "substandard" nurse like me on the unit.

And while I'm on a roll (am I ever not?)...about infection; we've recently been required to go to "handwashing" seminars, seeing as how insurance companies are planning to deny coverage should any of their insured's end up with hospital aquired infections (another lengthy post to come on this, I guaruntee). During the presentation, the well-known (I thought) story of Dr. Ignaz Semmelweis, the physician who originated the "germ theory of disease", based on his observations of the rate of puerpural infection when physicians treating pregnant women washed their hands between corpses and other patients and the laboring and postpartum patients. I assume we all know the outcome of this story? I assume we all know the story???? Evidently not...I was amazed at the number of nurses who had no familiarity with the story! Didn't this anecdote open most of our Med/Surge, Microbiology, Obsetrical, and Community Health texts, way back in nursing school? Sigh.

By the way...the aforementioned patient whose placenta so elegantly slid out without traction, and whose body (shockingly) required no Pitocin to keep its immedate postpartum blood loss under 300 mls, had been laboring most of the time on her hands and knees. True, it was a PITA to keep her baby on the monitor, but we managed. Just about when I thought my arm would fall off though, the same nurse I would soon have the previously mentioned conversation with came in to help with the delivery (so, we have our differences, but for the most part, we're always there for each other...just like any dysfunctional family). The doc was at the end of the bed, and baby began to crown. The mother was doing a fabulous job...her perineum was beautifully pink, stretching nicely with her short, slow, powerful non-valsalva grunts and pushes...no white, blanching, evidence of an impending tear. It would have been so easy just to guide baby out, and let the nurses help Mom while she lifted her leg over baby and turned over in bed...but no, the doc insisted, baby on the perineum, that the mother turn over in the bed immediately...and as she turned, baby's head ratcheted in the opposite direction, and you guessed it...a third degree tear ensued. Ask any other nurse on my unit and it occurred because the mother was on her hands and knees (grunting like a cavewoman I heard one nurse say...arghhhhh!)...and not because she was forced, at exactly the wrong time, to work against gravity and turn over! I could scream. I know the poor mother did...so unecessary!

In this same delivery, a young nurse, a nurse-midwifery graduate student, and an excellent new L&D nurse came in to help as well. She is a lovely young woman; confident; secure; patient; a breath of fresh air when things are getting intense and the primary nurse needs a hand or a new perspective. She soothed and comforted this mother with her lovely, calm voice and demeanor. In other deliveries I've seen her in, she just has a knack for gaining the absolute trust of the woman she is caring for. After the birth, I thanked her for her help, and complimented her on what a nice addition to the floor she has become. She, in an attempt to commiserate, I can only assume replied, "You're welcome...and thankyou; but it is all so much more pleasant and controlled when the mother has an epidural. I wish she had had an epidural...it would have been so much nicer!". I was so taken aback by her comment that I just let it slide by. I've always meant to gently revisit it with her, but have never been able to find the right time (or, I must admit, the nerve) to broach the topic with her again. This is a brand, new, "malleable" L&D nurse, a future midwife, an excellent clinician, with an excellent mastery of her craft, with so much potential to bring so much respect and compassion to her clients, and it turns out to be all an act???? How dissapointing. Why do we keep potentiating this?

And there are so many excuses why we don't change. I made no secret that I was reading Jennifer Block's book, Pushed during down time on the unit. I made certain to leave it conspicuously out on the table in the nurses station when I was with a patient. Did anyone ask me about it? No. Did anyone bother to turn it over, take a look at it? Not that I'm aware of. Instead, I overhead one nurse say "That's all well and good, I suppose, but it's different in the U.S. (excuse me, but the book was written by an American author, about American women, giving birth in the American medical system)...we've all intermarried with different cultures, and we have all different sizes of pelvises, and partners, and you just can't generalize about how easy it should be to give birth when you aren't a member of a more uniform culture". She never even looked beyond the cover of the book! She had no idea what the book was about; and, if her "theory" is so true, does she want then, to explain to me how so many of our not even five-feet tall Latina patients, giving birth to 8 and 9 pound-plus babies of big, tall, husky Caucasian and African-American fathers are able to do it so easily? I've seen plenty of tiny Asian women give birth to big babies as well, with very little, if any trauma or drama. Does this woman think that the pelvis of the American woman has evolved into something mostly inadequate for birthing, in the space of under 300 years? Please. It's not our pelvises that have become dysfunctional, it's our thought processes. To have read the book and had a rational discussion of it would have made it necessary to question the illusion of our own Golden Calf.

Finally, I get so frustrated hearing my coworkers referring to the midwives in town as "Lay" midwives!!!!! They don't know what a CPM is, they don't know what MANA is, they don't know what NARM is. Why????? The few times I've attempted to "educate" them about it, I got quizzical looks from them until I showed them printed materials from both groups, including the endorsements from physicians and state governments where they are recognized as collaborative members of the health care team...then I got little more than shrugged shoulders, and they still refer to these woman as "Lay" midwives...despite the fact that the founder of the most active group of midwives in this town is internationally known! She's a gem, she's a recognized expert in her field, she's drifting quickly into retirement, and we've never taken advantage of her opinion and expertise! What a loss.

For all my griping, I really do respect the nurses I work with. They can be nothing short of awesome in a situation that is going downhill fast. Most of them love what they do, and their patients love them. They know their stuff , particularly when it comes to high risk deliveries. I seriously believe that, in a city with too many L&D units, they are the best there are. They are the first person to be there if a nurse is in a situation that is getting hairy. If someone I loved or their baby were in trouble, these would be the nurses I would want to take care of them. Honestly, I would trust my very life with them. They are that good...I just wish that they had more respect for those who make different choices than they would. I wish they had more respect for the low risk side of things. I wish they would at least examine the other view before so staunchly defending their own.

I don't get it. I just don't. These are educated people. They know how to critically read research. The information is more readily available to them than it is to anyone else.

What Gives?????

Unbelievable!!!

2008-07-17T15:13:00.000-07:00

BirthTrack Labor Progress Monitor
Intense monitoring gearing up…

This device is FDA approved and actively being marketed to hospitals.

