As many of you wonderful readers know, I’m nearing the completion of my midwifery program. We midwives love metaphors, and on my plane ride home last night from the ACNM Annual Meeting in New Mexico, I was thinking about how I am at that point in my midwifery education journey of complete dilation: I have done the incredibly hard work of learning how to catch babies, do clinical appointments, flexing and stretching those muscles over and over, actively laboring to get into the rhythm of having those cervical exams, IUD insertions, Leopold’s maneuvers become second nature.
On June 6th I’ll sit for my comprehensive exam, which our program requires we take before we start integration (our final practicum). This exam is a test of all the knowledge we need to know to be safe, entry-level midwives. It’s a reassurance that if we pass, we at least have the knowledge foundation to get the most out of our final clinical practicum and do well on our certifying board exam.
One week later, I’ll start integration! I get lots of questions about what this entails: basically, it’s a 10-week final practicum, precepted by one midwife (although, I’ll probably work with 2-3 midwives fairly regularly). I’ll be essentially working full-time with my preceptor, seeing all her patients in clinic and on call-shifts. While my preceptor is there for support and in cases of emergencies, I will be largely responsible for patient care and charting, making management decisions as independently as possible. It’s my chance to truly integrate all the clinical and didactic learning of the past 6 quarters of midwifery school and really hone my own voice as a midwife.
How do I feel about moving from active labor into the pushing phase of my midwifery education journey, you ask?
I’d say about 60% thrilled and excited and about 40% terrified. Not because I don’t think I’ll do a good job, but because the gravity of the responsibility is heavy. I came to midwifery with some pretty lofty goals about my future practice and how I want to serve my community. Every day, I have questioned whether I’m on track to meet those goals and enact that vision. It is an incredible honor and privilege to walk with my patients on their individual journeys to health and well-being throughout their life, and not one I take lightly.
Like most laboring patients about to enter the pushing stage, I know intellectually that I am about to be asked to work harder than I have ever worked in my life…and getting to complete is usually no walk in the park. It’s one thing to know this intellectually and another to actually experience it. I tell my laboring patients when they get close to hitting that wall of despair that they will find wells of strength within themselves they they didn’t know existed. I know the same will be true for my experience in integration: I will have moments of doubt, but also will deepen my confidence as a midwife.
To follow this metaphor a bit further, the pushing phase of labor is engages different muscles and a different mental space. Suddenly the vision clears and the end-goal becomes clear again: I am thisclose to moving across that threshold from student to practicing midwife. While I will always be a student at heart (future PhD, cough, cough), it won’t be the same and it will come with a different set of responsibilities.
So…here’s to that little lull that sometimes happens at complete dilation before active pushing. I have a few weeks to rest, prepare, re-evaluate my clinical goals and priorities, before diving deep for the last effort before graduating as a midwife. I’m about as ready as I’ll ever be, so let’s bring it!
I recently received a request to chronicle my journey from “pre-nursing to CNM”–what classes I took, etc. Carolyn, sorry it’s taken so long to reply. Life as a second year student nurse-midwife is a whirlwind. Add in having a baby, and you have a perfect recipe for letting some emails slip through the cracks. Also, I realized that I simply cannot remember which classes I took when…and somehow, I seem to have lost the folder on my computer that had all my pre-nursing planning docs. Probably in a moment of “must organize everything! now!” I deleted it, thinking I wouldn’t need it again.
I chose to do my pre-reqs part-time, as I was working as a doula at the time and also busy volunteering at Planned Parenthood and with Backline.
Also: I would avoid applying to programs that require an entrance exam. Sheesh! That just sounds like more work! But I was lucky, the program I wanted to go to didn’t require one.
