Talk Back & Clinical Guidelines

In response to comments from previous post...

[::] I think I learned to never rupture before zero station, for fear of cord prolapse, except in emergencies.

[::] No, we don't have continuity of care. We technically can have it with 1 patient I think, but because there are really very, very few call shifts in any given month, it never happens. (For example, I have two, yes, two, call shifts for the entire month of November.) So I gave up on even trying to have my 1 possible continuity patient.

The ACNM has provided the following clinical guidelines as an educational program resource, and they make sure to point out that these are not the requirements for individual students to achieve competency. In other words, achieving these milestones do not guarantee you graduation, nor does not reaching them prevent you from graduating. Nonetheless, I compare my notes to these nonrecommendations to see where I stand. Already, I know that I am lacking in the number of births I should have by now, mostly because of the clinical crisis? lull? we're experiencing. Here's the breakdown (the ones I've completed already are bolded)

a. 10 Preconception care visits
b. 15 New antepartum visits
c. 70 Return antepartum visits
d. 20 Labor management experiences (maybe... need to check)
e. 20 Births (6/20)
f. 20 Newborn assessments
g. 10 Breastfeeding support visits
h. 20 Postpartum visits (0-7 days) More than halfway there...
i. 15 Postpartum visits (1-8 weeks) I think I'm close...
j. Primary care visits:
-40 common health problems
-20 family planning visits
-40 gynecologic visits including perimenopausal and postmenopausal visits

All of this to say, I really need to catch some babies... (as does the majority of my class) and if it doesn't happen in the next month and a half, I have a whole lot of catchin' up to do at integration... Happily, I've reached the other milestones before even leaving for integration.

For those interested, the NARM requirements are below:

Experience Requirements

I. As an active participant, you must attend a minimum of 20 births.
II. Functioning in the role of primary midwife* under supervision, you must attend a minimum of an additional 20 births:

A. A minimum of 10 of the 20 births attended as primary under supervision must be in homes or other out-of-hospital settings; and
B. A minimum of 3 of the 20 births attended as primary under supervision must be with women for whom you have provided primary care during at least 4 prenatal visits, birth, newborn exam and 1 postpartum exam.
C. At least 10 of the 20 primary births must have occurred within three years of application submission.

III. Functioning in the role of primary midwife* under supervision, you must document:

A. 75 prenatal exams, including 20 initial exams;
B. 20 newborn exams; and
C. 40 postpartum exams.

*The primary midwife has full responsibility for provision of all aspects of midwifery care (prenatal, intrapartal and postpartal) without the need for supervisory personnel.

Talk Back

In response to comments from previous post...

I think I learned to never rupture before 0 station for fear of cord prolapse

Yay!

Bellytales is back!

I'm so friggin happy to see her return.

The hemorrhage post is a great read for midwifery students.

I Never Talk About Births... What Kind of Midwifery Blog is This?

I hardly ever talk about my catches/ clinical experiences...

LadyA: Young, obese (actually she had my BMI which really bothered me), having baby #1 with family (mom, older sister who raised her while single-parent mom worked outside the home, and equally young father of baby) LadyA was on the unit when I arrived. She was induced for "post dates" at 41 weeks... and I highly suspect that she had an unfavorable cervix when they did it. In the beginning of my shift she was coping well with the contractions (she also wasn't really feeling them) She had been counseled during prenatal care about pain management and she wanted to try to avoid medications. Our unofficial policy is to explain all the pain med options with side effects, risks, and benefits on admission to labor and delivery so that the woman doesn't have to understand the risks/make these decisions in the middle of intense contractions, and then if they don't want anything we put everyone on alert to not offer anything unless the woman herself brings it up first. So she decided at admission that she wanted to try non-epidural medications first if it came to that. and she would let us know (rather than us asking her) So when the contractions got a little more intense, she started asking for an epidural but we reminded her of what she said she wanted initially. She said she changed her mind, so an epidural was placed.

So it's around 11am and she's 3cm/85% effaced/-1 station... unchanged from when she was induced early that morning. She has pitocin running at 4mU/min. Baby's heart tones start to get funky... a prolonged decel occurs, which leads to the midwife breaking her water to place an internal fetal scalp electrode, especially because it's harder to keep the baby and contractions on the monitor on fatty girls. This becomes more important when there are decelerations of the baby's heart rate because you need to determine whether they are variable (ok) or late (bad). Otherwise, it's not a good idea to break someone's bag of water at 3cm and definitely not at a -1 station.

Hours go by... still having funky decels, another one is prolonged x 4 1/2 minutes. The pit is turned off (it was at 8 by then), o2 is given again, she turns on her side... throughout the day, she has two boluses of epidural because she has a "window" of pain on her right side above the thigh that she rates between a 6 and 8. Eventually an IUPC is placed, and after that we try amniotic infusion- the 30 minutes after that gave us her most beautiful tracings of the night. But it was soon over, and back to her normal funky tracings.

The dilemma: Her contractions were not effective... MVUs of about 120... usually the pit is increased when this happens... but her baby did not like pit AT ALL... and then even with the pit off, the tracing took a long time to resume a more reassuring status.

