{this moment} friday, june 3, 2016

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The Fourth Trimester

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.

The Unexpected, Part IIa (Neil’s Birth Story)

A week ago today, B and I were repacking our bags. We had already been packed with the bags in the car since week 37, with plans to be at the birth center for a few days postpartum.

But, to continue the theme of the unexpected, on Wednesday night, we dragged those bags back in and made some adjustments.

I should back up.

Earlier that morning I had my 39 week prenatal. I went in alone, as B was meeting with our general contractor about ADU stuff. It was uneventful, as I didn’t have much to report. I’d been having Braxton Hicks for a while, but nothing to write home about. No discomfort, no cramping, no little leaks, not a drop of bloody show. Just lots of belly and swollen hands and aching feet and ready to be done with pregnancy-ness.

My midwife Katherine and I chatted a bit about my plan for school this fall quarter (class on Tuesday afternoons, no call shifts, starting gyn clinic at week 8 or 9 of the term), which had just started up again on the 28th. We talked about my Mega Naps, and then she did Leopold’s (external palpation of the uterus). “Hmm…I know we’ve been calling him head down for a while, but I’m having a hard time finding my landmarks. Mind if I do an internal exam?”

Normally, she and I both wouldn’t bother for a first-time pregnancy at 39 weeks…but to be honest, I was curious. To my complete and utter surprise, I was 2cm dilated, with a soft cervix at midline and about 50% effaced (thinned out). Seriously?! But I hadn’t felt ANYTHING!

However, she couldn’t confirm a head down presentation. Normally, if the head is engaged at this stage of pregnancy, you can actually feel the bone sutures through the lower uterine segment. She couldn’t feel them, so asked for my permission to have another experienced midwife, Laura, do Leopold’s. Sure, why not?

She came in and almost immediately after placing hands on my belly, her face softened, and she sighed. “Yeah…I’m pretty sure your little one is breech,” she said. I nodded. I had a feeling. She asked if she could do another internal exam to confirm, which was fine with me. The first exam wasn’t as bad as I was expecting. The first words out of her mouth were, “Well, you’re 4cm…”

Katherine and I looked at each other in disbelief. “Uh, she was 2 when I checked her three minutes ago!” she said. “Yeah,” Laura said. “She was 2. Now she’s definitely a 4.”

Holy sheeeeeeeet. I still felt nothing. This is freaking crazy! I thought to myself. My life is about to explode
We talked about my options and the information I needed to move forward. First order of business: an ultrasound to confirm the breech presentation and to check the level of amniotic fluid around the baby. If the fluid levels were good, I’d be a candidate for an external version, where the provider uses their hands on the belly to try and turn the baby from the outside. If it was low, the risk of a cord accident is higher, and it wouldn’t really be safe. I’d then be facing the decision of whether to schedule a cesarean or attempt a vaginal breech birth…which very few OB’s offer.

Everyone has their own opinions about vaginal breech birth. My own thoughts can be summed up as: I wish we could see more of it, but it’s hard when so few OB’s and midwives actually have adequate training on how to manage breech birth. So much of the increased risk is simply due to the fact that people don’t know how to safely attend these births. OHSU offers a vaginal breech birth program, but they have strict protocols about who qualifies and the requirements are pretty narrow. I wasn’t sure I would meet the parameters, and so in the instant I discovered Tahini was breech, I immediately started thinking about the potential that this baby would be birthed via a cesarean section.

The ultrasound appointment confirmed what we all suspected–a breech presentation, with an amniotic fluid level of 7.0, which is on the lower end, but not dangerously low. I was a candidate for a version. The question was where to do it. In the end, I opted to do it in the hospital, at OHSU, where I am a student and where I know many of the OB’s. It felt like I had the best chance to work with a provider who would be accommodating of my wishes…and with the expertise of an academic clinical setting, I’d have the best chance of a successful external version.**

So, Wednesday night, B and I went out to dinner at our favorite restaurant. We talked through what was likely to happen the next morning when we arrived on the L&D unit. They would do another ultrasound, on the off-chance that Tahini verted himself overnight (unlikely, but it’s been known to happen). I’d have my labs drawn and a urine sample tested. I’d get an IV put in and they’d give me a bolus of fluid before placing a combined spinal/epidural.

Some places do versions without medication, others with a drug called terbutaline, which relaxes the uterine muscles…and other providers point to evidence that a spinal offers the best chance at a relaxed uterus and successful version. Our plan was that if the version was unsuccessful, we’d just move directly to a cesarean birth rather than attempting another version a few days later.

After the spinal was placed (in the OR), they’d attempt the version with ultrasound guidance, stopping every two minutes to check heart rate and make sure Tahini was tolerating the procedure. As we ate dinner we talked through potential scenarios…and commented on how unreal this whole thing felt. It’s entirely possible, we told ourselves, that in 24 hours, we could have a baby. On the outside. WHAT?!?

