Firsts

The unfamiliar mini-bus taxi dropped me three long blocks past the hospital entrance. I turn tail and walk briskly towards the white towers with red crosses dotting the tops of them. There’s a disinterested secretary sitting behind a pane of glass.

“I’m an apprentice midwife,” the words catch on my tongue. Words Ciska told me to say to get up to the labor and delivery floor. They feel strange and exciting in my mouth, a half truth.

“4th floor, love,” the secretary replies, clearly disinterested in my newfound excitement at calling myself an apprentice midwife.

I burst loudly into the room and curse the heavy door. Rhoda is squatting on the bathroom floor, eyes wild, she meets my gaze and grunts in acknowledgement of my arrival. She closes her eyes and seconds later a deep moan bellows from the back of her throat. I am surprised and a little upset by the noise. I had seen a couple videos of births before, but had never been present at one. Rhoda was here, but not here. In between contractions she sunk to the floor, limbs completely slack. The only way we would know another one was coming was a flicker of eyelids before the gutteral groaning began again. Ciska nudged me down behind Rhoda’s back, instructed me to press on her hips during the height of the contraction.

The next one was different. A deep, “hughgggg” that came at the end of the moaning. Ciska immediately caught the change and she started bustling towards a small cart. My novice ears didn’t hear much difference so I was unsure why Ciska had suddenly left her post.

Rhoda reached back and grabbed me around my neck. “I’m not doing this anymore. I can’t,” she panted. I looked to Ciska to intervene. She was busy grabbing gloves and counting sterile towels with incredible calm. My brain ran in circles. What if I said the wrong thing? What if what I say is weird? “I know you can do it. You can do it.” was all I could squeak out before the next round of groans. I sigh. Ok, that wasn’t so bad.

I’m still caught up in the fact that I have no idea what I’m doing or seeing, really, when Rhoda hollers at me to push on her hips NOW. I’m snapped out of my self-conscious thoughts and return to to the physically demanding task of squatting with Rhoda and pressing with all my might against her hips for a full minute, every three minutes.

I look up and Ciska has near elbow-length gloves on. She’s smiling and holding her hands together in her lap. She sits on the cold tile and just watches. The next contraction involves screaming as well as moaning. I almost miss wiry dark hair pushing its way forward as my heart starts to race. I see an ear emerge as I peek over Rhoda’s shoulder. Suddenly there is a whole head floating between Rhoda’s legs. She reaches down in the pause between worlds.

“She’s almost here,” Ciska says calmly. She sits with her hands folded a minute more. “Ready?” she asks gently.

A smaller groan, a little wimper, and a great, “ahhhhhhhh” follow. Pink, squirmy limbs engulf Rhoda’s petite abdomen. I feel hot tears rise behind my eyes and one escapes before I can whisk it away.

“Birth time?” Ciska looks up at me. Shit. That was my job.

“Uh,” I glance up at the clock, stunned. “18:34.”

The dawn creeps in around the dark curtains and I check my phone. I see the text from my co-midwife from midnight the night before, “Admitting Sasha now, she’s 5 cm/90/-1, hopefully by morning I won’t need you!”

I text back, hopeful for that outcome, but expecting to hear otherwise. My phone buzzes a minute later.

“I haven’t gotten to sit down all night. She was 7 when I checked at 5, getting an epidural soon I think. It was a long night. I’ll need relief. Sorry.”

I lay in bed for a minute longer before breaking the news to my partner. I knew it was a possibility that I could get called in on an “off” day, but my heart feels heavy knowing I will soon be dashing our plans for a very needed escape to the woods. I glance at my watch: 0549. I burrow my way further into warm blankets and warm arms and get pulled in closer, an unconscious reflex. Just a couple more minutes, I tell myself. I want to enjoy this small moment of sweetness before jumping to action.

Quick coffee prep and a clif bar lands me on the road to the hospital. I meet my co-midwife by our lockers. She gives me report and I write, like I always have, everything I need to know on a quartered piece of printer paper. Every labor. Every birth. Every baby, written out on a pocket-sized card.

My co-midwife hands off care, we do quick hellos and goodbyes in Sasha’s room, and I settle in. She’s just gotten an epidural after a long night of a slowly moving labor. My job now is to get everyone to rest. I turn the lights down, turn the music down and slowly retreat out of the room.

We’re making progress after a good long nap, and by mid-afternoon begin pushing. I can feel that this baby just isn’t in a great position. We try side lying, we try the squat bar, we roll to one side then the other. I look up at Sasha’s eyes. She’s there but not there. I see how tired she’s getting. How much farther we have to go. I know we need a change of energy in the room so I step out to take care of myself. For the first time in hours I pee and grab half a stale donut from the nurses’ station. Chug some lukewarm coffee. Update one partner, then the other, “We’re getting there, going to be a while still.” Gentle, warm encouragement is returned to me by both, and I’m buoyed in that hard moment by unseen love and support.