And then, the family/nurse issues. We have a very specific guest policy concerning # of guests allowed on labor and delivery. And it's non-negotiable, unless you appeal in writing prior to arrival to the hospital. And once you select the people, you can not change them (so no taking turns) This patient had another sister who was denied entrance to the floor. It was not a pretty situation. Patient's family is arguing with the nurse, nurse is arguing back (and honestly being very rude and non-understanding about the situation which just made everything worse) and eventually the nurse is switched to another patient. The nurse was in the right, she was enforcing a policy, but her attitude was terrible. She complained to us that the patients were speaking Spanish to their family on the phone and she couldn't understand what they were saying but she just knew it was about her and her insistence that the sister couldn't come in. That was probably true as this family was very upset, even after I explained the policy to them again after the nurse left. But, come on, don't stoop to the angry person's level- you're the professional.

So anyway, after 12 hours our shift was up and we transferred care to the oncoming shift... of OBs only, no midwives on after us. When we introduced them to the patient it was obvious that a section was imminent.

LadyB came into triage a few times before being admitted. First time I sent her walking (multip with stretchy 3cm cervix looking very uncomfortable. She came back a couple hours later- no change, contractions still hovering at 7-10 minutes. I sent her home because she lived close and said she had a ride (who was there with her when I asked) and told her to eat, drink plenty of water, take a shower and a nap, etc. Told her it would probably be soon. Well she returned about 6 hours later, in active labor (6cm, contracting every 3-4mins, not able to talk through contractions) The nurses were irritated because she arrived by ambulance and obviously birth wasn't imminent. Well her ride ended up backing out and she didn't think she could walk to the hospital (her partner and children walked over) But such is life. So I admitted her, and the nurse gave her a nubain/vistaril combo (what she asked for and had with all of her previous deliveries) and she slept very peacefully between contractions and barely woke up during them. It worked great for her. She got an IV because she was GBS positive. When it was time for change of shift she was 8cm with a bulging bag and saying it was time. That's when we left.

I hate this about being a student. When the preceptor leaves, you gotta leave. I wanted to stay. She was sad we were leaving. I was shocked... well maybe not... that we were leaving when she was this close. Midwifery educators are so overworked though, so I get why they aren't as apt to put in over time. I'm hanging my hopes on the idea that real life won't be like this...

So, 12 hours, 2 patients, no catches, but a whole lotta learnin... my life as a midwifery student.

Talk Back

I love that I allow anonymous comments, I think it allows people to speak freely.

This comment was left on the last post about privilege at the library.

Why make it into a male/female thing? Maybe he was just asking to see if your smaller party could move. Or maybe he's just dumb. But don't get all feminist on him....and this is coming from a girl. We've got enough real issues to be mad about the sexist divide without drowning them out with somewhat over the top assumptions...

Here is my response...

I actually didn't think it was one kind of privilege more than another kind. It could of have been male privilege, it could have been white privilege, it could have been class privilege, it could have been all of three combined. It could have been none at all. I didn't "go" anything on him, because I didn't say any of that (male/female commentary) to him. And while I only listed the gender commentary at the time, believe me there was also racial commentary going on in my head! (And I'm sure if I would have wrote that down someone would have said "why does it have to be about race? lol)

I only said that they couldn't have the room. And, real talk, he was not entitled to it anymore than we were... and, after being here for nearly three years, I am very aware of the sense of entitlement of many of the students here. It's rude to walk into a private study session and expect people to leave so that *you* can study. I'm not going to pretend that I don't think race or gender plays into these situations. The real/bigger issues of feminism are only smaller issues working on macro levels. That is, the same sense of entitlement that makes you think we should move for you (the smaller issue) is what eventually leads to you behaving as though you have more rights than me (the larger issue.) I believe that changes in personal thought patterns lead to larger social change.

Is it daunting to you that I would think all of this from a seemingly simple interaction? Would you have responded differently? Do you tend to give people the benefit of the doubt in most situations? If so, why do you think you do that?

Rhetorical really, just thinkin...

Thanks for stopping by.

Privilege at the Library

I made it to the library... two hours after I had planned to arrive. My study partner and I were in a study room, when in walks a guy and his friends asking if they could have the room for their group. Ummm. Well...

My study partner: "mmm"

Me: "Do you have the room reserved?" (It is possible, though not common, to actually reserve the study rooms for your group)

Him: "No, we just have a lot of people and need a room."

Oh, in that case...

Me: "we are actually studying here, so no that won't be possible."

Hello!?! My study partner graciously told them where she had saw another available room before we settled on this one. Do you think they went to see if that empty room was still available? No, of course not (unless they went later)

Not today, brutha, not today.

My girl self is not required to give up study space for your boy self... I am equally allowed space in this place.

