AAT, Amish, and uterine infection

jmacmidwife

It has taken me a long time, but with more and more experience and confidence and knowledge, I can honestly begin to calm myself down once I start to get ahead of myself and freak out.  This isn’t rocket science. Believe me, I have taken a prereq to that and it is nothing like this. I got this, I do. Just a bit more practice and I’ll be ready to fly on my own.  I am actually getting excited about the day I finish without trying to downplay all the learning left I have to do. But I feel like I will get through this and come out the other side relatively unscathed. 

During class, my preceptor called me and asked me if I wanted to see a client who was not feeling her baby move.  She is 37 weeks and has been having blood in her urine and pelvic pressure her whole pregnancy.  I am really interested in seeing how this birth goes and if any anomalies are present.  So, after class, we met at the client’s house. We got to do an AAT!! How exciting! I have read about these in class and in power points, but to actually get the opportunity to do one and have a good outcome—excellent! Another great experience—so happy I am being included in this adventure!  After confirming that baby was in a good place, we finished our prenatal with this mom.  We discussed how she may not go into labor over Easter weekend as I will be in Louisiana dropping off the kids for spring break.  I have to send some pretty serious labor vibes her way so that she has the baby before I go and on a day that I am available.

So, we had our second uterine infection this semester—perhaps the universe is trying to teach me something? Hopefully, because I wouldn’t want to think that we are seeing them for a cleanliness issue.  That would be unfortunate, but I could work on washing my hands more often and being meticulous with what I touch when wearing gloves.  I used to laugh at the concept of sterile field in a hospital, but it is not so funny after seeing a new mommy lying helpless with a 100 degree fever and a uterus which has almost reached her umbilicus and tender.  As per Mayes, a rising pulse of above 90, which this mom had a pulse of 100 where it has normally been 80 her entire pregnancy, is a sign of deterioration.  The skin is hot and dry, which hers was also, and she looked acutely ill. Her lochia was scanty as well. So immediately after assessing and consulting with the physician, who ordered Amoxicillin and Augmentin, we went to the pharmacy and purchased these antibiotics and returned with instructions on how and when to take these. 

Ok, I guess I need to back up and give a history on this mom.  It was her first baby, although I wasn’t at her birth, apparently it went fairly fast for a first birth.  Except, the baby’s cord had to be cut fairly quickly after birth as mom was gushing blood.  Pitocin was given. Mom also suffered from a second degree tear, which wasn’t sutured per mom’s request.  Just to spice it up a bit, dad didn’t want mom given any medication for her bleeding, instead offering cinnamon or cayenne.

 So, as I imagine everyone does after an infection, one considers how they may have contributed to the problem and what they could have done differently and moves on from there.  Well, I imagine that there were at least a few times that the midwife was down there having the potential for introduction of bacteria.  I see it like this—a small possibility of infection from dilation check in labor, and a huge infection risk when the perineum was assessed after all the previous visits to that area had been made. Since the laceration was not examined at the postpartum visit, I am only speculating that an infection from that area could have further developed into a uterine infection.  Having the mother take impeccable care of her bottom and wiping postpartum is essential too.  So how did the infection ultimately resolve? Well, at the 8th day visit, we discussed how her husband did not want her to take the antibiotics, so she opted to take an infection powder tea made from goldenseal, elderberry, yarrow, dandelion, black cohosh, gum myrrh, blue violet, red clover, and hyssop. Take .5-1 Tsps. to a cup of hot water or take 2-3 capsules several times a day.  She said that her mother or mother in law came and applied some Swedish bitters on her belly and (I don’t know if the bitters caused the clots to leave her body or if there was some massage of her uterus involved), but she said some clots had been wasted. She looked much better and the baby had gained several ounces almost back to birth weight despite her having this infection and baby having a circumcision in between all of this. I have decided that my take home message would be that I need to respect the family’s decision to medicate how they see fit, while yes, a uterine infection is a serious life-threatening problem and I do need to have a strong informed consent about the dangers of this, I also need to respect their culture and way of life.  Most people choosing homebirths are not the antibiotic types and do seek alternate means of healing. Perhaps I need to be open to this as well.