I take several deep breaths and close my eyes while standing in the middle of the break room. I straighten by spine bit by bit, imagining a ribbon pulling it taught at either end. More deep breaths into my diaphragm. Humming as I breathe out each long breath. I bring myself back into the moment and open my eyes slowly. I smile because I realize how much my co-midwife has rubbed off on me with the perfect amount of woo.

I return to the room and pea soup green meconium-stained fluid is now trickling out onto the chux pad under Sasha’s bottom. Both the doula and I are excited, “One big push this contraction, Sasha, I think this baby has rotated,” I say as I turn one small light on. A deep grunt accompanies the end of this push and I can see a quarter inch of head staying visible between contractions. “Yes, yes, that’s it, that’s the push!” I start to pull my table around and reach for gloves.

“You give me three more like that next contraction and we’re going to have a baby,” I glance up at the clock. 17:30. We’ve almost hit the four hour mark of pushing. I feel such relief knowing that we’re truly almost at the end.

I reach for warm compresses and gather my instruments. I’ve done this hundreds, maybe almost a thousand times, but this time is a first. My first catch with the practice I have built from the ground up.

“You can reach down and feel her, she’s right there,” I encourage as we head into our last few contractions.

We have just another moment before more wrinkled scalp pushes its way through. I see a nose pop out followed by a chin. I pause, thinking of the moment, between two worlds, two realities. Being and not-being, mothering and not yet mothering.

My gloved hands grasp little shoulders and bring a fresh babe to waiting arms. There’s gurgled cries, and a quick release to nursery staff.

As I’m leaving, I give Sasha, her husband, and then her doula quick hugs. I have so missed hugging people I have cared for.

“Thank you so much,” Sasha says as I grab my fleece hanging on the coat hook.

“I did the easy part,” I chuckle, my favorite line since I was a student, “but you’re very welcome.”

I walk out to my car, sun still high in the almost-summer sky. I peel the red fleece I wear over my scrubs off, realizing it’s a bit too warm and my endorphins are a bit too high to be wearing several layers. My car starts with a grumble, music picking up exactly where I left it nearly twelve hours ago.

Ten years stands between these births. Ten years of transition from tender, tentative apprentice to confident, calm midwife.

I’m orienting a new grad to our practice now and see the excited glint in her eyes each morning. She’s taking in our world like a sponge, sopping up each little bit, no matter how onerous. I hear each day the new word: “midwife” fresh on her tongue; bright like summer berries.

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Down

I’m sitting at the nurses station staring at the electronic fetal monitoring, almost absent-mindedly. I’m writing my progress note, nearly finished. It’s a clean, easy note.

“S: Coping well, feeling more comfortable since epidural, supportive partner at the bedside

O: BP 116/74, T 98.2, P 88

Cervix: 5 cm/90%/-1

One small variable decel to the 90s, recovery to baseline variability and rate noted

A: G4P2, early labor, IOL for gestational hypertension, AROM for scant, clear fluid

P: Expectant management, anticipate spontaneous vaginal delivery”

I am about to hit submit as I watch the baby’s heart rate tumble to the 90s. 80s. 70s. 60s.

I am up and out of my chair charging down the hall. In the calmest voice I have I call out, “Can I have another set of hands in here?” I push the door open quickly and the pale blue curtain flutters dramatically in front of me before settling back against the wall.

We change positions, we keep as calm as we know how. Baby is unhappy in this position, can we roll to the other side? That’s the way, I know, it’s hard when your legs are numb.

“Do you want internals?” The voice comes from behind me and before I can even nod my ascent there are new instruments in my outstretched hands. Internal monitors help us watch a fetal heart rate more easily than relying on an external, ultrasound monitor. It’s attached with a little screw that twists right into a baby’s scalp. I show students how to place them by twisting it onto the peel of an orange. I try not to think about that too much as I turn the nob, feel the metal poke against my gloved hands and onto the baby’s head.

It takes me maybe 30 seconds to get it affixed, but those 30 seconds always feel like a lifetime. The “bleep–bleep–bleep–bleep” of the monitor shows that I’m attached correctly and I remove the guidewire. I hear, almost distantly, the charge nurse mutter, “great job,” as if my deft and quick actions in placing the monitor actually helped change the heart rate. It’s just there to give us an idea of what the actual heart rate is.

The baby’s heart tones slowly climb back up. I start breathing again, but my nervous system doesn’t get activated the way it used to. I just work the problem. I broke her water, is there a prolapsed cord? No. Ok, great, what’s our dilation? Still at six? Cool. We’re relatively remote from delivery. Let’s change positions again. Can we try hands and knees? Let’s run an amnioinfusion. Where is my back up physician? Clinic still? Let’s pull him out just in case. Is the OR ready to go?

