Winter in the PNW

I know that some people like winter in the PNW. These people, IMO, are crazy. Sane people don't like it being dark 16 hours a day. I don't want it to be 4pm as evening falls. I like the sun.

Nevertheless, particularly in years like this one when the sun makes occasional guest appearances, winter in the PNW can be beautiful.

Spoiled Children! aka The Christmas Frenzy

BittyPrincess, our solstice baby, is now officially 5. Where did THOSE years go? I can't believe it. If she was our last baby, we'd have all school-aged children. WOW. On her birthday, she requested shrimp pasta and a sunshine cake. Done and done, although the sunshine cake was really just a 11" round cake with triangle cut-outs and cream cheese frosting+food coloring. For some reason the cake wound up tasting a little like cornbread; strange considering the volume of sugar I dumped into it. It got eaten (a lot) anyway. No pictures, 'cause we suck.

From Boyness' birthday through Christmas, I must have used the stand mixer almost every day. I love that thing. I was considering how much it would suck if it broke the other day, when I accidentally smeared cream cheese into one of the venty-looking things that must help cool the little enginey-thing (how technical I am today!). I might cry. Cry, and never make angel food cake, frosting, or whipped cream again.

Anyways, ON TO CHRISTMAS! While our broke-ass little immediate family was firmly nonconsumeristic (not that you have a choice when your bank account is already negative) this year, spending (Santa included) just $20 per child, our extended families MORE than made up for it. In fact, Christmas at MIL's was like an overprivileged holiday marketing frenzy. Not that the kids minded. They each got top items from their wish lists from their uncle and his GF. The only thing that saved me from feeling upstaged (honestly, not that I would have minded, I was actually kind of counting on it) was the fact that they swirled around showing off the "magic" cloaks I made them all day.

We got very few photos. So here they are, the few photos we do have:





I told you we didn't have many. None at MIL's.

On we go towards a new year! Today, a day of recuperation from the gifting frenzy at MIL's. The kids are happily exploring their new toys and games. And I am needing to clean the last remnants of Christmas baking/cooking mess left in my kitchen and figure out what to do with the rest of the baked goods we do have, since nobody here has a serious enough sweet tooth to go through THAT much cheesecake or THAT many cookies.

By the way, having kids that are old enough to clean up after themselves (mostly) is AWESOME.

Been a While, Hasn't It?

There really wasn't going to be a totally appropriate time to restart this blog. So I'll just jump in. Again. With a massive batch of updates.

I am indeed completely done with midwifery school, no lie, actually completely graduated with all the licensing exams passed and fees paid. I even updated my blog headline to read "midwife" instead of "student midwife." Done, done, done, done done. Done.

I am also pregnant. Totally, miserably, planned-ly pregnant. Yes, they can go together, we can plan to get pregnant and then it can S.U.C.K. So far, my list of things that suck in pregnancy:

• Morning sickness. Extreme morning sickness isn't a fun, dangerous sport. It sucks.
• Gallbladder issues. Talk about a poorly designed organ.
• Ligament pain. Why don't we just have rubber bands there again?
• Blood expansion. Hello anemia. Let's just pile inability to carry oxygen on top of the other reasons to feel tired during pregnancy, shall we?
• Hormones, hormones, hormones. Usually it takes, well, a lot to make me cry. Now I can't make it through a commercial break.
• Relaxin (technically I could have included this with "hormones"). Could we not just produce this as we go into labor or something? How much snap-crackle-pop is a barely-30-year-old woman supposed to have, again? And how does this translate into inability to stand all the way up for the first 10 minutes of the day?
• Food aversions. How is it nutritionally beneficial for me to turn into a vegetarian?
• Maternity clothes. Just because skinny jeans are the "in" thing doesn't mean you can't carry anything else. "Buy your prepregnancy size"...BULLSHIT.

I'm sure there are many more that I'm not thinking about right now. I can't wait for this to be over. Distract me, please, somebody, something, the internet, I don't care, just make the time pass faster.

In the meantime, the kids have grown and been very kid-like. They are probably enjoying me being home more, but are showing it in strange and highly annoying ways. Boyness turned 8. BittyPrincess is turning 5 tomorrow, but we celebrated on Saturday in our typical disorganized holiday/birthday combo...we'll have to figure that out a little better next year, since I suspect she's actually starting to care that we're rolling two parties into one.

We're broke but the kids' Christmas wishes are modest this year.

I can't work because the timing is all wrong, and I feel only marginally better than shit anyway. I'm due April 20. We'll see how far postpartum I get before I get stir-crazy and set up my website and insurance contracts. I'm guessing not long.

I fully intend to start posting again. If for no other reason, because this blog has in the past been a great picture album. We'll see what happens.

Zoolights

Yes, I am posting this nearly 4 weeks after we actually went to zoolights. Don't get too down on me, now, I *am* posting.

We went (as it seems we do every year) on a whim. The PDZA has changed their policy and apparently members have to pay 50% of the admission fee now. BOOOOOO HISSSSSSSS NOT HAPPY. Really not cool of you Zoo. Maybe half price the second time you go, but FFS, I have a membership to this zoo and you'd think if it was open I could use it.

Anyway, despite having to pay for admission, we still appreciated that it was a gorgeous, clear, not-too-cold night. Full moon and all.






The zoo had even more lights than last time around, and even more of them were the new superbright LEDs. New this year, a tunnel of rapidly flashing rainbow-strips of lights. Very rapidly flashing. We stood under it for a while just to make sure the kids didn't have any seizure disorders we hadn't known about. Nobody lost consciousness, so I feel like we can pretty safely mark "no" for that bit of their medical histories for the forseeable future.

The zoo was gorgeous, the kids were highly Christmas-spirited, and we came home to have hot cocoa and revel in the oh-the-Decemberness of it all.

Cooooookies!

"They" (I'm not sure who, but a lot of people, so "they") say that baking is more like a science than an art. Like it's chemistry.

Bah, I've always thought, as any of my friends can tell you. On those somewhat rare occasions when I find enough time to bother cooking, I certainly don't have the energy to worry about things like where the tablespoon is. If baking is like chemistry, than I'm more an experimental chemist than a lab tech; maybe not so bad as the truly nutso 60's-70s "what will this do to the brain, better try it on myself!" sort, since I have yet to do anything truly ridiculous (like try to put bacon in chocolate chip cookies...yes folks, it HAS been done).

And then I made PERFECT chocolate chip cookies. Seriously completely totally perfect. A little bitty batch, just enough for the family to eat while they watch a movie. And, of course, no recipe.

BAH! I didn't even have a base recipe this time! No chance of recapturing this magic, ever!

Ah well, forward. The next time I have the inclination to bake, I think we'll be mucking about with brownie batter. Maybe I'll pay a little more attention to what I'm putting in the bowl, but somehow I doubt it. What's life without a little peril, after all?

Endings

This past weekend I attended my last birth as a student. The birth itself went gorgeously, nevermind the mind-bogglingly frustrating ordeal with the lab afterwards.

Leaving my site isn't so cut and dry. It is an agonizingly slow ending, seeing people postpartum that I like well enough and all, but at 20 dollars per round trip (usually to see just one family per trip because there are so few left) and with no compensation, it's getting old, particularly since I'm having to do some pretty financially stupid shit to keep the bills paid.

It is weird not to be pushing myself constantly. To arrive at that place I've been "almost" at for months now. Where I'm off call and life doesn't take quite as much planning.

Time to start up my own business, kind of. I'm not licensed yet, and can't accept insurance yet, not until I've got all my papers pushed and credentialing done. It never ends, truly; I'm sure it will hardly feel like I'm licensed when I'll have to start renew my credentials for the next year.

Website design, business cards, practicalities of sole proprietorship, here we come.

And she knows how to make people

BittyPrincess had a fever yesterday; it was pretty dramatic overnight but by midmorning she was running around only slightly crankier and more tired than usual. Getting 13 hours of sleep two nights running, when she averages a measly 8 (for a child her age this is a downright anemic sleep schedule) should perhaps have been a tip-off that she was getting sick. Either way, I skipped my clinic rounds for the day based on how hot she'd been burning in the night/morning, and settled in for a day of complete crankass bickering from my children. Sure makes me want to stay home with them...

Anyway, by evening I thought she was basically better. As I finished up our bookreading (Twelve Days of Christmas, but whatever, I let them do the picking) and everyone started getting settled in, BittyPrincess sat up in bed, leaned forward, and in high dramatic wide-eyed take-over-the-world fashion, said "I know how to make PEOPLE." She then settled happily into her bed, apparently prepared to dream about miniature-bitty-princess army creation.

Well, what a downright spooky thing for a 4 year old to say.

Not that I haven't occasionally been accused of plotting to take over the world, just that I never considered shooting people out my vagina to populate those plots. Or, that's not the intended purpose of my children, anyway.