Changes, perspective and Nitrous oxide

jmacmidwife

How is this experience affecting me as an individual?                      

I definitely value my husband more.  While yes, I may have sacrificed a lot to help raise our children, this has been by far the bigger commitment and the most trying time is yet to come.  When my children are home without me and he has to juggle his job and them, well, is going to be difficult to say the least.  I hope my mother can go and help frequently and that I can finish up with the NARM next February or August. 

I think this experience is helping me to see the other side of midwifery a bit more clearly.  For instance, I thought I knew it all or was close to it in Louisiana, especially surrounding what preceptors think of students or what politics they have to deal with. There is certainly more than meets the eye.  I am being exposed to how that looks, how hard that is to negotiate, and navigate. And that sometimes students don’t know poop.

Unfortunately, as a student midwife, I feel like I am getting fed up with the lack of communication with this process.  For instance, in our sheets we have to fill out with our preceptors, the one which describes breastfeeding experiences does not indicate whether we need those experiences to be primary or not.  However, my preceptor has said primary, which is fine, but when we hold our breath and try and count everything, it would be a lot easier if it was precisely delineated what we need to do.  I am all for NOT stressing the numbers of X, Y, and catches we need, but for heaven’s sake do us the consideration and communicate exactly what is required of us and when, especially considering the NARM guidelines are changing in the next year.  I love my preceptor, but if my family is not with me, I don’t want to be here for more time than necessary.

We discussed laughing gas at NRP the other day, except I really didn’t know how to respond, despite having read numerous articles about Nitrous Oxide.  A midwife mentioned the ease of getting birthing pools approved in hospitals, so I suggested laughing gas.  She asked me why I as a homebirth midwife felt comfortable pushing a drug and what the difference was between it and a narcotic.  Well, at first I was like, ummm, seriously, one is a gas and one is IV, but then I realized she was looking for a more philosophical answer, since they are both interventions. Well, since I didn’t have my spiel down I couldn’t really answer her in a way that I felt could explain my stance on laughing gas, so I went home and thought about it and came up with something like this…

Opioids like morphine have numerous side effects or the mother and can cause significant respiratory depression because it rapidly crosses the placental barrier and has a prolonged half-life persisting for 2-4 days. N2O is not an opioid but a unique method of analgesia and is used in nearly half of women giving birth in many western countries including the UK.  The pharmacologic pathway by which N2O achieves its euphoria is not well understood, but is thought to release endorphins.  Primigravids are less impressed with N2O. Part of its effectiveness is the women’s ability to control the administration of the drug and in part control the pain. Less effective than an epidural, but more potent than opioids. A 50% mixture of N2O with oxygen is safe for both mother and baby because N2O is eliminated through lungs and not liver. Potential adverse effects include nausea and vomiting and rarely loss of consciousness if too much gas is inhaled, but this can be easily remedied with a few breaths of room air. Mom’s control their intake of the gas and usually prevent this.  Toxicological mechanisms surround the inactivation of B12 leading to an impairment of folate and DNA synthesis, which may be the underlying cause of the higher rates of miscarriage reported in workers exposed to nitrous oxide.  Fertility issues can affect workers as well as a degeneration of the spinal cord.  However, the lipid solubility of the gas, the trace accumulations over time and the relatively short term repeated exposure greater than for a single exposure.  The benefits include not requiring IV fluids or EFM. Moms can shower and walk between dosings as it can be started and stopped at any time. This does not require an anesthesiologist! It is particularly helpful for women having fast labors, during transition, second-stage, and suturing. However, because N2O inhibits B12 metabolism, fatigue was experienced in pp women.  Some claim that this delivery system is contributing to increased greenhouse gases and occupational health risks for those around administrating gases have been suggested.  N2O is heavier than air, does not disperse uniformly but collects in clouds or ‘hot spots’ usually at floor level, especially in still air. There has been a possible correlation between mothers who use N2O for prolonged periods of time and amphetamines.

