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.

Hospital Hangover

It's amazing how much energy the hospital can suck out of me. Even though I'm still under a strict 'no touch' order until I get properly credentialed in the hospital, I felt like I worked for my money yesterday. And woke up today, feeling the worse for the wear, struggling to open my eyes and leave my cozy bed.

I spent the day battling our terrible computer system and filling out admission paper work in triage. I think I broke the record for the longest time ever taken to fill out an h and p (history and physical) - 5 hours. Perhaps I cheated in the breaking of this record, because the computer froze and my first version was lost entirely... By the end of the day, however, I felt like I had some sort of grasp on the many quirks and minimal perks of this system. The system has the ironic name of 'Sunrise' - which it is anything but. I would more appropriately title it "Darkness."

As the evening progressed into the later hours of night - the hospital got stranger and the cases got more interesting. I saw things that I had only read about in school. (Side note: this attitude always makes me feel conflicted, as it is a direct using of someone else's misfortune. I always want to preface stories like this with the fact that even though I learned from it it would obviously be better if it had never happened in the first place. The women I will write about probably had one of the worst days of their lives yesterday and I am happy only that I could be of minimal comfort). The interesting first case to walk through the triage door was a woman at 39 weeks pregnant who had been assaulted by her husband. I had presented on domestic violence during school and what to do - but in all honesty - a case like this had never confrunted me so directly. As I was leaving last night the husband showed up, started screeming, and created a mini-Maurie Pauvich episode on the floor. It was scary and sad and eye opening.

The second moments of chaos came slightly after. A woman who was 10 days post partum after a c-section came in complaining of "I don't feel well." Then she seized. And seized. And seized. My non-touching order allowed me to take her sobbing friend out of the triage room and explain to her everything that was going on - from afar - then chat her up about her own new baby, and how good of a friend she was for taking her bestie here. After the hanging of mag, and the giving of oxygen and the overhead paging of anesthesia and more chaos on the floor - she seized again. While no longer pregnant, this woman had an obstetrical emmergency that we all fear most.

I biked home late last night, images running through my mind, thinking "Wow. it's not just stuff you read about. Shit like that really can hit the fan." My experience in this job will inevitabley teach me so much about my field. It already has. I wonder what I will learn about tomorrow...

That's more like it...

I almost cried during a birth today - which I haven't done in a long time. It wasn't actually during the birth itself, but during the labor.

The patient was a young woman, in labor with her first baby, and accompanied by her boyfriend and her boyfriends family (mom, and two sisters). Her family was - well, we didn't know - the mom-in-almost-law gave the universal sign for "I have no idea - and don't ask..." with a shrug of her shoulders, a shake of her head, and a gentle roll of her eyes. She had dilated rather quickly, but things had slowed way down while pushing. She had been pushing for almost three hours - which- by any standards, especially my new medical institution, is a rather long time. We didn't think the baby was very big, the position seemed fine, and she was pushing with strength. Her family-in-almost-law was lovely and doting, and things should have been moving more quickly than they were. The docs were knocking on the door - both literally and figuratively - wanting to know what was going on - and starting to use the evil c-word when talking about the plan.

I was at a loss for what to do - we had changed positions, and used all the tricks up my fledgling sleeves. However, the midwife whom I'm shadowing today was almost eerily tuned into the woman's feelings. After a long hard push, the patient started weeping. Not a frantic 'this hurts like hell' feeling - but a deep, mournful cry or sadness. The midwife put her face close to the patients and stroked her hair. "I know this is hard," she said. "You want your own mom to be here with you. His family is wonderful - but you want your own mama now." The laboring woman's tears increased, and we encouraged her to cry as she needed to. She held her boyfriend's head, and cried, and grabbed the hand of her future mother-in-law - and cried. And they cried. And that's when I almost cried.

Voila. In about 30 minutes, she pushed out a screaming baby boy. It wasn't a shoulder or a body part dystocia. It was emotional dystocia. And she let it out. And it worked.

And.... we're back

After a year long-hiatus, I'm back to the bloggesphere. Perhaps inspired by a huge transition and a new job, or requests from disappointed family and friends to start writing again, or perhaps because I missed public reflection on my career choice.

In short... since I posted last - I've graduated from a master's program in nurse-midwifery, passed my boards, applied for and accepted a job as a midwife at a large public teaching hospital in an inner city, visited Costa Rica and Israel, eaten lots of felafel balls and musli, and settled into an apartment with my fiance which feels like home.