Blogging Through a Headache in Procrastination

I have a lot to do school-wise today. I have papers to write, thesis stuff, and at least a micro study before clinical in the morning. I was not anticipating going to clinical in the morning, so studying for that was not something I planned for until today, unfortunately. I always wonder if other students feel this drowning, sinking feeling I do about how much there is to do, and how very little I actually know about women's health, labor and birth and beyond. One of my struggle points is the patho/physiology of all of it. I can read it over and over again, but it doesn't stick. I really, really do have a memory problem, but there's no explanation for it. My daddy has a terrible memory as well... but I guess he's allowed because he's getting older... and he isn't responsible for anyone's life. Last time I had blood testing, my thyroid was fine and my vit B12 level was normal. But still I am always tired and I can't remember crap. But I have never been able to remember things like this, even as a child, so maybe this is just me. I wonder if my residency preceptor is kind?

Anyway, my point is I need to update/improve my black book for school/clinical because if I can't remember this stuff I at least need to be able to find it quickly. So add that to the list of things to get done today. And to top it off I have a massive headache that just wont quit.

Afternoon Plan (maybe writing it here will help me stick to it)

• 12:30 Paper (very short) for Professional Issues class
• 2: Data Analysis section of my thesis
• 5: Organize the binders of two classes causing me grief
• 5:30 Pick a nursing leader to analyze for a paper I'm writing later in the week
• 6: Head home to review for clinical in a comfy spot on the couch with something warm and possibly spiked

In other news, this weather is really taking a toll on the walking regimen that I so successfully started this summer. I'm also drinking a lot more coffee and cocoa, which isn't a good thing, as more coffee and cocoa equals more sugar- especially since I tend to drink them with a donut, muffin, or bagel in the other hand. Sigh. I also cook less and less now that school's back in, and the food prices are so freakin high. Me and the man can eat out for less than we can cook... unless we're cooking with a lot of rice or pasta, which is really not the ideal situation. I've also taken a play outta the man's playbook and been eating frozen meals, which I HATE. But they're so quick. Midwifery school this semester + increasing frequency of bad habits = expanded waistline sure to follow. And what's worse? I crave smoking. isn't that odd? I'm not really a smoker, but I do smoke every now and again from the man's stash. But lately I've been really wanting to. Ugh.

Post-Midterm Exhale

The midterm was tough. But of course it would be. I'm glad it's over. I actually ended up going to sleep the night before for about 6 hours, instead of studying through the night, and I am so glad that I did. We still had class after the exam and I had class the rest of the day, too. I needed those hours to be able to function.

Today I went to the bookstore to browse and have a treasured marshmallow mocha latte. I browsed a book on taking risks by Ben Carson, and was so grateful to have found it. He talks about where and how he grew up, and how going to college at ivy1 was one of biggest risks he would ever take in life, among others. He talked about how at first it was just a big deal to actually get to the ivy league schools, but in his first semester he realized that the real challenge was going to be staying there. He realized he wasn't as smart as he thought he was... that the ivy kids were much smarter... that the SAT scores that he once thought were stellar- because they were record breaking for the public school district in his city- were below average... were the lowest of anyone at that table that day...

I remember that realization, too. It wasn't exactly the same because I was never under the impression that my scores were stellar, but I do remember being very shocked. Sad. Frustrated. Down right teary at the fact that I was... am... so far behind everyone else based on the drastically different educations between me and most of those who are able to attend this institution.

Then he talked about being at the bottom of his class, and how he wasn't an auditory learner, and how he had encountered an advisor who suggested that he wasn't cut out for medical school. No one has said this to me at school, but I have received my share of "you're failing and maybe you should leave" letters. Same premise, but much more cowardly in my opinion.

Anyway, all of this to say, it was great to get all of that from like 10 pages of a book... the feeling of familiarity... the encouragement from seeing that someone who has faced even more than you have, has been exactly where you are standing and came out on the other side... and not just made it, but turned out be Ben Carson... is so useful.

It was exactly what I needed to give me the faith to push on for the second half of the semester. This is it folks. I have only 1/2 a semester of classes left in midwifery school. I just have to hang on, and finish strong. I can do this. I can do this.

The man and I had a special dinner tonight. We needed to reconnect. I'm glad we took the time to make it special, otherwise life gets old, right?

My next countdown is to our trip home to my family's place this time.

Midterm Madness

My midterm is tomorrow, so today is a non-stop study fest. (Yesterday was a failed non-stop study fest... I did manage several hours though!)

When I was relearning the shoulder dystocia material I was so completely shocked by the Zavanelli Maneuver... wherein you put the baby's head back into the vagina. I just kept re-reading it like no way... there's no way... just in awe, lol.

Now I'm relearning breech delivery and I am equally astounded by the maneuver wherein you allow a baby to simply hang from the vagina for a few seconds if you couldn't reach the chin of the baby to flex her head. Here is a great pictorial (with commentary) of a vaginal breech delivery... it's the first place I've seen good pictures of this step in vaginal breech delivery. I am freaked out by the pics of the baby hanging there!

I can not see myself doing vaginal breech deliveries on purpose, although I have absolutely no problem with referring a woman who wants one. But at the same time it reminds me of "without providers, there is no choice." I have a very clear stance on believing in woman's right to choose abortion- meaning I would provide abortions if in the position to do so... but what about breech birth? If there are no providers willing to do it, there really isn't choice (with a skilled professional available), right? We don't spend much, if any, time discussing these issues in midwifery school... we spend our time with the science and the skills... which, honestly, is overwhelming in and of itself, so I understand. But I can only hope (and, really, I think it's the case) that my peers are thinking about all of these things in their own time as well.