Hopefully, someday we will all have access to more choices for laboring women, which are safe, easy to use, and inexpensive.  In the meantime, we need to unite ourselves with the dentists and figure out an approachable plan of action to present this to Congress or ACOG.  If European women have this choice, we should seriously consider it or encourage our mothers to birth there. 

Feed your baby

jmacmidwife

Tonight we visited a mom who IMO is not feeding her baby.  This baby is over 9 weeks old, but only weighs 8 ounces above her birth weight! Now I know every baby is different and grows at a different weight.  Plus, I know breastfed babies grow healthier and leaner than formula fed ones, but really—only 8 ounces in over nine weeks?? That is less than an ounce a week whereas the normally fed baby gains 4-6 ounces a week.  Plus, breastfed ones normally gain faster than formula ones in the first few weeks! Now this baby weight problem didn’t just come out of the blue.   I distinctly remember at the 1 week visit seeing a baby who had not regained birth weight, and was left to cry in the pack-n-play while we just stared.  We asked if we could console her baby, but the mom said no just leave her—ummmm. Seriously—red flags!

I’m sure there were visits in between, but, at a 6 week visit, my preceptor and I discussed what if this baby had not reached 10 pounds then we would have to have a serious conversation with the mother about supplementing or what is wrong. Well, we went into the visit and the baby had not gained anything and we didn’t really discuss in a serious way, IMO, the situation.  So, we essentially discharged her from our care because baby seemed to be alert, active, and reaching milestones. While yes, those are signs of a healthy baby and I will eat my words if nothing comes of this troubled relationship, but I don’t understand why we are not intervening or haven’t intervened more yet.  Yes, maybe it is just me and my insecurities that all will not be okay if I just let it be, but since the baby’s pedi and another midwife have been dragged into this family’s care, since they saw obvious flags too, I am uneasy with being so blasé with this issue. 

If I was the primary care giver, I would be writing a letter to all involved saying where I stand and what my professional opinion is on this. So, tonight’s visit was to drop off a baby scale for the mom to weigh the baby at least once a week and report back to another midwife. While this is great, the mom instantly seemed defensive on how the baby has already gained 2 ounces this week—ummm, again, that is a diaper change, lady!! She went on to say how her other daughter was small like this and she was as a baby. Ok, yes genetics play a huge part—I will agree with her, but most moms who are having weight gain issues will be begging you to try and help them get the baby to up to weight regardless of her wishes to exclusively breastfeed. So, the baby woke up form a nap and mom said, well she is probably hungry, but I am not feeding her for another 2 hours because we are on a 4 hour feeding schedule per pedi suggestion that she was breastfeeding too often and the baby was not getting enough hind milk. Ok, so your pedi must have said that she needed to supplement with something in the meantime—right? IDK of any pedi who suggests an underweight baby be fed every 4 hours.  HMMMMM.  Ok, well I just read an article a few weeks ago about how that whole hind milk/foremilk separation issue was a bunch of hooey. While yes, more hind milk is at the need of a feeding, it still is in the beginning too.  So baby sucked vigorously on her hand while we were there.  I asked if she was doing the nipple sandwich and massaging the breast while breastfeeding and she said she used to.  She said also that sometimes she pumps after feedings and gets about 2 ounces to feed to baby with a spoon or syringe since she doesn’t want to confuse the baby with a false nipple—well, hello I don’t care if the whole neighborhood takes turns breastfeeding your baby—you have to feed it something!  At this point, nipple confusion is the least of our concerns, lady! Ok, moving on—she says that mother’s milk tea does wonders for her and she instantly feels like she has oodles of milk.  Another really comes to mind—I have known many, many, many breastfeeding mothers and can I honestly say that I know none who have benefitted tremendously from that tea unless they were downing gallons of it. While yes, I have seen great results on Fenugreek and Blessed Thistle or Reglan and Domperidone, but MMT?  Nope, not buying it.  She wasn’t supplementing with any other medications yet either.  And what about baby’s sleeping patterns?  Oh yes, she falls asleep on her own usually sucking her hand and sleeps all night.  WOW.  So many 9 week old babies are doing that—not!  If the baby is not growing, she should be breastfeeding around the clock with no stretch longer than 5 hours.  I have a feeling that her Ferberizing method is backfiring in her face and that is what is going on.  I am really getting sick of these crazies who want to schedule feed their babies.  Seriously ppl!  And it is so hard not to compare these babies with ones of similar age who are doing well.  If I could do tonight over again, I would have asked her how much the baby is going to the bathroom—not that that is always an indication of baby’s well-being or if the mom changes diapers as often as I would, then amount of wet and dirty diapers may not be accurate.

