Progress

Oh, boy! I received my credentialing packet (read: 6 inch stack of papers) for the hospital my practice is affiliated with and have been working on that. I have to say it is the most daunting part of this process. Actually, it's horrible. The amount of information that is needed is ridiculous, some of it I wonder if I can even provide. I am kicking myself for not keeping better records on the very specific details of each and every woman I cared for during her labor. Urg. But can't change that, so I have to do my best.

What is great, however, is that I can start in the office seeing women while the process is being completed, so that will be good.

I've recently been conflicted on how to proceed with this blog. Not sure if I should, not sure if I want to keep this up. I am overwhelmed with the thought of being a new nurse midwife in full time practice. Yet, I can't imagine not having this avenue to vent and discuss issues and situations in this field. So I don't know...

My Last Shift

My last shift as a labor nurse was today, and my last birth in this role was with a woman who was also a labor nurse. When I got report in the morning, and was told what she did, I thought it was an ironic way of ending my labor nurse career.

This woman worked more years than I as a labor nurse but worked at a different hospital. The hospital she works at is known for some major old school obstetrics. This place still does routine episiotomies, tethers women in bed, elective inductions as early as 37 weeks, and even have a few doctors that will do maternal requested c-sections. I get report from the off-going nurse and learn that she has recently received an epidural and plans to sleep until it's time to push. I hurried into the room so that I can catch her before she falls fast asleep (I hate waking sleeping women once comfortable with an epidural!).

So we chat some, and I offer her something to drink. She balked. "I'm supposed to be NPO!" (Nothing by mouth).

"We allow clear liquids here, even with epidurals," I said. I hate that the word "allow" is in there, but that is what it is.

She is clearly surprised but very happy to accept some apple juice. I get her settled, turn down the lights, give her the call light, tell her I won't disturb her for a little while unless she needs me or its time for some assessment.

Next time I see go in to see her, she is waking up. She's still very comfortable but curious how much further she's dilated. It hadn't been a long time since her last check, and I said since she was ruptured exams are kept to a minimum. Unless she was feeling an urge to push, the doctors will not be anxious to do an exam.

"Really? It's been two hours... our patients get checked every two hours on the dot without exception!" she said.

"We try not to unless necessary," I responded. Of course we have our exceptions depending on who's on call. But overall, if someone has been progressing in their labor, we just let it happen.

We continue to talk and then she asked, "If I am checked sometime soon, and I'm fully dilated, can I labor down?"

Laboring down is awesome. I can tell you I am all for it. It's a great way of helping a woman who would probably push for hours with a dense epidural with no urge to push and needing to be told each and every time when she should push. It cuts down on pushing time, and may help protect the perineal tissues from excessive trauma.

I tell her we use laboring down fairly often under certain circumstances. Again, she is surprised. Laboring down is not allowed at her hospital If you are fully, pushing must be started no matter what and the clock has begun to possible c-section for "failure to descend".

And so by lunch time she was fully, and not feeling any strong urge to push. Laboring down was the plan. She labored down for about two hours and then she started pushing. Her pushing was not all that superb so I tried all sorts of positions with her. She even said she wished she could sit to push, and I said, "You can!" She didn't believe me, because she thought this was not possible in the bed.

Now this is when I couldn't believe a more experience labor nurse had no clue how to manipulate a labor bed to help the woman in a sitting or squatting position. I even got the squat bar and showed her how to use it.

"I had no idea! Our patients with epidurals lay on their backs only," she explained.

Wow.

She went on to have a nice birth, a beautiful baby boy weighing 8 pounds even, and put him to breast immediately. She offered him up to go to the nursery but I said there was no need to- it would be better for him to stay with her. Of course she was very happy to keep him with her.

As much as I was saddened and a bit appalled that this very experienced labor nurse had no idea some of the very basic labor support methods nurses can use, I was so glad that she got to experience them first hand. Hopefully when she returns to work she will remember what she learned and teach her fellow nurses.

Please Recommend

I am asking for your recommendations on pregnancy and birth books. I am currently have two books in waiting that I want to review in hopes of coming up with a few recommendations for my soon to be patients/women.

Also, anyone know how I can get my hands on a complementary copy of Our Bodies Ourselves: Pregnancy & Birth book?

Yes, I am shameless...

On "Medwives"

I've seen and heard this term quite a bit. I am sure most of the readers here have heard of it at some point, but for those wondering "what is a 'medwife'"- it is typically a derogatory term referred to nurse midwives who practice with a medical model. I've worked with a some at various points in my nursing career who were labelled as such, and have even heard some call any midwife who chooses the CNM route or any midwife who does birth in a hospital as a "medwife".