I am dreading/stalling on bleeding and infections... sigh... I need an outdoor break and pep talk, then maybe I'll be ready....

On Writing a Thesis in Midwifery School

I had another interview this morning. I was encouraged by hearing this student's experiences in her program. She has faced a lot during her midwifery education but continues to push forward... quite amazingly. I can't wait to transcribe this interview and see it in print.

I don't write much about the process of writing a thesis. I had initially intended to write about it regularly so that people could see what the process (or at least my process) looks like. But I guess because I'm writing it while also taking a full course load (unlike how it is normally done in the humanities wherein you usually set out to write it after all of your classes are done and you can give it your full attention) and because it seems like a boring process, I haven't been writing about it at all. Collecting the data (interviewing) isn't boring- that's the exciting part, but writing down the methods and analyzing the process is all a little dry to me right now. However, I think it's really important for people who are considering taking on the task to have an idea of how it works, so I will start to write about it a little bit here.

First, in the beginning...

At our school, no one has to do a thesis. Everyone has to do something, but it does not have to be a thesis. You can do a literature review... a term paper... an artistic piece, etc. Actually, few students actually do a real thesis. I decided to do a thesis because I'm going to get a PhD after this and I didn't want to apply for a program without a thesis under my belt... I think it proves something. And for the last few weeks, I have been thinking that another plus to doing a thesis is that it may be easier to convince a program to let me do a secondary analysis for my dissertation since I have already learned/been through the whole primary data collection scenario. Also, I simply couldn't imagine leaving this institution without a hardbound thesis... I mean this is a research institution! How dare I not take full advantage?!?

So, I'm writing a thesis. The topic was a no brainer for me... I never found much about the experiences of black midwifery students, and according to my own experience I knew we had a story that needed to be told. Now, if I were just one year later coming into this program, my thesis could not have been done... the new rule is that you can only do a thesis that is a branch of a faculty member's larger ongoing research project. I take issue with that, but it doesn't affect me, so whatever! I'll let the next class fight the battle for why they can only research the stuff that's important to their professors... with very few faculty of color, there are bound to be some things (ie my topic) that no one is currently researching! I hope they find some topics that are at least close enough.

So you pick a topic, and a project type (thesis), and then you look for a (thesis) advisor. At my school, there isn't a whole committee, only one advisor. This is great because the fewer people who read it while it's being written, the fewer people you have critiquing it = the fewer changes you have to compromise on making. I suggest you look for an advisor as soon as you have an inkling of a topic. Don't wait to the last minute... each faculty member can only advise so many students, and you don't want to be stuck with whoever happens to be left. You can pick an advisor based on on many things:

• 1) Topic match. You choose this person because they've researched something similar to your topic and will have a lot of info to share with you which will cut down on your leg work. They will be able to point you to seminal texts and authors which will save you precious time. You know they'll have passion for your topic because it is what they've decided to spend their career thinking/talking/writing about.
• 2) Methodology match. This person may not know anything about your topic, but they might know a whole lot about the methodology you're using. For example, I'm doing qualitative work, specifically, interviewing people. It doesn't matter what I'm interviewing them about, what matters is that my advisor has spent years working with this type of methodology. So she knows how to conduct it, how to analyze it, and how to write it up. In this case, it isn't about the topic, it's about the method. (This is what I chose... and I had to make sure that she believed in my topic... I have no time to convince people that our voices are worth hearing... not right now!)
• 3) Personality/needs match. This happens when the advisor is just a good advisor, period. It doesn't matter the topic or methodology, she knows how to get you through your project smoothly, and on time, based on her ability to motivate you and point you in the right direction. If you're a procrastinator you may choose someone who has very rigid deadlines who's going to push you to the finish line. If you're very hard on yourself/perfectionist, you may need little direction but choose someone who's a little more laid back and who encourages you that "yes, that chapter is complete, move on to the next one!"

The most important thing is that you finish the project. Yes, quality is important. But in a program where a thesis wasn't even required, and they make you write it with up to seven classes going on at the same time... quality is going to be subjective, ya know?

So the next step, for me, was a review of the literature. Go here to read all about that process. I suggest that you keep an annotated bib along the way, otherwise you'll be frustrated by not remembering if you've read stuff, or forgetting the point of what you read, or forgetting why you thought it was good in the first place!

So that's it for now. Next time I write about it, I'll be talking about the IRB process.

In other news, I've been studying for my midwifery midterm. It's a lot of information of course. I feel like I have a good handle on VBAC, shoulder dystocia, active management of labor, and antepartum bleeding. That leaves a lot left uncovered! I have study group from 6pm to midnight tonight... what a long night I'm in for.

I went to see The Secret Life of Bees yesterday. I was so distracted by the darkening makeup they used on Alicia Keys. Ugh. We come in maaaaaaany shades, why did they feel the need to darken her skin so much?!?

I'm going to see The Duchess today for my midday study break, hope I love it!