I’m learning to live in the space of “nowhere to go but up.” Instead of fear, despair, panic, all there is to be done is to work the problem. I think about that baby’s heart rate. Did we know why it suddenly plummeted? Probably cord compression somewhere. When I was a new midwife in tense situations my heart would start to pound in my ears. I could feel the fight-or-flight coming on. I would make good decisions but always would end up buzzing by the end of it, adrenaline surging, brain a little foggy, taking hours to come down again.

Now? Now I surveille the problem, almost more annoyed than anything. I run through all my tried and true steps. Change positions. Fluids wide open. Turn off the pitocin. No, putting on an oxygen mask just makes us feel better, it doesn’t actually do anything, remember? Repeat as needed.

My back-up physician grumpily texts me “well, I’m here” after I tell him that we’re out of the woods–for now. I see him poke his head onto the labor deck, joke with him that I scared away the heart rate decelerations by calling him out of clinic. He sighs. Things like that used to get to me. Make me feel like I should have waited to call. Now, I live in the glorious space of “not giving a flying fuck.” I highly recommend it.

About 45 minutes later one of the nurses bursts into the call room. “Heart rate is down again.” I spin and jump out of my chair, not running, but my quick, short steps carry me to the labor room. I walk in to a room with low lights, the nurse handing me a packet of gloves and the sound of gutteral pushing.

“Let’s have a baby!” I proclaim. My exam reveals that all the cervix that had been holding this baby up has melted away and all I feel is smooth, round fetal head in between my fingers.

We have a couple quick pushes in the minutes that follow and there is suddenly a squishy new human that has just joined us. My favorite thing is walking new, non-gestational parents through cutting the umbilical cord. “It’s chewy, yep, keep going,” I coach as they fumble with the bandage scissors.

“You’re free into the world, little one,” I say to this wildly blinking, flailing, new creature that had caused me so much anxiety, fear, and grief just an hour before.

I sigh deeply, still sitting on the edge of the delivery bed, looking up at the new trio above me. Eventually, I quietly stand up, peel off my sterile gloves and wash my hands to my elbows in the sink. I find little speckles of blood almost up to my biceps at every birth. After cleaning and warm goodbyes I sneak out of the delivery room before returning to the rest of my day, no one able to tell from the outside the incredible depths, highs, and new beginnings I’ve just witnessed.

You’re free into the world, little one.

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Blank

The nurse catches me as I slip out of the delivery room and jams several empty lined pages in front of me. The pooled blood on the top of my clogs is still wet. I glance at my watch. 3:34 am.

“What are these?”

“Downtime forms, EPIC is down from 2-5, remember?”

Our charting system was down for updates, which often happen in the middle of the night when fewer people are using it.

My brain is exhausted from many hours of pushing and a long, complicated repair. The lines start floating in front of me as I hand write my delivery note. I feel naked. I am stripped away of all the pre-filled text and buttons to remind me what meds and orders I’ll sent my patient to the postpartum unit with.

In that moment I felt like my mind was drawing a blank. What was the exact dose for postpartum pitocin? Am I missing anything in my delivery note that I’ll have to transcribe into our online charting system in the morning?

I felt raw and vulnerable. As if suddenly all the facades that made me feel like I knew what I was doing were rapidly disintegrating around me. Me being a midwife in that moment meant that it was just me and my brain, putting pen to paper.

I am living daily with this feeling as we build up the structures and scaffolding that will be the basis for our new midwifery practice. Not only are we mostly putting pen to paper (in the form of google docs) to design every aspect of our care from practice guidelines to how to send labs, to who we consult with and about what conditions, but we’re also doing it while actually caring for patients.

There are many analogies that get thrown around the start-up world. One is “build the plane while you’re flying it.” The other that I feel deeply is the duck smoothly floating over the water but no one sees the wildly disorganized flippers paddling beneath the surface.

Each day the care we provide feels more and more real, one more brick, one more stone placed over our pattern. So much so that today, while talking to my co-midwife she said, “So, Ellie had a question about planning for her next pregnancy, can I run this by you?” A next pregnancy. I hadn’t even begun to think about the possibility that families would be having second, third, fourth babies with us.

It hasn’t been an easy year. I have learned things, almost against my will. How much glycine do I need to deactivate this ultrasound cleansing solution? How do I, the Queen of the Luddites, make a spreadsheet with conditional formatting? How do I build a clinic culture that is simultaneously homey, friendly, fiercely dedicated to evidence-based care? And how do I make that care seem effortless while figuring out how we fit into our broader, broken health care system? When you start in a void, each step towards filling the cup feels monumental.

I glance out the small window. It’s a blue bird day, rare for mid-February. I’m sitting at the edge of the delivery bed, gloved hands folded, as close as I get to prayer. We all have our little rituals. Mine is to gather my clamps, bulb suction, and scissors into the placenta bin in case a babe needs a quick release to the nursery staff. I ask for warm water. The warmth of the water feels strange against my gloved hands as I fully submerge a sterile cloth in it. My brain confuses the signals, can’t quite figure out that while my hand is deep in water, it is also somehow dry. I don’t know why my brain hasn’t gotten used to this sensation. I’ve done this now hundreds of times. We’re minutes away. I glance at the clock.