I started taking pre-reqs in the fall of 2011. I had no background in the biological sciences, so I took an intro bio for health sciences, which was a pre-req for the A&P series as well as for microbiology
Medical Terminology (online)
Anatomy and Physiology I
Anatomy and Physiology II
Anatomy and Physiology III
Submitted application in December of 2012
Accepted to accelerated RN/CNM program
Continued working as doula, studying Spanish
Summer 2013: Began the 5-quarter Accelerated Nursing Program at OHSU
Chronic Care: Clinical and Didactic
Population-Based Care: Clinical and Didactic
Acute Care: Clinical and Didactic
Integrated Practicum (on L&D/MBU)
Studied for and took NCLEX
Started working part-time as abortion RN
Fall 2014: Began the 2 year midwifery program at OHSU
Health Assessment and Diagnosis for Advanced Practice Clinicians
Advanced Patho I
Reproductive Health Care Mgt
Concepts for Advanced Practice Nursing (online only)
Advanced Patho II
Advanced Pharm I
Antepartum and Postpartum Care: Clinical/Seminar and Didactic
Left RN job to focus on school
Advanced Pharm II
Intrapartum Care I: Clinical/Seminar, Didactic
Evaluating Evidence (online only)
Intrapartum Care II: Clinical/Seminar
Midwifery Foundations (reviewed history of midwifery, scope of practice, etc)
Fall 2015: Had a baby, so took time off from gyn clinical until 8 weeks PP and did not do any IP care
Started part-time RN job in an out-patient primary care clinic to fulfill RN hour requirement for APRN licensure in OR–OR APRN’s need 384 hrs of documented RN experience to qualify for licensure…but pretty sure we’re the only state with this requirement
Advanced Gyn: Clinical and Didactic
Intrapartum Care III: Seminar only, no clinical
Foundations of Teaching Midwifery (“How to Be a Preceptor 101”)
Concepts of Advanced Nursing Knowledge and Leadership (online only)
Winter 2016: made up gyn clinical hours, started IP clinical hours from Fall
Primary Care for Midwives: Clinical/Seminar and Didactic
Intrapartum Care IV: Clinical/Seminar
Spring 2016: made up IP clinical hours from Winter
Integration Seminar (resume writing, negotiating contracts, liability, etc)
Final Integration: 8 weeks of working full-time as midwife with clinical preceptor
Take board exams
Apply for state licensure as CNM/APRN
Apply for NPI and DEA license (to prescribe narcotics)
Find job, get privileged and credentialed, live happily ever after as a midwife!
Every year, the first year students of our program throw a send off party for the second years as they wrap up their didactic requirements and prepare to head off into integration (an 8 week final practicum very similar to a medical residency, in which we essentially live the life of a full-time nurse-midwife, working all clinical and call shifts with that midwife and taking on as much leadership in clinical care as one can without being fully licensed).
As an acc bacc student I attended this party and felt such awe and inspiration, watching how confident (even though they said they weren’t) the first and second years seems as they shared advice about how to survive life as a student nurse-midwife. I simply couldn’t imagine how in a few short years, that would be me–catching babies, running prenatals, attending to patients’ every day health care needs. It was both wonderful and yet impossible to imagine.
Last year I ended up not going, because I was still in my first trimester of pregnancy and simply too fatigued to make it. I hadn’t started taking call yet and while I was starting to feel comfortable in the prenatal care setting, I still felt like a complete imposter.
Tonight, though, I attended the annual send off as a second year. It was such a surreal experience, and in many ways, isn’t quite as immediate for me because I’m a quarter behind the rest of my cohort (having a baby in the middle of midwifery school will make you adjust your timeline a bit!).
As impossible as it was to imagine a year ago, I am a different midwifery student now.
I’ve been a part of over 50 labors and 20 births. I’ve logged almost 450 hours of L&D call, with another 200 hours to go before integration. I’ve seen over 80 individuals for prenatal care. I’ve been involved in over 30 postpartum visits and over 60 gyn visits. I’ve placed 10 IUDs. And I have almost 400 hours of RN experience in a primary care clinic.
More importantly, I’ve started to find my own voice, however shaky and uncertain it may be, as my preceptors start asking me to sit in the driver’s sit and take the lead. They ask me what orders I want placed and they type it in the computer and click “sign.” Done. They ask me how I want to manage a labor and why, and then step back and let me see the outcomes of those decisions (within safe parameters of course). They ask me for my understanding of the evidence and then tell me to go in and direct the conversation with the patient about why we’re making the recommendation we’re making. That I’m making.
It is terrifying but also…I’m starting to remember why I’m here, finally starting to feel more at home in this role. There was a period where I kind of forgot, where the pattern became “just get through this term, survive in one piece, don’t ask for too many extensions from one class.” Having a baby cured me of any last vestiges of perfectionism in my work (oh, don’t worry, the impulse still lingers…but oh so faintly now). As my preceptors move back and encourage (read: push) me forward, I’m remembering that I was drawn to this work because I love talking about the things that matter most to people: how to feel good and safe in their bodies, minds, and spirits. There is nothing more satisfying than partnering with a patient to come up with a plan to help improve her quality of life.
As I sat around listening to my fellow cohort offer wisdom and advice, I was struck by just how much we have learned in this past year together and how much more at peace we are with how much there will still be to learn upon graduation (suturing workshops, anyone???).
There’s still a lot more to come before I can say I’m on the home stretch (this spring I’ll be cramming another quarter’s worth of call into 8 weeks so I can have enough of my integration done that I qualify to participate in Convocation with the rest of my cohort)…but it’s beginning to feel like it’s possible, which is more than I could have said a few months ago.
I wish I could say there will be time for more blog posts, but I’m not sure I can make that promise…so if it’s quiet here till August, know that I’m sending love and solidarity to all you midwifery students out there balancing school and family to pursue this wild journey of becoming a midwife.