Yesterday was my first true-day at work. I am only allowed to observe, as I am not yet privileged at the hospital. What a different place from the small, touchy-feely hospital where I did my training. There are no tubs, and only one doppler for intermittent auscultation (vs. continuous monitoring... the not-evidence-based-standard), which certainly speaks to the lack of it's use and there are no tubs in any of the rooms. There is a contraption, hidden in a closet, called an aqua doula - a portable tub which requires about 10 different small metal pieces to hook it up to be filled in by a sink (!!). Um, yeah, you guessed it. No one uses it.

Perhaps auspiciously, however, the first birth I witnessed there was a precipitous totally unmediated birth by a 19 year old woman. She was in control, in rip-roaring labor, and ready to give birth when she arrived. I learned, in watching her birth, that as new as I am, I have my own style, and was surprised by some of the hand techniques of those around me. I found myself, although rendered to the side of the bed to observe only, desperately wanting to touch and jump in hands first. It was not the birth that I would have conducted exactly, but it didn't matter. I was reminded, that even with 1 clueless but curious male medical student, one nervous ER intern catching, one experienced midwife, one inexperienced observing midwife, one nervous boyfriend, and two nurses at change-of-shift, birth is beautiful.

fits and spurts

This school year is starting out with a squeak and a jolt - in some need of oil to make it run more smoothly. It has been moving in fits and spurts - long 14 hr days to New Haven and back for class, 12 hour call shifts with a beautiful birth, job applications and no success, and lots of down time in between. I have been trying to get ahead on school work - I know that when the wheels are greased this year will fly by - but at the end of some days, it's hard to point to what I really accomplished. Putting together some Ikea furniture, writing a short paper, starting to flush out a lit review for my thesis? Sometimes it doesn't amount to much - and I miss the feeling of being a nurse or midwife when someone says thank you at the end of the day because you worked your butt of for them...

In due time - it will run smoothly. I must seem like a real schmuck for complaining about free time.

Here are a few photos I took on my last day in Lusaka. Things I had been meaning to photograph for a long time.

I jogged by this bike repair/car hub stand often - and always wanted to photograph this guy and his wheels. My last day there I finally was able to meet him. He was piss drunk falling all over himself to allow me to photograph him - happily doing a modeling shoot. Fall from grace?

Perhaps the opening photo for a future power point. The sign from the labor ward outside Chilenje Clinic what I took when going to drop off thank you notes and eye glasses.

A tuck shop in Chilenje.

The drunken friends of the bike repair man, offerin my Shima to eat. I gracefully said no.

Luckily, my PPD test came back negative. But what a scary sign! This was all over the University Teaching Hospital.

Nurse writes in the Times

A nurse after my own heart - writing about her experiences. Trying to gain something new. It shouldn't be unusual to hear from a nurses prospective, but it is. Kudos for the Times.

School has started - but is certainly not in swing.

My new apartment is wonderful here in Cambridge.

Life is trucking again. This article reminds me to take advantage of every moment. Important to remember, especially when things get busy.


http://www.nytimes.com/2008/09/09/health/09case.html?8dpc

Ina Mae in Zambia

A Zambian Midwife and the baby bundle in Chipata.

In my last week here I have been reading Donna’s (my host) copy of Ina Mae Gaskins Spiritual Midwifery from 1977.  This book is groovy in the true Simon and Garfunkle late1960’s sort of way.  Besides being an integral component of the midwifery cannon of literature, it is a fierce, if not dated, reminder of the potential pleasures of having a baby – and the essential role that trust, sensuality, surrender has in birthing [this is an Ina Mae term as is Puss, Rush, groovy, heavy, loving, tantric, psychedelic, telepathic, get high with each rush, smooching….]  

I have really been enjoying it. The first half of the book is birthing stories, each about 2-3 pages, written by women and their partners about their birth experience with the midwives on The Farm – and before the farm existed when they all lived and traveled in a caravan of school buses. (Yes, I’m telling you, those were the groovy days.)  While the stories are full of breech deliveries, premature births, tight cords around necks, and even a stillbirth, the excerpts by the women convey such a sense of satisfaction with their birth experience – even when there are episiotomies and hospital deliveries involved. They talk about loving the midwives, loving their partners, and feeling blessed no matter what the outcome.