Probes monitor real-time cervical progress and “lets you know” when the baby is ready to come out or that labor is not progressing. Takes all the guess work out of labor.

http://www.barnev. com/www.barnev. com/indexea78. html?CategoryID= 177&ArticleID= 188&Page= 1

“Barnev's Continuous Labor Monitoring System, BirthTrack, enables obstetricians to make decisions based on accurate and timely information, resulting in significantly improved medical care, reduced costs, and a lower risk of malpractice.”

A note to Mothers to Be - http://www.barnev. com/www.barnev. com/indexecca. html?CategoryID= 163

I'd file this under the "Now I've Seen Everything" label, but we all know it wouldn't be the last entry.

Back to Basics...

2008-07-17T11:17:00.000-07:00

...as far as this blog is concerned, at least. Obstetrical Nursing.

One of the frustrations I've always had about what I do is the amount of misinformation that women today seem to have about their care during pregnancy and birth, as well as the complete lack of information on the part of some. Lately though, I've come across situations that make me begin to understand why more than a few physicians and nurses have that "rolling eyes" attitude towards women who want non-interventive births. Here is one of the more memorable examples in my own experience...

A family came to the L&D floor where I work one morning for a planned induction with one of the most conservative physicians in the area. Interestingly enough, this is one of the few practices in town that has nurse-midwives on staff, but this family was being cared for by the physician...they had never met any of the midwives. The expectant mother was accompanied by her husband, her sister, and her daughter. The husband was of a culture quite a bit more traditional (read that patriarchal) than the U.S. (as if the U.S. isn't patriarchal enough!) and his wife and daughter seemed to have adopted his customs in dress and, to a good degree, behavior. The sister was...I just can't find a "nicer" way to say this...a brash, loud woman, with garish, red, "trailer park" hair, who described herself as her sister's "doula", which she pronounced "Dowla" (think "towel" with an "a" added). When she introduced herself to me as such, I instinctively (and stupidly) corrected her "You mean doula (pronounced "doola")? "No, DOWLA", came the response, and she whipped out and handed me her sister's birthplan, all four pages of it, and set about helping her sister into bed.

Now, mind you, this family was here for a planned induction; but the birthplan, laid out "check off" style (copied from the internet), included every possible option from homebirth to a planned cesarean, and had statements like "labor to start naturally", "no I.V", water to break on it's own", "intermittent monitoring", "labor in water if desired", and, my personal favorites, "no enema" and "no shave prep".

WTF???????

Remember, that this family had chosen the care of one of the most conservative docs in town, at one of the most conservative hospitals! It was obvious that they had neither discussed this "plan" with him, nor had they researched the options available to them (unfortunately, our hospital does not offer labor or birth in water), or current birth practices. I mean, we all (don't we???) know that laboring mothers have not been given enemas or shave preps for nearly 30 years in this country! Had this mother been unconscious when her daughter was born? So, I sat down on the stool reserved for charting at the computer, birthplan in hand, asked the mother "Did you discuss your birth wishes with Dr. ____________?", to which the sister piped up, "This is a birthplan, not a wishlist!"

Enough. I had been in the room only five minutes with this family, and I had already had enough. Now, I'm not one to play "boss-nurse", but now I copped my best "Nurse Ratched" 'tude, looked "sis" square in the face and responded "And you got your dooola training where"?

"I'm self taught".

"Obviously"..."Well, my question was for your sister, not you, and hers is the only answer I will accept.

So sis turns to her sister, who was absent-mindedly smoothing her dress (she did not want to wear the hospital gown) over the fetal monitoring leads and says "She wants to know..."

"I assume she both can hear, as well as understand the question, and, again, I asked your sister the question. Please be seated, or leave the room".

Eyes squinted, shoulders squared, breath sucked in, mouth opened and something (equally loud and beligerent I assume) started coming out, but I stopped her before she could get the first syllable out..."Shall I call security?".

Glaring at me with the evil eye, she slumped down into the rocking chair next to the bed.

I continued with the mother. No, they had not discussed their birthplan with the doctor. I asked her if she understood that this was a planned induction of labor, which, by current practices of this doctor necessitated an I.V., that labor would be started by the use of drugs, continuous fetal monitoring would be required, water labor was not offered at this hospital, and that this physician would in all likelihood order her water to be broken as soon as possible. As much as I would like to, I could do very little to honor her birthplan.

She simply looked at me with a blank stare. The "dowla" left the room to "complain to your boss", and the husband left to call the doctor. Shortly after, "dowlasister" returned to the room, gathered up her purse, and left in a huff "You don't need me in this place!". Dad returned to the room, carried on an animated conversation with the mother in another language, and then turned to me "I can at least bring some tapes and other things in to make her more comfortable?" "Of course" I responded, and set about starting the mother's I.V. and getting her medical records for the stay started.

Fifteen minutes later husband was back in the room pushing a three-tiered cart piled with all manner of blankets, pillows, and two, count them two huge Rubbermaid tubs! He proceeded to take the top off of the uppermost tub, pulled out an air mattress, dragged it to the center of the floor and began to inflate it with an electric pump!

It took me a minuted to believe my eyes; then I told him that we couldn't allow the mat on the floor because it could impede the movement of people in and out of the room, especially if we had to move quickly, and especially in the event we needed to move his wife out of the room in her bed. He glared at me and began shoving the half- inflated mattress into the cabinet that is meant for an instrument table. I again apologized for not being able to meet their expectations, but that for their own safety, we could not allow the mattress. I would do as much as I possibly could to make their experience as comfortable as possible, but we had to work within the reality that this was, unfortunately, not a natural labor, but a medically induced labor, and that we needed to be able to move in and out of the room unobstructed. I also encouraged him to take as much of their "equipment" as he could back to their car, because we could not guarantee its protection should we have to leave the room for surgery. Not that I expected surgery, but you never know what might happen. Plus, he wouldn't have to worry about dragging everything to the postpartum room after the baby was born. He reluctantly agreed and started to pack back up his cart.

When I returned to the nurses station I was met with a cacophany of hoots and howls about the "nutcases in room 28", and comments about having "Jesus"on the floor (dad had long dark hair and a beard, and was wearing a long coat-like garment and sandals). I was glad to be going off shift for the day.

