Firestarter

You know what totally sucks for all involved? Telling a woman that she has a sexually transmitted infection. And she's married. And she wasn't sleeping with anyone but her husband.

My clinical this semester has provided me with some extraordinary experiences in this technique. Once was with my preceptor as we examined a 30-something with numerous herpes lesions. As she lay on the exam table in lithotomy position, she burst into tears. We cultured the lesions and confirmed the diagnosis. Another was a 23 year old, fresh out of college and newly engaged. She came in complaining of an increase of vaginal discharge. It wasn't really bothering her, it just didn't "seem right". We offered her the whole work up, and chlamydia was the culprit.

But nothing compares with the 50 year old woman who just learned that her husband of 32 years was involved in some weird underground S&M ring and had a hunkering for one night stands. She wasn't having any symptoms, she just wanted to get checked out. She had several small warts on her labia. Everything else checked out fine, but needless to say, genital warts aren't fun either. They were so small she hadn't even noticed them. We applied tricholoroacetic acid (TCA) and sent her home seething. She said her next stop was the lawyer's office. She had already made an appointment.

One the other end of the spectrum, I've had a 40 year old hyperventilating in the exam room because she was petrified she was going to learn she had an STI. Based on her symptoms, it sounded like good ol' yeast. And on exam, it was classic for it. A wet mount proved good ol' Yeasty Pants was paying a visit. It took my preceptor and I a good 15 minutes convincing her that it was just yeast.

Oh, the adventures of student midwifery! I am sure the best is yet to come.

C-Section Rates By State

Our Bodies, Our Blog has a post linking c-section rates by state. Only a few states were listed, as c-section data can be difficult to attain. I learned that one of my alma maters has the highest c-section rate of that state. I guess I shouldn't be surprised given that there was a very low threshold for c-sections, and there were days that all we had were c-sections.

Salvation

My semester is coming to a close soon, and I have somehow managed to be ahead of my school work today. So I thought I'd allow myself to procrastinate a little bit before moving on to the next bit of work laying ahead of me.

The other day I was in a major department store, looking for a gift for my preceptor. An older woman wearing way too much make-up and large circa 1980 spectacles covering 75% of her face approaches me and asks what I was looking for. I told her that there was nothing specific, and I'd get her when I needed help. But she was one of those persistent types that wasn't going to let me go that easy.

She asks who I was shopping for, and I tell her. She launches into a story about her son who is a graduate student interning at a major media firm in Chicago. She was dropping names left and right, like I might actually know who they are (as far as I know they are the idiots putting out the lame ass McDonalds commercials). Then she asks what I am in school for. When I tell her, "nurse-midwifery", she starts cooing and squealing like a pig being thrown it's slop.

She starts telling me that there are so many jobs out there for this that I'll have no problems. I said that I think she meant nursing jobs, not nurse-midwifery jobs. She says, "No, no, nurse-midwifes (yes, she said midwifes, this is not a typo). I know there are jobs!" I begin explaining the difference, that there are tons of nursing jobs but in this area there aren't many nurse-midwife jobs available. Again she tells me I am wrong.

I began to explain the demographics of midwives in the area and the obstetrical dominance that marginalizes nurse-midwifery practice. And then I realized, why am I arguing with this saleswoman? I am happy that she thinks nurse-midwives are great and that there is a strong demand for them, but would educating her make a difference?

It made me think of the J&J nursing campaign (which, by the way, I can't stand) that was launched to the public. My understanding was the purpose was two-fold: increase the numbers of people entering the profession and help the public understand the importance of nursing. My problem with it was that you can't possibly convey what nurses do in a 30 or 60 second commercial slot without ending up with some hokey saying and little vignettes of smiling nurses holding the hand of an elderly person in a wheelchair. Is that really effective?

There has been some talk (somewhere, can't remember where) of putting a campaign out for nurse-midwifery to help the public understand what CNMs do and gain their support. But can you imagine what that spot would look like? Some midwife would be shown holding a newborn, smiling over at the mother who is sitting pretty in her hospital bed. Or some other such simplified scene. In my opinion, I find this potential campaign insulting... even more so than the J&J campaign.

The question remains: how do we strengthen the nurse-midwifery profession and have the public's support? I can't foresee this being an easy task.

I'm Just A Girl

I'm not kidding you guys with this at all. There is a German company that has put out the "erotic scent of a woman". They say it's not a perfume. I sure hope it doesn't smell anything like this.

Don't go opening that link at work or in any public computer. I'm giving you fair warning.

Virtual Insanity

I've been working on a paper about maternal requested cesarean delivery and to my (somewhat) surprise have found that it is likely just media hype. I think you'd have to have your head in the sand to not be aware of this phenomenon; look at all the celebrities who have had cesareans just because.