I will admit that I would personally find it insulting if someone called me a "medwife" because I went into midwifery to protect the right of women's normal life experiences with childbirth and such. My personal philosophies do not align with the medical model of childbirth for normal, low risk women (which is the majority of those giving birth). But, I have used medical technology in caring for laboring women both as a nurse and a student midwife (and soon to be practicing CNM!). I don't view this as a bad thing, but for some it would put me in the "medwife" criteria just for the sheer fact I have used medical technology. For instance, if a women truly wants medication, an epidural, or whatnot- I'm okay with that- although you all know my pet peeve is women not taking the risks for such things into consideration. I've cared for women as a student midwife who had prenatal complications that medical intervention was called for in some way. But does this mean I can no longer be truly considered a "midwife" in the spiritual and literal sense? I say- hell no!

But as I've said, I've seen what most refer to as "medwives" in practice. Not often, but it does exist. However, I think many times CNMs get labelled incorrectly as "medwives" because they work in hospitals that have high levels of medical childbirth care. I've come to see this as something that is inevitable in this push/pull type struggle between the obstetrics and midwifery cultures. Turf battles, if you will. Many times if a CNM wants a job, and wants to serve women and their families, they have to enter into such environments. I think for these CNMs, its a necessary part of trying to be a change agent in those medical models. Like, a group of CNMs who finally manage to get a practice going at a hospital that for years and years was only attended by old school obstetrics start by changing little things in the care- like no routine IVs in low risk women, and then no continuous monitoring on low risk women, etc. And over time, all these little changes add up and have changed the culture of childbirth care for that hospital. Sometimes going into an environment like a bull in a china shop does not work as effectively, as much as you want to turn things upside down to make it immediately midwifery friendly. So.... I don't know. Sometimes seeming to be a "medwife" might be necessary given the situation and environment until things really start changing.

I think the "medwife" thing is a double edged sword when it comes to nursing, too. Nursing staff have a strong influence on the care environment. There are plenty of nurses who provide care to laboring women as if it were a disease. Many do not feel comfortable unless monitors and IVs are strongly involved in the process. So imagine a midwife trying to do things that go against what the nursing staff is comfortable with. That's tough- but at the same time if the midwife is doing things that lean towards a medical model of care- then she is called a "medwife" by the same staff. I've seen this plenty, too.

So what are your thoughts on this? What do you view as a "medwife"?

Sunday Afternoon Enthusiasm

Today I am feeling very enthusiastic about my upcoming career in midwifery. I begin my new career in early June, which will start with office midwifery and well women gynecology. Once my hospital credentialing is completed (which, for those unfamiliar with this torturous process- is a lengthy paper trail that is completed and collected by said applicant, which is then scrutinized, verified, and processed by a designated hospital credentialing coordinator. Once this is done- which in itself can take months- is presented to the hospital board of directors for every one's a-okay seal of approval to set foot on the care units of their blessed hospital.), I can start doing births!

So, in my enthusiasm today I have done some minor blog appearance updating. I've updated some links, as well. Also wanted to throw out a question to you- I've been approached quite a bit by others who want to "guest post". For the most part, I've ignored this- but if something was appropriate I thought it might be interesting. What do you think?

Why I Became A Midwife

I have to say, I never set out to be a midwife. Actually, I never really set out to be a nurse either. Growing up, all I ever really wanted to do was be a writer. I wrote a lot when I was a kid, and even as an adult began writing fiction seriously (although no one ever seems to take you seriously when you say you write fiction). But it was very clear during high school my writing was not going to be cultivated as a practical career goal. And I was into biology and whatnot, and a teacher suggested nursing. Specifically, a teacher suggested I go to a local hospital's "Shadow A Nurse" program for high school students, and I was all for a legit day off from school. Funny thing was, as much as I ended up liking the Shadow A Nurse thing, I knew I didn't want to take care of sick people. And I was totally fascinated with the labor and delivery ward. And it was still a ward, likely the same type of ward I was born in.

Anyhow, back to why I went into midwifery. Like The Beatles say, it was a long and winding road. My first obstetrics job was in a large city hospital that had high c-section rates and low tolerance for normal. Of course, I didn't see it as that at the time. I saw childbirth as this very dicey event that was wrought in terrible danger. A lot of women needed c-sections. A lotof babies needed rescuing from the process. There were no midwives. And frankly, why would people see a midwife in a hospital when they were for homebirth, right? And while we are at it, only crazy people who want to take their and their baby's life in jeopardy....ya....so you get the culture I was in at the time. Of course I didn't see it this way back then. I just saw a lot of anti-normal practice and took it for the norm.