And of all the million little unexpected consequences of this whole midwifery gig on my children, I didn't really think evil-army-creation was going to be on the table. Overly detailed information about all things baby-making (and all consequences involved), yes. Inability to make iron-clad plans for days with the kids, yes. A little too much talk about vaginas and birth in public places...ability to say words like "nipple" and "vagina" without blushing...disconnect/lack of understanding about how 99% of the population does this whole family-making thing...all expected consequences.

Luckily, this morning, the evil army is made of paper cutouts.

Exam complete

That was a long day. But it's done. And now just the waiting part...4-6 weeks before we know whether we passed or not...

I got some questions after my exams about whether it felt good to be done. It doesn't. I'll be done when I have my license in my hands. Maybe then we'll have enough money to celebrate with something other than air-popper popcorn and a movie we already own.

Breech Birth Video

I came across this video today and I have to share it. In it, a baby is born in footling breech position. It is not a particularly quick birth. What makes it amazing is how well you can see how baby is active in the birth process.

http://www.youtube.com/watch?v=jD5939e5PZ8&NR=1

I'm not sure that I will be doing breech births at home, well, ever. Not that I might not be singing an entirely different tune at some point in the future, but my intention in the meantime is not to plan breech births at home. They are riskier, it's true, which doesn't mean that they should never be done, just that new-minted-midwife me isn't going to be the one doing them. How difficult this choice is may make these births more triumphant when they're successful (which I'm totally happy about, I'm just not sure I'm the practitioner that can help with that). In the meantime, living semi-vicariously through the videos and others' accounts, knowing full well that I don't yet have the knowledge or the patience to be as hands-off as the midwife in this video is. I want this kind of birth to be an option for women. Right now, the standard is c-section for those women whose babies are in heads-up position at term, and it is darned hard to get any other kind of birth without splitting entirely with the medical community. Thank goodness for trained practitioners (of any sort) who know their stuff and are willing to attend vaginal breech births. I just wish there were more of them out there. Maybe someday I'll be one of them.

Zits, Hormones, Tanner Stages, Oh My!

Yesterday Girliness packed her own bags to head off to camp, with only minimal guidance from me. She reads by herself at night, up in her bed, increasingly complex little novelettes.

And yes, she now stands solidly in the preteen hormone storm.

Complete with one heck of a zit on her chin. And yes, she is suitably horrified. Horrified, and willing to wash her face thrice daily with acetone nail polish remover (yuck) if that is what it would take...luckily, we're starting with a simple soap and some witch hazel toner.

Not a TON of body changes yet, but she's definitely getting a slightly scarier grown-up-ier look about her.

Hormonal highs and lows r us, lately. Not in any kind of pathological way. In that way that makes all great parents sigh "my baby is growing UP!" when they throw a huge hour-long temper tantrum because *gasp* they are asked to put away their clean shirts.

Boyness is picking up the slack by acting perfect. I don't know what possessed him but he can keep doing it. He even mastered the art of *knocking* on my door when it is closed, a task that just a week ago seemed beyond his 7-year-old comprehension. His mental development may finally have caught up with his bulk! Oh happy day! How long do we have in this reprieve before the preteen hormones claim another victim in my household, turning my boy into a raving lunatic?

Graduate!

Or so I'm told ;). I haven't seen the document yet. But I had a pretty uneventful (aside from a few dirty looks) exit interview today, and turned in the last little bits and pieces of my paperwork. I had to leave a birth to do it, which is something I've never done before, and that sucked. I may or may not have been really standoffish at that birth with the knowledge that I might wind up waving goodbye before the birth was done. If that was my intention, it was my subconscious that made it so.

Also this morning, I missed dropping girliness off to camp.

Tomorrow, a little clinic, and time in the afternoon to visit friends.

THERE'S the Calm

This week I did only a little clinic. People I've been following are trickling slowly out past their once-weekly prenatal visits and into the lengthy span between 2 and 6 weeks, and then beyond. So I had a full-length day on Monday (after a birth on Sunday morning and another on Monday morning, both wonderful), left early on Tuesday and Thursday, and didn't go at all on Wednesday. This remains, as I happily catch my breath, the most demanding practice I've worked at. And I can see the light at the end of the tunnel, that time when everyone I'm following has given birth and is happily holding a healthy baby, and the four-times-a-week drive to and from Olympia is a distant and fuzzy memory; when the $500 per month I'm spending on gas and bridge tolls is happily tucked away into credit card bills, school loan payments, and non-essentials like rent and electric bills.

Here it comes...*sigh* oh happy distant day not behind the wheel!

I decided, since I had to do all that darned paperwork anyway, I was going to count my hours, contacts, and births in July even though I'd finished all my numbers. In going through those things, I discovered that although I took a long weekend off at the beginning of the month for health reasons and incidentally missed about 30 hours of work in one shot (not covered in the blog, don't wanna rehash it, thanks, I'm fine), I still averaged over 50 hours of clinic and intrapartum time per week. This not including the approximately 14 hours per week I spend on the road. Ouch. No wonder I'm feeling a little done. I've got some world class working-mama burnout that I've managed to only narrowly avoid all through my time with this practice. The numbers are illuminating, here in a month without a particularly heavy client load, where my only excuse is NOT spending several days of the month in or around Seattle for school-related things.

Speaking of which, I faxed off a veritable mountain of paperwork yesterday, and got a nice little "she's clear for her exit interview" kind of email from my clinical coordinator.

Until I stand over someone faxing my transcripts and certificates of graduation to the Department of Health, I am not going to be at ease about this. Even then, I'm not going to be *happy* about it. I'm not taking it personally, as so many students seem to have. What I do know is that there is one person at that school that is screwing over a lot of students, and it is NOT OK. She is not following the rules in letter OR in spirit, and is treating students like recalcitrant children instead of full-grown adults who hold lives in their hands on a near-daily basis, and have jumped through some SERIOUS hoops to get where they are. Deciding suddenly that we've done ANYTHING on a whim or are trying to get away with ANYTHING, with the amount of work we've done, is not just insulting but wrongs us as people.

Complaining on the eve of a merger with another institution, when things will change dramatically, is to a certain extent pointless. Nevertheless, there will be at least a little bit of (wordy) bitching coming off my desk headed towards Bastyr, the school board, MEAC, and NARM.

As good a student as I am, I never thought this was how my last interactions with the school would shape up.

Oh, and...

The school, of course, couldn't just let me graduate without some drama. A scant few weeks before the licensing exam, already having paid the fees, and with a "you need to repay in full if you can't be there" notice on my fridge, I get:

"We can't officially graduate you and release your transcripts until..."

Well fuck me, you don't say? I am pretty sure that I, in fact, have to do next to NOTHING on that list. I read my handbook and can quote it. And I did, with only moderate amounts of snark, which got me out of some but not all of the things on their list.

The easiest thing is to roll over, do as I'm being asked, and watch the red tape dissolve. My preceptors think I'm ready for practice (are referring a few people to me, actually) and are interested in making sure I can take exams and get licensed on time; they've humored the school in providing a second set of evals just two weeks after their last set (what do they expect to have changed?), and working with me to be able to sign a few things that if the system worked as it should, my program coordinator would be signing for me.

There are several reasons this pisses me off:

- We had a check in last quarter that made it sound like I was about done, and said NOTHING about several of the items on that list.
- Some of those requirements aren't in the handbook, meaning that they AREN'T requirements and the school has no right to hold my transcripts while they wait.
- In fact, the school has no right to hold my transcripts AT ALL. The state needs transcripts to show that I've done the coursework, they don't need my graduation papers for me to sit the exam, just before the license. The school is effectively holding my papers hostage. The transcripts are mine. That can't be legal.
- The NARM skills checklist - a 22 page long list of things our preceptors are supposed to sign off as we master - has a "safety" where if you don't manage to do some of the skills, the program director should be able to see that you've covered them in your coursework and sign you off. Which the program director is REFUSING to do. This is not OK, it really isn't. Why say you have that safety there if you don't? There are skills on that list that I'm not going to get to do. My preceptors can sign off after we review and drill; but this is something that the program director is supposed to be able to do, since we reviewed and drilled in our courses. So why not fucking sign? I passed those parts of the curriculum. I thought that was the stated reason for the hefty curriculum at this school; so that we have knowledge that we need when we encounter those things that aren't so common, that we'll not see in our practicum. Why are they being such ASSES about signing it off? I have all of 3 things left. My preceptors haven't seen me do them any more than the program director has...but my program director, unlike my preceptors, has access to my exams and course work and could verify that I know what to do. I don't get it. It feels like making life hard just for the sake of making life hard. It feels, again, like holding my papers and transcripts hostage.
- I have to do a fucking EXIT INTERVIEW before you'll release my transcripts? Again, not in the handbook. Those documents need to be at the state office...and you're telling me that I need to do this, oh yeah, and you're going on fucking vacation next week? I think fucking not! I need more notice than "do this or else, oh yeah, and it will be extraordinarily hard to do this and you don't have enough time."