“We’ll have this baby before noon, I bet you.” My statement is returned with a focused nod and grunt.

The happy thump thump thumping of a heartbeat starts to slow, a signal that the penultimate contraction is coming. Seconds later a deep moan and the catching of a breath.

“Here we go, that’s the way, right into it.” It’s taken years of talking people through this moment to land on the right phrasing. I know that the words I say don’t matter, it’s the tone, the encouragement, the confidence. First shiny dark hair, then the tip of an ear. Little cheeks push their way through and we pause at the shoulders. A gorgeous thick cord is wrapped around a soft little neck and without a word I deftly pull it up and over. Gentle, gentle pressure down and a white little shoulder is visible now. I tuck my hands around both arms and follow the natural curve upwards, right to this new parent’s bare chest.

This new being that has just joined us is bare. Fresh. A tabula rasa–blank. And full of so much possibility.

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Dear Preceptor

The past few weeks we’ve been interviewing midwives to join our practice. A couple times we’ve had very intense and deep conversations about the hardest parts of midwifery. After a particularly long and hard day, capped with an interview that unearthed all of our traumas as midwives, my midwife colleague suggested we take a step back.

We all took a minute to ourselves, all of us deep in thought, remembering the traumas that we have witnessed, yes, but for me, my mind went to the trauma that was done unto me as a student. My midwifery education wasn’t all bad, but for nine months I was paired with one particular preceptor who did immense damage to my self-esteem and faith in midwifery as a whole.

I have tried, over the years, to remember my teachers who inspired me and celebrated my growth. I think of those first teachers, Ciska and Susan, often. They were the South African midwives who took me under their wing and lit a passion for midwifery and birth care within me. Christine, my first midwifery preceptor in the US whose ease with patients and passion for education reassured me I had chosen the right path.

But often, my mind strays to the midwife who betrayed me. Who took so much from me. And the faculty who I confided in and kept me in the site anyway. My story is unfortunately not uncommon. I have spent my career thus far trying to be the kindest, most encouraging preceptor I can, as if that can possibly undo the trauma I endured. I have thought often about reaching out to this midwife, but know that this wouldn’t actually heal my trauma. My therapist recommended writing a letter anyway, even if it’s just for me.

Dear Preceptor,

I came to you so green, full of equal parts passion and data. From the first moment we met, you made it clear precepting me was a chore. You told me over and over that my school should be paying her because of how irritating it is to have a student*.

I sat with a patient who got pregnant with an IUD in place. In one of the few moments you let me speak, I asked how she felt about the pregnancy and you quickly cut me off and said, “Of course she’s overjoyed! Babies are a blessing!” I knew instantly I couldn’t practice giving comprehensive options counseling with you. I also knew people who were unsure of their pregnancy plans were unsafe with you.

I asked no questions. It was made clear to me that there was no amount of data or studies that might convince you to practice in the current century. I had to hold two separate sets of information in my head at all times–what I was being taught was evidence based practice and what you would do.

I wish you would have left me alone for exams but you never would. A survivor of assault lay before me, and I was learning to practice affirming consent and anticipatory guidance. I slowly explained what she might experience during the exam, and I felt your hands push mine forward, before both she and I were ready and loudly proclaimed, “Just get it over with, it’s easier that way. Stop explaining, that makes it worse” and you went on to talk about your new shoes, or purse, or weekend plans. I can’t remember because I was chocking back tears.

So many births, you grabbed my gloved hands, hard. Pushed my fingers onto perineums and pressed. Hard. I recoiled. I hated the sensation and felt deep in my heart that running my hands over the perineum during pushing was not only an invasion on a sacred birthing body, but created more swelling and trauma to these delicate tissues.

I refused to do a pelvic exam on an anesthetized patient in the OR with one of your physician colleagues. You mocked me for it. You told me he would never take me seriously and that you now also doubted my desire to learn.

Each birth that beautiful quiet space was invaded with your incessant chatter, refusing to recognize the gravity of the birth room. Each birth, you told me that I didn’t know what I was doing. You refused to trust me, to let me lead, to try. You undermined me and told patients I was just a student and didn’t know what I was doing. You corrected me, harshly, in front of patients. You snatched instruments out of my hands. You never told me I had done a good job.

Each week in our clinical debrief class I cried. Some weeks I sobbed for the violence done to me. Some weeks I sobbed for the violence I saw done unto patients. Some weeks I sobbed for the violence I was instructed to transmit to patients. I asked over and over again to be removed from the site. I was told there was no other site available. One week, close to the end of a term I was told I was in danger of failing the course because I couldn’t “deal with the stresses of midwifery,” and that I should talk less because I was “scaring the other students.” Because I was so young and scared to push back I kept going. I should have refused to go back, damn the consequences. But it was not my job to protect myself from harm after asking so frequently for help.