Random thoughts

jmacmidwife

RSV parameters:  Runny nose, cough, low grade fever, retraction, nasal flaring, blue around the lips, nail beds are not pink, hard to wake, not feeding well. GBS directions: insert the swab  1-2 inches inside the vagina then pull out like wiping go over and around rectum. Some moms call breast infection a breast cold. If a mom’s bottom is sore and stretching and itching it is usually from healing. If it is painful, sore, or burning it could be infected.  Corn silk, uva ursi, cranberry, lots of fluids, wiping back to front, no powder or heavy soaps used down under, cotton undies, clean undies, and garlic help fight uti. Slippery elm and aloe can be used for constipation. For thrush, drink green tea, black tea bags can be brewed and placed, when cool, on mom’s nipples. Grapefruit seed extract, gentian violet, and acidophilus are all good for fighting thrush infections. Having a good diet, free of dairy foods and sugars can help. Wash hands and nipples often. Boil pacifiers and everything else that goes into baby’s mouth for at least 20 mins each day. A vinegar wash can be used afterwards to help fight infection.  A parsley poultice can be used for sore nipples.

I am going to incorporate breastfeeding education prior to birth. We need to change the language around breastfeeding—instead of saying milk comes in on day 3, we need to say, expect your milk to increase on day 3 or so, to make mothers believe in themselves and in their bodies.  I think that is a huge deal and once they see that they indeed do have milk—they are more relaxed that they are going to be able to adequately take care of their babies.  They just don’t need one more thing to be concerned with after birth and I think that takes away from the anxiety surrounding breastfeeding and awaiting that milk to come in.

My neonatal resuscitation certification is expiring in a few months.  For this new class, a new edition of the book needed to be purchased, the 6th edition, which had many changes.  One of the changes to the new text was baby not being separated from mom, which honestly I do not remember not being in the older text.  I guess I assumed that was obvious, but I also need to remember that this book was intended for in-hospital personnel and not home-based providers in a different healthcare delivery system.  It surprised me how different my perspective was on the material in the class.  It was not like it was all new material, but since I had taken the class almost two years ago, knowing much less about birth, this time around provided much more gravity to the information.  This probably should not surprise me, but it did in an alarming way.  I thought I was prepared to perform neonatal resuscitation, but clearly, I wasn’t.  I am thankful to have had the opportunity to take the class now, but wish I had taken it right before starting my clinical or at least prior to attending births. I feel much more confident in identifying a baby in need of assistance and performing resuscitation, if needed, now even though I wish never to have to do this. 

Another interesting idea is that babies that undergo a hypoxic event will naturally cool themselves, so maintaining heat is no longer indicated for a compromised baby, nor is it indicated for a mother in shock.  In fact, it is best to keep them cooler than hotter—so no hats or heating pads!  We are also moving towards a resuscitation model using less if no oxygen in combination with out pulse oximeter.  Now, I know that pulse oxs are great tools, when you have room to move, have a third person, and need them.  I think it would be a great idea to have access to them.  I honestly think that is one tool I may use often in normal situations, but worry that it is not feasible to utilize in an emergency situation in the field. I wonder, too, what the Amish and other cultures already weary of all the technology we provide will think of one more gadget? Overall, it was an interesting day with lots of great ideas to keep in my back pocket.