When I returned to work that evening, I learned that Jesus's wife had given birth uneventfully to another lovely little girl, and that everything had gone smoothly...after the father had once again inflated the airmattress on the floor, and the whole family had spread themselves out on it to watch a DVD! They had actually refused to move, so their day nurse stopped the induction (wasn't interested in catching a baby on a mattress that had been God only knows where), and called the doctor who left his office during a busy day of appointments, stormed into the room bellowing at the top of his lungs to the woman and her husband while the 10-year old ran races with her imaginary friends up and down the hallway outside the room. To this day no one knows what Dr.___________ said to the couple, but within minutes "Jesus" was meekly pushing his cart and Rubbermaid containers out to the parking garage, and mom was obediently climbing into bed.

Seriously! This actually happened!

Yes, this is an extreme example; but it's not the first time families have come to the hospital expecting things that could not be provided to them, or not having the slightest understanding of what their doctor was planning for them. They just obediently showed up at the hospital on the day "scheduled" for them, and expected things to go smoothly. If they had taken the time to think about what they would like to happen, they had never discussed it with their doctor. Many families who appear with birthplans do the same thing this family did...print one off of some site on the internet, and check off the items that some book not revised from the late sixties or early seventies suggested they put in it. When we ask them if their doctor has signed their birthplan, they seem surprised that this was necessary at all. They don't understand that it's not the hospital (as if the hospital in and of itself is a decision making entity), that determines how their care will be given, it's their doctor. Nor do they understand that they may see their doctor for, oh, 10-20 minutes...long enough for him or her to breeze in and catch a crowning baby, hand him or her off to the nurse, catch the placenta, stitch up any tears or episiotomy, and leave. Over and over I hear mothers and their family members ask "When is Dr._______ going to be here? only to be told that the doctor only comes at the end of labor. Of course, I don't know why doctors don't tell their patients this.

No, I'm not crazy about doing births the "medical" way. But Navelgazing Midwife put it best, I think "When you buy the hospital ticket, you go for the hospital ride." Of course I want your birth to be the best possible experience for you. I want to honor your wishes as best I can; but understand that I am limited to both your doctor's orders and hospital policy. If you want something different, you need to get your doctor or midwife's agreement first, and if it is something that is not normally done at this hospital, your doctor needs to make certain the arrangements can be made, within reason...and this all needs to be done weeks before your due date! Only if mothers and their families make their preferences known ahead of time, based on accurate information, can they begin to encourage change in a system that sorely needs it. It won't happen overnight, and it won't happen all at once; but it can happen, if it is handled realistically and with respect to the environment that health care professionals and workers have to negotiate.

GOING HOME

2008-06-30T20:59:00.000-07:00

Today I went home. It was wonderful and heartbreaking at the same time.

To me, home isn’t a perfect place. It’s where you feel loved, comfortable, accepted, encouraged. You love the people you spend time with there, but you don’t always agree with them, or sometimes even like some of them terribly much! Home is the first place you want to get away from when you want to assert your individuality, but the first place you want to go back to when you need the comfort of the familiar. You may disagree with some of your loved ones…heck, you may drive each other nuts sometimes, but you always love them…and they love you.

Yesterday I went to church, for the first time in months. In the past year, I’ve gone from a fairly regular church-goer, to a “Holiday” that is, “Christmas and Easter” Christian. Mostly, I’ve just chosen the path of least resistance, choosing not to leave the warmth of my bed and softness of my husband’s arms, in lieu of fiddling with the hair and makeup, and the aggravation of goading the rest of m y family out of bed. It’s just so much easier to snuggle back down under the covers, or to head home after a long Saturday night shift rather than detour to church on the way, sacrificing another couple of hours of precious sleep.

Or is it? I seem to go through a period like this every few years, although I think this has been one of the longer strays. Each time, after a few weeks, I begin to feel a little more irritable and restless than usual, and the tiniest bit isolated. This takes its’ toll on every relationship I have…with my spouse, my boys, my coworkers, my friends...even my patients. I am more in a hurry when I needn’t be. I am more prone to worry about things that either I can’t change, or that I don’t want to put the effort into changing when I can. When I finally get myself back to church though, my perspective seems to bust out like a swollen river through a dilapidated flood wall.

My congregation is huge…we are considered one of the six or seven “super-churches” in my area. We have I don’t know how many thousands of members, and probably just as many more casual visitors on any one given event . We encompass three distinct buildings, the original “traditional” one , the newer “contemporary” one, and the newest of our congregations, but the oldest, smallest building, in a decidedly “urban” area. The common pastoral staff over these three “campuses” is a group of people who are amazing in the way they manage the administrative and spiritual needs of this multi-faceted congregation. Even more amazing is the sheer vibrance of this place. It is filled with the most loving, caring, compassionate people I know…people who possess a faith so solid I can only hope to grow into.

Like any “family” though, there are problems. Suffice it to say, for now anyway, that I am a somewhat liberal woman who is a member of a rather conservative congregation, where the recognized leadership is mostly male. A few of my personal beliefs, particularly those on human sexuality, are in direct conflict with those actually outlined in writing as the core teachings of my congregation. This is difficult for me…who am I to disagree with individuals so highly educated in religious history, practice and principle, and whose support, counsel, and yes, wisdom has always been a mainstay of my support system?; but there it is…I just can’t accept every core teaching, no matter how hard I try; but the one thing I am certain of is that I love this place, these people…and they love God, His creation, and I am humbled to know that they love me. This place, these people…are my home.

I wish I could say that this grand love I speak of was how I conquered my laziness, and got out of bed on Sunday morning to attend worship, but I can’t. I slept until noon , enjoyed a long, hot shower, primped in front of the makeup mirror, got dressed, and headed out in the early afternoon with my family to attend the Celebration service for the life of my friend Steve, of my most recent post. Steve died peacefully just over a week ago. This is a tremendous loss…not only for his family, but for many people. Steve was an incredibly loving, optimistic, accomplished man. To “meet” this wonderful man go to http://www.marriagejunkie.com/ (scroll down to the June 24 entry), and http://www.royalgazette.com/siftology.royalgazette/Article/article.jsp?articleId=7d8588f30030018&sectionId=118. Be sure to read his online journal as well, at www.caringbridge.org/visit/stevejudah.

So Steve, as he had been doing for most of his life, brought me, and I’m sure others, “back home”, even after his earthly death. During the service, his beautiful daughters and their husbands spoke of him, as did several of his friends and accomplished colleagues. What was central during each of these tributes was not only what an incredible man Steve was, but how many people whose relationships…with their spouses, their families, their children, their coworkers, their God…he guided towards wholeness, not only during his illustrious career, but during his dying as well.