One argument I have come across is that cesarean by maternal request is a woman's right. It's her body, her baby, so she can have a cesarean if she wants. I understand the feminist philosophy behind this, but is this angle being exploited by the obstetrical field to legitimize more cesarean births? The latest stats say that 30.2% of all births were by cesarean in 2005. That is roughly 1 in 3 babies born by surgery. And depending on the state and/or hospital you look at, those numbers can be higher.

There is an article in the November issue of Bioethics regarding this issue. The framework in which the author examines this "trend" is feminist, and argues against cesarean birth by choice. I do not have access to the full article, so I am just going off the abstract. But I lean in this direction.

Whenever this topic of cesareans comes up, there is always a backlash of "if it weren't for c-sections, we'd not have the great advances in maternity care today." I agree, to a point. Absolutely there have been numerous lives saved by the advances in cesarean birth. I certainly don't see them as an "all bad" procedure. But that doesn't mean there isn't risk. The World Health Organization states that there are no improvements in perinatal mortality with cesarean rates over 15%.

But getting back to my original point, this "trend" may just be all hype. Perhaps its just the media and the celebrities playing up these c-sections. I've also read that it may be related to the obstetrical perception of more women requesting c-sections without medical need, yet studies have shown that most obstetricians receive very few requests. So in other words, the obstetrical profession is out there saying the rise of c-sections is largely related to maternal request but there isn't data to support this belief.

Virtual insanity, indeed.

Unbelievable

I realized that I haven't posted any google searches here on REBIRTH. The insane internet searches that bring people to my blog have not stopped with Life & Times. Oh yes, they continue to bring the strange and curious right here.

Ban doulas
Say what? (Or back in the day, I'd respond, "Word?") Are you kidding me here? Why would you want to ban doulas? Doulas are great! I even have a whole post about them. Doulas provide awesome labor support to women, can reduce the need for pain medication and epidurals, and release hospital staff to do what is unfortunately taking up too much of their time (documentation).

Secret discreet diapers
Good luck finding some, because the ones I've seen are anything but discreet. And no, I don't need them. I just know about them. I'm a nurse.

Jumping rope continuously while pregnant
And why the hell would you be doing this? Are you not uncomfortable enough?

Hide the erection
Yes, please do.

Nurse touched erection
Where did I write about erections? Because I can guarantee that it wasn't because any nurses I know (including myself, thank you very much) were going around grabbing erections that happened to be exposed throughout the unit.

Cystocele fuck
How is this possible? Anyone?

Pregnant FTM
I had to look up what FTM means. And again, when in the world was I talking about this?

Deep Cover

While teaching my first childbirth education class, I had a dad make the comment that nurses who have not been through labor and birth themselves should not teach the class, nor care for women who are in labor or postpartum. At the time it didn't bother me at all. I knew that my years of experience in obstetrical and maternity nursing more than qualified me to care for such women and their families. The nurse I was training with in the class was quite perturbed; she had several pregnancy losses and finally had her first child not too long before. This nurse had a planned c-section so she didn't experience labor and felt this dad's comments were insensitive.

Nine times out of 10, I get asked if I have children by the woman I am caring for. And most are visibly disappointed when I say, "No, I don't." I have added the comment, "But I do have several animal children" to keep them from probing any further. (You'd be surprised how many will ask why I don't have kids, when did I plan to have them, and do I even want them at all). In the past I didn't mind being asked if I had children or that some were disappointed that I don't. I know that these women who are asking that are looking for a way of connecting with me, to trust what I have to say and how I will care for them.

But you know what? I'm starting to see my fellow nurse's point of view. Does it really matter if I have children or not to properly care for women? Does my 10 years of nursing experience not count for anything? What if I was an oncology nurse? Could I not care for a woman with breast cancer because I have not experienced it personally myself? Of course not, and those thinking that I am not fully qualified to care for mothers and their babies would never pose the same expectation in any other setting.

Are You Gonna Go My Way?

I was caring for a young girl who was laboring beautifully. She wouldn't describe it this way, with each contraction an exclamation of how fucking awful it was....and then she would continue on text messaging. She didn't want any pain medication, but kept talking about being numb. I was confused as to what she wanted, and talked to her about her options. But she wasn't having any of it.

After a couple hours of the fucking awful contractions and text messaging (oh, and sneaking in some glances at I Love New York 2 on VH1), she said she was ready for some medication. I called for the doctor, who said, "So we'll get you an epidural."

I said something about her asking for IV medication, but the doctor turned to this young girl and said, "Do you really want to be feeling this or do you want to be numb?"

"I want to be numb."

"An epidural, it is!" exclaimed the doctor.

And so the epidural goes in without a hitch. I suggest that maybe she could get a nap. She said she'd rather watch tv. Either was fine with me. She was happy.

But then the baby wasn't. The baby's heart rate took a nose dive. I told her to roll onto her other side as I opened up her IV fluids and put the oxygen on. She said she didn't want to. She was comfortable. I told she had to. Her mother came to my side and told her to do what I asked. And she began to complain. She would not move.

