labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Thursday, February 28, 2008

Let's Talk About Sex

One of the surprising, yet very good things, that I have found providing gynecological care is how the young women are so open with discussing their sexual issues with you. I suppose I had never really thought much about discussing such things myself, perhaps because there really isn't much to discuss, and so as a provider I hadn't really given it much thought either. Well, except for the lectures and assigned readings on sexuality and the like. And obviously nothing bothers me about such things; it's just that I am pleasantly surprised that women are seeking advice and help. Much, much different of our parent's generation, I'd have to say.

For example, I asked a divorced 50-something woman who told me she was in a new relationship if she was sexually active. Now, I was asking her this for actual medical reasons, as if she was sexually active I'd offer sexually transmitted infection testing and counsel her on safer sex practices. This is a routine thing for anyone who is sexually active (I ask the married women, too, can't assume anything...and I think if you offer something like STI testing it should be across the board). But you would have thought I asked her if she ever murdered a newborn child. I had to back track and explain, and tried my best to un-offend her.

On the other hand, I've asked women in their teens, 20's, 30's this same thing and no one bats and eye. And some will open up with issues or questions that they have. I think there is something admirable about this, that women care about making all parts of their life good. I've recently learned that there are physical therapists that specialize in "pelvic" therapy. Who knew?

Saturday, February 23, 2008

Stem to Stern and Back Again

This post holds new meaning to me now that I am actively involved at the perineum. For each birth I have done, only one had an intact perineum. I feel horribly when the woman ends up with a tear of some sort, and fortunately nothing has been bigger than a second degree laceration. But I end up questioning my hand maneuvers, or if I should have done something different to prevent the tear that does appear. One of my preceptors told me to not put the blame on myself, some women are just going to tear no matter what. But still....

Stem to Stern

There is one thing that bothers me in my line of work: 4th degree perineal tears.
One word: OUCH.
Fortunately, it's unusual. But it's just awful. It looks awful prior to repair, it looks awful after repair, it's awfully uncomfortable to say the least, and my heart (and perineum) goes out to those who end up with one.
Some of the nurse's I work with have said that some tears actually have a sound. Like a pop or a ripping noise. I can't say that I have heard it, and I am so glad that I haven't. I don't go listening for it either.
I've just had a marvelous idea for my research project (if I make it that far): looking at the correlation of the women's diet and perineal trauma. I'm going to see what research has already been done with this. It comes to mind because I have noticed that women with vegetarian diets seem to have larger perineal tears and longer healing time. Hmm...
But the worst has got to be the risks that are associated with 4th degree lacerations. Like fistulas. Imagine every time you poop or fart that some leaks into your vagina. Ya, that's a fistula. It happens.
Take for instance the phone call I received from a woman who delivered 2 years prior. She was still dealing with the sequela of the 4th degree laceration she suffered during a vacuum extraction. She had surgery on the fistula, but it didn't end up correcting it completely, and so she was facing yet another surgery. And she was angry.
Apparently she was trying to obtain her medical records for the birth. She felt like she was being lied to by the delivering physician. I'm not sure exactly why but she felt that he was hiding something. Either way, her medical record happened to be missing some vital components (which is probably why she was suspicious). I asked her, "Are the nurses notes from the delivery in your record?"
She didn't know. I told her to get them. If her nurse at delivery was prudent, then everything that happened would be documented there.
Not only was she angry about the records and whatnot, she was angry because it ruined her marriage. It caused a great strain on the relationship because she was in pain for so long, requiring surgery, trying to care for an infant, and her marriage began to dissolve. I can see why. She said she couldn't blame her husband for feeling like he didn't have his "original" wife. Because he didn't. He had a women who was dealing with chronic pain that took away an intimacy; it took away any future children. She said it was frustrating because people she spoke with couldn't understand why it would affect a marriage the way it did. They thought that he should be more understanding. He was trying, she said. But how could she expect him to love an angry, depressed woman?
On an aside, this was the one and only time I recommended looking into an elective c-section. I worked with one physician that did them for prior severe perineal trauma and she would be a candidate. But then she reminded me in order to have a c-section she'd have to have sex. Oh...ya... I knew that....
Her case is probably extreme. But either way it sucks. I pray for perineums at every birth.
"May the perineum remain supple and intact. Amen!"