The farm midwives placed a lot of importance on working through psychological blocks and interpersonal dynamics between partners on the ability of the woman to both safely and fulfilling deliver the baby.  They tell the women often that ‘tight lips equals a tight bottom’ and encourage the mothers to ‘smooch’ their partners, and get out all of the psychological crap between them.  The men play an integral role in the process – and many women write about how they relied heavily on the energy given to them by the presence of their partner.  They create an environment of love and trust and sensuality – as they say, “a baby should come out in the same way that it was created…”

And then I sit up. And I’m in Zambia. And birthing in the clinics here could not be any more different than the loving, groovy rooms of Ina Mae’s farm (indeed – they are all home births – the rooms designed and created by the mothers themselves).  And I wonder – should this privilege of a fulfilling birth experience come only after basic sets of safety standards have been met? Is this the equivalent of Maslow’s hierarchy of needs? That only after the basics have been met (shelter, food, safety) can one actualize one’s self and experience true fulfillment?  Or is birthing opposite? Is it especially important to create a kind, loving, mother-friendly environment in low resource settings? Or is the question a completely mute point? Is it important for ALL women, regardless of financial status or geographical location or health status to have that kind of experience? 

Yes. To both.

Here is why I think this kind of experience is especially important in a place like Zambia – besides the fact that (I believe) it is a human right to have a humanizing birth experience. 

1) One of the reasons that maternal mortality is thought to be so high here is the low rate of facility births.  Many women deliver at home – with traditional birth attendants – and not in the hospital.  The government has made a big push for facility births because the staff is trained to handle complications and there are more resources than at home.  However, after describing the birthing practices here – including the occasional hitting of women, yelling at them that they are ‘uncooperative’ – and leaving them virtually alone until they grunt and push – my mom said it best: “Why would the women come to the facilities to have their babies?” Even if it is ‘safer’ – it is less pleasant – more isolating- less fulfilling – and therefore less chosen.  If more emphasis was placed on creating a pleasant birthing experience for the women – perhaps that would reduce the maternal mortality just by getting the complicated cases near the interventions that could save lives.

 2) There is physiologic and anecdotal evidence that decreased stress leads to fewer complications in birth.  Separating a woman from her family, her partner, her loved ones, and placing her with a care provider who she perhaps less than trusts increases her adrenaline, which blocks the oxytocin (the contraction, orgasm and breastfeeding hormone), which slows down labor and increases risk of complications. So make her happy and decrease complications.  Sounds easy, no?

But the other parts of me thinks- do all these niceties really matter? Or are they just that? Is it basic skills in safety that are at the crux of decreasing the number of women who die in or after childbirth?  

During my presentation to HSSP to update them on the preliminary results of the project – I talked about the ubiquitous ‘baby bundle’ – as I call it. After the baby is born, it is whisked away and wrapped in a cloth diaper, then a towel, then a crocheted blanket, then a huge fuzzy adult size blanket – so it looks like an overstuffed burrito baby – which is so large in diameter that it is tough for two adult arms to completely wrap around it.  I talked about how that baby bundle reduces any skin-to-skin contact that the mother-baby pair gets, and I included in my list of recommendations that more emphasis be put on the importance of skin-to-skin contact in the hours following birth. 

After the presentation, the deputy director, an American woman, expressed her dismay in this reduced skin-to-skin time due to the baby-bundle, to which her Zambian colleague responded "everyone in this room was born into a baby bundle. We all survived."  Which is true.  It’s a good point.  And it calls into question that, which I think, from my midwifery background, is ‘essential.’

So what is the answer? Should each clinic around the world strive to create the groovy experiences as Ina Mae and her team does? Or should it be a strictly safely first approach? Or is it an obvious combination of the two that is important? 

It is this question of mother-friendly services that brought me into midwifery in the first place, back in 2002 in Tanzaniza, inspired by Mary Kroeger. I think it is this question that will keep me active and passionate about this profession.  I think one thing is clear – there is no harm in providing mother-friendly-fulfilling birth experiences. So why not include it?  We could all use a bit more Ina Mae. 

[There is an international effort to improve the friendliness of birthing practices. It came out of the work done by Mary Kroeger and her wonderful colleagues:  International MotherBaby Childbirth Initiative - www.imbci.org]