That Old Problem

I reposted three posts from last year that deal with being a fatty girl in nursing school and practicing skills, including pelvics, on your classmates. They're listed in the archives under 2007. I put these back up because a friend, a dear blog follower, is now going through the same things that I was going through when I wrote those posts last year, and I wanted her to be able to re-read what I wrote, and what you guys had to say, again. I have also been discussing this with those who I've been interviewing, and it's been interesting and sad at the same time. I want everyone to know that in some places there is no choice but to participate... that professors actually require, demand, coerce students to participate in these clinical didactics. I want it to be known that I find this appalling. Seriously. Not that we would practice on each other (that can be beautiful) but that we would not have a choice... in this profession, especially... to dictate what happens to/who touches our own damn bodies.

There is a new article in the latest Journal of Midwifery and Women's Health (Sept/Oct 2008, page 403) that discusses this phenomenon. The author calls for us to re-examine the practice of students practicing on each other. She brings up some very valid points surrounding informed consent... basically students have the same rights to informed consent for procedures performed on them... and that informed consent is not valid if it's under coercion or fear of the person consenting.

I totally agree with the author.

It's time to re-examine it, and NOW, before somebody sues, or worse, women are traumatized.

((HUGS)) to my friend who's dealing with this. You're beautiful. And Kind. And good people, period. Your body belongs to you and only you. You have a responsibility to yourself to protect your body (and mind and heart and soul) from gross violation. What happened to you in lab is not acceptable and you have every right to be angry and hurt.

More Fat Talk

*I wanted to highlight the last comment from Pamela because it says so much of what I was thinking in class... I wish I had had the clinical experience to say some of what is said here...

My favorite accusation is the one that blames overweight women for the increase in maternal morbidity.

I tell you what, gestational diabetes is a joke as it is presented. the only "GD" I accept is women on the verge of type II diabetes before pregnancy and then, with natural decreased pancreas function in pregnancy, have blood sugar issues. Can we just get rid of the GTT? please? and why so many varying, and conflicting, lab values for "diagnoses"?

In my practice, the worst hypertensive and hyperglycemic cases have been from thin women. Especially blood sugar issues - usually related to women older than 40 who have poor diets.

I can't even get over how few providers know about using a larger cuff to measure BP on heavier women.

I just get sick of the "fat=big baby/hypertension/diabetes/cesarean section"

More and more plus-sized women are being set up for cesarean sections right from the start of care based on these biases. And guess what? Plus-sized women do not heal well from cesareans. So maybe the increase in complications with these women are based purely on fatphobia.

In my medical records, 14 years ago, I was labeled "obese" because I weighed 165 pounds at the start of my pregnancy.

I contacted a midwife in the city I'm moving too ask about their risk-out criteria for homebirth with their practice. I told her that I am obese, and still want a homebirth. She told me that they didn't automatically risk out for that, and explained that they'd have to decide after meeting me and seeing my personal habitus. She said their primary concern is not being able to do good fundal massage in the case of hemorrhage. I had never thought about this, but now of course I think about it often. lol. Every classroom session for me now is fear inducing. I always leave class thinking "should I really be trying to get pregnant?" I have so many damn risk factors that it has taken the joy and positivity out of even the idea of being pregnant. The worse days are the maternal mortality days. I have to spend ALL DAY reminding myself that birth is a natural process and that, yes, there can be complications, but there can also be low risk intervention free homebirth for fat women that doesn't end in death. Seriously I have to go through all that... not only for myself, but for the women I will see this week and the next and those in the following year who deserve not only evidenced based information, but also the right to hope and happiness. So much of how we process and experience birth is mental... how sad would it be to instill fear in a woman when she needs it least.

And thus we return to the balancing act... telling her risks without sounding all doom and gloom. Being realistic about what she can change and what she most likely cant or wont. Hmmm. What I can change (and already have) is what I eat and how much exercise I get... I can take a multi or prenatal vitamin everyday... I can refrain from large doses of alcohol and coffee... what I can't change is the risk factors I have associated with race, ethnicity, and genetics...

Navelgazing also writes a lot about fat.

I wrote about it a few times over the course of my education, but I think I've lost all patience and have so little energy to repeat myself in the classroom!

Fat & Communication

Today I've sat through a two-hour lecture on preeclamsia and a one-hour lecture on gestational diabetes. I feel like I've had these lectures several times... and I have... but still I don't feel like I know the information. I sometimes get distracted by the conversations that happen around the topic. Today I was distracted by the tone of fat bias in the classroom, especially during the gestational diabetes lecture. One comment was about an obese woman who had the nerve to continue to eat steak after her gestational diabetes diagnosis. Oh the nerve of this woman. Steak! Imagine. Now of course, steak- and meat in general- has come to symbolize all that people who eat differently than the majority of the folks enrolled do wrong. And of course we then get to sugar and refined carbs. And don't forget the dunkin donuts in the morning and the McDonalds for lunch and dinner that all of us fat people are eating every single day. (Seriously, this is what was said today about how overweight and fat women are eating... without any caveats, any "most" or "many" nomenclature, and with lots of classroom laughter) Lately I've begun to tune out the things that bother me in the classroom. I figure I don't have the energy to care about these things when I have so many more important things to learn in my 9 hour classroom day. But fat bias is one of those things that, as the only obese patient in my cohort, is hard to sit through. I think a great future research project would be to interview obese nursing/midwifery students about their experiences in the classrooms of the medical field. I think we'd get an earful. I rarely say anything in class about this because, come on, how predictable... the proud fat girl defending the other fat girls.