It was a time filled bittersweet tears and almost raucous laughter, both a mourning and a true celebration. It was also a tremendous personal gift. Call it what you will…Coincidence, Divine inspiration, or simply enough of an emotional release to break open the “blocks” I’ve been experiencing...in my writing as well as my spiritual, physical, emotional, and professional well-being...when I left the service Sunday all confusion about my own earthly “transitions” seemed to have melted away. Decisions I had been wrestling with seemed to have suddenly become “no brainers”. I knew exactly in what direction I wanted to go, and I had some pretty reasonable ideas about how to get there. More importantly, I got just enough of a spiritual “kick in the backside” to realize what was most important, regardless how many twists, turns, and backslides my path will inevitably take...indeed, even if I never reach my anticipated goals. If I value , nurture, and above all love the people with whom I am in relationship, whatever the outcome, my life will be a good one…not easy…and certainly not without pain… but satisfying. Goals are good things; but it's the journey that counts.

What a relief; and what a tremendous blessing.

METAPHOR FOR STEVE

2008-05-02T18:37:00.000-07:00

Years ago, my husband and I discovered a wonderful place to unwind and regroup at a rustic inn located in a hiker's wooded paradise an hour or so by car from our home. While we were there, I had the most profound conversation with the owner of the inn, Ellen...

Ellen had taken over the management of the inn from her mother, Ann, who had died several months before from mouth cancer. The inn had long been a dream of Ann's, one that she had been able to bring forth in spite of countless obstacles; and just as her dream was coming to fruition, she became ill. During her transition from life on this earth to whatever "hearafter" she, I, or anyone reading this might believe in,she wrote a short book..."A Journal of a Dying", that chronicled her last weeks, and the love, support and care she received from her daughter and woman-friends as they accompanied her to that door through which only she could pass.

After learning that I had once worked with a hospice organization, and was at the time, both a doula and a nursing student hoping to study midwifery, Ellen gave me a copy of her mother's journal to read. I spent three hours of a rainy Saturday, snuggled in a chair by the wood stove in the common room of the inn, and devoured the book. Ann spoke clearly to me, and whoever else had the opportunity to read her words, "hear" her voice through the pages she wrote while she waited to step into eternity. The last chapter of the book was written by Ellen, as Ann had lost the strength to write. It was a bittersweet ending, but one filled with the joy and hope brought by knowing beyond a shadow of a doubt that this life is not the total of our experience...it's just the beginning.

I was so overwhelmed by the book, that I sought out Ellen to tell her how much I loved it. She responded with the most amazing thoughts. I can't remember her words exactly, but they were something like this...

"I knew you would appreciate it. I remember having my own children; and while my mother was dying, I remember thinking how similar dying seemed to labor...it's unimaginable pain; it's incredibly hard work; the people you love do everything they can to help you through it, but you know that, ultimately, the only person who can do this is you; and just at about that point, a "peace" comes into the room; a laboring mother seems to become unaware of what's going on around her...she's moved inside of herself, accepting the inevitable, gathering all her will and power to get this done; the dying person begins to seem as if they have one foot in this world, and one in the world they are about to enter; and then, just when you think you you can't take another minute, not another second of this, a life tumbles into the room, or through to the next dimension, and there is sense of profound relief. No more pain, no more struggling. Lots of tears...but also a sense of joy...as bittersweet when a loved one dies, as it is a celebration when a loved one is born. It's two poles of the same experience".

I was speechless (and if you knew me, you'd know how extraordinary that is). Ellen's metaphor was so profound to me. I've never forgotten it. Indeed, I'm privileged to see this miracle of transition several times a week as I nurse mothers through their labors; I remember seeing it when I worked in hospice, and I saw it when I held vigil with my mother, my brother, and my sisters as my father died.

And now I'm seeing it with Steve...a wonderful, anointed, learned man, a special friend, someone who my husband and I, although we don't see him often, will miss dearly when he dies. I wrote this entry for Steve, his beautiful (in every sense of that word) wife Sharon, and their three equally beautiful daughters. Steve is dying. He's fought his disease with all the strength and resources at his disposal; and now he's accepted, probably more fully than anyone else, the inevitable outcome of his journey.

It isn't fair! He's too young. He and Sharon were just getting back to that "just you and me, kid" phase of their marriage when the responsibilities of parenting give way to more time for each other, and a future filled with grandchildren, travel, and many more happy expectations. He's well-known in his field...his contributions are huge...and there were many more to be made; but those are my gripes. Steve seems to have made his peace with it. Here, I want to share parts of the last few entries he's made in the online journal he keeps to communicate to his family, and to scores of friends, clients, and colleagues who love him dearly...

+++++

Wednesday, April 30, 2008, 10:22 PM, CDT

This is such a strange and surreal time - standing in the gap between earth and
eternity. I feel that all I need to do is
take a nap or exercise and then everything will be
normal. Then I recall that I'm wearing a powerful pain
patch, taking anti-nausea medications, am getting IV
fluids for advanced and terminal cancer. I'm blessed
to have wise medical counsel so that I can experience
these beautiful though surreal days of quality.

I believe that shortly I will be called into eternity. I will be
called by a new name and go to a place that has been prepared for
me. I will recognize my new name when I hear it. When we
encounter God, there's always a change. and often a struggle accompanies this transformation (ed. emphasis mine)
I'm living the struggle, encountering God in
new ways, being changed...

Friday, April 25, 2008, 04:37 PM, CDT - Greeting Friends and Family,

An interesting thing has been happening. Various persons have
responded to our current circumstance by saying that they feel
called by God to show love in a special way to us. I'd like
to put this in a larger context. Think of the words like
calling, promise, covenant. One way God calls us to serve is
by specifically laying on our hearts something that we can
promise to another person. For example, someone could say, 'I
promise to look out for you in your dating relationships with
young men in the absence of your father.

So times like this transition between earth and eternity
provide a special summons to think through these
opportunities. I want to challenge you to think about how
God may be calling you to make a divinely inspired
commitment, promise, or covenant to someone's needs that
you are keenly aware of and you are equipped to serve. Is
God speaking to you?

In this simple and practical way we are loving one another.
And that's what it is all about.