Same with the next job at another city hospital. I even remember this one shift where a homebirth midwife had come in with a woman who was ruptured with meconium for 3 days or so with no progress in the woman's labor and all of the nursing staff, residents, and attendings carrying on about it. This was my first experience ever with a homebirth transfer, and by this point I wasn't opposed to homebirth, but certainly wondered what the story was there. I was not their nurse or involved in any of their care, but the bias within the staff was so thick and the lack of respect for this woman and the midwife were so obvious the blind could see it. But again, this place was of a similar culture as the first place: normal birth didn't exist and a birth could only occur with any amount of safety with large amounts of intervention and technical monitoring.

However, this was the same place I began to see normal birth. There was a large midwifery group there and many of those midwives really did normal births. Intermittent monitoring, low intervention, spontaneous pushing....and the babies and mothers did so well that it was hard to ignore the difference.

From there I ended up working in another large city hospital (#3, if you are counting) that clearly was just turning out a product. At this point I was so fed up with the system that I began talking with the midwives of this large group about my feelings and thoughts about normal childbirth. I found that they also saw things how I saw things, and I started to read more about midwifery. But I never thought of becoming a midwife.

Fast forward to my last RN job- the one that inspired my blogging- and I wanted to protect normal birth. I was reading more and more about our backwards maternity care system as well as our horrible stats when compared to other countries that have high numbers of midwife attended births with better stats. I was seeing things I felt hindered normal birth, and even some practice that was a detriment to it. And by this point, I realized the only way I felt I could really help protect and preserve normal births was to actively participate in them as a midwife.

An opportunity opened up in my life to go back to school, so here I am. Now I am a CNM, and so ready to protect normal birth. I had a preceptor when I was in school who had always fought an uphill battle in her midwifery career, and gave me a great piece of advice: make small changes quietly until it adds up into something no one can ignore. I'm not so sure I have it in me to go hog wild and do big crazy things (at least, anytime soon) so I think her approach is the way to go. Isn't that something like the saying "walk softly and carry a big stick" or something? Or am I getting that saying wrong?

Keeping Religion Out Of It

I've never been one to feel religion should cross the lines into health care. Before I go on, let me just say that I am not talking about the birth where the woman prayed throughout or a blessing was done for the baby shortly after birth. Because in those cases, the people are doing what they believe and their faith has helped them through the experience without involving others into it who may not share the same beliefs. Those things do not force others into care decisions or take away options. It is those things I have a problem with.

For instance, I recently stumbled upon a website of a birth center that is faith based in their care. Ok, totally fine. Absolutely wonderful for those women who want faith based care. I wondered, however, if this birth center was the only birth center in that area (I'm guilty- I didn't search to find that out) and I was a woman who really really wanted a birth center birth but wasn't Christian. Perhaps I was a Wiccan woman, and didn't want Christian prayer to be a part of my birth. Would that be possible? Could the birth center meet my needs outside of just having a birth center birth? I don't know...I guess it would be a dilemma for me if I were that woman. The practical thing to do is make and appointment and see how it goes and express my concern; but what happens when it's clear the midwives at the Christian birth center can't keep God out of it or the numerous religious relics make me uncomfortable?

Catholic hospitals come to mind as well. Clearly Catholic hospitals deliver faith based care. I realize that this doesn't mean that each person who comes to care for you performs mass or whatever, but it does guide what services are offered. I have personally never chosen to get my care at a Catholic hospital because I have a problem with places that deny certain aspects women's health care. I've even chosen not to work at Catholic hospitals for the same reason. I had been naive about their denial of birth control, emergency contraception, and abortion services until I was in nursing school and did an internship in a teen clinic. After being there a short time, it seemed like a major oxymoron of care. It's mission was to provide pregnancy care to inner city teens, but they couldn't discuss birth control with them!!! What the fuck? Does that seem wrong? It sure does to me! It seems to me the best way to serve these girls is to get them on birth control and discuss STI prevention. And what about the rape victim who asks for EC but is denied it? I would hope that she was at least told where to find it, but there are some providers who, based on their faith, would not.

I know many would say, "Just go elsewhere", which is fine when there is another local hospital to chose from or you can easily get yourself to it. But I do know of some areas, even near me, that the only accessible hospital for some is a faith based institution because its on the bus route. Getting to the non-faith based hospital would require more difficulty.

I've even worked with nurses who've commented on a patient who was being treated for a second trimester miscarriage or even a fetal demise at 30 weeks say they are being punished by God because of their previous history of abortions! Good grief! You know, fine, whatever, if you want to believe that, but keep your freaking mouth shut about it at work. Religious beliefs should not factor in your care for that woman. It makes me nervous, frankly, that somehow that would permeate how that nurse might treat that woman.


Ok... now I feel better getting that off my chest.

Hear Ye! Hear Ye!

Labor Nurse has a job!!!! Woo hoo... a jobby job for a new midwife has finally materialized!

So, I guess the question is: do I keep writing here on this blog, or start anew? Because "Labor Nurse" doesn't exactly reveal what I will now be doing.

Either way....

Woo hoo!!!