Until this point, I haven't had issues with the school largely because however much asshattery I encounter, it's been forewarned in handbooks or at some point in our education. BUT NOT THIS. This is NOT OK. Setting us up for failure, much?

Yes, I'll get it done. Yes, I'll be OK. That isn't the point. The point is that I could very easily NOT have been able to, and I wouldn't have had the warning I needed to ameliorate that. The school has told me over and over again that I'd be able to take the exams in August. THIS IS THE KIND IF SHIT I WAS TRUSTING THEM TO TELL ME ABOUT, and they don't even have the "it was in the handbook" excuse, because it FUCKING WASN'T.

Mad, mad, mad.

Car Dramaz!

I thought, yesterday as I went in to clinic, that I'd just do a quick couple of visits and leave in time to see my Fran off to work (starts at 1pm). I sweated my way through clinic; in Washington the temp was over 100 yesterday, which is truly exceptional here, and the clinic building (typical for Washington) has no A/C and was, effectively, a solar oven. I walked out to the car thankful to be gone during the hottest portions of the day.

And it didn't start.

Crap, crap, crapcrapcrap.

As I sweatingly encouraged the car to start *with the force of my will and strong words* I got several offers of "I don't know what I'm doing but can I help?" which were of course not helpful, and which caused in me an irrational hatred (I said it was irrational) of those not-terribly-helpful people and their terribly-functional car A/Cs.

What else could I do? I called my man to help. That's what we get married for, right ladies? Kinda?

He got to the clinic at about the time he was supposed to get to work, all three kids in tow. He succeeded in starting the car, which ran limpingly (and stinkingly) in the parking lot, and as we were about to caravan our way to the mechanic, the office manager ran out "[client] is pushing! [midwife] is coming, be ready to jump in her car!"

Of COURSE after a week without a birth *this* would be the moment!

I left my husband with the car problem, the kid problem (erm, they're in a parking lot at 105 degrees, and I can't even say it was a dry heat), and the not-at-work problem, and ran off...we figured there would be a baby, I'd be gone 3 hours total (how long it takes to catch a baby, monitor everyone for complications, clean up, and leave), so maybe they could just wait for me?

Our mama/client/patient was not pushing when we arrived. She is a wonderful, wonderful person, and I don't hold that the least bit against her. It was just inconvenient.

She birthed in a home in the shade, which was about 20 degrees cooler than the clinic building for most of the day. That bit was at least a little convenient.

In the meantime, my family went to several air conditioned establishments in the Olympia area, spent too much money on purpose (which my husband tells me was a twisted act of passive-aggressiveness) - too much money being $50 all day, at this point.

To make a painfully long story short, they spent 10 hours in Olympia, a baby was born healthy if a wee bit early, Fran got the car running AGAIN as I came back to the clinic, and we dropped the car off at the mechanic's shop at the bright and early hour of 11:15 pm.

---

So, a few words of not-explanation?

I don't know what to do with this blog anymore. I wrote a lot when I was staying at home and writing kid-foibles. I wrote a lot when I was in Vanuatu, and had no need to worry about anonymity.

Last week I went to three births in 24 hours. Which is something to write about, except that it isn't. They aren't my stories to tell. They are significant in my life, yes, but in many ways it has transitioned into being what I do. It feels odd to say it, but birth is my work, and you wouldn't write about the minutiae of your work day either. The interesting bits aren't mine to tell, and (darn those federal privacy laws - kidding, really, it's an ethics thing) this isn't a protected space to talk about anything that could identify anyone, which in my community is pretty much anything at all.

I am tired of being broke, and ready to stop being a student. That much hasn't changed.

Approaching licensing, I feel anxiety. My preceptors believe I am ready for independent practice. I know that I can handle independent practice, and yet, I'm scared of that responsibility. In that way, being a student is a sweet deal; there are some people that are more my clients than my midwives', but if I did something wrong they'd be there to either catch it or take the blame. Not that I do wrong things, just that there's a safety net there that I'll be going without shortly.

I also feel anxiety about starting up my practice and money. I've been whining about money a lot, I know. We are at a place we've never been before, without enough money to pay our monthly expenses and at the end of our credit limits on our credit cards, scrambling to figure out how much we can charge on which cards to pay whatever car repair expense we need to pay. And starting up a business costs money. A medical business more than most; I have equipment to buy, yes, but I also have malpractice insurance to buy and in this state, you pay for a year in advance...and I don't have that money. I'm taking this thing one step at a time, because I can't just make money appear so I can't do anything differently. At the end of my student time, I'll probably need to find paying work that isn't my profession, so that I can make enough money to start up. Which is galling, because once I start up I'll have money. Business loans are next to impossible to get when you make what we do and have as much debt as we do. Funny how your school loans count against you for that.

I didn't mean to start whining about money again, but there it was. I know a few people who are students are reading this. Hopefully in a year my song will be different. Right now things are difficult. I'm not burnt out on midwifery, I'm not soul-dead from my student-hood...but things are difficult in this transition time.

Where's the Calm?

I think I just have to face it...I'm not done with practicum yet. Technically I am, but there's this pesky contract, so last month I still averaged 40 hours of clinic and birth work per week, without counting drive time (and the occasional day stuck in Olympia just because it costs $15 to make a round trip home, and I'm not doing that even if it means I'm stuck without anything I really *want* to be doing for 4 hours...I have escaped, from time to time, into a fiction book at a park). And then there's fact that I don't really WANT to pull out of practicum early (on time? before my contract ends, either way), not when every new thing I see there is one more new thing I don't have to do solo later.

I honestly don't know what I'm going to do with myself once my clinic obligations are over. Imagine whole weeks stretching in front of me without the structuring influence of clinic time, or even *gasp* being on call. Any way I start up, I get at least a month with absolutely nothing structured for me. THAT is a crazy concept.

This week, I have reaffirmed that I detest prelabor rupture of the membranes. Stop sending that scenario my way, please. Enough hospital transfers with nonexistant labors. Enough prodding women who really, if they weren't ruptured, we'd tuck into bed and see a week later in actual labor. This phenomenon is seriously getting on my nerves, and I harbor no illusions about it disappearing when I've set up my own practice. I just dislike it. A lot.

Despite all of this, I have rediscovered fiction books. Or the fact that my library has them and can order more of them. And the fact that I read quickly, after all, something I'd forgotten in the haze of TRYING to read hundreds of pages of very dry text every week.

Also discovered that the weather still dislikes me, at least a little. Yard sale day dawned with lots of thunder. Not a lot of rain, but effectively chased off the (not so big) masses. And off to Goodwill we go, 'cause I'm not into hanging on to this stuff.

Three

Three births this week. Some drama at one of them, but it all worked out in the end. It would have been four, but I put myself off call to do some babysitting and missed one.

So much for slowing down after graduation, eh?

Yesterday I mailed out very-slightly-belated thank you cards, put checks in at the credit union, and promptly withdrew a largish cashiers check to pay NARM for the privilege of taking their licensing exam.

We are, this month even more than in the recent past, finding rent at the bottom of our pockets. I am looking forward to getting paid for this work at some point, and wondering if I'll have enough money to continue paying for gas to get to and from clinic in the meantime. I'm tired of it all, and at the same time, aware that I'd miss it terribly if I stopped. I think that it is more that I am tired of the pace than that I'm tired of what I've been doing, if that makes any sense.

Closed

I turned in my senior paper today, two copies neatly aligned in their binders, ready for cataloging.

This morning, I presented to a mercifully small audience, all of whom were familiar to me in some fashion or another. The presentation went smoothly. I'm happy with how it went, for the most part, although there was one question asked in the Q&A that I misunderstood at the time and could have answered much better.

For once I am not sitting on pins and needles. I know I have passed.

There may be little red-tape spiderwebs hanging unexpectedly in the corners, but I'm walking over the bridge and graduating tomorrow.

Moving from juggling children and school and clinical placement, to juggling children and business tasks and my own clinic. I'm not ready to face that, quite yet, although my preceptors have been encouraging me to. I don't know how long I'll need after this placement is over to feel human again, to be ready to retool myself as my own midwife. I expect it will be short, and don't want to be sitting around twiddling my thumbs and waiting for the papers to go through when I'm ready to go.

The births last week were gorgeous. Healthy happy moms and babies in clinic earlier this week, adjusting to their new lives together.

I'm looking forward to the deep, deep sleep of the not-on-call tonight.

The numbers are DONE

Two births in the last two days, and my primary birth requirement is DONE.

This is a good feeling.

Technically, we have a 60 birth minimum and I'm hovering just under 120. I don't think 60 would have been enough to be competent.

I'll have a busy week next week getting my last few things checked off for school.

I have a couple of clinical requirements that remain unmet, but when I look them over, the list is mercifully short and won't be difficult to polish off.

The need to finish off the senior paper and prepare it for presentation looms large in my mind.

Still no more babies

I was hoping for an overnighter over the weekend. Tonight wouldn't be bad either.