Wednesday, April 23, 2008 10:38 PM, CDT

Greeting Beloved. This is the most important message I've yet
sent to you from my perspective. This morning I h ad a most
surpassing spiritual experience. I want to place it into
three parts (1) the context, (2) the message, (3) and the
experience.

(1) The context is that we had just decided to pursue hospice
care in order to have quality of life for the remainder of my
life rather than furter treatments or interventions since my
diagnosis is terminal. I see th is as an opportunity to
celebrate the transition between earth and eternity. So with
this backdrop I went to sleep at 12:30 AM and awakened at 5:30
AM with an incredibly crystal clear message. The message
follows:

(2) Peace.
Life Death
Live a good life.
Do Good.
Accept Salvation through Christ.
Die.
Live Eternally.
Peace.

(3) Lastly let me convey the experience. I had the most
overwhelming experience of PEACE that I have ever had in
my life. So my wish for you is that you too find Peace
as God calls unto you.

I love you. thanks for your ceaseless prayers and support.
Steve.

+++++

This is the best way I could think of to pay tribute to such a
remarkable man, and his beautiful family...to share his words in context with the words Ellen shared with me all those years ago. In response to Steve's
encouragement to make a "covenant to someone's needs"...that I am "equipped to
serve", I'm blessed with several, at least. My estranged friend Kathy will be getting a bouquet of yellow roses on her 50th birthday this month (she's from Texas); I'm seeing my husband, and my love for him in a whole new light...and my life in a perspective that, while it is full of potential and possibilities I now
remember to remind myself is a gift, just as it is in the here and now; and I'm blessed
to be "equipped" to provide nursing care to women as they labor to bring their
babies into the world. I'm blessed to be able to say that this is my calling.

Steve's calling was to help people heal their relationships...with their partners, their families, their God, their selves. He continues to do so in no less
a profound way than he did while he shared his gift in countless books, journal articles, or, most importantly, face-to-face sharing with those he felt called to serve...and who felt called to reach out to him. His work has "given birth" to renewed marriages, healed relationships, and a unique form of therapeutic communication that is being taught and used with great success all over the world.

I can't quite bring myself to say the the words..."I will miss you, Steve". Because your presence will always be strong in your written works, and in the love you shared with the people you guided through pain to healing. It will be strong in my memories of your voice, your smile, and yep, that little sigh of frustration I could just barely hear, and that oh, so subtle quizzical look on your face when I just wasn't "getting it".

Steve, I "get it" now.

And I thank you.

Thanks. It seems like such a tiny word relative to all you have done for us.

That is how you loved your God; that is how you loved everyone who ever had the
privilege of meeting or knowing you.

And yes, that is certainly what it is all about..

WHERE HAVE YOU BEEN......

2008-04-07T08:45:00.000-07:00

??? I've been asking myself, at least in terms of this blog. After all my "talk" about needing to get back to writing, I should think I'd have been back here many times since my last post.

I suppose I shouldn't be too hard on myself. At the time of my last post, my family and I were in the process of moving to the most amazing house we've ever lived in. We absolutely love it. I do not, however, love the piles of laundry, and the piles of "stuff" in my dining room and garage which have yet to be unpacked and placed in their new "homes". I so look forward to the time that the house is organized, and I can return to making meals in my non-chaotic kitchen (we've become fast food junkies these past few weeks of transitioning), get back to swimming, which has gone on the back burner as of late, and especially get back to writing and working towards whatever future may present itself to me.

Sounds a little "new agey", doesn't it? "whatever future presents itself to me". Well, actually that is not an original idea of mine. I've started reading Eckhardt Tolles book that is being discussed by Oprah (yes, Oprah). As far as her online "class" goes, I have yet to participate live...I started behind and I hope to catch up to them by the last two classes...but I am enjoying the book. I'm not certain I agree with every idea that is presented in it, but that is precisely the point of the book...finding what works for you. In the first weeks' discussion between Mr. Tolle and Ms. Winfrey, Mr. Tolle, talks about his writing, and how the words just would not be written until the timing was right. He knew he wanted to write...but something just did not click until one day he received the thought "move"...and he moved from England to the West Coast of the U.S., at which time the words for his book began to tumble from his heart, to his head, out from his fingers onto the page. When he would return to England, he wasn't able to write new material...he could edit and proof, but new words wouldn't come to him.

Another point from the first chapter of this book was look at your life not as what you wanted to do with it, but what life wanted from you. That thought appealed to me. I love what I do right now...despite all of its frustrations; but I've always wondered if I want to continue it indefinitely. I don't think so. For one thing, the energy, both emotional and physical required by the job is tremendously stressful and tiring. For another thing, the frustrations of watching women submit themselves to a system which doesn't seem to respect them as rational, thinking, responsible human beings with the right and ability to make choices about their birth-giving times is overwhelming sometimes.

And then there is serendipity. That is the only word I can think of that describes so many of the things that have been placed in my path recently. Our new home, for example. Right now, for a number of reasons that may or may not come out in future posts, we are renting, rather than "buying" (if the way we "buy" our homes in this day and age truly constitutes ownership), our home. A year ago, when we thought our lease was about to expire, we went looking for, and thought we had found the "perfect" home to rescue us from our tiny, run-down half-double with it's growingly psychotic landlord and deteriorating neighborhood, we found out, much to our dismay, that a clause I missed prior to signing the lease required three months notice prior to the expiration of the lease date, in order for the lease not to automatically renew for another year! I was crushed! Although the clause was very unusual (that is to say, unheard of), according to the legal research I did, getting out of that lease would have been a nightmare of what was already a nightmare of living next to a landlord who was quickly becoming insolvent, and who would do just about anything to keep from losing one of the only renters (me), who paid him on time. We decided to "table" our house-hunt, waited out the year, gave our three months notice, not knowing where we would end up, and one day my husband walked into the door and said I've found an amazing house. You have to see it. I did, and I loved it...it's practically perfect for our needs, and we never would have found it if we had been able to follow our origial plan for our first "perfect" prospective home.

Another perhaps serendipitous occurrence happened a few nights ago at work. Things were a little slow, (unusually so), and I took the opportunity to ask a Nurse Midwife who happened to be on the floor that night what made her risk getting her CNM when she needed to stay in a town that had so little openings for them. Her response was that at the time, her family would have been able to move with her upon graduation, but she "lucked out" and found her current position. She then proceeded to tell me something that I was not aware of, that the opportunities for CNMs in our city are opening up, and began to name them....