We came home and repacked our bags, preparing now for a potential hospital stay of 3-4 days. And then we tried to sleep. I was asked to not eat or drink anything after midnight, and plan to arrive on the unit the next morning between 6 and 6:30am. We didn’t really fall asleep till close to 1am, I think. And even then, sleep was hard to come by. How do you sleep the night before your life could possibly be changed forever?

Part IIb to follow…

**I should clarify: most of the time, I feel that the out of hospital is a safe place for most aspects of perinatal care. However, I do think in the scenario of breech and versions, there is a lot to consider. Sometimes versions can cause cord issues, which can lead to hypoxia for the baby…and the best way to avoid that is to be able to do a version with ultrasound guidance and immediate access to an operating room. While I fully respect the choice to attempt a version out of the hospital if someone is fully informed of the potential risks, I personally didn’t feel comfortable taking that risk and opted for an in-hospital version with a spinal/epidural in place so that in the event of an emergency, my team could move directly to a cesarean birth and minimize the length of time my baby might experience hypoxia.

I also think there’s something to be said for the academic clinical setting and the ability of providers there to gain LOTS of experience because they see a higher volume of breech babies than in a birth center. For me, when considering my options, I definitely wanted to know how experienced my provider was in versions, her success rate, and what her threshold of comfort was in continuing the version vs. transitioning to cesarean. These are all factors that anyone considering a version should be able to freely discuss with their care team.

In sum: I adore my midwifery team and would not have had my prenatal care done any other way. I still believe and practice under the premise that midwives can and do provide evidence-based, safe, compassionate care and are the ideal care provider for a low-risk pregnancy. I just don’t happen to believe that breech presentation is an entirely low-risk condition.

Prepping for Call Shifts: Part II

Welcome back for Part II of Prepping for Call Shifts. My first post explored the nuts and bolts of how I prepare externally—sleep, stuff I bring, pre-call routines etc. This post is more about how I get ready emotionally and mentally for 12 hours of being a midwifery student on call. It’s also a window into how I communicate my learning needs and goals to the preceptor I’ll be working with. My experience so far is that this communication piece is critical for a successful call shift.

This is not a cut and dry “routine” with concrete steps, per se…but I have found over the past term and a half that there is a bit of a process that seems to be evolving and I’d love to both share and also hear from other students and practicing midwives about what they do to prepare emotionally and mentally for being on call.

Making Peace with the Trepidation

Let’s be perfectly frank. I often find myself at some point in the few hours before my next shift feeling both excited and nervous/jittery at the same time. “Maybe another birth today!” is the first thought. But there’s no getting around it…the responsibility of stepping into the midwife role feels daunting. I never really feel prepared enough, even though I’m constantly reviewing protocols for the high-stakes complications.

That’s just an element of midwifery that is inherently part of the work: labor and birth are unpredictable, often flowing without complication, but that can quickly change. I would add that triage calls are a whole other category of unpredictable. You just never know what’s on the other line. I have yet to experience a true shoulder dystocia or postpartum hemorrhage or severe preeclamptic patient…but I know it’s only a matter of time. So, before each shift, I try to take some time to sit for a few minutes quietly and just breathe. This is after the bags and food are packed, coffee is made, scrubs are on. Just a minute or two to be still and breathe in some calm energy.

Clarifying and Articulating Clinical Goals

After that initial sinking feeling of “Oh, gosh, am I ever going to feel competent?” has had a chance to bubble up, make itself known, and then settle again, I try to spend a little bit of time before the shift thinking about my clinical goals. I have a running list of things I want to be working on, informed partly by our course objectives and partly by my own level of confidence in certain skills or aspects of clinical judgment. Of course, I never know what’s going to come in, but I review the things I’ve highlighted as priorities and then think about how I want to present those priorities to the midwife on call for that shift.

The midwife will often ask, “So, where are you and what do you want to focus on today?” That’s an invitation for me to be as clear and honest as possible about what I feel comfortable with and what I still find slightly terrifying. I find that just naming it helps.

Key current example: For whatever reason, I’ve mostly attended multip births so far, so I haven’t had the opportunity yet to do a lot of laceration repairs. Of course, I’m thrilled for those folks—easier recovery for them! But it means that I still sweat bullets at the thought of getting started with a repair and often feel like even figuring out how to approximate tissue is a challenge. I will just come right out and say so, letting my preceptor know what I think I might need to feel supported in the event that I need to do a repair. I also quickly review with her what I’ve been doing on my own in the meantime to try to keep my hand-skills fresh.