Awaiting a couple of multips who live faaaaar (one of them about 2.5 hours straight out my door to hers) from my house. Oh so totally not excited about the driving. Give me some clients out my way and I'll be a happier student-midwife-thing.

Submitting my application to NARM soon, once I can scrape out $700 to pay the exam fees (scroll down, reference earlier rant on the ridiculousness of that fee - yes this is in addition to the state fees, which are already paid). They've got us here, pay or no license. Additionally, it needs to be in the form of a cashiers check or money order, which makes me nervous. I know NARM is legit, it's not that, it's sending a (for me) big already-taken-from-my-account check through the mail that makes me upset. I'm not understanding what all the bother is about with refusing personal checks, either, since they can always just hold their approval until the check is cleared. And I think it's easier to counterfeit a money order than it is to get a personal check through and rescind it (I did business on ebay, remember, I haven't tried any of this personally but it's aaaaaaalllllll been tried on me).

I think I'm rambling. At least I'm posting, right?

I did my first solo suturing/repair job on US soil last week. I was pleased, my preceptor was pleased, the woman was pleased, I feel really good about it. This was one of the few remaining skills on my checklist (overseas preceptors can't check you off, which I think is really inconvenient but makes sense since they didn't really look at what they were signing). The rest I probably won't actually get to do. I don't imagine I'll be manually exploring any uteri, for example, until that moment when there is no more experienced midwife present and I just need to do it. Like all the other skills before it, there will be the need and it will happen, and I'll have done it.

Can't Complain

Seriously, I can't.

I have lots that I COULD complain about.

But it can't really override how happy I am to have warm weather, sunshine, visiting family, and a *very short* time until graduation.

Happy, happy, happy.

Happy, happy.

Happy.

And in case you didn't notice, happy.

A great birth on Thursday night, and then straight to school for some seriously pointless class time (happy to see my classmates, though, which I always enjoy!). Pointless as it was, there was a nice walk involved, nice visiting time, and I got a few more pre-graduation things off my checklist.

I think the knowledge that all I've really got left is my senior paper is really nice. I have only two weeks to finish it (a little less, actually), but it is almost there and I'm sure it will be fine. Our topics this year are really boring, so I don't even anticipate a lot of people at the presentations.

Off to something fun today. On call as usual, but das' ok.

Jumping the Hoops

The check to the Department of Health did not bounce, thanks to a very-appreciated infusion of cash from my parents. <3 I love you Mom and Dad! Your little note made me feel so good it's hanging above my dresser for a bit, too.

I got the graduation invitations in the mail today, so they'll be heading out to all my peeps tomorrow. Some of them will get hand delivered, as there is a serious lack of notice issue going on here (grad is in just 3 weeks!).

The house has been hit with some sort of mini plague that seems to mainly involve annoying coughing and really pissy children. They'll get over it eventually, I'm sure.

I've been attempting to wrap up the senior paper, to move that off my checklist; this endeavor has been only semi-successful, since I don't really want to think about it anymore and since sunlight and gardening beckon. If only I could write the damn thing with my subconscious while I did more interesting things with the rest of my brain. That would be some serious multitasking right there.

Despite the fact that I'm approaching graduation, my to-do list grows paradoxically longer. Argh.

The stars aligned and births happened in their time last week, and this week we rest, or so it seems. Since there is someone in dates, I'm not technically off call. But it felt good to have the board relatively clear.

Just one birth this week, and not as a student; I watched a good friend catch her own baby. It was the most amazing birth I've ever attended, and not just because she was my friend. Much love to her and to her baby, as they babymoon now.

Thankful

Thankful for friends who watch my kids on little/no notice.

Thankful for grandparents who spoiled Boyness yesterday :).

Thankful for two births far away on the same day, saving me many hours of driving.

Thankful for sunshine on my patio, growing tomatoes, and happy children running amok in their pjs in the early afternoon.

Wishes, and scattered updates

My wish this week is that I could schedule babies to come on my husband's day off. Or while I'm already at clinic. Or during the night. Just not in the evenings, basically. At my old site we had this great thing worked out (not sure what kind of magic this was...) where my preceptor would call about 5 minutes before my husband got home from work for the night, and I'd get home before he left in the morning most mornings (he'd shuttle the kids off to a prearranged location if not...mornings aren't a big issue for us). The problem is that he doesn't get home until 11. Who the heck wants to watch someone else's kids until 11pm, if I can't get them in the meantime?

It would be way easier if I could tell babies not to come (or be in the process of coming) between 6pm and 11pm.

There are also too many people postdates or needing to have babies soon, and I am a bit apprehensive that there will be a bad scene involving multiple births at once. And I keep telling my preceptors that my student midwife friend's birth is where I'm going if there is any kind of conflict, but I'm not sure they quite believe me. They have the link to my blog, and if either of them is reading: I'm serious. That's where I'm going.

I need to cleanse this negativity and work my way back into a place of knowing it will all work out. Which somehow, it does. Two discouragingly long births with hospital transfers back to back last week, and a bout of illness, and my mood has tended to the depressive for a few days. It'll swing back into balance.

In other news, there is another student at my site now. HALLELUJAH. *see the relief emanating from my body* less clinic *see the happiness*.

My preceptors seem to think that they are entitled to the number of hours I was putting in before the arrival of the second student, and have decided to give me some "projects." Maybe it was the look on my face, or maybe it was always their intention, but the projects are thus far things I'd need to do for my own practice anyway. And totally things I can do at home. I don't care how much I need to do at home. I just want to *be home* sometimes.

(Money rant ahead...no worthwhile text in the remainder of this post...)

I mailed in my midwifery license application yesterday, complete with a check that I don't have money in the bank to cover. Ack! This process is SO expensive. And we wonder why more low income women don't become midwives. Seriously, DUH. It is hard to come up with this much money. THREE TIMES what I was paying for rent during most of my studenthood. OUR MONTHLY INCOME. This money is not easy to come by. Why is that so hard to understand, oh people-who-sit-agonizing-over-why-more-women-don't-do-this? At this point we HAVE to come up with the money or it has all been for shit, but damn, it's not even about not having this kind of money "laying around," it's about living paycheck to paycheck with less than a tenth that money left over every month for "nonessentials" like car repairs and kid shoes.

In short, *NARM THIS IS YOU* where the hell do you get off charging that much (ahem, $700 test fee for student midwives WHO HAVE YET TO MAKE ANY MONEY AT ALL) on top of what we're already fucking paying the state, who at least has an excuse (this is the only time they get money out of us and they need to administer the program)...AND THEN COMPLAINING THAT MORE MINORITIES AND LOW INCOME WOMEN AREN'T MIDWIVES.

What. The. Fuck.

It must be easy, those-who-set-fees, to be in a position of relative financial stability and say "oh, they can come up with that money, they have time to prepare." Yeah, when? While we're racking up student loans with no pay? While we're demanding our spouses refrain from taking overtime, and stay home with the kids some days while we're at marathon births, not earning anything? While we're expending massive amounts of money to commute ridiculous miles to clinic and more births than we'd ever DREAM of doing in a month in our own practices? WHEN, WHEN, WHEN are we supposed to be building up this money?

It's all bullshit. I don't know how I'm getting that money into my account. I just know I have to.

It's funny

How doing way too much clinic can make an onsite week seem like a walk in the park. And allow a few literal walks in the park, too. I missed just one birth, someone who wasn't particularly attached to me (I like her, just don't have any special connection).

Fighting off a UTI and hoping that the weekend is easy on me.

Meanwhile, last week we challenged (dairy-allergic) boyness with a milkshake after 4 years of dairy avoidance and 6 months since his last exposure...and he didn't react. He turned around and told his Nana that he didn't react, who went ahead and overdid the dairy. And now this evening I can't tell if he's acting like a little ass because he had many dairy things to eat or because he just came back from his spoil-them-rotten-can't-say-no Nana's house.

He is not the only child to get on my nerves lately. It has taken Girliness three days (not counting the sleepover days at Nana's) to fold *one load* of laundry and get it out of the living room. I don't need that shit. Just fold your laundry, Girliness, and we can get down to the fun parts of our lives.

The wrap-up post

This is the wrap-up post for the Vanuatu trip. You know, the post I never wrote, and now feel the need to include in my blog, here a month and a half after my return. The one where I muse on all things going-overseas-for-clinical-rotations.

I'm still not going to do it, not really anyway. If you want to know what it is like, read the rest of the saga, it is fairly complete.

You should also read T's blog, which is fairly complete as well, and has more pictures than mine:

http://farawaybabies.blogspot.com/

Her experiences coincide with mine, but many times we were either not present for each other or were solidly sitting in separate roles even while at the same birth.

---

I would do it a again. I gained so much from this.

I don't feel bad about invading someone else's culture/space/whatever, an objection that I understand but didn't see as some big deal here. I didn't go as someone totally clueless, to make mistakes; I went as someone almost ready to start up independently here at home, in need of experience, and I gave good care in a place where it was very much needed and appreciated. Neither did I go to change how things were done, to be some sort of know-it-all rescuer or some stupid shit like that. I went to learn, to experience, to participate. And I did.