And, at this point, my relationship with my class has moved to a completely professional one. I no longer participate in weekly check-in, and I am so proud of myself for making this decision. It was important for my sanity, self-esteem, and overall happiness. After being called hostile multiple times by one student who then started crying per her usual emotional state and my supporting of her feelings about me- with an apology and a hug to calm her despite my disagreeing with her outburst, and feeling very attacked and unsupported myself- I realized that I sit through a lot of teary, "my cat is sick...my dog is dying" kind of check-ins. Check-ins that don't serve me at all because my brand of emotionality does not involve crying in front of strangers and lamenting in a "whatever am I going to do" kind of exasperation. I realized that unless I was crying about the kinds of things that matter to them, very little support was going to be offered, and very few of my cohort has the ability to respect different ways of communicating one's feelings. While I think that people who desire support have a responsibility to communicate that to those who might be able support her, I also think that people who would like to call themselves friends have a responsibility to at least consider observing when someone whose first instinct is not sobbing might be stressed herself.

The other day I wrote that we lost a student. The primary (and only as far as I witnessed) concern of many in my cohort was who would get her now-available call shifts. I was appalled. We lost someone. Someone who started this program with us is no longer with us. I feel like that deserved a moment of discussion about what we could/should/might do as a class to acknowledge this situation. I'm not talking about a sit-in to get her re-enrolled or anything dramatic like that. I'm talking about compassion... acknowledgment of the loss... reaching out to see if there's anything she wants to talk about... something. Something other than vying for her shifts.

The Current Happenings

We're back home finally. I did not manage to get my license because I lacked some official paperwork I needed. I knew this would happen, and I'm glad I did a dry run. I now know where the board of nursing is and what time I need to get there (an hour before the door opens) exactly what paperwork I need, and the process that I'm going to have to follow to get this done. While walking away without my license was very frustrating, I'm glad I drove the five hours to figure it out (I had been given incorrect info on the phone - which someone else told me was very likely) It was worth it to see family, too. On the downside, my hair sucks. I do not like the style I ended up with. I really, really miss my dreads. I came close to crying thinking about it.

I need to seriously buckle down for the rest of the semester... 8 weeks left... My midwifery midterm is next week and covers:

Bleeding (AP, IP, & PP)
Intrapartum infections
Abnormalities of labor
Abnormal presentations
Shoulder dystocia
Preterm labor
Post-term pregnancy
VBAC
Initiation of labor
Active management of labor

sigh...

...the best part about midterms is the extended hours of the libraries on campus and the studious vibe of the university... coffee, laptops, pajamas, good times.

Last week I caught my sixth baby, the first without a preceptors hands posed in case I needed them. She stood waaaay back, and I didn't realize it until it was over, a few days later. I felt good about that birth, despite the fact that it qualified as precipitous and one of my gloves was only halfway on... and the bag of waters broke on the perineum and sprayed me, barely missing my open mouth- I didn't have on birth gear(mask! and gown) because it happened so fast...

Oh the life of a midwifery student.

We Lost One

There is a discussion about a midwifery case that's currently in the news over at navelgazing's place. My small group decided to use this case for our ethics roundtable. We will discuss what supposedly happened in this case, and then embellished variations (which we will very clearly separate out from the actual case) to stimulate discussion. We have a very home-birth friendly cohort, so hopefully the discussion will be good.

As for the rest of the semester, I'm up to my ears in pregnancy complications and thesis writing... and I'm supposed to be up to my eyeballs in policy analysis, but I'm behind in the reading for that class... it's so dry. So, so, dry. I need to get my arse in gear. I have a lot due in the next few weeks, including a presentation in professional issues in midwifery. My topic is "black midwifery" but I don't know what I'm doing yet. I'm considering doing a talk on the history of the short-lived Tuskegee School of Nurse-Midwifery, but I don't know yet...

We lost a student from our cohort last week. She will be coming back next year, but is no longer a member of our class. It sucks to lose someone. This program is very, very difficult. Most days I feel like I'm barely here... like I'm waiting for the other shoe to drop... like someone is going to come and say I, too, am no longer in my class... that I will have to return next year... that 2009 is not my year after all. I look at all I'm learning and I think "there's no way I can do this." But then I remind myself that of course I can do this- everyone thinks they can't when they're at this point of the program, but then they all do it. But then I am reminded by situations like hers that making it is not a given. At any given point in time, you can drown instead of barely treading the water. There's such a fine line between having your mouth under the water and having your mouth and nose under the water... and I can't swim...

but I can hold my breath for a very long time

Hopefully I can hold it long enough to float my azz back to the shallow end.

We came down to our inlaws place for a few days to get some business in order. I need to go the state board of nursing to apply for a license in this state, and I needed to get my hair rebraided.
Unfortunately this all fell on an ovulation weekend, so yet another month is gone on the baby making front (and my temps/cycle got all messed up because I'm sick) But it was good to be home.