Our last birth did the most damage to me. I dream about it sometimes. It was the birth of a patient that I saw for her first OB visit. Young and unsure herself, she was in labor several weeks early, alone, and scared. She pushed for hours. We were approaching the limit of what I knew was safe. You cut an episiotomy, but too early. I knew this wouldn’t fix the problem.

On my exam, I told you something felt off. Bone pressed against too much bone. You told me I didn’t know what I was doing. I saw the swelling on that babe’s head get worse and worse. Finally, a head emerged, and I saw something I had read about, but never seen. We call it “turtling.” It’s one of the first signs of a shoulder dystocia, a rare but terrifying emergency where the baby’s shoulder becomes impinged behind the pubic bone. After the head is out and a shoulder dystocia is identified we have mere minutes to get the baby out.

The birth room erupted in chaos. You screamed and screamed for the patient to push harder, the nurses also screaming, nothing coordinated, no one talking to one another. I heard the overhead page for the back up physician. The baby finally emerged. He was little, and clearly in distress. You pushed me out of the way and told me to go help with the resuscitation. I had done my neonatal resuscitation training, but had never seen one. All I remember is the baby’s wide unblinking eyes looking up at me like a scared fish.

There was no debrief. You yelled at the nurse for calling the physician. You told me that there is no way I would have ever gotten that baby out. I was weeks away from graduation.

The damage you did to me was permanent. The damage you did to your patients, also will be permanent. I wish for so many things, but I wish I could have stood up for myself. I wish I could have told you what I thought of what you were doing without risking my ability to continue my education. What we do, how we treat our students and those we care for is a huge responsibility and you failed us all. I wish I could know that you were no longer inflicting pain on other students or patients, but I looked up your license and it’s still active.

I have healed, over these last 8 years, and grown into a compassionate, thoughtful midwife and educator. But it was no thanks to you. I don’t know who hurt you so badly that you feel empowered to inflict such pain on others, but I don’t have to have empathy for my abuser. I have tried many times, but I don’t owe you that.

I have made it my career ambition to never see another midwifery student so injured as I was and I wish it wasn’t borne out of my experiences. Your voice will forever be in my head but now I can quiet it because I have the maturity and life experience to know how very wrong you were.

I have thrived despite you, not because of you and I will never forget it.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

*for the record I think preceptors or precepting institutions should be paid, it is vital and hard work that is primarily done by women. Institutions that train residents are given funding by the federal government, it should be the same for nurses and nurse practitioner students.

Dear students, if you are being abused by a preceptor, don’t give up if your faculty won’t listen. It shouldn’t be your job to stand up to your abusers, but if your worst option is sitting out a year, or waiting a quarter or two until you can find another site, I guarantee it will be worth it.

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Alone

When I was in college I dreaded being alone. Each night I found myself without plans, without my boyfriend or roommates I silently sulked at the world. I was the poster girl for “Everyone’s Hanging Out Without Me”

It has taken me well into my 31st year to enjoy, or even seek out solitude. The solitude that I enjoy though is a far cry from the forced separation from friends and family that we have all grown to expect. I travelled by myself for the first time last fall, brought on by a continuing education conference I wanted to go to, and a desire to try out being alone for an extended time.

I exited the plane into the middle of a warm fish tank. The humidity instantly soaked my skin and forced my waist-length curls to stick to my shoulders and neck. I had chosen the Big Island of Hawai’i as my first solo adventure, her moon-like appearance the exact opposite from my lush Pacific Northwest home.

While travelling alone for nearly two weeks I settled into a happy rhythm. I woke to the still-cool breeze floating through my open windows, curtains fluttering and filling like sails. I read voraciously, unlike I have since I was a book-hungry teenager devouring texts as soon as I laid my hands upon them. Kona-grown coffee and freedom to do what I willed filled me with a buzz I have rarely experienced. I talked to myself, and strangers, often. I was assertive with my time, adventuring out to as many parts of the island I could get to. There was no one else there at the end of the day to decide if I had made my time worth it but me.

Then there are the unhappy alone times. The times when it seems as if the morning will never come, the strip has looked bad for hours, but not bad enough. Not good enough either. Worry and despair and exhaustion fill you in those dark alone times. Self-doubt, anxiety, imposter syndrome creep into the tired recesses of your brain. You’re never truly alone but the weight of decisions, the feeling in the room all relies on your skill. Your skill to appropriately calm those who need calming or to subtly raise the hairs on the backs of the necks of those who might need more prompting that things are not all right.

All you have to rely on is your own instincts. At the deep, dark, end of the day, I can honestly say that my gut has never been wrong. Have I always listened to that gnawing feeling, that intuition which acts as my own internal compass? The times I haven’t I often come to regret it.

Is it easier to “go with the flow” and be reassured by things that shouldn’t be reassuring? Easier to watch the boat sail into choppy waters without raising a red flag, and risk being seen as the one being overly cautious or alarmist?