Wednesday, February 20, 2008

A Surprising Doula

I was caring for a young woman from an African country that is steeped in paternalistic notions and demoralizing and sometimes inhumane treatment of women. She had not been in the US for very long, maybe 2 years, and kept herself surrounded within the local community that remained mostly African. She didn’t work outside her home, and had very little contact with American culture, other than her TV and fast food (this was something I saw her eat several times during her hospital stay…such a shame that this is what American culture she picks up…).

In her home country, childbirth and anything pregnancy related was women’s work; men keep out of such things. The women support each other during labor and with child-rearing, and expect that the men are not involved. Perhaps they don’t want the men involved, I’m not sure. But this young woman I was caring for brought along her father-in-law and a friend from her neighborhood.

The friend was known to be the woman to go to when in labor. She was essentially the local doula in their culture. She was also very “Americanized”, and acted as the liaison for the laboring women in the hospital. She helps these women through this very modern medicalized American way of birth, and helps the woman’s voice be heard in this foreign environment.

This particular father-in-law was there because his son, her husband, had to work and so he said he was her transportation. He sat in the corner of the room not making any effort to engage himself. When we would talk with the young woman, and sometimes ask her what she wanted to do, she turned to him and asked what she should do. The father-in-law would say something quickly and turn back to the TV. She would then answer us, presumably whatever he said. They spoke to each other in their native language, so I can only guess this was the case.

Soon this young woman’s labor became very active, and to my surprise, the father-in-law came to life. He helped her into different laboring positions, encouraged her to walk, and then walk some more (he was very big into walking during labor), to get on the birth ball, to breathe, and they prayed together. When she started saying she couldn’t do this any longer, get her an epidural, he spoke to her in a soft tone. She nodded to his words, and continued with the walking, the birth ball, and later sat on the toilet for some time.

The friend told me that the father-in-law was telling her that she was a strong woman just like the women of their village, and was going through her labor just fine. An epidural, he said, was not natural.

When it was apparent that it was getting close to the time she was ready to push, he laid his hands on her belly and performed his own version of Leopold’s maneuvers. He announced that he wasn’t sure the baby was head down and in the right position, but we assured him that in fact the baby was head down.

When the baby was born he was one of the first to hold him, and pronounced him healthy and vigorous. Later, after the birth, my preceptor and I spoke with him and the friend. We learned that back in their home country he was actually very involved in childbirth, and many of his family members called upon him during labor. He caught several babies himself, and learned to watch for signs of danger. He had no formal training, other than what he learned during his own experiences. I was impressed with his knowledge of labor support, and I’d imagine he could catch a baby with mom in non-hospital like positions (squatting, hands and knees) better than some professionally trained birth attendants.

I guess the argument can be made that perhaps he was involved in childbirth to further keep control of women in his culture, but given that it was the actual culture that dictated men stay clear of such womanly things, I think he was probably taking risks in such a venture. Our culture dictates that men (namely the father) should be involved in childbirth, yet I’ve never seen an American man so knowledgeable in labor support and the benefits of non-pharmacological measures. I’m sure there are some out there, I’ve just never crossed paths with one yet.

Saturday, February 16, 2008

The Red Thread is Still Red

This is an old post from Life & Times. The reason I am having it reappear is because the person I write about has been in my mind, much like it was before she had her first baby. It makes me wonder if I am thinking about her suddenly for the same reason.... perhaps she'll be on my unit on my next shift.