Rambling, part 2

Yes, the life of a homebirth midwife is very different than the life most of my peers are headed for!

What comes to mind when reading the comments of this post... which I am so grateful for, it feels good to try blogging consistently again... is, these are like two very different careers. A CNM working full time in a private office asking for her own office space is not over the top. Nor is requiring a substantial salary. She's seeing the same number of patients a day as her peers... she's providing the same basic care... she requires the same equipment... she deserves a place to hang her degrees, consult her patients, and eat her lunch in peace just like the other providers... and she deserves to be compensated equally for equal work. I am not a midwifery martyr. Working for years without payment is unacceptable to me. But good luck to those who can afford it. It reminds me of a conversation we had one day about how midwifery is a" rich white woman's hobby." I bucked at that comment because, as always, I was thinking about the granny midwives, and I never seem to meet any wealthy midwives. But now I can see how people came up with that, and after being in this environment for a while I have learned that many wealthy people do whatever they can to look otherwise. That doesn't mean that I buy into this definition of midwifery, but I get it. It gets at a subgroup of women who might be able to afford to work for free for several years and still pay bills and have partners who are home 24-7 raising babies and supporting them in their life journey. But I think the more likely scenario is struggle. I'm done strugglin. Spend most of my life strugglin. Don't intend to spend the rest of it doing the same.

There's such a huge difference between a provider who sees maybe 10 patients a month and one who sees 20 a day. It's one thing to have a rough patch of 24-48hrs of active call time for one or two patients at various times during the month, but it's another thing entirely to be at the hospital for 24hours and then in clinic for 10hours directly following that, twice a week, continuously, every week. I think that's unsafe.

I believe in homebirth. But I don't want a homebirth practice. (not to mention it's illegal for CNMs in Nebraska anyway) I'd have my babies with a homebirth midwife in a minute (if I weren't risked out for this pesky, fluffy adipose ;o) and I wanna catch a baby or two in my lifetime, but otherwise, homebirth catchin is not in my future!

If I know one thing for sure, it is that midwifery does not come before me and my family. And I'm ok with that. I hope I can find a good balance though.

Rambling

We are experiencing what seems to be an extreme shortage of clinical space and preceptors in our program, and probably programs around the country. Students spend a massive amount of time complaining about the lack of clinical sites, especially after dishing out six figures worth of tuition, fees, and living expenses for their midwifery education. I have been somewhat silent about all of this in my program because I feel like I have about as much clinical time as I can handle. It is true that I wish(ed) for my diverse clinical experiences, but at this point, just having a clinical site is about all I expect. I was talking to a professor about the challenges of recruiting clinical faculty to a program. Most of it made pretty good sense... 1) The pay isn't the greatest- you can make much more in private practice, which makes it hard to compete. 2) Academic faculty who have spent the last several years earning a PhD don't want to spend all their time in the clinical setting (duh, they got the degree to conduct research)

But the one that has me thinking is 3) We younger generation of midwives simply refuse to give our lives over to midwifery anymore, and she cited this as a major issue. I think this is interesting. She said her generation of midwives basically lived midwifery, it was very much a part of their identity. She spoke of how husbands would bring babies to midwives on site to be breastfed, and how it was possible because midwifery was the kind of profession that was woman/family friendly.

Times have changed.

My classmates and I often talk about balance as a pivotal part of life. Not one peer that I know of intends to give their life over to midwifery. Basically this means to be on call 24/7... to provide real continuity of care... to embody what I think many people think of when they think of midwives. In a recent conference day we had about malpractice, work environments, credentialing, privileging, etc we, as a group, made a list of the things we wanted/expected as working nurse-midwives. Most of us want dedicated call and clinical times... meaning you're not on call at the same time you're working in the clinic (many midwives do not have this- if someone goes into labor while they're working in the clinic, the must leave the clinic to catch the baby, and then come back to finish up... the patients are either re-scheduled or covered by another provider) We want something like 2 days of clinic and 2 days of call... and would be nice to not have clinic the day you come off call (ie- be on call from 7pm-7am on Thursday, going straight to clinic at 8am Friday) We want malpractice insurance to be covered by our employers (in most cases it is) We want good salaries... specifically, salaries that enable us to repay these massive loans. We want good benefits. The list went on and on. I kept looking at thinking, yeah this is a good dream list, but of course you have to give a little bit of something up, your first job isn't going to be perfect. Nonetheless, it's good to see it written on paper. The discussion moved to how practices are set up to ensure that midwives can have lives outside of work. Basically, in order for you to be on call only twice per week you need 3 other people in the practice who also take 2 days a week, or similar. This means that you won't ever really have real continuity of care because the patients you may see on a regular basis still only have about a 1 in 4 chance of actually having you present at their birth. Now, following the "it isn't about you, it's about them" logic, this might be ok... the woman meets each provider once, but sticks with you for prenatal care, but she understands that you may not be the one attending her delivery. This is how it's been done many, many places for quite a while and it's working out fine I guess. But what about the women you'd like to be present for, or who really, really are choosing midwives for continued care including the birth? Well, we call them "special" patients... meaning you either gave them your home number, or you made a note on the chart that you are to be called if they present to the labor floor. (At my institution, students call these patients their "continuity" patient - meaning it's one of the few, few patients they will get to see regularly in the clinic, and then be called when the woman goes into labor, no matter which student is actually on call that day. As far as I know, we're only allowed one... I haven't had one yet. AND if she goes in at a time when no midwifery faculty are on the clock- which is rather often, you still lose the opportunity) So when speaking to a newer midwife (graduated 2006) she was telling me that she used to "special" a lot of patients at first, when she was new, but now she hardly ever does. Why? because she doesn't want to be on call all the time. Which was precisely my professor's point.