Keep on learning

jmacmidwife

I forgot why I included this in the journal. I think I was talking out loud and we were discussing latent labor in class and when do you know when real labor begins.  In my doula experience, I usually encouraged moms to get to about 4cms and it was all downhill from there, whether it was factually based or not, is up to interpretation.  I also told them that contractions would get only so painful and then they would just get closer together but not anymore painful.  Maybe this is when those endorphins finally catch up and help the mom cope with labor? 

I think I found evidence to support my claim in Zhang et al research verifying most nulliparous women entering active phase between 3 cm and 5 cm.  Most clinicians use 4 cm as when active phase begins, but individual differences need to be accounted for like grand multips remaining in latent labor until 6 cms. We may further redefine false labor as prelabor, described as inefficient contractions not leading to cervical change.  Caregivers should ask women when their labor started and how they knew, rather than when regular contractions began.  Listen to mothers instead of applying arbitrary times and signs to identify onset of labor. 

One study found that women in prelabor actually experienced greater discomfort than women in labor. The diagnosis of labor can only be made with serial VE.  The risk associated with therapeutic rest is that it may prolong dysfunctional labor. Can offer moms 50mg of Benadryl to allow for therapeutic rest and progression of labor while the mother sleeps.  Hydration decreases pituitary secretion of antidiuretic hormone and oxytocin. Membrane sweeping has the potential to initiate labor by increasing local production of prostaglandins. Insufficient evidence to suggest that enemas or castor oil works as induction methods. Wine was used to stop labor until the 1960s. It may inhibit secretion of oxytocin by the posterior pituitary inhibiting contractions. Ethanol does pass through the placenta but is quickly eliminated by the newborn, but not without causing similar effects like morphine. AROM should be reserved for women with abnormal progress. PP hemorrhage and chorioamnionitis were more frequent in women who have longer latent phases. The majority of patients are in active-phase labor by the time the cervix reaches 4 cm, but many are not.

Cord blood, babies, and caths

jmacmidwife

I need to review charts always before births and mark somehow the ones who are Rh negative and require cord blood to be collected after birth.  Tonight we almost missed collection as the mom had a quick birth—she was only at the farmhouse for about 10 minutes before baby arrived.  So, after birthing the placenta we realized she was negative and had to try and aspirate it from the placenta with a large needle. It was not fun. So, if you don’t have your red top tube available after birth for cord blood, you can try and find some juicy veins to get blood out of placenta or wait a few minutes for placenta to drain into bowl that placenta is sitting in. Then suck up all that blood.

I need to get better at handling babies, too. Twice now I have given vitamin K shots only to have the baby move its leg. Well, duh, of course it is going to move it isn’t like the mannequin you practiced on. So, I need to grip the baby leg and prepare for baby to not like it. Sigh. It is ok. We will all survive.

I had the opportunity to attend a birth where I wasn’t really invited, which was cool, but what was uber cool was cathing the mom after birth.  This mother who was on like her 10th baby or so and had a history of bleeding, so after the baby arrived we watched her like a hawk and sure enough ended up giving her some medication, but we wanted to get her up to go to the bathroom after the birth and she just laid there and asked for a cath!! Um, who does that? So, here we go—offering to cath her!! Woohooo! And guess who gets to scrub up and do it? Okay so I was so excited I almost forgot to scrub up, but I got to insert one and hold the pan and it was cool. Nice experience. So thankful for the opportunity.