The women at the maternity ward there do amazing things with the cast-off and donated equipment - much of what is donated having been used for years before arriving in Vila.

I met some infuriating people. Some exceptional people. And many, many beautiful laboring women and their families.

It all seems like some sort of alternate reality, now, back in my own midwifery-USA world, back to the grind with my family in tow. On call all the time, driving insane distances to clinic and births, and over-thinking everything. Working with women who are taking for granted that babies are going to come out alive and healthy, who are living under the expectation that we are capable of stopping the horrible extremes. Who hire us to prevent something that we might not be able to prevent. THAT is the big burden of midwifery. THAT is why we often intervene too much, why we transport for anything that raises risk the slightest little bit, no matter how small that magnitude. I'm not sure that we're always safeguarding women and their babies when we act the way we do. I think we're often safeguarding the expectation that we're safeguarding the women and their babies.

Which is, oddly enough, not to say that we do anything wrong, really. Just that we are perhaps bringing an energy into this whole thing that isn't as much about keeping women safe as it is about keeping the image of safety safe.

This was perhaps not the morning to write this, with the kids yelling in the background and the caffeine and sugar from my morning coffee unalloyed by protein to keep the shakes at bay...but I'm not finding a good time, so it just had to get written and placed in the past where it belongs, so that it can gather some perspective.

Home again, part 2

I got one day at home before we left for Oregon, to spend a weekend with the step-in-law family. It went fine, but it wasn't home. On Easter, the kids ran about finding eggs obviously hidden by the grown-up contingent, we drew chalk mandalas on the sidewalk, and before we departed for our 8 hour return drive, we all ate chinese food on our hosts' patio while the children ran around in sugar-high bliss.

And into clinic again. Clients mostly welcomed me back warmly (one in particular that the midwives didn't think would want me there after the break smiled when I entered the room and said "now you're ready for my baby, right?"), and none with "who the heck are you again and why do you want to be at my birth," which was nice. On Thursday, a whirlwind tour of the Aberdeen area. I am having difficulty wrapping my head around the fact that there are clients out there, more than two hours from my home, whose births I am supposed to drive to. They have been warned it may not happen. I have heard of midwives who have two hour or more radius' for practice, and I can't see how that is workable.

Tired, tired, tired, and ever-so-happy to arrive in Friday, where my only obligations are a little kid-shuffling and playdate action.

Lest this become a whine-only post, I have a kid funny. While in Oregon, we went out to breakfast. BittyPrincess climbed into my lap and commented: "Mama, you smell bad. You smell like coffee, but not like our good coffee at home, you smell like bad coffee." That's my little PNW pre-coffee-snob.

Home again, home again

I'm too busy enjoying being home again to give a comprehensive post. Not that anyone really cares about my flights and such.

I do need to share that I wound up staying 3 hours for a second "last day," during which I found out that the mec-decels-two-Nikis-there woman named her baby Niki (not sure about the spelling).

I'm heading down to Medford, Oregon to spend Easter with some extended (read virtually unknown) family. Not entirely happy about leaving so soon after I got home, but I know as much as I want to just sit around with my family, the kids would be restless with that. It might be good to be with them, but busy. I hope.

Last Day in Vanuatu (I think)

I went to what should have been my last day at the hospital today.

Only we were so busy that I didn't get all my papers signed. "Come tomorrow, first thing, we'll get it done right away" the nurse in charge said, working on her 3-o-clock report at 5:30pm. I went to say goodbye to the ladies working evening shift, and they gave me hugs and handed me a wrapped package, which (curiosity got the better of me, that and the certainty it wouldn't stay wrapped through customs) turned out to be a lava-lava. If I ever get a chance to wear it, I'll remember both them and all the laboring women walking the halls in their lava-lavas here.

I did two births today. Shortly after I arrived, I did a CTG strip for someone who had been at the hospital overnight already, and found some pretty significant late decels (with every contraction). I took her off the CTG for long enough to put a new admit on and seek consult (which turned out to be less than helpful).

The first birth was the mom with the decels, which hadn't improved but hadn't gotten terribly worse over the 5 hours since I first saw her. The student nurse who was supposed to be assisting me totally disappeared ("I wen lunch," he told me, unhelpfully, later). I grabbed a newcomer from Australia who shared my name (Niki and Nicki), and who, had she come earlier, would probably have been a great friend. I have done births solo here a few times (maybe 5 or so?), but the slow labor for a 3rd baby, the mec, the late decels...I wanted someone else there. The meconium got heavier and heavier until it seemed like it must be coming straight from baby out without any dilution at all. The decels got worse with pushing, eventually not recovering and hovering at 60 even between two contractions. Oxygen to mom, I ordered (easier said than done...). Some recovery. Not back to baseline, but up into the triple digits. Baby was born, thankfully, less than 10 minutes later, and did not require anything more than a little suction and stimulation to come around.

So many moms here have meconium. So many babies are totally fine. My feelings are now pretty thoroughly mixed on the subject of meconium, after managing so many births with meconium that it just doesn't seem significant anymore. I know that this isn't acceptable in the Washington-State-out-of-hospital type practice, have no fear. I'm just not scared of it anymore. Neener-neener.

The second birth of the day looked to be pretty easy. 42 year old 2nd time mom, who had her first baby 17 years prior, but seemed to be laboring along nicely all day. She got to complete and wouldn't push. "Tired!" she cried at us, over and over. "No push, me no save push! Me no wantem push!" When the midwife-in-charge came in and authoritatively ordered her to stop whining and start pushing, she made a disgusted face and solidly ignored the commands. Four hours later, three of which she spent rotating her baby from OP to LOA to OA, her baby was born with the aid of a vacuum. Shitty last birth for me, really. She was also the first to be visibly disappointed to have a girl. "Thought it would be a boy," she sighed, and turned away. "Yufala sure?" she rejoined, moments later. Yes, we were, that was a little girl that was dragged reluctantly from her body. (Hopefully this doesn't sound too harsh. I spent a large part of that labor rubbing her back, her shoulders, her legs, speaking encouraging words and waiting for her to get down to business and push out a baby.)

Shitty last birth, maybe, but I'm leaving knowing that I'm far, far more ready for practice than I was when I got here. This is a good feeling.

We'll see tomorrow, I suppose, if I get dragged in for another "last day," since I don't actually leave until 2pm.

Newborn Exam Day

I did no fewer than 13 newborn exams today. I did not, of course, catch all of those babies (I caught one and observed two others); there was a baby backlog when I arrived and a steady stream of babies in preparation for discharge. Today, there was a dad that WANTED to be there for the birth, supporting his wife and crying happily once his baby girl was born, following her to the warmer and taking pictures, and then singing along to some R&B type music he had on his phone, appearing to mesmerize his daughter with his swaying. Luckily nobody in the packed-full labor room seemed to mind, one mom in a world of her own across the hall, the other right next to him humming along, his own wife rather engrossed in hating being sutured (not that it was awful, but who in their right mind would LIKE that?).

No drama on the ward today. Two of my favorite people were on day shift, so that's what I did. A nursing student (they are not assigned shifts the same way I am, and I think they just have a number-of-hours requirement) that I'd signed off on one of her first vaginal exams a week or so ago assisted at a birth today; she was too busy standing there crying happily to administer the syntocin that they do routinely around here, which was such a lovely thing that I couldn't get upset. She'll get over that eventually, but hopefully never completely.

I left a little after 3, which left me enough daylight to go get changed and walk into town for some food at the waterfront. Chicken and fries and oversugared soda cafeteria style right next to the water, sharing a table with a woman and her shy 3-year-old granddaughter who were on the island for the weekend from "the next island over that way," which pretty much meant nothing to me. It was good to sit and talk though, and hear about her family. I think I understood most of it.

On the way back to the "resort," walking through the village-in-a-city area, I heard the rather unlikely sounds of a trombone and a trumpet, practicing two different scores simultaneously.

Back now, it's dark outside, and should I decide to leave the TV on I would have a choice between Meerkat Manor and rugby. Maybe I'll try to figure out the rules of rugby (football, as they say here)? It seems to involve short-shorts and jumping atop one another. Beyond that, the rules elude me.

Maybe just some reading time tonight, instead.

Doldrums

This morning all the women were discharged from the ward.

No, seriously, all of them.

OK, so there were two hang-ons whose babies were under 2k, in the extension ward. But the not-anyone-there-ness of it all in the main ward was pretty astonishing.