And off I went, once again considering the huge step of going back to school at my age, to get a masters. There are a lot of things up in the air regarding that quest...and a number of things I feel I should do before I seriously pursue it...get organzied at home, get certified in Women and Infant Nursing, and as a childbirth educator, study for, and take the GRE (it will take a high score for me to be considered a truly competitive candidate), and to take the local Community college up on its offer of a part time teaching job. Each of these steps can be accomplished in the next year and a half, and, with the exception of the GRE, each will serve to provide me with additional knowledge and "fall back" skills, whatever I end up choosing...rather, whatever Life (or God, or the Universe) chooses for me to do.

Who was it that said "The journey of a thousand miles begins with but a single step"?

Time to take that first step.

Why am I "in Transition"?...

2008-03-16T02:47:00.000-07:00

...For a lot of reasons. I'm not willing to say just how old I am yet (early midlife will have to suffice for now), but I am getting to that point in my life where the transitions are more about getting older than they are about growing up. My boys are teenagers now...the older of the two will graduate from high school in a few months and head off to Marine Corps Boot Camp (reservist for now), and then start college. My youngest will graduate in two and a half more short years. The empty nest looms.

I hate saying this, but I can't stay solely a Labor nurse indefinitely. I love what I do, despite its frustrations and the tendency to burnout; but it's taxing work, physically and emotionally. I wonder sometimes just how long my back and knees will hold out. Losing weight and exercising will help that tremendously, but there has to be a limit. There are a couple of nurses on my unit who have worked until retirement (over age 60), and even come back in a limited capacity...a shift or two every week or so. They inspire me. Emotionally the work can be rough as well. I know this sounds sexist, but it's unfortunately true...wherever the work force is dominated by females, witchiness happens. I get tired of the constant bitching and gossiping. Not that everyone is that way, nor do the ones that do it do it all the time; but it does affect moral on the unit, and for me, tends to burnout. Hospitals being what they are (a business as well as a service), dealing with the "corporateness" of it all can be frustrating; and finally, particularly because I work on a unit that deals with a lot of high-risk situations, and a lot of patients who live in not-so-good situations, the work can be emotionally taxing. Optimism can be hard to come by sometimes. Having said that, I do work with some amazing women, incredibly skilled and experienced nurses from whom I have learned much; and I have experienced many rewards in working will all kinds of families.

I need to generate more income. I didn't graduate from nursing school until I was 40, and I still have the student loan debt and lack of retirement savings to show for it. I'm looking at ways I can do that...teaching, consulting, maybe even writing. Teaching, particularly looks like it will happen before long; I've been talking with a local community college about becoming a part-time clinical instructor and occasional lecturer in their program; that will entail reducing my hours in my current job, and working during a different time of day during the part of the week I'm teaching (I'm a confirmed night-shifter), and that will be a big, if welcome change. Change can be challenging...even the good changes.

Finally, I still think about getting an advanced degree. At my age, I wonder if it will be "worth it"; but there is so much I want to do that a Masters or even higher degree might open the door to;and there is so much to learn. I just wonder if there is time enough to do it before retirement. I can't imagine ever being completely retired...I'll always want to stay involved in my field as long as I can, in at least some small way...but the reality is that the older you get, the less opportunity there can be, in terms of employment, unless you're in upper management...and even then ageism can get you, even if it technically is illegal. Financially, it will be difficult to justify the extra expense of another degree if something doesn't change drastically in my finances.

There is always hope.

Why Blog?

2008-03-16T00:43:00.001-07:00

I used to think blogs were goofy; I mean, who cares about what Joe or Josephina Schmoe or anyone else out there thinks about anything? I thought bloggers were just lonely, dysfunctional people with nothing better to do, or extremist types who were using the internet to spew their venom (I respectfully exclude Arianna Huffington from either group...I've always liked her blog). Furthermore, who could possibly care what I have to say about anything?

Shame on me.

I've found there are lots of blogs out there that have good information...many of them I've listed on my front page. I think you have to be careful...there are a lot of good and not-so-good motives for blogging; but being a discerning and reasonably intelligent person, I think the blogs I've been reading have been well worth the time I spend on them.

Take Navel Gazing Midwife for instance; the stories she shares renew my faith that we can find a way to make birth less clinical and more woman-centered; that women will stop being afraid of the awesome power of their bodies and celebrate, rather than shrink from that power. Barb is willing to talk about when she changes her opinion on a belief, based on life experiences that have matured her...even when those experiences have been born of her own mistakes and misconceptions. She's willing to share her anger and her joy, literally pour her heart out about her feelings about her experiences...and I identify with so much of what she says that I feel validated about my own feelings...i.e., there are women out there, women of more experience, that feel the way I do...I'm not crazy after all (neurotic, somewhat...crazy, no).

The writer of At Your Cervix amazes me; she is willing to share such personal things about herself...her weight, her decision making process about turning to weight loss surgery, and her subsequent success after that surgery; she posts pictures of herself...I'm not ready to put myself out there that far yet, but I appreciate her being able to...it's encouraging for a woman who also struggles with obesity; I love to read what she writes about her experiences as a Labor and Delivery Nurse...particularly her cynical but humorous accounts of patients with their myriad of silly complaints, the abuses of the public system (taking ambulances to the hospital for little things like a cold, when a friend or neighbor was available to take them but just didn't feel like it for whatever reason), inappropriate behaviors (why, oh why do people bring dozens of people with them to the hospital in the wee hours of the morning, including sleep-deprived toddlers who are unsupervised and into all sorts of places they shouldn't be?), outrageous expectations (no, we aren't going to pay for your cab-fare home, and no, we don't provide free meals to your family), and amazing ignorance about what is happening to them (no, you can't get pregnant again if you're already pregnant!!!). She tells stories of women and families that are bringing children into the world under painful circumstances (teen mothers, addictions, abuse, crushing poverty). Again, she validates my frustration; but for every nut-job out there there is a woman or family who do not abuse the system, who do behave appropriately, whose expectations are realistic, and who will provide a loving, secure home for their child; At Your Cervix shares some of the most heartwarming stories of them, and how she served them (as well as the not-so-lovable patients). She inspires me to be the best nurse I can; and isn't the title of her blog the funniest play on worlds? Hilariously creative!