The Red Thread

There is a saying from Chinese folklore that I had come across years ago that stuck with me. It's referred to as the Red Thread. According to this ancient thinking, an invisible red thread is attached from ourselves to others in our lives. The red thread may stretch, shorten, tangle, but never break. This saying is used quite a bit among the international adoption community (mostly China). I have always believed that the people that are in our lives are always connected to us. And those that we do not see or have contact with in the current, like the people of our past and of our future, somehow remain invisibly connected. Hence, the invisible red thread.
I had a very close friend for several years when I was in nursing school. We met when I started working a new job at a local hospital. I didn't know what to think of her initially, as she was very chatty and sometimes spastic. But eventually, we ended up being fast friends. She was also in nursing school. She lived close by. We even had a mutual friend without knowing each other for many years. Our friendship carried through my entire nursing school career, but started to fizzle soon after. Things at first seemed to be related to her moving on with a new boyfriend, but soon it was evident that she was doing some very hurtful things that I had been unaware of.
Now, hang in there, this does have an obstetrical related piece.
So once I became aware of the mean spirited things that she had done, I ended the friendship. One clean cut of the knife and I was done. We both remained in contact with our mutual friend, but never with each other.
Life went on, but I somehow was always in on any new updates in her life. The mutual friend liked to keep me informed whether I wanted to know or not. I am sure that this mutual friend was doing the same in reverse direction but I never cared to ask. And so through the years I heard of her trials and tribulations (and believe me, this girl had tons of it, even when I was friends with her). Then I lost contact with the mutual friend and no longer heard about my ex-friend.
This past spring I remember very clearly having sudden thoughts about her. I came to the realization that we continued to have many similarities or coincidences in our lives. We both dated and married men we had known for many years prior to the courtship. We both moved to the same state once we were engaged. We both married at the same age. We both continued to work in the state we were originally from. And for some strange reason, I kept feeling that she was pregnant. I had no reason or proof to substantiate that. But I felt it very strongly.
I went to work one April morning. It was quiet on the unit. There were only 5 patients who were delivered. Only one patient was in labor; I saw that it was her name on our census board and almost fell over. I had been assigned to work in the nursery that day.
She had no idea that I worked there, so I knew that she wouldn't purposely have her eyes out for me. But I was so worried about it, so paranoid for some reason that my entire shift felt muddy and I had difficulty concentrating. I told all of the other nurses I was working with that I knew her, what she did to me, why we were no longer friends. I was reassured by her nurse that she had no plans of walking the halls.
But there was something inside me that could not settle. I wondered about her labor. Was she doing ok? What was she having? Did she know? What did she look like now? How did she look as a pregnant woman? I wanted to know, but then was upset that these thoughts were running around my head.
She did not deliver on my shift. The next day I was again assigned to the nursery. Her baby was the only baby in the nursery when I came on shift. I worried about her feelings about me caring for her newborn. But then I reasoned that my signature on any documentation was my married name, which she wouldn't know, and she wasn't in any condition (according to report) to be coming to the nursery. Her baby looked just like her. Same features, same face, same petite frame. I wondered what she would think of me holding her baby, shortening that red thread.
At the end of the second shift, as I was walking towards the locker room, I saw that her door was wide open. I had to walk towards it to get to the locker room, there was no way around it. It was dark in her room, but I could clearly see her silhouette in the bed, sitting bolt upright. She was facing the open door. I kept walking, then made the turn to the locker room, causing that red thread to stretch back to its previous length.

Wednesday, February 13, 2008

Boobs For Grab

I am sure each and every labor nurse has had some part of their body taken hold of by a woman in labor. I have had my hands, arms, waist, and just recently my boob grabbed at in some form of pain or desperation.

Normally I let the woman hold on to me without much ado, but if they start hurting me then I tell them to let go. For instance, the woman who hated me, Kelly, would have ground all of my metacarpals of my hand together if I let her.

But the boob was weird. It occurred with each push, and as she continued to hold on with each push she grabbed on tighter and tighter. She had the whole girth of my boob in her hand, and no matter how I positioned myself the two seemed to meet. The problem was that I couldn’t exactly move away a great deal as I was assisting in her positioning. I also didn’t want to call attention to it. From what I could tell no one else noticed that my boob was in her grasp, so I wanted to keep it that way.

I also wondered if she realized what she was grabbing. Did she think she had my upper arm (they are equally as squishy)? Or did she know what she held on to?

