Today was a difficult clinic day. Particularly because of one patient’s difficult situation, of not wanting to be pregnant early in the pregnancy, but avoiding the issue and choosing the ignore the pregnancy instead. Now, into her third trimester, she was forced to reveal to family that she’s pregnant, and is realizing the effects of having taken drugs and undergone procedures without revealing to providers her pregnancy status. High risk pregnancy, more appointments, more surveillance, more experts to speak with. Termination is no longer an option, and she is overcome with emotion, with circumstance, and with what feels to her like a forced continued pregnancy and adoption circumstance. Both she and her mother were in the room crying when I walked in, and I found the strength to say out loud, “You are not alone in this. I am here with you.”
Below is a journal entry from my time during midwifery integration, or “residency” period. Today brought these stories back to mind. Apologies for the technical language.
I feel like I’ve entered a very strange world. This arena of urban healthcare, where there are lackadaisical approaches to patient safety, patient support, and patient care. This is a world where nurses pull out epidural catheters, residents don’t know what a Bishop’s score is or for what it’s used, there’s no attending on the floor for over 5 hours, and a postpartum patient with BPs in the 170s/110s isn’t seen for over 30min because the residents and the nurses are bickering over whether she should be put in triage or admitted. A world where the nurse brings in an anesthesiologist to talk to the patient about epidurals without informing the midwife that there’s a change in the patient’s pain. A world where when the patient changes her mind to not do an epidural, and then again in an hour to do it, the anesthesiologist yells at her for not doing it earlier, reprimanding her for being in pain and spiking up her blood pressure. A world where gloves and lube are difficult to find, even after looking in multiple patient rooms. A world where we counsel the patient on risks and benefits of amniotomy, the patient decides she’d like for us to break her bag, and the nurse says we can’t because there’s no scrub tech to take care of the baby for another 90min, so we have to wait in case there’s a precipitous delivery after we break the water. And by scrub tech, she means a person who will clean the baby and the floor after the birth. A world where we wait because of a role that others could fill if needed. A world where the midwife decides to not break the water because she’s making great progress, and when the scrub tech is available and the patient again asks for her water to be broken, the nurse yells at the student midwife for making her get the amnihook and then put it away. A world where the woman and baby in labor are the last thing on anyone’s mind.
This was the first labor I have ever attended with a doula present. After two doses of miso, the woman’s cervix had not made any progress. The midwives I was working with decided that a foley bulb was the next best step for her management plan. The woman wanted a labor without any pain medication, and was only slightly crampy with the miso. She was a stretchy one centimeter dilated when I started to put the foley catheter in, and it took a few minutes to finangle it past her external and then internal os, causing her significant discomfort. The doula was at the head of the bed, soothing her as she cried, holding her hand. This was the first experience I’ve had where I felt like I was an implementer, a worker of a system with which I disagreed. At 41wks and 2days being induced, clearly her body was not responding to doses of a medication which are meant to work with an existing body system already in progress. Watching the doula as I stretched her cervix and poked a rubber catheter under her baby’s head, I was disappointed in myself. Not able to find another way to help her. Not able to argue that we should just wait, since that wasn’t an option anyway given that she was already admitted and miso #2 was documented to not be working. I wanted to be the doula, wanted to be hating the system, but instead I was the system, I was the one inducing her, I was the one… She understood our plan, asked thoughtful and educated questions, the doula prompted a few more, and she agreed to the process. Part of the rationale for a non-expectant management was that there would be no midwifery coverage overnight, so the docs would be watching her, and this is something they wanted in their management plan. And the midwives, myself included, agreed. But it still didn’t feel quite right. Clearly her body wasn’t ready.
Thankfully she went on the have vaginal birth 12hrs later, healthy mom and healthy baby. But in that moment I didn’t like the midwife I was, the midwife I wanted to be. And I’m not quite sure why. Again, I provided the information, she agreed and consented. But I could see the situation through my eyes, where I truly believe in the process, I believe in the body’s abilities, and induction at 41 and 2 starts to (sort of) be indicated. And I saw myself through the eyes of the doula, who I wished I was in that moment. Easy to hate the midwife shoving the foley tube through. But I wasn’t the doula, I wasn’t the hippie midwife, I was the midwife implementing the medical plan, to which I had agreed with my nurse-midwife mind, discussed with my nurse-midwife education, and implemented with my nurse-midwife clinical skill. I’m thrilled that the labor resulted in a vaginal birth, and that mom and baby were healthy. Because a midwifery-initiated induction, that might have ended with a c-section, an induction about which I had emotional misgivings, would have been upsetting for me, and, more importantly, I’m sure for the mother. There must be other ways to do inductions that don’t make me feel like I’m doing something wrong, where protocols are still open for discussion, and where gaps in midwifery service doesn’t hinder the midwife process.
The birth I attended on Friday was beautiful. A 17-year old who knew what she wanted but was regularly influenced by her mother’s presence in the room, a mother who didn’t want her to have an epidural (leading her to use IV narcotics at first), a mother who laughed at her attempts at pushing, a mother who disparaged her attempts at breastfeeding. I’ve had mothers like that in the room before, and encouraged the woman to tell me what she wanted for pain medication, encouraged her to ask her mother to leave for the birth, which she eventually did and resulted in effective pain management and effective pushing. The nurses ridicule patients, telling them they’re not trying hard enough if they don’t push for a full ten-count, leave them alone for long periods of time in a room that facilitates loneliness, tied a bed, tied to cords, no intermittent auscultation available as an option because the nurses don’t know how to do it, no walking epidural option, no monitoring in the shower available and thus no showers as a comfort measure option.
I requested a hospital placement, and plan/planned to look for a midwifery practice that delivers-in hospital for a number of reasons. I plan to work internationally as a midwife at some point, and I have rationalized that learning all of the options available to women, practicing clinical approaches and medications in a fully-operating hospital in the United States will better educate me in how to negotiate lower-resource areas in the US and abroad. I think what I’m experiencing is an example of how the medical model of birth has really gone wrong. Where midwives storm into rooms assuming amniotomy and IUPC is the only way to ensure contractions can be measured properly. Where woman feel alone in birth. Where evidence exists externally, read for enjoyment but not practiced. I was lucky that the day was somewhat quiet and I could provide labor support, find ways to connect with the women and hopefully make them feel powerful and strong, to trust in their bodies and the process. Once voice in that system felt overwhelmed, but present. I long to know what the experience is like when the process is the starting point, midwifery care is loving and supported by other practitioners in the same building, to experience a beautiful birth not in bed and not with 12 cords attached to the woman like a sticky spiderweb keeping her within arms length of the medical model.
In my head I keep whispering to my labor patients: I am here with you, you are not alone.
I hope she heard me.