I'm rambling, but it's just what's been on my mind as I contemplate what kind of midwife I want to be. I meeting with a new midwife tonight for coffee to discuss some of this stuff, maybe I'll walk away with even more perspective.

I Feel Encouraged

I had to stop my life and write today because I feel, for the first time in a while, encouraged. I just finished another interview for my thesis. For those who don't know, I am interviewing black nurse-midwifery students across the country. I remember in the beginning I was looking for other brown midwives in cyberspace, and couldn't find many, if any at all. Well, there really aren't that many of us. I scouted each nurse-midwifery school looking for students to interview, and some schools sadly responded that they didn't have any, some even said they hadn't had any in years. That made me teary. But I have done several interviews now, and even though we are small in number, we are drowning in fortitude. They make me feel like I can do anything. It is a blessing unto my soul just to hear their voices. It has been a long journey, and most times I don't know if I'm coming or going. But today, if nothing else, I feel a little less alone in the journey. There are things that come up in interviews that make me want to cry, but there are other things that make me happy. Most of all, I'm just grateful that I had the conviction to take on this project. If not me, who? That is my mantra.

School is eerie this semester. I haven't had any exams, nor any papers due yet. I've mostly been studying haphazardly and working on my thesis... which is an experience all its own and maybe I'll write more about it here sometime. But at the very least I will say, it's hard to write... and even harder to have someone constantly critique it. I have not found a groove for studying this semester. My study group is all over the place, we haven't met once as a group yet. That will probably change as our first exam draws near, but so far, nothing.

I feel behind in my knowledge. I don't feel prepared for residency at all. I'm calling it residency, but that's not exactly what we call it at school. Most students just select a place off of a list provided by the school, but I worked very hard to set up my own site. This was important to me because I've spent all of my time working with the faculty of the school. For me, this has not been ideal, but it has been supportive in its own way. It means I've had a very limited exposure to other ways of midwifing. I've had very little to no chance at continuity of care with patients. I've had no clinical interaction with midwives of color. I think this last point is huge... I think it has negatively affected my assimilation into the profession. There are many, many days when I don't want to be a midwife anymore... where I can no longer imagine myself as a midwife... where I can't remember why I'm here... when I can't remember what this has to do with my own history. I think not being able to be precepted by someone who I identify with has something to do with it, and I wasn't clear about this until now.

But I said this post was about feeling encouraged. And it is. As I was saying, I wanted to set my own residency site... well months and months later, I have it! I started this process in June, and now I have a signed contract for residency with a black midwife far away from this institution! I met this midwife at the ACNM conference this past summer, and I asked her if she would have me. I laid it all out there... 1. what I'm looking for (a site in the city I would like to work in post-graduation, to be with family) 2. why I was asking her (she's black, yes, but also because she's accomplished and when I asked around at the conference, everyone told me to go find her - that she was who I was looking for) and 3. how badly I wanted it (badly...teary-eyed badly.) She said 'yes' on the spot, and when she randomly, fondly pointed out that the last student she had precepted for residency some years ago happened to be pregnant, I felt the universe hug me. I am not pregnant, but I hope to be by the end of the school year, so it's nice to know she won't have a problem with that. It matters that it's some distance from the school (hundreds of miles) because it means I have a greater opportunity to see a different way of practicing. The patient population is also different. Currently I spend more than 50% of my time providing care to patients who only speak Spanish... even though I don't speak any Spanish. This is incredibly frustrating and tiring and disheartening because I don't feel like I'm providing the best care. I'm having to shout at an interpreter phone all day, who then translates to the patient, the patient then screams back into the phone, etc. It's just... sad. The last two babies I caught were born to women I couldn't even speak to, and there are never interpreters on the labor floor. Usually the preceptors or nurses- who speak enough Spanish to get by, but that's it. I have not been able to take a Spanish class (but one is offered on another part of campus) and at this point I don't foresee it any time soon... especially after spending years learning French. So I am happy to be moving to a place where I will be more useful. Having this work out for me also means that the man and I are headed home. That's right, we get to go home to family. Technically, it's his home and family, but that's good enough for me... for now. If I can't have my own family, his is definitely good enough. Back to love, we go. The man, as you can imagine, is head-over-heels excited. He's already started planning the packing and moving, and then he'll head down before me to start his new job hunt.

This time I did actually cry when I got the news... I mean sobbed. I just feel like I need this so badly right now. I need this to fall in love with midwifery again.

So this news + talking to other midwifery students on the phone = encouraged.