[This is where, if I had not been busy wrangling a wiggly 5 month old, I would have inserted a picture of the freaking AWESOME uterus cake and uterus piñata that the first years made us for the party. Ah well…letting go of the perfectionism in action!]
Well, that flew by. Tahini has been with us for almost four months now.
Being a mama to an almost 4 month old, a full-time midwifery student and a .4 FTE RN doesn’t leave a lot of blogging time these days…but life is good right now. He’s growing like a weed, grabbing everything and putting it in his mouth, laughing, and trying desperately to roll over. Being his mama is amazing, frustrating, exhausting, exhilarating, mundane, tedious, profound, and so full of love.
But one thing is clear: I’m a mama…but I was called to be a midwife long before Tahini arrived and I have no regrets about continuing my program rather than taking time off to be home. It was not easy coming back to class 2 weeks postpartum, or starting gyn clinic at 8 weeks postpartum…but I don’t regret it for a single second, because I love my work so much.
I loved learning about gyn this fall, even though I wasn’t quite as sharp or organized as I would have liked to have been. I loved getting to work with menopausal patients and hear their stories and help reassure them that yes, they still deserve a rich and fulfilling sex life if they want one. I loved getting to explain pelvic exams and Pap smears to adolescents and young adults in for their first gyn exam and then perform gentle, thoughtful, empowering exams that helped patients understand their bodies. I adored getting to talk about contraception and family planning with patients of all ages and intentions about how they wanted their families to look. I loved getting to insert IUD’s for those that wanted them, and taking them out for those who didn’t.
I started taking call again two weeks ago. I’ve caught three babies so far this quarter and have been slowly finding my hands and voice again on L&D. I’m enjoying my primary care class and seminar, along with my last intrapartum seminar, and can’t wait for my primary care clinical rotation to start this weekend. This winter is my last quarter of course work as a midwifery student. In the spring, I’ll just be taking L&D call to catch up on the hours I missed from the fall…and then this summer, I will complete my final integration (practicum) as a nurse-midwifery student. If all goes as planned, I should be sitting for my certification exam in late summer/early fall, about a year after Tahini was born.
I’m so, so grateful for the amazing guide, Alex, at the Montessori infant community that Tahini attends full-time during the week. I rest easy knowing he’s in a safe, nurturing environment while I continue to pursue my life work. I firmly believe that Tahini will only benefit from seeing his mama doing work she loves, even if that means I’m not always home, or able to attend to him all the time while I am home. I cannot imagine not being a midwife, any more than I cannot imagine not being Tahini’s mama.
Parenting was not meant to be a solo endeavor even if you choose not to work outside the home…but especially when you do, having your village around you is essential. I’m so glad Tahini is learning from Day 1 that he can get his needs met from his mama…and from his papa, and his Mike and Mo and Anne (our housemates and Mo’s mom) and his Alex…and most importantly, himself. I will not be there for him every second of every day. My greatest wish for Tahini is the same as for my patients: that he may thrill and delight in his own body, his own mind, and his own heart, feeling confident that he can accomplish anything he sets out to accomplish with his own power. I’m just the midwife here, here to help support and guide.
Part I (On getting pregnant in midwifery school)
Part IIa (On the discovery at 39 weeks that our little Tahini was breech!)
We arrived to the labor and delivery unit at 7am. Out of habit, I used my ID badge to swipe in and walked up to the nursing station as if I were about to put my name and pager number on the board. B looked at me and smiled. “You’re cheating,” he said.
“What?” “You’re not the student midwife now, you’re the mama. Mama’s don’t let themselves onto the unit with their ID badges. They press the call button and wait to be buzzed in, like everyone else.” He squeezed my hand affectionately.
Oh. Right. Time to take that hat off and put on the mama hat.
After getting settled in our room with labs drawn and IV placed, the third year OB resident came and chatted with us about the plan for the day. She also did another ultrasound and surprise, surprise, Tahini was still breech. Other surprise, my amniotic fluid level (AFI) was now reading 4.6, down from 7.0 yesterday. Not sure how that happened, as I didn’t have any leakage of fluid…but sometimes there can be variation in calculation of this measure. In any case, 4.6 is low, technically considered oligohydramnios (Greek for too little water). As I mentioned in the last post, the risk with oligohydramnios and a version is that the cord doesn’t have as much cushioning, so risk of cord accidents and stillbirth increase quite a bit.
I wasn’t entirely convinced they would even do a version with such a low AFI, but the resident said to sit tight and she’d go consult with the attending, who would be overseeing the version. She had been recommended to me as a skilled and compassionate OB, one who would be happy to work with us to have as calm as possible a cesarean birth if that’s what needed to happen.
We waited around a while for lab results, for the OB’s to finish morning rounds, for the resident to consult. Being an “insider,” I wasn’t alarmed in the least that B and I had over two hours to work through two Tuesday crossword puzzles from our book and for me to take a little nap, along with a visit from the anesthesiology resident who would be performing my spinal/epidural.