Midwife With a Knife helps me understand the reasons why obstetricians make some of the decisions they do...she shares a lot of the medical knowledge she has. Sometimes something she writes about piques my interest and I head out to the medical library at the university to get more information about the topic.She shares the thoughts of a woman getting through residency, and helps me understand what residents are up against; I still get frustrated about some of the things I see out of the residents I work with, but more and more, thanks to MWWAK, I realize that I don't always have all the information I think I do when I pass judgement on a particular behavior or decision by a resident; MWWAK has helped me learn.

My friend C's blog is sort of like a journal...I imagine my blog will serve that purpose for me as well. Things that C might not say out loud she puts on her blog...and I learn more about who she is and what drives her. My guess is that that C is learning the same thing, just from organizing her thoughts and writing them down in a tangible place...and I'm pretty certain that I will do the same thing. Again, just like the other bloggers I read, I'm amazed, and grateful for how C puts herself out there. She, like most of the other bloggers I read, places quotes, pictures, music and other downloads on her blog, and I want to do that eventually as well. Already in building this site, I've learned things about manipulating my computer that I didn't know before...and I'm looking forward to learning more

It looks like blogging can be a way of meeting and communicating with others who share my beliefs and passions...and that is always fun, and often life-enriching. Amazingly enough, someone far away from where I live has found my blog and left a lovely comment (I'm so excited; my first comment!!!). Several years ago I stumbled on a site on the internet where women with similar interests shared their experiences with each other. Over the years we've become a real community. I've talked to several of my internet friends over the phone, corresponded with several of them privately, rejoiced with them when children were born or adopted, wept with them with shared disappointments, got into some pretty heated (but ultimately respectful) disagreements with them, encouraged and been encouraged by them when things were tough for one of us; I get a kick out of "talking" with women from all over the world. I wouldn't stop logging into that site for anything; and now I have another way to meet people. I'm enough of a cynic to know I have to be careful; you never truly know who is on the other side of those communications...unseen to whoever is reading your posts, a person can make themselves out to be anything they want to be; but over time, you can, if you are cautious and judicious, pretty well determine who is genuine and who is not. Interesting world we live in, isn't it? It seems that nearly as much communication is happening over the internet with people we've never seen, as with friends, coworkers, neighbors and aquaintances in a face-to face encounter.

So I decided to start a blog myself; If I've nothing of value to say to anyone else, It will be of value to me; already I've busted that writing block wide open, and I seem to feel more energetic about other parts of my life as a result. This is a release for me. I think it's a good thing.

Did I say in my last post I was going to be more succinct in the future? Guess I'll have to work on that. Looks like I also need to work on those run-on sentences!

For Anyone Who May Still Be Out There

2008-03-13T00:25:00.000-07:00

Ok, so the first post was a little (!) wordy. I'll get better. More succinct. You get the picture. Coming soon, my discourse on what used to be my opinion of blogs and bloggers.

Just Do It!

2008-03-12T20:36:00.000-07:00

I used to love to write...maybe it was because I was younger, less jaded, and so passionate about things I thought I knew a lot about; maybe it was because it organized the myriad of thoughts buzzing around my over-occupied mind; and a little, well maybe just a little more than a little, a few people, including one very special professor, told me I did it rather well. For the past couple of years though, I have done very little writing. Burnt-out maybe? Overloaded with work and stressful life changes? Probably.

Then I met my friend C.

C. is a young woman almost half my age, but more my equal than anyone my own age I know. A woman with a passion for many of the things I also love, a woman with an amazing future, and a huge contribution to make to the world that I'm looking forward to watching unfold.

C. and I run loosely in the same circles...but they're circles that I mostly float around the periphery of because for the past three years I've immersed myself in my job and my home-life; I managed to keep abreast of what was going on in the field by lurking on chatboards and email lists, occasionally posting to them, and the occasional email or telephone call to or from friends and colleagues I had for too long neglected in my tunnel-visioned life.

It's taken me most of my life to come to the conclusion that there are very few coincidences. I always used to hate it when people would say "Everything Happens for a Reason". Bullshit (sorry, but that's the way I always internally responded to that drivel); I mean, the world can be a pretty rotten place. People we love die, friends drift away, marriages fall apart...does someone want to give me a reason this happened?????, I would think (or say outright if the mood struck), when something particularly horrible happened to me or a friend or aquaintence....; but what I've slowly come to believe is, that no matter how painful a life event may be, no matter how purposeless it seems, if we're emotionally healthy enough to ride it out, we can eventually give meaning to that pain. So, I still don't believe that "Everything Happens for a Reason"...but I do believe I can learn from whatever happens to me, good or bad...if I give it enough time for the pain to dissipate a little, for the emotional wounds to heal a little, for the scars of cynicism and disappointment to soften a little...and if I just quit struggling to figure out "why" something has happened, and to just accept that it has, and accept that this is going to hurt...maybe for a long time...but I will somehow get through it.

So how in the world does that philosophical soliloquy relate to meeting C., and how does meeting C. relate to my deciding to start writing again, by just putting something, anything, down on paper (or the computer)? Well, it's a long story; but I'm going to try to give you (whoever the "you" is that I'm writing to...I'm still a little ambivalent about blogs...more about that in my next post) the "Readers Digest" version...

Eighteen (eighteeen!...God, how did that happen?) years ago the first big tragedy (maybe the only one, because I tend to overdramatize a lot) of my life occurred. My firstborn infant son died at the age of three weeks after surgery to correct a heart defect. At the time, I though I'd absolutely die from the pain of that loss; but I didn't. And as I slowly emerged from the days and weeks of grief I crawled through in the months after his death, I began realize I had been given a gift from this precious "lost" child. I had loved being pregnant. I was overwhelmed with the sheer power of giving birth to him; I was overwhelmed with the immediate love I felt as I cradled him close and kissed his little face; he made me realize just how much I would love being a mother; and, as time went on, I found my my other calling...one that I might have ignored had I not crossed paths with this precious little soul.