My last three months have been filled with wondering if the loneliness I feel is the right kind. The good, warm, sunshine soaked, self-directed alone or the terror of the dark night that doesn’t seem to end. Most of the time it has felt like a combination of the two. I knew prior to starting this new job, literally building up a clinic and midwifery team from swatches and threads, that it would be a challenge. I knew I would be pushed in ways I hadn’t yet experienced. I worried that now was not the time but feared that if I didn’t take this leap, this well-supported, encouraged leap, that I would always regret recoiling into safety.

I have been given the opportunity of a lifetime but many days feel crushed and terrified by the imposter syndrome living within that the day is soon coming where it is discovered that the Empress has no clothes. What lies ahead feels so big, so full of more growing pains but, pain, like in labor, that has a meaning, has a beauty and an instinct and a primal drive behind it.

I’ve been learning a new language and drinking from a fire hose and building a plane as its flying and telling myself I’m having type 2 fun. It’s been so easy to get bogged down in the weeds–how are we going to get sinks? Why is our electronic medical record not letting me send prescriptions? Why am I in so many god damned meetings?

It’s easy to drown. It’s easy to shrink away, to let the loneliness, the aloneness eat you up. But what the aloneness is making me do is lean hard on the support of midwives and doctors (ok, just the one doctor at my job, we all love you, Kate <3) that I trust implicitly. Being alone makes you strip down to brass tacks, sharpens and hones what is actually important and worth fighting for, worth raising the red flags for. Helps in determining what requires calling in the cavalry and the subtlety of compromise and building trust and teamwork.

I recently started re-reading The Martian, a nerdy deep dive into what it would take to get a single man off the surface of Mars and safely back to Earth. Our Martian was alone, but even in his aloneness, he had the whole world rooting for him and problem solving with him.

A few weeks ago I was talking out my fears, my loneliness, my trepidations with my mom as I walked down by Lake Washington. As the small waves lapped up on the retaining walls I recounted all the things that could go wrong, all the reasons why I shouldn’t be doing what I’m doing, all the stress and fear and everything that I was holding.

But.

But what will happen if things go well? What if it works out, my wise mother asked me.

Well, I sheepishly state, in that case, in that case….I slip my sandals off and let my toes dive into surprisingly warm waters, in that case, we change the world.

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Midwifing During a Pandemic

I don’t know how to start writing about this. I don’t know how to not write about it anymore.

I think back to February. Patients start bringing their concerns to me about this new virus. I brush it off and tell them the most important thing they can do is get their flu shot because that will be a far greater risk to them.

I am in denial

I see the headlines changing daily. Life continues as normal here. I have a birthday party on Leap Day.  The city is shut down two weeks later

Some days I can hardly process the whip-lash we all experienced in those early days. Wear a mask, it’s important.

Don’t wear a mask, no one wears them right, it’ll hurt more than it will help

My patients see their world closing in around them. Clutching their growing abdomens they ask what birth will be like. I tell them I can’t predict what the world will hold for us in 24 hours, let alone 24 weeks.

I get in trouble at work for sending out a mass e-mail saying we shouldn’t be seeing routine visits right now, as my anxiety begins to skyrocket about my own risk. Through the end of March my clinic operations look startlingly normal. A relic, now from the before-times.

We get a department-wide email the next day to reschedule all non-essential visits.

We are finally allowed to wear masks in clinic. We re-use the same mask all day, going against every infection control protocol I have ever studied. I am issued one N95. For emergencies.

My every day life feels more and more like an emergency

Internally I am battling my own anxiety, dealing with my own, completely unrelated heartbreak. I am the duck sitting on top of the water. Moving calmly but feet thrashing and uncoordinated below the water line.

My role now turns more to therapist than midwife. But no longer can I give reassuring touch. No hugs. No “everything is a season, everything will change.”

We are hurtling towards the unknown. What does living through a collective trauma look like? Is this it?

We soon get the answer. Black-led uprisings erupt in every city. THIS is what living through collective trauma looks like. It has been happening for 400 years but now white people are paying attention. These two pandemics, each with their own cause, are pointing out all the weaknesses in our world

How do we build a better world, how do we hold on to hope that these twin pandemics can ever be overcome in a country built on inequality?

Everyone talks only about the pandemic. We cannot look away. We cannot even think about a world where this virus doesn’t run our daily lives.

We bake our sourdough breads, we cross stitch, we wait out the apocalypse while tending our plants and our children and hope that our sacrifice will be worth it. Some cope better than others, but we try to stay connected, try to re-invent the happy hour, now over zoom.  We wave and pretend. This is fine.

My ability to cope has gone up and down, rising and falling, almost tide-like. Some hope and optimism for a few days, a week if I’m lucky. Then something hits. Fresh rounds of outbreaks, more police violence, hell, even a plant that isn’t doing so well.

I become jealous of the insects stuck in amber. They simply become frozen.