By the end of the shift, we'd placed two women and their babies on opposite ends of the ward. One caught by another midwife, one by myself three minutes later. Another birth I managed beginning to end, although I did make a consult call for some decels (the mind-boggling answer I got was to break her water...wtf...). Out came a very white looking baby. And by this I do not mean distressed or hypoxic, I mean white; the midwives were looking to see if this woman was married to a white man and even went so far as to ask her the race of the father. I'd gotten so used to dark little black-haired heads that it was quite a surprise to see light-brown-almost-blonde hair and pale skin coming into view. This mom had a history of a prior stillbirth, and in a moment of "something looks wrong here" panic I slapped on the fetal monitor again, to find the heartbeat steady at 140 just as it had been mere minutes previous. I contemplated cutting a cord on the perineum for the first time, as the baby got tied up with a tight nuchal cord and the typical somersault maneuver wasn't working, as there simply wasn't enough slack, and we got a tad-bit stuck at the armpit level. Some breath-holding and cord-stretching and baby-twisting, and everything came out fine. I was of course alone for the ordeal, or the midwives would have been appalled that I didn't just cut the cord (which would have taken at least as long as what I did...).

A teary phone-call with my family this evening. I am ready to go home.

Thanks, T

For leaving the anti-diarrhea meds (...erm...brb...)

Anyway...the woman I was talking about yesterday had her baby overnight and was happily on her way today.

The ward is so full that they are sending women home 12 hours after delivery, sometimes a tad less if they are doing really well. There were 90 more deliveries in March than there were in January.

Nevertheless, today was a very slow day. Sat around doing nothing, or the VCH version of nothing, which involves making beds, folding gauze, making cotton balls, re-reading matron's reports, tallying births for the month, and then finally just.sitting.there.doing.nothing. As I didn't want to kick myself for leaving before something exciting, I stayed for the full shift, and then wound up staying a bit after for someone who had been on the ward for two days and who had finally found herself in labor, a misoprostol (cytotec) induction.

Just after that birth, the reason I am thankful for the anti-diarrhea meds kicked in, and I left the hospital in a hurry.

Feeling much better now, watching some crappy TV. And that pun was unintentional but I'm leaving it.

Chugging along

Another shoulder dystocia yesterday; this time I was not alone, but the midwives (two of them!) who were there apparently didn't understand "hip flexion" "legs up" "need more room here, bring her knees up" and about 5 other ways I was attempting to communicate what I wanted them to do (ARGHARGHARGHARGHARGH!!!!!!!!!) until I finally repositioned the woman myself. And a floppy baby. The midwife refused to pass me the bag and mask, told me I had to cut the cord and take the baby to the station. Goodbye good heart rate. Baby came around after a few more minutes, but had no muscle tone even after she was breathing on her own, for a good 20 minutes. The ped's opinion was that she'd suffered hypoxia - the midwife that was with me uselessly stared and didn't inform her of the dystocia or the rescus, so I jumped in with some information. I am not sure what was going on with the midwife, but her mind was not there and I may avoid working with this particular midwife for the rest of my stay here; the others have been varying degrees of acceptable to great at working together at births. Baby looked healthy and active an hour after birth.

Two more births, without issues.

At the end of the day, I checked a primip that had been in the hospital all day and working really hard. I couldn't figure out what language she spoke, and she was off in labor-land. Not Bislama, but English, it turned out. She was only 3cm. I was not prepared to stay and do a lot of labor support, but did take time to provide her and her partner some information and some coping techniques, kind of an impromptu 30 minutes of childbirth ed. She was very tired. "There is only one muscle in your body that needs to do the work right now," she finally woke up and understood, "think about letting all the rest of your muscles sink down into the bed and rest."

I hope that she delivered without incident last night. If she is still there when I go in (in a few minutes), I'll be glad to provide support and receive information back with full fluency, but unhappy that she hasn't delivered.

Babies, babies everywhere!

T came in to the hospital today with me, and stayed until 1.

She missed the first birth of the day by about 20 minutes, a multip that came in at "8cm" someone said...6-7 was more like it when I checked, but whatever, her fourth baby came out 30 minutes later, a girl. The messiest birth here so far; pee and amniotic fluid everywhere.

I won't go through all the births today. Four catches, three observes (two of those vacuum deliveries - in case you're wondering, T, Dr. B is substantially better with that particular apparatus than Dr. D was). Two vastly different repairs: one a skin-level repair that came with a big 'ole baby; the other a dramatically deep 2nd degree that came with a little bitty baby. Lots of cleaning. Only a few moments here and there to catch my breath, 11 hours at the hospital.

Never look too bored around a doctor

Especially one that loooooves to chat about horrible things.

You might get chatted at and invited to a c-section "we anticipate to be really difficult, you'll see us sweat, that will be good eh?" This woman had a previous stillbirth after undiagnosed partial previa --> full abruption --> distressed baby --> c-section --> dead baby --> couvelaire's + massive hemorrhage. She'd elected a vbac attempt, and after hanging out at 4-5 for 12 hours, with good strong contractions for 6 of those, she was talked into (offered, whatever) a c-section. After quite a lot of difficulty placing the spinal, the operation went off without issue. Mom lost a fairly small amount of blood, her uterus and intestines cooperated and returned to her abdomen (ick), baby was happy and healthy and vigorous.

I got back to the maternity ward after the time I'd decided to leave.

Rewind a bit.

When I got in yesterday, a couple of mothers had delivered and pregnant bellies were all over the ward. I helped move people around, settle people in, and then the boring bits start. All those pregnant bellies were in various states of not-really-labor, including one that just needed to listen to her baby and go home and a few that thought they had ruptured membranes, but probably didn't.

The family from the stillbirth the day before came to pick up their baby. Another hour of wailing and mourning and sadness.

Cycled women through their "CTG" (amounts to an NST), checked early-laboring cervixes for non-ruptured moms, and settled into the boredom.

About an hour before I was intending to leave, the above-mentioned doctor caught me rolling cotton balls and dunking them in alcohol with a rather resigned and bored posture about me.

When we got back from the c-section, there were several suddenly active-labor-looking moms on the ward. One I'd checked and found at a 4 just before tackling the alcohol swabs, and she wanted to know if she could go in and lie down. She didn't have to push, she said, she just wanted to lie down. She looked like she was going to push, so I told her to go ahead, ran to eat something, and was fetched by her husband not 45 seconds later. I found her 9cm, broke her water, her cervix almost-dissappeared (could feel the tiniest edge of it) and told her she could push. She had a lovely girl of substantial-for-here size just a few minutes later, intact perineum, happy mom-baby.

As I was getting the instruments cleaned up, another mom I'd checked earlier and found at a 2 walked into the labor ward (usually if they do this themselves, they're pushing already). She was 6-7cm and in hard labor, and her relatives briskly escaped the room (why?!). I ran about looking for them so that I wasn't stuck doing labor support, and found her husband instead, who gamely entered the room and rubbed his wife's back, looking only mildly horrified. Just half an hour later, a spontaneous push, and when I checked she was complete. 20 minutes later, another substantial-sized baby, her second girl, this time with dad as a witness for the first time since I've come here. Sure, he was plastered to the wall beside his wife's head looking apprehensive for most of the pushing, but his face lit up when his daughter cried. Mom, alas, had a substantial second degree tear that took a good long time to repair, and no matter how much lidocaine I injected (nor how little she seemed to notice the needle while I was injecting the lidocaine), she was in pain during the repair. I'm rather sure she detests me now, but I'm also rather sure that I did a good job putting her vagina and perineum back together, and I did as well as I could to get her pain relief in the process. "Don't worry," said the midwife to the dad (who appeared not at all worried), "next time you have a boy, it will be easier too..."

I cleaned, rearranged, prepared spaces, and left. As I left, the midwives predicted a line into the admissions room and through the labor ward all night. I predicted a solid sleep after over 12 hours at the hospital (preceded by 3+ hours of doing school work). It turned out I had to battle a monster cockroach before settling in, but I did sleep.

Won't Come Out

I arrived at the hospital today and was handed a chart. "8cm, you want to do this one?" OK, I shrugged. A couple of hours later she was fully dilated, and then she refused to push. She didn't say "no" or stomp her feet, she just...didn't do it. We cajoled and talked and changed positions and threatened and finally she settled in to heavily guided pushing. At the 2 hour mark, with contractions 7 minutes apart, we began pitocin augmentation. No progress. At 3 hours, we informed on-call obstetrician, the same woman that paid us little attention yesterday. We fared slightly better today, although she still did a shitty job of informing the woman of her plans. Baby was high, not managing to make his way past the pubic bone, despite the now-effective pushing efforts. We suspected acynclitism and so did the OB. She made the odd decision to try a vacuum (too high! ack!) and then, after three failed attempts, the forceps...I'm not sure what she thought she was doing, but any idiot could see she was doing it wrong. The blades were positioned incorrectly, the handles wouldn't lock, and she kept asking the male midwife on staff to help her pull in an uncoordinated fashion. To do all of this, she cut a truly nasty episiotomy.

As this was going on, across the room, a woman delivered her stillborn baby. Her baby had been alive during the night shift; late decels were recorded, no response was made, and her baby was dead when the morning shift came on and checked in with her. It isn't certain that this baby's death was preventable, particularly with the long response time for the OR staff, but it is a definite possibility.