At the time, I was a 30-year old mid-level manager at an insurance company, teaching mostly 20-somethings how to process medical claims. I had done fairly well for myself, but I was bored...B-O-R-E-D. I had gotten away from my initial goal of going to medical school, and, I was getting a lot of "rubs" from my superiors about how "smart" and "talented" I was,; so I, with overinflated ego, decided to go back to college on a premedical track. I got pregnant at the end of my first year, three weeks before I was to sit for the MCATS. Early pregnancy and I did not get along too well, I was exhausted most of the time, so I decided to sit out the testing until after the baby was born. After all, I was planning to quit my job and return to school full time then, and would have lots of flexibility (because...babies couldn't take up that much time, now could they?...Oh, the ignorance of youth). Well, second trimester things felt a lot better, I reveled in decorating the nursery, buying all manner of "crucial" baby equipment, embraced my growing belly and the attention of prospective grandparents, and friends who doted on me with showers, casseroles, and offers to clean my house during my "confinement"; and then Jonathan came tumbling into the world, and after a beautiful birth, and wonderful first two days of life, he tumbled into the pediatric intensive care surgical unit of our local children's hospital, and I began, for the first time in my life, to become an adult...and I was only on the first step, having had that extended adolescence that we children of the Seventies are so famous for.

Well, despite the utter mental and emotional chaos of those three weeks of Jonathan's life, I was aware enough to notice what was going on around the pediatric SICU. The nurses were incredible. I was fascinated watching them manipulate the lines and monitors, start IVs, change dressings, comfort the babies, comfort their families, interpret test results, act fast when a baby was starting to fail, and have everything prepared when the attending surgeons would strut through giving orders for things the nurses had already anticipated. These men and women were hands on. Each morning the residents would shuffle through, examine all of the babies, make copius notes on charts, and take their daily beating from the attendings. The ones who seemed to fare better were the ones who treated the nurses with respect. The nurses would give them tips on how to survive the grilling, educate them on what was going with each complicated case. The ones who dismissed the nurses with that "Me Doctor, You Nurse" attitude got nada...and they were the ones who got tortured the most during morning rounds by the attendings. Each morning and each evening they would glide through the unit and disappear again, leaving the nurses in charge of the precious little souls; and I came to realize that, if I got into medical school and went through with it, I would always regret it. I was a nurse at heart. Ok, so I don't make nearly as much money, or get nearly the respect that a physician gets; but I love what I do, and that's what counts.

So, three years, two babies, and one marriage later I went back to school...managed to claw my way into and through the college of nursing, and at the ripe old age of 40 I graduated with my BSN. During school I found my "niche" in courses that dealt with women's issues, and I was introduced to the profession of midwifery. I got involved with the local direct entry midwives in town, and through them met many women who were involved in one way or the other in caring for childbearing women. When I graduated, I went to work as soon as I could in Labor and Delivery, hoping to return to school someday to get a Master's in Nurse Midwifery; as I became immersed in trying to survive as a new nurse, and a newly single mother, I drifted away from daily contact with my college community, but I kept in touch with them over the phone and internet; and every now and then I'd see a post from a doula named C., and they were always thoughtful, insightful posts. Several years after that, I walked into work one night on the new unit I had just started on two months before, and the Charge nurse handed me a chart , rolled her eye and deadpanned "Birthplan. Doula. You're the "Earthy-Birthy" type, they're all yours. Let me know when they're ready for their C-section", snickered, and walked away. I muttered and bitched all the way down the hall, walked into the room expecting to see the usual arrangement of I.V, epidural pump, beeping monitors and sleeping laboring mother, but instead I saw a beautiful young woman sitting on a low "birth stool", arms wrapped around her husband who was kneeling in front of her, and a slender young woman with short, sandy hair, down on her haunches behind the woman, talking softly into her ear, massaging her back, encouraging her, reassuring her husband, and soothing her lovingly through every powerful contraction that swelled through her body. C. literally loved that woman and her husband through a long and painful labor, to its triumphant climax of the birth of a precious baby girl who went immediately to the breast, latched on securely and stayed there with C.'s gentle, confident, non-intrusive assistance. No IV. No epidural. A laboring mother that moved, moaned and swayed through her birth. A baby that went to the breast as if she had been doing it all her life (she had!). I was overwhelmed. After three years of working Labor and Delivery, I was finally beginning to accept what was in the beginning to me, a stunning and disappointing conglomeration of elective inductions, scheduled cesareans, and medically managed "painless" via almost universal use of the epidural, births. I had long since decided that becoming a Nurse Midwife was out of the question, because you couldn't buy a position as one in this major-medical-school-physician-controlled city, and I couldn't move to another city or state, thanks, unless I were willing to give up custody of my two sons to their father. I wasn't. In three years, this was the very first unmedicated, "natural" birth I had seen! C-section, my ass! Take that, Charge-nurse biotch!

So, I had become pretty disillusioned with the world of birthing as accomplished in the 21st century. But when I met C., that began to change. She and I soon discovered, during the course of this lovely birth, that we were indeed the same women who had corresponded sporadically on an email list related to birthing issues. We planned to meet for lunch to get to know each other better, and that lunch turned in to a three-hour gabfest that would have gone on for hours more had we both not needed to get back to our "real lives". Our friendship has grown over the past year (two years?) facilitated by late-night phone calls to discuss one or the other's frustration with some of the outrageous behaviors of certain physicians, nurses, and yes, even midwives, long, "talky" lunches where we shared our lives and passion for our work, our kids (my teen boys, her pre schoolers and teen stepdaughters), my remarriage, her enrollment in college, and her realization that she was "smart" (make that brilliant), her evolution to wanting to study nurse midwifery to, "Hell, I don't want to take orders, I want to give them...the right ones...and I don't want to give up my patients if they truly need high-risk care or a c-section...I'll go to medical school!" And she will, I'm convinced of it. She's gonna be a true, "Midwife with a Knife". And I want to be the first person on her staff (if I don't croak first). C. has refreshed my hope that birth can be more than a darkened labor room that becomes a garishly lit sub-surgical suite with its beeping monitors and pumps. She's reignited my passion; She's given me tips on how to get babies to turn from posterior to anterior and avoid an almost certain c-section for their mother; she's helped me reframe some of my observations of women during labor; she's introduced me to other women involved in the field, she's referred me to books, blogs, and all manner of information that I suck up like water. C. and I are never at a loss for words when we get together.

And C. has a blog. So, I decided, well, if she has time for a blog, what with school, work, husband and kids, then maybe I should start one...that would at least get me writing again, even in an amateurish way. I've got to kick this "block" I've let fester for far too long...and, as whoever might torture themselves by wading their way through this first psuedopsychotic ramble of mine might notice, I think you can agree...

It worked.