I feel this tide rise and fall among the people I care for. Some make jokes. Many are now unemployed and teary in my office. Most feel on the edge of sanity but can’t quite put a finger on it. Of course you are, I say. I have to be the one holding it together. I can’t use the own tissues in my exam rooms. You’re doing the best you can. This is a normal reaction to extreme stress. I repeat as needed, 10-15 times a day with each new set of eyes, the only part of my patient that I can see and connect with.

Do I take my own advice? Of course not. What midwife is good at listening to the words she tells others and applying them to her own life?

Who midwifes the midwives through this?

We feel lucky to not be on the front lines caring for COVID patients, but guilty that our skills don’t translate to being helpful if we were called upon.

Instead, we deal with fear. We try to reassure the best we can under normal circumstances, but how do you comfort a soon-to-be-parent that they won’t be separated from their baby, when they might? How do you comfort a laboring person, who has to let their instincts take over but they can’t quiet their fear?

How do we quiet our own fear? I feel numb most days. Sardonic. Sarcastic. My voice weary when I mean it to be confident, strong, reassuring. But of what can I assure people? That I am also only human? That I wish they had consented to a virtual visit because each successive person I see puts me at higher risk?

My fuse is short. All our fuses have been shortened, so much taken away, so little to help cope. I started writing today to be a voice of ease, calm,  to say, your midwives love you and care for you. We are here for you.

Some days I feel like I can barely be there for myself. And that is what’s raw and honest and true. Some days I feel stuck in caring. Trying so desperately hard to care at the same level I always have. But now this is a struggle, and it feels ugly and hard and like the empathetic centers of my mind are betraying me.

Most days I want to shout, I am trying. We are all trying. No one expected the apocalypse this year. No one figured that so many aspects of normal life would have to continue while we contend with this world-changing event. But, as always, people get pregnant. People have babies. People need abortions, and your midwives, we’re here.

We love you and care for you.

 

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And Now For Something Completely Different: High Pass Challenge Reflections

I usually spend most of my time here writing about my midwifing and occasionally my parenting, relationships, and biking, but mostly in relation to my life as a midwife. Recently, I did a wild and crazy thing that I think probably deserves some reflection all on its own.

This winter I broke my elbow on my bike while commuting to work and it was probably the scariest, most painful thing I have ever experienced. I didn’t really know how I’d feel getting back on my bike and was unsure if I would ever want to ride again. I healed, slowly but surely, and have a large, angry red scar over my right elbow that will always remind me not to take icy corners too fast.

Coming into the spring I felt so grateful to have healed and to have use of my body in ways that I hadn’t for the past four months. I had been a pretty serious rider when I was in grad school and fell in love with the city and its surrounding hills and paths and waterways by bike. After I started my first full time midwife job I was spending long hours commuting by car and my long 30-60 mile weekend rides were becoming a distant memory. I’d still ride around town, out to meet friends, but my bike became more a method of conveyance instead of a tool for me to be an athlete.

Getting pregnant and staring down hyperemesis put an almost immediate stop to my bike riding for several months. Also, because of my aggressively framed racing bike I had to stop riding altogether around 24 weeks. After baby E’s birth I struggled to love my postpartum body and instead of feeling strong and healthy, I felt squishy and exhausted.

As a plan to help stave off some winter blues, my therapist encouraged me to get some good rain gear and commute through the winter for the first time. I’ve never been a fair-weather rider and am not scared to get soggy, but commuting through a cold, dark winter seemed daunting.

The day I fell was sunny and bright, but brutally cold. My legs were warmed up, I was about 2/3 of the way to work, and coming around a corner I felt my whole bike come out from under me. The next instant felt hot, searing pain radiate from my shoulder down. I heard my helmet crack against the pavement, instantly grateful I was wearing it.

The rest of that day remains incredibly sharp, but it’s the proceeding weeks following surgery, physical therapy, and near-endless boredom that are fuzzy for me. I didn’t think much about my bike during those months but the day my surgeon and I had our last post-op visit he asked if I’d gotten back on yet. It hadn’t occurred to me to do so, but that very next day I rode around town slowly and cautiously to run some errands.

Quick rides turned into commutes, then I really got a bee in my bonnet. I was so grateful to be healed, to have use of my body, and wanted to feel strong and fast again. I set a goal of riding a 47 mile route in June, and instead rode the 67 mile loop. It was a lot of climbing, and at the end I wished I had hopped on the Century (100 mile) loop instead. I started making plans to ride a century of my own this summer, and then found The High Pass Challenge.

The High Pass Challenge is a 104 mile out and back ride with roughly 7,500 feet of climbing that starts in Packwood, WA and heads up to the Mount St. Helens blast zone. It’s a rigorous ride, and I wasn’t sure I was physically capable of completing it.

The morning of the ride was cool and foggy. I woke up and stared out of the sunroof of my partner’s car we had camped in the night before. I was really going to do this, whether I felt ready or not.

I rushed to pack my jersey full of snacks, had a last minute worry that my tires weren’t full enough, and the start line bell blasted. We were off!

