I am having a good week clinically, but for some reason just the sight of the snow in downtown Chicago recently brought this post to mind. I have also been reminded that the smallest detail can bring up a memory that I had no idea was so big. So, here’s to the big and small memories that we carry with us everywhere, and the brief stories of a few of my memories. Happy Thursday, y’all.
This past week was tough, and last night’s end to my shift on Labor and Birth felt like a culmination of difficulties that has my cup running dry.
I’ll admit that I have favorite patients, and three of my favorite prenatal patients had difficult weeks.
One had a very difficult birth, not understanding why she had an episiotomy for a baby that now feels so small. She had complications a few hours after delivery that made her immediate postpartum period anything but normal. She also does not understand why she is being sent home when the baby unexpectedly has to stay another day. When I see her postpartum, she is crying and has already worked her way through multiple boxes of tissues. She is trying so hard to breast feed and pump, with the baby separated from her for monitoring. She is very uncomfortable from the episiotomy and difficult inversion pains, but does not want to take medication because she wants “strong and healthy” breast milk. Her young boyfriend, angry over having to leave the baby in the hospital while they go home, is taking his frustration out on her, and her family is vocal with me about their dissatisfaction as well. She had her baby last week, I call her personally to set up a one week postpartum visit for support, and she did not show up to her clinic appointment.
One, recently married and excited about a quick pregnancy, has devastating news after a first ultrasound. She and her husband call me at the hospital after their appointment with my consulting physician, and are taking the weekend to decide what to do.
One, excited to try natural labor, to be up and walking as much as she can, tells me postpartum that she did not feel much pain, that she was confident in how well she was doing after she got to the hospital in active labor. She walked for many hours, and then the midwife told her it was time to break her water. Per culture at our hospital, she then was confined to the bed, unable to continue to walk around. She says she was not told that before having her water broken, and would have declined that intervention if she had known. We spent a lot of time prenatally talking about the benefit of being up and walking, to let gravity and her body guide the course, and she was proud of how she was doing. Now frustrated, she tells me, the day after, that her labor stopped once she was told she couldn’t walk anymore, and then they started the hormone to get her cervix changing again. Then the pains became too strong, and she opted for the epidural. When I walk into her postpartum room, the baby is on a pillow in the middle of the bed, unwrapped and squirming, and she is sitting in a chair a few feet away, looking at the baby distantly. She tells me that she is worried if she holds the baby too much, the baby will be fussy with other people. I sit down and spend time with her and the baby, giving her space to talk, assuring her she did a great job with her labor, telling her that babies need touch and need to be held, especially after being held close to her body during all those 40 weeks prior. I encourage her to follow her instincts with the baby, knowing that she wanted to follow her instincts all along but somehow couldn’t. Inside, I feel guilty for building up her desire for an up-and-active labor, frustrated knowing that I would have handled supporting her process differently, and angry at a culture slow to change.
I sit down with the nurses to talk about the belief around restricting the woman to bed after the water breaks. Each asks questions about the woman’s gestation, her dilation, and contraction pattern. With each question, I ask why it matters. Each nurse in turn says that regardless of gestation, dilation, or contraction, if their patients bag of water is broken, they have to stay in bed. A few months ago, a baby was born in the bathroom in triage, and everyone is on high alert for damage control. There is no protocol that a woman cannot walk after rupture, but it is a systemic practice, and the nurses verified that they teach it to all new nurses. I try to challenge this approach of fear, that baby’s don’t just fall out, and unmedicated women will be vocal when the baby is coming… All to no avail. They challenge me right back, saying that they aren’t in the room constantly and neither are the providers, and my reputation could be on the line in the community if a woman is displeased with her birth and if it I happened in the bathroom. I respond that I have a woman upstairs who is displeased with her birth in the bed. And then the conversation ends.
Thirty minutes before the end of my shift, a midwife patient comes to triage. Early in labor and with her water spontaneously ruptured, she will be staying. No midwife is scheduled for tonight, and her labor will be ascribed a management plan not dictated by her own body. I know this, and it is affirmed when I pass her care to the doctors at board report. I find myself saying out loud, to the nurses in triage, that this is not what I went to midwifery school for. And it’s not. But in many other ways, it is. This has to change.
The business model of the practice in which I work is changing, and with it is changing how midwives will relate with patients we see in the hospital. There is also a change in how many hours midwives are required to work, with clinic time and hospital time in competition. I returned to this site after rotating here as a student because of the uphill battle of midwifery in the hospital specifically, my belief in the importance of midwifery for the women in this community, and for the midwives themselves who have put so much work into the midwife practice here. I want to be at the hospital more, not less often, exactly for these reasons. Many things feel out of my control, and when I came here to feel like I could slowly make change, already feeling out of control is contributing to this week’s feelings of defeat.
This morning, I awake early to walk the dog. Opening the front door, the ground is covered in inches of snow. It is early enough that it is still silent: that heightened snow-silence that reminds me of how loud everything else has felt. And with a deep breath, and a few steps into the quietly crunching snow, I find myself working toward feeling renewed.
I made it an extra long walk.