Spring 2008 Week One, In Review

This first half is for future midwifery students to see what books we use, what classes, what skills we learned and how we learn new skills, and for those preparing to enter direct entry (ie:accelerated) NURSE-midwifery programs, the speed with which we are expected to learn these things...

First, let me say, I am exhausted.

But my class schedule this semester (the halfway point of the program) is better than last semester (thank you universe ;o):

Antepartum (prenatal care)
Intrapartum (labor and birth)/Postpartum
Advanced Pharmacology
Midwifery Pharmacology
Research Seminar

Main Midwifery Books this semester:

Varney's Midwifery
Human Labor and Birth (Oxorne & Foote)
William's Obstetrics
A Fetal Heart Monitoring Guide
Articles, articles, and more articles!

My schedule: Class two days a week (after intensives which is two-three weeks of all day classes five days a week), antepartum clinical two days a week (2 short days of prenatal clinics at the local community women's center - I LOVE my site!), and call once or twice per week! A heavy load, but exciting.

Skills learned this week:

Suturing (which I love, but of course hope I don’t have to do). Belly tales has a post about her first day of suturing, which describes the purpose and anxiety, and then she has an awesome pictorial post about the process of learning it. These are great posts so I don't feel the need to repeat. We also practiced on boneless, skinless chicken thighs to approximate flesh which is, of course, harder than foam! Also, she alluded to the items being provided for them...we had to buy everything. (The foam, chicken, instruments, and sutures...look for medical discount supplies online, and buy expired sutures which are much cheaper for practice. There is absolutely no need to buy expensive stuff because you will not be using these for anything other than practice - the hospital stocks the instruments, you can not bring your own!...But, of course, if you are going to be doing homebirthing, then YES you will need to buy good stuff since you'll be using it for more than practice...but hopefully not often) Along with suturing, you learn how to cut an episiotomy.

Venipuncture. They sprung this one on us. I was not amused. Maybe on Tuesday or so, she said “and Friday you will be learning to draw blood and start IVs…on eachother.” Ugh. Talk about anxiety. I managed to find the vein and poke my partner but as soon as I hit resistance, I pulled the needle right back out, scared, LOL. No IV insertion for me that day. In my defense though, my partner was so damn jumpy and nervous and tense. I did get blood flow though when I removed the needle, which means I was in the vein and that was enough for me. She did a stick on my hand, and it went fine despite the fact that I hated it.

Cardinal movements of labor. This was done with my partner and I taking turns being on the hospital bed, legs wide the hell open in lithotomy position with a fake baby on our bellies or under your shirt that you push out while she practices hand maneuvering and the teacher turns the baby's head to mimic the head positions of birth. She preferred for people to hold her legs back for her turn, I said just give me the stirrups for mine...that leg holding stuff is too intimate for me with people I don't really want all up in my space. Not the most fun activities this week, *sigh.* Now I will have to read the chapters and memorize the mechanisms (ie:cardinal movements) before my first day/night of call.

Vaginal exams. (sterile speculum exams, and how to check for dilatation in centimeters)

Leopold's Maneuvers. To determine size, position, etc. of baby inside the woman's pelvis. (Photo)
Fetal Scalp electrode. Where it goes, why we use it, and how to put it in...all demonstrated on a pelvis model.

Intrauterine catheter. Again, where, why, how.

Pudendal Block. When, where, how and why.

There's probably more, but I'm tired of talking about it. We also practiced sterile gowning and gloving for birth. The didactic content included everything that goes along with the above skills, and topics such as genetic counseling, intermittent auscultation guidelines, etc. A doula also came in to talk about her role as doula and about labor support techniques. It was a loooong week. And those were just the midwifery classes.

Now, on to other things...

One of the things that struck me this week was how medical midwifery education is for the CNM. Now, of course, this was not news to me, I researched all of this before selecting a program, and I'm well aware of the whole "medwife" thing floating around. But it's still...odd...how we learn midwifery in this setting...even knowing it would be medical, I am still shocked by just how medical it is. But more than that, it was a long week of frustration in terms of how we refuse to tell ourselves the truth about the kind of care we provide. For example: We were having a conversation about continuity of care. Continuity of care is simply the woman having the same provider for her whole pregnancy, or even including pre-conception, and her labor and birth and post partum check up. Our professor kept mentioning this continuity of care that we are providing as midwives. Eventually I had to ask (it was irking me) "is there a definition...a statement from the ACNM discussing the definition...of continuity of care that we are using to determine whether or not we are really providing continuity of care (COC)?" She didn't really answer that, but she re-iterated what COC was. So then I had to make a statement leading into another question: "As far as I've seen, the nurse midwifery practices around here, faculty practice included, acts more like the OB practices in that they share a pool of patients and the patient is rotated through a group of providers, midwives and OBs included, so that by the time she delivers, she has met each provider in the practice at least once before they deliver/catch her baby. How, then, can we say that we, nurse-midwives, are providing continuity of care when we do not really follow each patient from prenatal to labor to birth to post-partum?" She hemmed and hawed, and said it was still COC because the woman is seeing the same "team" of practitioners for all of her care. Bullshit.