Back to the woman I'd been with most of the day. After all this traumatizing predictably-ineffective intervention, the decision for c-section was made. The episiotomy was repaired, which the OB accomplished skillfully (finally). The far-flung team was called and drivers were sent.

This poor woman also had a very strong urge to push, which she could not stop. She bore down despite the heavy swelling and the stitches. We monitored her baby intermittently, and he didn't seem to mind the pushing, so we encouraged her not to push but didn't go to any great lengths to stop her. We prepped her for her c-section, and waited. For over an hour. Her baby moved no lower during this time.

Her c-section, once begun, was fine. Her baby had a massively molded head and I truly don't think he was going to come out her vagina - there was no more molding to be done, his head now sweeping back from his face in dramatic form.

Despite the large number of women walking around the ward in various states of labor, we left after the c-section. We'd run right on through shift change and were feeling like we'd had quite enough for one day, thanks.

Another work day

Arrived at the hospital around 9:30am, and found a woman having recently been started on pitocin for augmentation (after spending all night at 4cm, and inexplicably having her water broken around midnight). We discovered that her second child had been a stillbirth after a cord prolapse, something that hung somewhat over this birth.

A female OB came in, did a very ungentle exam, and T may have talked her into giving this woman another few hours to let the pitocin work; we don't know whether that is true, because she didn't ever really talk to us despite us talking to her.

Meanwhile, T had managed to bring up the reused suctioning tubes at precisely the right time, which led to a review of appropriate indications for suctioning AND *hallelujah* the ordering of many disposable tubes so that the reuse would end.

Anyway, by a bit after 11am she was pushy, and by 11:42 she was "complete"...ok, actually, she was 9cm, but she had a strong urge to push, I thought the cervix would go away, and I lied to the other midwives there so that they wouldn't stop her pushing. Her cervix did indeed go away, she took a bit longer than expected to push out her baby, but eventually out came a very GDM-looking baby. Not just big - this baby was big by Ni-Van standards at 3.98kg, but was not technically macrosomic - it was about the proportions. Pull as I would, I could not get this darned kid's chest out. Poor kid was starting to cry less than halfway out, his mom had lost her pushing steam, and I pulled, then another midwife pulled (same results as when I pulled, so she stopped) and then T finally piped up with a "you HAVE to push your baby out now," and out he came.

Her postpartum went smoothly.

Boredom and cleaning.

In the waning half-hour of shift, a woman who had a c-section for twins 10 days before came in reporting bleeding and fainting. This woman's English is excellent, and we had a much easier than normal triage conversation, which revealed that she was indeed bleeding too much. The OB was called - a different one, but again, a very ungentle exam. He admitted her for observation overnight.

As I attempted to leave (seriously, I was picking up my backpack), a dad flagged me down for help with breastfeeding.

Still, we left only a little late.

To the market and back, ate in our room, watching and hating-but-not-enough-to-turn-it-off Australian TV.

A day off, and that #*&@(*&#$ partograph

On Wednesday we took the day off. We walked into town to get sandwiches to take to the beach, and went to the market. Someone who had been doing labor-support of some sort at the hospital for a relative was at the market. Shamefully, we had no idea what her name was, but she remembered us, shook our hands, and gave us a largish bunch of the itty-bitty bananas they have here. We also ran into one of the midwives there, and paused to take photos of us being not-at-work. It was fun to be recognized. Kicked the day off right.

We proceeded to spend the rest of the day reading in the shade on the beach, the prettiest day here so far. We went snorkeling a couple of times along the effortlessly-easy-to-access reef. And I had entirely too much fun swimming out to the floating thing and diving off. We didn't leave until 5pm, and nobody else was on the beach for a good portion of the afternoon - why, we didn't quite know. We didn't find a bus right away, so we walked to the main road. There, we caught a ride in a very-full bus with much happier than average drivers, listened to "Johnny Be Good" and other classics on the radio, bouncing along the road with the windows down, all packed into the bus. I was unnaturally happy with it all.

We did not go to the hospital on Wednesday.

On Thursday I arrived at 11am and found the hospital in relative disorganization (always somewhat disorganized, but usually in a "but I know where everything IS" fashion). Women were crammed in all manner of odd places. At 11, when the discharge routine is usually finishing up, they were just getting started. A student nurse was walking around in a fog, completely incapable of answering (yes we communicate fine, I've worked with him before) my questions about who was where and why the heck there was a postpartum mom in the store-room, and where on earth was I supposed to take this new admit and where was her chart?

It all got sorted out in the end, most of it by the time T showed up at 1. Women were in actual beds on the actual ward, babies were looked over and given their little blue cards and birth certificates, and things were calming down dramatically.

In this mess, the woman I'd thought I was admitting but in fact had been looked after previously and just not documented, was not dilating very well.

At 3, at shift change, a nurse named Viri who typically works evening shift in the NICU came on. I was roundly admonished for walking home on Tuesday. The hospital has truck drivers that will take you home, something that is not worth it for me because I am staying a whole 5 minute walk from the hospital and the truck often takes half an hour or more to catch. Apparently, Viri and the midwife were worried about me, and made the driver circle the block several times to see that I was home OK. "It was so dark! Didn't you hear the dogs? It's too late to be out!" I feel like the little family groupings sitting up and chatting in the areas I walk through make the lack of danger pretty clear. That, and the friendliness of the people I talk to there. The midwife and nurse, I think, are either living with a little bit of extra caution sunk in from the not-too-far distant past (about 20 years ago).

My admit - the one we were talking about, anyway, continued to dilate slowly through the day. At a little past 4pm, she was 7cm and well past that #*&$@(#*&$ "action" line on the partograph (there are two lines on the WHO partograph: the first, the "alert" line, is the 1cm per hour line, and passing over that just means you should pay some attention; the second, the "action" line, presumably means that should someone pass it, you should do something about it). She was not distressed, her baby was not distressed, we figured breaking her water would set things in motion. The very-senior-midwife on duty, however, took issue (vocally) with our plan, because apparently over here AROM is not "doing something," and chose to also initiate pitocin augmentation without waiting to see if the membrane rupture did the trick on its own.

She had her baby a little after 5pm without issues. Her first three babies had been boys, and she was extraordinarily happy to have a girl. She called for her partner enthusiastic about telling him they had a girl at last, but we couldn't find him. "He went out to walk," said another father who had been pacing the hall with his wife all afternoon. After unintentionally setting several other men in the area on the task of finding the new-again dad, we did a flurry of hospital chores, settled everyone in, and left at a respectable hour. Viri clapped my shoulder on the way out, and let me know that it was getting dark, I should hurry home, but I didn't need to wait for the truck at this hour. Good luck, good night...

Boyness2

Yesterday T and I went in to the ward to find it overflowing with pregnant ladies. We grabbed a multip that looked like she was rocking along and brought her to the labor ward for the admissions check, since admissions was full. She turned out to be 7, so we stayed there. Her labor had begun days previous, with up-all-night contractions slowing during the day, until this morning they accelerated.

And stayed there. We chatted between contractions. This was her second baby, her first had been born 9 years ago, a girl. She told me I was lucky to have my three children, since she had been trying to have another baby since her girl was 2 years old.

And T caught two babies and observed two more, while I stayed there. Unexpectedly, the hours rolled by. Contractions came and went, and progress - the measurable sort, anyhow - was not achieved, although I now suspect that there was dramatic baby-head molding going on beyond the reach of my fingers.

She told me she was exhausted, that she "got no moa powah." She told me she wanted to go "to the theater" (OR for a c-section), although she stopped telling me that after I told her that this hurt, but a c-section would hurt more, since this would be over when she had her baby but a c-section would keep hurting. She told me she needed to be cut last time, T told her that was on the outside and wouldn't help now, it was the inside that needed to open. Her contractions spaced to every 10 minutes, though still strong, and her cervix stubbornly held on to its last centimeter with a big 'ole swollen anterior lip, and after 3 hours of this we began some IV pitocin on a veeeery slow drip (this was a mildly agonizing decision for me to make, but her contractions were really not doing the trick and she really wanted to be done), which brought her contractions back up to once every 4 minutes or so. After laboring for a while on her back and side, the way women here usually do, she actually took my suggestion and got on hands and knees. Once freed, she followed her body to her feet, to a squat, to the floor, where she eventually began pushing spontaneously (finally) and delivered a very molded-headed baby over an intact perineum (right on past that episiotomy scar) while rocking between side-lying and flat on her back. She dropped promptly off to sleep once the placenta was delivered (in my paranoia I checked her blood pressure a tad more often than is common here, but she was actually just sleeping), still on the floor.



She named her baby boy after Boyness, because "your Boyness' mom was with my Boyness' mom when he was born."