Hodgepodge of thoughts

jmacmidwife

I had the unique opportunity of attending a peer review with some pretty awesome midwives and students today.  I enjoyed the nonthreatening environment of eating at a restaurant while discussing cases and having some really helpful, nonjudgmental feedback.  There was a question of boggy uteruses and what to do with them.  The lower segment can be held and the fundus milked to get the clots out. You place your hand on the lower segment and squeeze your hands so that they open change-purse style and clots can come out.  Also, instead of rubbing or massaging a fundus, you can hold and clamp down on it so that the uterine wound heals.  The rubbing may cause the wound not to be able to stop bleeding.  

I had the opportunity to assist with a pap today.  It was my first time being an assist with that.  It went kind of like this—mom on bed, legs apart, relaxed as much as possible, can put pillows under bottom or place bottom on end of bed so that when you turn speculum, it won’t hit the bed.  Tell mom she will feel your touch, place two fingers at introitus, lube up the speculum, warm lube in hand if necessary prior to putting it on spec., or warm spec in hand.  Insert spec at an angle and then make horizontal. You should be entering at an angle down to the tail bone so you don’t have to pull spec out and look for cervix after opening spec. A light source should be available—a flashlight will do.  Find cervix and using brush turn 5 times to the right and 5 times to the left. Take out brush, pull spec out a bit before closing it. Again, remove at an angle. Brush head goes in liquid container, and everything else can be thrown away. Make sure to put mom’s name, birthday, and date and time on vial. Diagnosis is postpartum on lab sheet. 2 requisitions are needed for the lab with paps. 

I admire the Amish’s respect for herbal medicine, but have heard so many good things about homeopathics that I want to be able to deliver a good description of these to them, when and if the time comes.  Plus, if the need arises in labor for a homeopathic, I would have already explained it prenatally or would have the speech down pat so I could just let it roll. I have decided my homeopathy spiel should go something like this…

Homeopathy and allopathic medicine complement one another.  Homeopathy (homeo meaning same and pathy meaning illness) is a holistic system of medicine which has been described as long ago as Hippocrates.  It follows a rule of like cures like using highly diluted forms of animal, plant, or mineral.  In other words anything that can make you sick, in safe doses, can make you well.  Homeopathy is a safe, convenient, easy treatment system which avoids the undesired effects of conventional medicine.  Homeopathic remedies come in tiny pellets, either with a milk or sugar base, which dissolves under the tongue.  One to two pellets is considered a dose. They are low cost and over the counter. Remedies are specific for each woman, yet there is no harm in changing remedies if it does not appear to be specific for that woman.  Once the medicine has been evaluated and evaluated to match the person’s vital energy, health will be achieved. 

Luckily, I was already a doula; so much of the labor support information has been a review. It has been helpful to review these positions and when exactly first stage and latent stage exist.  I have always enjoyed reading Penny Simkin’s books. Attending births as a doula, apprentice, and birth assistant has really aided my perspective. I really trust birth and the processes behind it, so much that I feel much more comfortable with managing this part of pregnancy, more so than prenatal visits. I guess it is just because I have more experience in attending births than prenatals. It surprises me that I am not more comfortable at prenatals, but I guess I’ll get there someday.

Likewise, I have always been interested in expectant management, so looking at third stage again, more in depth is nice. My prior knowledge has mostly come from hospital observation and Internet research, so actually reading the midwifery texts and gaining that perspective should add to my understanding that much more.  I always thought active management was the work of the devil, but actually there is some sound reasoning behind it.

Having already gone through the BS associated with other midwives in other states, I can honestly say I try and steer clear of everyone.  I am not here to make friends.  I don’t care what everyone else is doing. I just want us to make more midwives.  While yes, I would love to love every new midwife that is born into this profession, the fact is, I don’t have to like them all nor do I need to be friends with them.  So, already seeing how unsisterhoodish this profession is, has helped me hold on for the ride and keep my eyes on the prize—just gotta get done!