Tell the truth.

WE ARE NOT PROVIDING CONTINUITY OF CARE WHEN WE PRACTICE IN THIS WAY except for maybe, m a y b e, when there are only two providers sharing the load and the woman see these two providers back and forth, similar to midwifery care provided with back up OB care for emergencies...We know the benefits of these kinds of set ups for the provider: you can be a midwife and still maintain some semblance of a personal life because you will not be on call very often. You do shift work, you catch whoevers baby comes while you're on shift at the hospital...whether you've ever met her or not. And in the case of our professor, who only does intrpartum work, almost all of the patients she delivers are women she has NEVER met. This was not something she hid from us, she said it upfront and discussed the challenges with this (since this is likely to be the case for us this semester as well) but what I was getting at was we need to use truthful language, and not use the midwifery's legacy, herstory, as an equivalent to what we're doing now, as nurse midwives. This is crucial because once we allow ourselves to call catching the baby of a woman we've never met "continuity of care," we start down this slippery slope that leads to us calling unnecessary interventions necessary, or making routine ways of caring in the hospital setting equivalent to original midwifery ways of caring. There's a difference, a big difference, and we need to call these differences out, front and center, other wise, the country will just have a new profession of OBGYNs who "don't do c-sections." (ie: we do not have to do what everyone else is doing, in fact it is dangerous)

More examples: We were talking about monitoring using the machine, vs intermittent monitoring. The professor said that the women we care for at the hospital do not have to be hooked up to the external monitors (which makes it impossible to move around because the machine is set up next to the bed, with cords that keep you right there in bed)...that there is policy in place for us to use intermittent monitoring (which means instead of keeping a monitor on 24hrs straight, you can just check the baby's heart tones every 15 to 30 mins wherever the woman happens to be (in the bathroom, on the floor, walking, kneeling, rocking whatever). The professor made this seem common place. When, in fact, in truth, in all my shifts on labor and birth, I have never seen a woman who was not hooked up to the monitor...I have never seen intermittent auscultation practiced! I mentioned this, and then asked for a role play scenario of what we, as student midwives, can do and say to make sure we use this way of monitoring on the floor. "What conversation is had, when, and how, in order to use this practice?" She had no answer. She said "you'll see." But the truth is, I've had a shift with her already, and I know she doesn't do this, neither do any of the other midwives I've worked with on that floor...and I just did two shifts about a week ago! When we do not present the reality, we make it so much harder for ourselves.

I would prefer you, the one who's supposed to be teaching me, to tell me that you argue with folks on the floor about being able to use certain skills and avoiding interventions....that the way to make sure my patient gets appropriate care is to argue this way, vs that way...that this argument for why she doesn't need pitocin is much more effective than that argument...that the way to slow down the ticking clock to c-section is to... These are the conversations, role play scenarios that are more helpful, more truthful, than "midwives believe in decreasing interventions"...yeah ok, of course they do, but how can I do that in the constraints of the setting I'm placed in? And let's talk about how we can claim that we don't believe in unnecessary interventions, and still do all of these interventions...this is a big. damn. deal. if you ask me...conflict of morals, and all...why did I learn how to cut and repair an episiotomy and 1st, 2nd, and 3rd degree tears BEFORE I learned how to prevent the need for such by protecting or hands off of the perineum? What you teach first and why has to have meaning...because what we learn first and why, has an effect on our practice, young moldable minds, we are...and I think we're supposed to learn about these contradictions at "home," meaning among ourselves...with other kinds of midwives, not just nurse-midwives, not in that indoor vs. outdoor conversation sort of way, but in that how can we discuss what's outside, if we aren't willing to deal with what's happening inside our own midwifery community?

This is on my mind for real folks because when people purposely choose to turn away from OB medicalized care (I'm not including those who haven't made the choice but rather were just sent to us, right now) they are expecting to be served in the ways that we claim to serve. Look at what they want...can we provide this? Are we providing this? (It's important to note that there is a difference between the types of midwives and the care they choose/or are limited to providing) but even if it's not homebirth, are we doing what we say we do?

I know I'm not the first one to talk about this, but it seems like a conversation that isn't really being given the consideration it deserves, especially in the classroom.