Crappy Day (sensitive readers skip this post please)

Mid-week last week, a 16-almost-17 year old primip had gone for an ultrasound to evaluate size greater than expected for dates at 21 weeks, and was found to be carrying conjoined twins. Because the twins shared a heart, termination was recommended. After a not-very-informed discussion (this based not on being there, but on what the doctor told me about the plan), the family agreed that the pregnancy be terminated as soon as possible, which translated into misoprostol induction on Monday.

The misoprostol caught up to her finally this morning, and T and I were present when her babies delivered vaginally without issue, completely unresponsive and unmoving although with a heart beat. The babies made no attempt to survive. Their mother was relieved it was over. The family is taking the babies home to bury.

Not too much later in the day, we began the admissions process for a woman in labor at term with her third baby, and were unable to find heart tones. She reported last feeling movement early this morning. The ultrasonographer was on lunch and unreachable, so every person on the ward tried again, and again, for almost an hour, unsuccessfully. The mom reacted very little to this. By the time the ultrasound happened, the expected conclusion was fetal demise. The ultrasound confirmed a non-beating heart. The mom was still not reacting much to this news at all when we left, even laughing with the hospital billing person. This baby will be almost a pound larger than her other two, and as she was already in labor (although just 2cm), she will likely deliver her dead baby some time tonight.

Perhaps the only good part of our day was greeting the postpartum women whose babies we had caught yesterday and the day before.

I was amazed yet again at how much the women on the ward seem to enjoy having each other around. When the labor ward was full the other day, two of the immediate-postpartum moms wanted us to remove the separating curtains so that they could chat, which I found amusing. In the overheated, overcrowded "extension" room, where moms and babies stay if they need a bit longer for whatever reason - usually low birth weight - I've walked past to see groupings of moms talking, playing cards, nursing babies in a circle. I won't say it is ideal, just that the sharing of space doesn't feel as bad as I imagined it would.

We've seen a fair amount of the hospital and are concluding that the maternity ward is the highest volume spot but is in a state of furthest disrepair. It is also the hottest spot in the hospital, and this is not our imagining. It is shameful. The doctor that is the most motivated to make changes seems oddly focussed on crazy little things like the boards that are used for bandages maybe carrying staph bacteria (not a problem that has been encountered...) instead of things that are actually making people sick, like the inappropriate reuse of suctioning equipment. We are not here to fix anything, we are here to participate and to provide good care the way we know how. But it is hard to see things proceed in such a mal-coordinated fashion.

T and I both left early; T because she felt unwell, myself because it was just an hour until the end of shift and I was very hot and very done, and there were more people there than things to do already. I had taken to sanitizing all the surfaces in the delivery rooms (um, is this ever done? oh the disgusting things I found), but once all the handles, knobs, and cabinetry were done, I was about finished with scrubbing things with gauze.

We are back, in air conditioning (oh lovely air conditioning), being overheated and exhausted in our room.

Bored-and-not

Yesterday (Monday), T went in to the hospital a couple hours before I did, while I stayed behind and did some business-plan writing and blog-catching-upping. She admitted three women, and when I arrived, one had delivered, she was coaching the second - a primip who had been pushing for an hour already - to push in a variety of positions, and another woman was writhing in looks-like-ready-to-push condition across the way with nobody in attendance. I went out, found her chart, and did an exam; she was complete, and relieved to be "allowed" to push. She pushed for about 15 minutes, and then we had a 5 minute shoulder dystocia that I was completely alone for, with T across the hall just having caught the other baby, which began to cry as I began to move through maneuvers. What ran through my mind? A passage from Gabbe - "you must not pull desperately on the head." I find that somewhat random and not entirely helpful, but the maneuvers are so entrenched in my mind at this point that they were pretty automatic. Hip flexion, Rubins, posterior shoulder, sweeping for an arm...Woods Screw maneuver - pushing both shoulders simultaneously, in this case counter-clockwise, to find the spot where they would come through - worked, and out came a floppy baby with a blessedly acceptable heart rate. T came across the hall just as the baby was beginning to respond to my stimulation, to let me know she was available - I told her the baby was coming around, thanks, I'd call if I needed another pair of hands, since she was all of 15 feet away. Baby cried vigorously at 2 minutes after suctioning and further stim - at which point I lunged back at the bed to catch a placenta - and by 5 minutes was happily snuggling with her mom, who had uncharacteristically requested her baby be handed to her.

This episode was then followed by 6 hours of utter boredom. Two primips arrived, one at 3cm who was still at 3cm when I left, and another at 4cm who was at 5cm when I left, both of them laboring quietly and with the help of relatives. I sat and read, watched the midwife and nurse play computer games, chatted, and was in many similar ways completely sleepy and bored out of my mind.

10 minutes before the shift completed, we got an interesting phone call...they were sending someone down in labor. The catch here is that this woman hadn't known she was pregnant.

Apparently, after having her fourth child, she had begun depo provera and had been getting regular shots for 10 years, including during this pregnancy, uninterrupted. She continued to have monthly "cycling" with light spotting, which happened even during this pregnancy. At some point a few weeks previous, she had become suspicious of pregnancy because she had felt strong movement, but then her monthly bleeding occurred on time, and she concluded that something else must be wrong. She came in to the hospital in labor, still not totally sure what was going on and entirely unprepared to give birth or have a baby. We felt her belly and concluded that she was somewhere around 38 weeks, we couldn't know really but it seemed reasonable that she was at term.

She apologized to me throughout. For what, I'm not sure; maybe for not having prior care, maybe for not having her things with her, maybe for having another baby at all, maybe she was apologizing to herself and her baby by apologizing to me.

Her baby came quickly. Fifth baby, after all. Vigorous boy in a sludge of mec, looking 40-ish weeks old. Mom had through the swift (half an hour from admission and being told that yes, she was pregnant to having a baby) labor apparently managed to come to terms with the fact that she was having a baby. "Wun smol boy!" she repeated after us. After she'd delivered her placenta, she sat up in her bed, nursing and staring at her baby. "Gonna have a STORY to tell when I get home," she said.

I wandered home through the ever-so-dangerous (insert eye-rolling here) alley, through the usual chorus of "good night"s from the people living there, a bit past midnight, and sleep was not far behind.

Busy, Busy, Busy

Yesterday (Sunday), T left for an overnight to see the volcano at Tanna, and I left for what was supposed to be a swing-shift at the hospital from 10-6 but wound up being a bit longer.

I arrived to find the ward pretty quiet, a situation which changed dramatically over the next hour as we admitted 4 women, all of them primips and all but one of them hovering around 5cm. They labored into the afternoon; shift change happened at 3, leaving myself, one midwife, and one nurse on staff. At 4 a multip showed up at 5cm. Two of the primips were creeping their way slowly (for here) towards the finish line, and it looked like we were in for a bit of a rush. Another primip showed up fully dilated. Fortuitously, an advanced nursing student showed up at this time as well, and although he required the midwife's continual supervision (something she doesn't think I need...hahahahaha), he was another set of hands. We split up one per bed, with three women in the four-bed labor ward (which they typically like to have only two women in at a time).

The multip's contractions had spaced out to almost 10 minutes, and although she was eager to push, her cervix was a firm 8cm which didn't yield well during a push, so I discouraged it. Someone opened the door and pleaded tearfully for me to come check her relative who was "so much soa now, please you check?" Which I ran out and did between multip-mama's contractions, to find her at 6-7cm, which was only slight progress from her last check 3 hours previous.

The fully-dilated-on-arrival primip delivered first, which I observed while the student nurse and MW Tamanu did a four-handed catch.

The multip delivered next, as I held back a decent sized anterior lip of cervix; this birth I managed completely with the student nurse swooping in to give a shot of pitocin on my request, and MW Tamanu showing up to suction the baby for some random unexplained reason (breathing fine) about two minutes after the birth (ok not so random, since there was moderate mec, but this was a pretty nonsensical time to suction) - both of whom disappeared rapidly because they were still cleaning up from the first birth, while I was occupied with the mom's somewhat-larger-than-average blood loss and they were entirely uninterested in the matter. Her placenta came out fine, her blood loss ceased, her baby looked fine hanging out in the warmer, and another primip began to push.

MW Tamanu proposed that she monitor multip-mom and baby while I managed the next primip's birth. I had feared for this primip's perineum since I had checked her on admission, because of the difficulty admitting my fingers for the VE despite her good attempts to release tension and her apparent calmness about the exam. She had perhaps the best pushing control I have ever seen, and she breathed and slowly pushed her baby past an intact perineum with absolutely no issues whatsoever. Her placenta arrived just 3 minutes later. The entirety of her blood loss, I could have cupped in one hand.

All this she did less than 25 minutes after the first mom had delivered.

We got the babies their shots, registered the births, got the moms and babies sorted out and into their beds, and I left the MW and the student nurse to handle the remaining women, one of whom had been admitted with SROM and no labor and continued to have a non-labor, and the other who I had recently checked at 7cm looking no closer to delivering. I walked back to the room through the usual chorus of "goodnight"s from the village-in-a-city occupying the block adjacent to the hospital, and fell into bed at 10:30.