The resident returned around 9:30 and sheepishly apologized, noting that three other little ones decided to make an entrance that morning. “No worries,” I smiled. “I know how it is around here.”
“Oh, right,” she said. “You’re a midwifery student. You totally get it. Well, thanks anyway for your patience.”
We then chatted about the plan, which was that the attending felt ok about attempting a version in the OR under spinal, but at the slightest indication of distress, we’d move straight to a cesarean. That felt completely reasonable to me.
And so it was that a little before 10am, I was being prepped for my spinal/epidural. B and I had just a few moments to ourselves to let it sink in that October 1st was the day we’d be meeting Tahini. In just under an hour, he’d be in our arms. We both laughed a little when I asked, “Does it feel real?”
“Nope,” he said. “It won’t feel real until he’s here. And even then…” I nodded. Yup. That was exactly how I was feeling.
The placement of the spinal/epidural went smoothly. Having seen tons of them placed, I knew exactly what to expect: they first wash your back with a cold ChloraPrep solution and then inject you with lidocaine to numb the area. That was the worst part–it stings going in…but after that, all I felt was a strange tugging sensation in my spine. I tried not to think about what the anesthesiologist was doing and just focus on slowing my breath.
Almost immediately, I felt my legs go numb and become heavy. The nurse and anesthesiologist had to help me lie back down and then the team finished the rest of the prep for the version: a pulse oximeter was placed on my finger, a blood pressure cuff on my arm, a nasal cannula (which was super itchy the entire procedure and very distracting!) was placed to provide extra oxygen during the procedure. A foley catheter was placed, as I no longer had control of my bladder. I remember commenting that it felt so strange–I could tell my legs were still there, as the numbness was more tingling than complete lack of sensation…but I couldn’t move a thing.
Someone asked me what music I wanted…I was a bit flustered by the tingling sensation and nasal itching, so I said the first Pandora station I have that I could think of: Django Rheinhardt. It’s often what B and I will play on Saturday mornings while we make a slow, lazy brunch. I instantly breathed a little deeper, mindful that breathing already felt different with the anesthesia in place. I had been told that sometimes, patients have the sensation of being short of breath if the spinal anesthetic flows up the spine…but in general, I should not panic and that it’s a normal sensation. I remember slowing way down and just focusing on each breath.
Someone dimmed the lights. B and one of my midwives, Liz, came in and arranged themselves at my head. I kept my glasses on so I could see what was happening. Everyone paused to confirm we had the right patient, etc., then we got started on the version.
The first attempt lasted about two minutes. I could feel mild tugging and pressure as two residents, overseen by the attending, used their hands to try to move Tahini in a counter clockwise direction. They were able to get him to a transverse (horizontal) position before his heart rate started dropping. In medical terms, this is called a deceleration.
Normally, baseline fetal heart rate varies between 110 and 160 beats per minute. A variable decel is a random, quick drop in rate with a quick return to baseline. An “early” decel often coincides with a contraction, and is usually a sign of head compression during the pushing stage of labor. And a “late” decel is a drop in heart rate after the contraction, usually a sign of chronic placental insufficiency. A variable decel can be caused by multiple things, but usually, it’s transient cord compression. You can also have a prolonged decel, which is longer than 2 minutes but less than 10.
Tahini’s heart rate dropped down to 80 beats per minute. It wasn’t quite technically a prolonged decel, as it only last one minute, but I vaguely remember the room getting quiet as the residents focused on the screen showing the heart rate. As a student midwife, I can assure you that one minute of heart rate at 80 can feel like an eternity. B remembers the whole room was completely focused on listening to the heart rate on the monitor. It wasn’t tense, yet, just very, very focused.
At some point, the attending came over and looked into my eyes and said, “We’re just having a decel here…we’re going to give your baby about five minutes to recover before we try again.” I remember thinking, “Five minutes…that must have been some decel.” I didn’t know at the time exactly how low it had been, which was probably a good thing.
After five minutes, the attending was honest: “I’m okay attempting one more time, but your baby didn’t particularly like that first attempt…so if his heart rate dips down again, I’d like to move directly to a section.” That was fine with me. Another dip would confirm that for whatever reason, Tahini wasn’t going to tolerate further attempts, and that potentially, there was an issue with his cord that was impeding the version.
I didn’t have a strong sense of time, but it seemed like the second attempt was shorter, maybe only 30 seconds. Both residents and the attending had hands on my belly, trying to move Tahini’s head down. B says they were putting quite a bit of force into it, but Tahini wasn’t budging…and his heart rate dipped again. “Doesn’t look like he wants to move further…and he’s really not happy here.” As they spoke, apparently Tahini just slipped back into his former breech position.
The decision was clear: Tahini would be born via a cesarean section..and it was going to happen very soon.
Part IIc to follow