Goals

jmacmidwife
  1. Describe your goals for this semester.                                           

One of my goals is to learn the newborn exam and gestational age assessment.  My friends, who are midwives, discuss these scores and exams and I am excited to be able to finally know what they are talking about.  Right now, I look at a baby and see a baby, but look forward to the day when I am looking at a baby and notice those creases, breast buds and ears immediately and can tell how old baby is. I know that sounds silly, but I like when I know something and can be proficient in it.  I look forward to feeling like I always knew the baby exams and have been doing them forever.

Another goal would have to really understand fetal position.  I enrolled in one engineering course in college and withdrew from it because it was a 3-dimesional course.  I had such a hard time wrapping my brain around how to see objects and incorporate them on a blueprint or in a computer program.  So, working backward and seeing my books with the 2-dimensional babies moving through the pelvises, then having to imagine the outcome will be challenging, but one that I have been looking forward to and working on.

I really want to learn how to cut the cord and put on the tape (not the clamp).  It looks simple and easy, but I have never done it.  I would also like to help a mom birth a placenta and what that feels like.  I don’t like touching the uterus after birth, but need to learn what a boggy versus firm one feels like.  Also, I hope to get some shots and blood draws under my belt.  I hope I can put all my new learned skills to use if necessary.  I can’t wait!

We didn’t have a hemoglobinometer with us today, but needed to check or at least get a ball park estimate of the iron level of one client.  So, if no field test is available, we can look into her eyes, by pulling down the bottom eyelid and checking the conjunctiva.  If it is white or light pink, then iron level is less than 10.  Also, you can look at the creases of the hands.  These should also be pink.  I am also learning how important it is to keep your equipment in working order. It gets tough in those bags sometimes and by calibrating periodically, the BP cuff and other items is crucial to obtaining accurate results, especially when gathering baseline information. 

I also learned that when checking a fundus after birth and the bladder is full, then the uterus could be off to the right side and/or boggy.  Additionally, when doing a fundal height or palpating the baby during a prenatal, and the mom has super strong ab muscles, you need to push delicately, but firmly.  This will enable you to get an accurate measurement.  I am really curious to witness this mother give birth (it is her first) because I think she will have great strength to align her baby and uterus.

I also had the opportunity to give a Rhogam shot today.  There is much more to that procedure than I thought. First of all, I had to fill out all this paperwork in the box so that the mom had a record of the lot number and shot info.  Makes sense we would do this, but I just hadn’t thought of it before. I guess when you have it done in the hospital, you never see this info as it should be in the chart, I assume.  After properly injecting the shot, it was nice that the mother had a good outlook on the whole Rh factor issue. She said that the good that comes out of her receiving the shot is that there are more women in the community that are positive, so her son will not cause his wife to have to get the shot.  It is so nice that some people have such positive attitudes.  Plus, if the mother has Rh negative blood, we need to determine the father’s blood type so that the mom can be informed on whether she would like the Rhogam at 28 weeks.  If dad is negative, we do not have to worry about the baby being positive. It is a nice feeling being able to draw blood to determine if we can be conservative in our treatment.

Snow day

jmacmidwife

This semester presents many expectations for me both personally and as a student midwife. I would expect to get better at managing my time, especially if I want to be as successful as possible.  So far, I have been falling short of this goal, but alas the semester just started 2 days ago, so I won’t be so hard on myself.  It was a snow day, so, I can’t expect to be that ahead on my assignments just yet, but I am anxious already—and that was the expectation I was afraid of.

I was called to a birth the other night and had to go without my homework being completed. Although a higher power intervened and I ended up with the day off due to inclement weather! While yes, this has to do with time management, it also goes hand in hand with the nature of midwifery in that I have got to be wiser and finish what is required first, even if it falls before managing time.  I know that if I want to stay with my preceptor, I need to maintain my grades.  Facebook and Pinterest will still be there when the semester is over. I don’t know why I need daily reminders of this!