"Please, please roll onto your other side," her mother begged. I pushed the emergency light by this point and was expecting the barrage of people to come in.

And then I said something that got her to listen. "I don't care that you are comfortable. You need to get onto your other side now. Your baby's heart rate is down and moving onto your other side can help!" My tone was not nice. I felt like I was reprimanding her. Yet she listened.

After a few minutes the heart rate came back up. She looked scared behind her oxygen mask. I paused to catch her eye. "Listen," I said, "I want you to know I didn't intend to sound mean, but when the baby's heart rate goes down I need for you to help me."

This came to mind because I have been reading about birth trauma. I find myself reflecting on interactions I have had with the women I have cared for and wondering if I have made anyone feel scared or traumatized. I certainly don't think I am above it; I mean, I do work on a labor and delivery unit in a hospital... with a very medicalized approach to birth...I am part of a system that can take total control over every move. I learned labor and delivery nursing care under a medical model. I am sure that there were times I fell under the belief system of The Man. I try very hard to be the advocate for the woman I am caring for, but it is very hard to follow through with that in this environment. Hearing myself sound so authoritarian and bossy was a startling reminder of this.

This girl ended up with an emergent cesarean birth. The doctor said that no one could go in with her; hearing this pushed her into a pile of tears. I went to her side and said, "I will be with you the whole time." Once she was transferred to the OR and on the table with 6 people over her, prepping her, shouting out different things, I stood at her head. The anesthesiologist had the "gas" mask on her but big tears were streaming down her face. As the room spun in a controlled chaos, I put my hand over hers (strapped down, of course) and squeezed. For a fraction of a second I felt guilty for doing this as I watched the people who came in to help doing her abdominal prep or gowning the doctors. She hung on until the anesthesia kicked in. And I hoped that I did something to help her feel ok about what was happening.

Oh, and once she was awake in the recovery room she was text messaging again.

Polly (the fast version)

I've been finding that I have a soft spot for the young girls who come in with a laundry list of problems. My first real introduction to this type of girl was in my primary care rotation; an 18 year old who was essentially homeless and couldn't even scrape up enough money for tampons and had soiled every last pair of underwear she owned with her period. Most would look at their history and cast them off as losers, possibly junkies (whether or not they did drugs), without second thought. But how can a young person go so astray? Where was the positive adult influences in their lives?

Take, for instance, Polly. She's only 14 years old. She has been sexually active since she was a mere 11 years old. She said she has had up to 20 partners so far. Her first pap smear was significant for low grade lesion. A colposcopy was negative, and two repeat pap smears were still showing some atypical cells.

Remember, she's only 14.

When I walked into her exam room, Polly's eyes revealed how quickly she would retreat if things made her not feel right. I made sure to make eye contact with her, and hoped that I conveyed openness. I asked her all the usual questions, you know... all the fun gyn stuff, and then asked if she was having sex with anyone now.

"No," she said. "But I have a boyfriend." Who is 18. She'd been with him several months and he was "cool" with not having any sex with her. Polly said she was trying not to have sex and make her relationships "real". I told her I thought that was really a good decision.

As we continued to talk, I noticed that she was trying to cover her arms. It soon became obvious why: she's a cutter.

Now, I have never understood the desire to hurt oneself. I do know that the cutting itself releases endorphins, helping the person feel better. But still, I've always found crying and moping a much better way to releasing my emotions. Anyhow...to each his own....

I put a hand on her arm and asked about her cuts. Polly didn't say anything at first, likely because she was trying to come up with something. She must have realized that it would be hard to explain symmetrical cut marks that were equal distance to each other in an orderly fashion down her forearm.

She gave the typical teenage shrug, and the "I don't know". But soon she was talking about living in a group home for kids with behavioral problems, and how her father put her there because he didn't know what else to do. Her mother was a distant memory of her toddler years. It was her father, she said, who also decided she needed gynecological care, and from what she was saying he sounded like he was very much involved. He was the one to make sure she kept her follow up appointments, and hammered in how sometimes abnormal pap smears can lead to cancer if not treated properly. Polly's dad also came in to discuss with the doctor in an earlier appointment what would be the best birth control for her, because he didn't want to be the parent with "his head in the sand". And of course, he kept up on when she was due for her Depo-Provera shots.

I asked Polly if she was ok with all this, and how her dad knew about her gynecological business. She said she loved her dad, but couldn't live with him. She was glad that he didn't just "dump her off" at the group home like the other kids were. She was one of a few that had a parent who visited them regularly.

I could go on and on about all of her problems. I've barely scratched the surface here. But my fundamental question here is, what the frig happened to her? Why would this girl be making such bad decisions at such a young age? What could make such a young girl get off to such a bad start?