I also try to give a quick run down of the things I feel pretty comfortable with now—getting a good history, doing an initial assessment, management of an uncomplicated early labor, giving SBAR to an OB if we need to consult on a patient’s care or possibly co-manage, informed consent conversations for various scenarios, for example. This helps my preceptor know how involved she should be and how much space she should give me in doing these things on my own. Knowing that we’ve set this foundation up in the beginning of a shift helps the whole shift run more smoothly.

Chart Review in Advance

One of the nice things about having EHR access from home is I can keep tabs on how many midwifery patients are on the unit throughout the preceding shift. Especially if it looks like things are going to be busy, I try to prep as much as possible before I go in, knowing I may not provide direct care for all of them. However, having quick notes jotted down on my brain before I go makes report go a little faster, often saving precious time if there’s an imminent birth or change of plan at shift change.

I personally like to do this prep regardless—sometimes we’re short on time and I don’t get as much time as I would like to review the course of prenatal care…but there are often lots of pearls to be found if I take the time to read through that history. In addition to all the usual labs and other medical things, I try to make note of at least a few small personal detail that will help me make a connection with each person I work with, particularly when I haven’t met them in clinic before. It takes some time at home, usually no more than a half hour or 45 minutes, but I generally find it’s worth the peace of mind of coming in feeling a little more prepared. Perhaps as a practicing midwife, this need will feel less pressing…but for now, it’s become a part of my routine.

Cultivating Flexibility

The way our call shifts work this term, we’re not assigned to one single preceptor for the entire term. The benefit of this model is that we get to see lots of different approaches among our clinical faculty practice. The downside is there is less consistency and it can be frustrating to be told one thing by one preceptor only to have another preceptor tell you something different on your next shift! This is a more ongoing thing, but I find that before each call shift I have to consciously remind myself to not go in with expectations if I’m working with someone less familiar and to just ask her what her preferences are around certain things (pushing comes to mind: hands on or hands off? Or placenta delivery…to twist or not to twist—I’ve seen lots of variation!). Being open to new perspectives, even when working with a familiar preceptor, is important—no two labors are the same!

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These are the core things I find helpful before a shift…some days feel more organized than others. But I’m trying to establish the habits I want to have as a practicing midwife now, as a student, weaving in threads of practice that I observe from my preceptors as well. What are the things you find most helpful in the mental and emotional preparation as either a student or practicing midwife on call? Share them here or on Facebook, I’d love to hear from you!

Prepping for Call Shifts: Part I

I’ve been wanting to write more about my experience with call shifts so far but finding it difficult to know where to start. Then, I had this idea that maybe a good place would be to explore how I prepare, both externally and internally. So, Part I today focuses on external prep (which, in my opinion, is a lot easier, although it still takes a while to find your groove, I think. At least it did for me).

I’ve been taking call now since April, and according to Typhon (ah, Typhon!), have logged about 230 hours of intrapartum call. I mention this, because 230 hours seems like a lot…and most days I still feel like I’m just barely keeping up. Just in the past week, though, I feel like I’ve turned a little corner…it’s amazing how having a routine really does seem to help.

So, without further ado, here some of the concrete things I do to get ready for call.

1. Get sleep! As much as possible. I don’t take 24hr call yet. In theory, I could choose to if I want, but for my own learning, I’ve found that 12hr shifts are plenty. Yes, sometimes it means I miss those near shift change births…but I would rather those mamas have a fresh team, ready to jump in, than be worried that my fatigue might contribute to an error. Those babies are going to be born no matter who is there–it’s really not about me at all.

If I’m on for a night shift, I sleep in as late as I can and try to take it easy during the day. If I can’t sleep in, I’ll try to get a nap in from 3-5ish. It’s a tough balance, because sometimes it’s slow and then if I slept a lot during the day, I can’t nap well in the call room. But, I always err on the side of more napping rather than less. For day shifts, I’m in bed the night before by 10 at the latest. I have to be up, showered, dressed, coffeed and walking out my door by 6:20 on a weekday, 6:30 on the weekend to arrive in time for report.

2. Pack food! Easier said than done at the end of the term when I’m pooped and just heading down to the cafeteria sounds so easy…but especially as a pregnant midwifery student, I need more than cafeteria BLT’s to keep my energy up. I try at minimum to bring a sandwich, some fruit, yogurt, and whatever leftovers might be lying around in the fridge, so that’s two meals I don’t have to buy. Also, my call bag is always loaded up with Lara bars. I try to keep a stash of crackers in my bag, and bring cheese and apples as a quick snack while charting. We SNM’s also do a pretty good job of keeping our own stash of chocolate in the SNM cubby above our desk.

IMG_21913. Speaking of call bag…I don’t know how other people do this, but after a term and half of trying different things, I’ve found it easiest to have two. The one on the left (my beloved Linus bike bag, which hasn’t actually been on a bike in a while now…), is always packed with a spare set of clothes, toiletries, my stethoscope and a few sets of sterile gloves, along with my food and water. The other bag (a conference bag that’s actually useful!) is the one I’ve been using to shlep school stuff in: books, laptop/iPad, my planner, papers…

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So what all is here?