Both of these realizations lead me to my next expectation which is that I will be busy learning and growing.  I am super excited to be learning from such a busy practice and am again blessed to have the awesome opportunity of engaging in the Amish culture.  I continue to learn so much each day and expect that to continue.  It is such a gentle and kind atmosphere to learn the ropes of midwifery.  I expect to become much more comfortable with their customs and likewise demonstrate more respect for their culture.  I hope to become much more proficient in my spiel.  I am very green at anything involving newborns, so I expect to learn oodles of information about babies.  I am actually looking forward to tackling the newborn exam.  I know.  I think I am crazy and I haven’t even been to one class yet!  ACK!  Let the fun begin.

A much needed break

jmacmidwife

I can’t wait for the end of this semester, not that I didn’t enjoy every minute of it, but I am done for now.  I have been mentally exhausted by failing my first skills exam and finding out that I do not have to take first semester classes, just learn the skills. It has been like losing the winning lottery ticket.  My emotions have been all over the place this week—from pack-up-and-leave mad to over-the-moon happy.

Surprisingly I was not sad about my skills exam. I was more pissed off.  I have worked very hard at memorizing the skills verbatim as instructed and doing the skills adequately.  I thought I deserved the right to finish demonstrating the rest of the skills, even if I did not “pass” 2 out of the first 3. It was the fact that I was humiliated in front of my peers which gets me.  No one deserves to feel that way over anything really, including skills which they had obviously put some time and effort into.  Just because all the pieces did not come together as a full-fledged qualified midwife would have done, doesn’t mean I did not complete the skill to a level of understanding.  The trash can not being moved closer or the room not being set up exactly right, does not mean I cannot perform the skill. 

When I am running my own midwifery program, I guess I will do the skills test out a bit different and explicitly say what is expected.  Likewise, I will not grade on technique, but of a holistic understanding of the process.  Just because you forgot a bandage, would not be grounds for failure, if you can explain why you didn’t put one on.  Plus, I may judge that if someone forgot a certain step in the skill, like failure to check the expiration date of the medication that that would be an automatic failure, whereas forgetting a bandage, which would not kill the client, would not be an automatic ejection, but this is just my rational brain at work. 

Additionally, I don’t know how long it will take me to feel comfortable doing these skills as I didn’t go into midwifery to do medical skills.  I do not want to approach midwifery from a medical angle and obviously do not want to embrace it.  Is that wrong that I am different?  I also know that some of the students did the steps out of order, according to their own style.  Plus, some did not say them verbatim.  So, we can throw the word standardization out the window and insert the word subjective. 

It was annoying, to say the least, to hear from fellow exam takers that they also could not get ALL the medicine from the ampule as I could not. The difference in our outcomes—them passing and me not– was that I told my instructor that I could not get it all out and they just kept going, as if they got it all out. HMMMMMMM.  So, moral of story might be that if it is close enough, one should cut corners to pass the test. Well, I don’t believe that is the best policy. I have integrity and do honestly want to become a good midwife. And even if I never use these skills again, except to pass the NARM PEP skills test, then so be it. I would bet money that none of my fellow students know the skills verbatim; but, since they could act convincingly medical, they passed.  I hope that is not how this whole game is played because I stopped playing games once I left the state of Louisiana.

I do not intend to hurt anyone’s feelings or blame anyone for the outcome of my own actions. I will take full responsibility.  I am trying to learn to release my energy in a more positive way, but this is my defensive reaction right now.  Perhaps I should look at this failure scenario from another angle—that maybe I am being held to a higher standard or more is expected from me, since I will succeed at this profession?  Well, that is the positive spin I will leave on it for now.  It makes me feel better than the alternative that I was put in my place by a cruel game involving power and control.  

Another line that I have heard this week (and that is its own journal entry) was that if I want to be a midwife, I need to step up to the plate. I get that, I really do. And that may be what is happening right now—the transformation that was touched upon—from Doula to Midwife—and the losing sight of shore which must accompany that journey.  Maybe me failing my skills was the push I needed to get off the cliff and fly?