A big pot hole for my confidence

Many times throughout my days at the hospital I pause, and think to myself "I should really write about this on the annals..." but alas, the transition from brain to post has been a challenge I have not, until this morning, overcome.

Let's see - in short - since August 20th I have caught a bunch of slippery babies, transitioned from watching to being watched and now, to flying solo at the hospital, and (last, but most certainly not least) have gotten married. It has been a blur of a past few months, which have left me curled up in the fetal position in the late evenings sipping on a glass of wine, watching Mad Men if I am lucky, or, as has been happening as of late, baseball with my now husband. Doing anything remotely taxing on my brain has seemed, quite honestly, out of the question.

In general, orientation has gone well. I have done tons and tons of admissions, and have caught less babies than I had hoped, but enough to keep my adrenaline up and my love of midwifery current. I have been feeling rather confident, and ready to take on the challenge of being the sole provider in the room at the always-different moment of birth.

Until yesterday, I suppose, when my confidence took a bit of a nose dive, and reality of being the new provider that I am set in with the steely cold vengeance. The day started out quiet- and from 8:30-9:30 I even broke out my knitting project for a lovely secluded moment in our cozy call room. Then, as most days do, the pace picked up as woman after woman presented to L and D triage with contractions, pain, bleeding, and the like. There was even a woman who came in after having fallen on her belly after being chased by a pit-bull. Somehow, during report, the type of dog was always mentioned, as if it gave the gravity of her case more umph to say pit-bull, as opposed to, let's say, a poodle (she was fine in the end, with a bruised hip only, pit-bull be damned).

Two of the admissions were mine. One, an 18 year old girl from Puerto Rico with a far away look in her eyes throughout labor, turned my confidence around and spun it on it's wobbly head. After admission for spontaneous labor, she progressed without any pitocin or epidural (yes, a rarity where I practice, and something to be stangely proud of, I suppose) to full dilation around 6pm - right before my change of shift. I decided to stay for the birth, my numbers have been rather low and had been with her all day. Her pushing was somewhat disorganized - but, without ever getting the hang of it externally, she managed to move the baby down to almost crowning... which is when the baby began to poo and poo and poo (meconium, thought of as a sign of fetal stress). Pediatrics was called to the delivery as is protocol after meconium, and the nurses changed shift as she was about to crown.

The new nurse in the room was a woman I had never worked with before, and she seemed to be against what was going on from the moment she walked into the room. She was exasperated with the disorganized pushing, with the fact that our sweaty 18 year old was pushing into her face, not into her bottom, and with me trying (usucessfully) to get her up and squatting. The girl resisted, the nurse resisted, and, after two ungraceful attempts, I let her back on her back with her legs supported back, to the position everyone seemed to want but me. Somehow, through my failed squatting attempts, the frustrated nurses coaching, or the tenacity of the pushing mom, the baby crowned. And crowned. And crowned.

It was one of those moments when I wished it was the 1970s and I could just cut an episiotomy and free this child from the tight skin of her mother. But I didn't, knowing the research that perineum's torn naturally heal better than those cut by our scissors - so we waited. And the impatience and frustration in the room seemed to grow as did the beads of sweat on my chest. Just as I looked up to see the fetal heart monitor and get a sense of the heart rate, the head popped through the perineum, restituted, and the baby was born (Mistake #1 - never look up from a crowning baby). I placed her into the birth soup - unslickly- while I clamped and cut the cord... I felt like my hands were adorned with lead gloves rather than latex - and they seemed to move slowly. As I brought the baby over to the warmer to meet the team of pediatric residents waiting to greet this child - I placed the baby backwards on the warmer for their liking (Mistake #2 - head should always face the room). Moments later, there was a low hum of griping that I had clamped the cord too close to the umbilicus for their liking. Mistake #3. So far, without anything bad actually happening, I had annoyed all providers in the room - and was feeling like crawling under the sheet with our 18 yr old patient to hide.

I couldn't do that - but instead delivered her placenta - and she hemorrhaged. She was low risk. First baby. Not a prolonged labor. Got pit after delivery of the baby. And voila. A gush of blood that wouldn't cease. Pit IV. Cytotec in her bottom. Pit IM. Still bleeding. Then I called in the attending and she started to slow down... It wasn't a mistake, but it didn't go well. And I felt like it was bad thing #4.

On inspection she had a 2nd degree tear - like a natural episiotomy - that I sewed up slowly. The nurse that had been so frustrated in the beginning continued to remind me, through snide comments and remarks, that I was horribly inexperienced. I couldn't wait for the moment that, 2 hours after my shift was over, I could leave the room, write my note, and say goodbye. Before I left I hugged and kissed my smiling patient, and told her that I was proud of her. She said thank you. And I thanked the nurse for bearing with me and my newness. She didn't even smile. She just reminded me to take the cart out with me as I left the room. While I know it was the patient who was most important in this case, I couldn't help but focus on the nurse. I walked out of the room feeling ashamed. I was proud of my patient, but was not proud of myself.

Today I feel a bit better about it - it was my first unsupervised delivery ever. In my life. And while it wasn't slick or beautiful - it was safe - and the baby was born. And her bottom will heal. And her iron will replete, and all will be well. I will try to remain proud of myself for what I did right in that room - and not the little things that I did wrong. And so I will move forward to the next birth, and hopefully my list of mistakes will begin to grow less with each birth, and the number of smiles will grow more... both mine, the nurses, and the patient.

Off to clinic. No more time to reflect. I just need to jump back on the horse and continue riding on.