  • After trying it both ways, I’ve found it easier for me (read: more time to sleep in) to bring a clean set of scrubs home with me so that I can come to my call shift already in scrubs. Door to door, I’m 20 minutes from the hospital without traffic…so not having to get there early enough to change into scrubs means an extra 10 minutes of sleep! Unless my scrubs get messy on a shift, I come home in scrubs, shower right away at home, and return the dirty ones on the next shift.
  • The little black moleskine notebook is where I jot down lab values I need to work on memorizing, protocols and/or questions I have–basically things I want to look up later. It does not contain any identifying patient info (that’s kept on my brain, and tossed at the end of each shift–see below).
  • Pager and stethoscope, of course. Also, Lara Bar. Always.
  • Toiletries. Never underestimate how a quick toothbrushing and some deodorant can perk you right up after a night call nap!
  • Fetal position wheel…this was a gift to all the first year SNM’s from the Oregon ACNM affiliate and it’s come in handy for both myself and for patient teaching. Basically, the little fetal head rotates on the card, so as I’m palpating sutures, I can adjust the head on the card to reflect what I’m feeling, and then use it to help explain to laboring patients what their baby’s position is. It’s always in my pocket!
  • Suture kit. I always throw it in my bag for the slow days, so I can practice knots. I’ve got a stash of sutures and felt in there, too, and in the call room, the SNM’s keep extra yarn and one of those Ethicon practice boards. I haven’t actually used it a ton…but I like being prepared.
  • Reference books. The two I always bring are Lisa Miller’s Fetal Monitoring book and Lauren Dutton’s Clinical Midwifery Pocket Guide. I used to bring my Oxorn and Foote, but there’s a copy in the call room, and it’s a bit bigger, so I don’t bring that one with me anymore. Feminist Midwife posted a photo a while back on Facebook of her copy of Dutton’s Pocket Guide…mine is rapidly approaching a similar “full of post-it’s and written-in notes” appearance. I’ll often go directly from jotting questions in my moleskine to looking up quick answers in Dutton, and then make a list of follow up things/articles I want to look up back in the moleskine.
  • Water and coffee thermos. ‘Nuff said.

Other things not photographed:

  • Laptop/iPad for getting schoolwork done on slow shifts (sometimes, especially at night, I’ll stay home because I’m so close…but often there are 2-3 hr lulls when it’s nice to have my own computer to work on stuff).
  • Copies of my CNM Brain (Lena’s IP Brain_Summer2015).
  • My clipboard with other reference docs I’ve created for both antepartum and intrapartum (again, on a slow day, I like to review algorithms, etc. More on that in Part II!).

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What do you all bring to call with you? What’s your pre-call routine? I’d love to hear it, either here in the comments or on Facebook!

ACNM60: Sunday June 28

  

Gearing up for the official first day of the ACNM annual meeting tomorrow…today was a day to get registered, get organized (notice the color-coded highlights and tabs for each day?) and help Nursing Students for Choice set their booth up. I’m looking forward to an awesome day tomorrow…here’s what’s on my docket:

8am-Noon: Clinical Management of Early Pregnancy Loss

10:30-11:30: TableTalk Discussions: Modernizing Oral Histories: Midwifery Presence in New Media

(Yup, this overlaps with the first session….but I’ll be leaving that a bit early, because the second item is the presentation I’m doing with Stephanie and Robin!! Come on down and join us for lively discussion on how new media is changing the way we tell stories and create community as midwives and students!)

  
11:45-12:45pm: Pregnancy After Transitioning: The Male Gendered Experience with Fertility, Pregnancy, nad Birth Outcomes

2pm-3:45pm: Opening Session

4-6pm: Nursing Students for Choice Booth in the Exhibit Hall (come over and say hi, get cool buttons, and enter the raffle to win awesome posters and other prizes!!)

6-8pm: Midwives for Sexual and Reproductive Health and Abortion Caucus Meet and Greet

Events I’ve highlighted in orange that I want to go to, but can’t…but hope to find the slides for or catch up on later:

10:30-11:30am: ES110 Infusing Diversity into Clinical Teaching: Moving from Health Disparity to Health Equity

5:30-6:30pm: ES122 The Unmet Need for Family Planning–What Midwives Can Do to Help

6:30-7:30pm: Region VII meeting

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So looking forward to a great first day tomorrow and hope to meet up with those of you who are here! I’ve already met a few of you and have so loved getting to put faces to names! What are you fired up to attend tomorrow? Do share! 

Be sure to check out updates on Facebook, Twitter and Instagram throughout the meeting!