And Now for a Word from Our Sponsor...

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...

...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!!!

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...

...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

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

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......

??? 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.