Saturday, February 9, 2008

My First Catch

One of the things that surprised me during my first birth was that I wasn't really nervous. I didn't realize this until after everything was over, and that I noticed that I was able to actually think clearly and not panic. Although I did notice at one point my hands were shaking (while I was holding some kelly clamps to clamp the cord) from the adrenaline. Some would argue that I should be nervous, it being the first birth I attended as a student midwife, but I felt prepared.

My first catch was as normal and uneventful as births go...not uneventful for the parents. Mom pushed spontaneously...oh how nice to see how the body works naturally! She just listened to her body and pushed when she felt like it. There was no cheerleading or counts to 10, no urging that she hold her breath, or insistance that she push for 3 long pushes with each contraction. She got in the position she wanted, and rested when she needed. My preceptor just threw me right in there, having me do all the hand manuevers and what not. As the baby was being born, my preceptor put her hands over mine to make sure I was sliding them where they needed to go.

And it was so nice to put this little baby skin to skin with his mom. We waited for the cord to stop pulsing before cutting the cord (dad didn't want to), and inspected her perineum for tears. There were none. We clean mom up, and helped her nurse her baby.

I walked out of the room feeling like a lot of what happened is the way birth should be...un-interferred with. This story may seem anti-climactic, but when I think about it I feel that it is because there wasn't any "drama" or major interventions that accompanied it (much like many of the births I see at work). And is so very exciting because such a birth exists. A nice, normal, quiet birth.

Thursday, February 7, 2008

Catching Cannon Balls

I was telling my brother how I have finally caught some babies.

His reply: “So, what, do they shoot out of a cannon? Is that why you have to catch them?”

Obviously he was being funny, but he isn’t familiar with the midwifery lingo.

And yes, I will be telling you my baby catching when I have some more time!

Tuesday, February 5, 2008

Blogging on Safety

Being the Queen Of Procrastination, I was searching for some good blog reads when I came across this post about the safety of birth. I find this blog writer's perspective interesting and refreshing, and respectful. She points out debate isn't actually listening to the other's side; I agree in most cases, and in particular within the "birth debate" that goes on in our country. I say her post is respectful because despite her own personal beliefs on birth safety, she is respectful of what everyone feels. Not an easy find in our birth related blogosphere.

Goons to the Visitors

One thing I am noticing as a student nurse midwife is how loud nurses are. Wow. I’m not sure I am liking how this comes off. I’d imagine to visitors it appears that we can be a bunch of obnoxious goons that would prefer to eat chips and salsa while reading People magazine and gossiping. Yikes. I’d be pretty leary of the likes of us if I were one of them.

Yet I am not immune to this. When I am at work, I love when we have a moment to sit down together at the desk and trade stories and laugh our asses off. It’s fun; it makes our horrible days more bearable. I’m just as loud as any of the nurses at my clinical site.

One thing this has made me acutely aware of is how our nurse’s station is designed. Our secretary, who is the check point to any woman coming in for one reason or another, sits just in front of our nurse’s station. It’s essentially a pod like area with some tables and counter space that is halfway enclosed with glass walls. It’s not sound-proof, yet we act like it is.

I can think of countless times when a woman, who has not called her doctor to say she is coming in, just shows up at our front desk with one complaint (or more) or another. The secretary, who is always informed of who to expect at her desk, will come back to our desk and say, “So and So is here from Dr. Y’s practice. Says she’s having pain. Did anyone know she was coming?” Of which we all turn to look at poor So and So and size her up, see if she’s smiling (many times she is) and declare that my ass she has pain (a famous line by the charge nurse) and drag her feet to the triage room. There usually are many other comments from the other nurses, none of which are even said in something resembling a stage whisper. We might as well get ourselves a megaphone.

It also makes me think of the poor little medical students (many of whom are not poor nor little but they are all younger than me so as far as I’m concerned they are babies in some way) that enter our nurse’s station ever so hesitantly and when they find enough courage to cross the threshold shrink into a broken chair and slide into a corner. Is it because of us? Are we big and scary to them?

On the other hand, we have had a few that have no problems staking their territory like a male alley cat and over-powering the attending. But that’s another story.

So, what’s my point? I guess I am getting more than a nurse midwifery education here. I am finding that stepping out of the RN role makes me look at everything so differently.