The first 15 miles were flat to slightly downhill. It was 7 a.m. on a Monday, so traffic was light and the fog gave us a nice cover to warm up our legs. I passed lots of farmland, and off to the east I watched as a giant heard of elk run in an undulating block. I rode briskly but not too fast. I didn’t know yet what was ahead of me, and I wanted to take in these easy, beautiful miles before the big climbs started.

After turning off the main highway, I hit some rolling hills and had my first climb of the day. It was short, about a mile and a half, but steep. Right after that climb, I returned to more rolling hills and felt like my pace was on track to land me at the peak at a pretty impressive time.

I rolled into the first stop, which is at 25 miles, feeling warmed up, strong, and like I was about to totally crush the rest of the course. I’d covered the first 25 miles by about 8:45, so a little under two hours of riding.

I took off from the first stop feeling happy and healthy and strong. I fell into a groove climbing and hit the first long uphill. I pedaled under the thick forested cover and weaved up and up and up the switchbacks. It was a steady climb, but the grade was shallow. I was working hard, but wasn’t exhausted by the climbing. I rode mostly by myself, passing and getting passed by the same folks a few times. We exchanged pleasantries but mostly kept our heads down, focused on the work in front of us.

Eleven miles of almost straight climbing took me about an hour and a half. By the time I reached the water stop at mile 36, I felt simultaneously so close to the end, and so far. I was still in relatively good spirits leaving the mile 36 aid station, but I wasn’t prepared for what I met on the other side. Four punishing miles of climbing at varying steep grades (between 5-8% grade) wore me down. Even more demoralizing was seeing every single mile marker as I was reminded of exactly how slow I was climbing. I started getting physically uncomfortable and at that point had a very difficult time getting out of my head.

I stopped at the mile four marker coming out of the station (roughly mile 40) and had a few minutes of panicked breathing. How much more climbing did I have? How much more could I take? Could I make it if the next 12 miles were like this?

I talked myself back on my bike, and was rewarded with having almost completed all of the major straight-up climbing. The rest of the 12 miles were still extremely steep, and I covered about 1500 more feet of climbing but at least it was rolling and there was some variation.

I came around a big turn and suddenly I was in the blast zone. All the trees were barren and I could see clear across the big canyons and up to Mount St. Helens. I had never seen it before, and it was amazing to think of all the damage that was done if the area still looked like the moon 40 years later.

I started seeing more riders come back down and many waved or encouraged me onward. I screamed past a sign on a big swooping downhill that showed me seven more miles to go. Seven. That’s like, one and a half commutes. Almost there, almost there.

As I came down the last hill, I powered up to the clock. “Bib 77 in at 5:19!”

I hopped off my bike and walked in little circles. I should have felt more relief, but the last twelve miles showed me that instead of 52 hard miles of climbing followed by 52 mile descent, I actually had about 65 hard miles of riding and about 20 downhill followed by rolling hills to the finish.

Because of this realization, I didn’t take much time at the top. I grabbed a snack, refilled my bottles and headed back out of the valley. My legs were tired and my neck ached. The blast zone was completely uncovered, so the heat started to get to me. By the time I turned the corner to head down a several-mile descent I couldn’t feel my legs burning anymore. All they felt like were achy logs, ceaselessly moving up and down.

I stopped at the first aide station 25 miles out from the start and started to come undone. I was so tired and I just wanted it to be over. I wanted to call it, hop in a car, and let my tired body have a break.

The last covered miles of forest were more rolling hills than I had remembered, which made me angry at myself for not paying more attention on the way in. I finally made it back out to the main highway and knew I had 15 miles of slightly uphill riding to do. Gone was the gentle fog, and now the sun was beating down and the highway was busy with logging trucks and RVs. My feet were so numb they hurt, and I had to stop several times to just shake some feeling back into them. I thought of my partner at the end of the race, knowing he’d be there waiting and so proud. Thinking of my support team and loving friends and family at home, I knew I had to keep going. Almost there, almost there, almost there became my mantra.

The finish snuck up on me, and all of a sudden I saw the big green tents. I pedaled down over the grass and drank it in. My body had worked so hard and it didn’t let me down. I looked around at the other tired cyclists and supporters. It felt surreal. It was simultaneously harder and just as hard as I thought it would be. My final finish time was about 4:40 p.m., just under the 10 hour cut off.

It’s been a week now since hopping off my bike at the end of those 104 miles and now I’m not sure what I’ll do next. At first I felt like, “I’m never doing a race like that ever again,” and then by mid-week started having dreams of riding up Snoqualmie Pass on the John Wayne trail, joining my local Rondeneuring group, and, of course, someday completing the historic Paris-Brest-Paris 1200 km race that is the pinnacle of racing for long-distance riders.

We’ll see what the rest of this summer and fall hold for my riding, but thanks for following along on my crazy journey and encouraging me and telling me I’m nuts, and telling me to get on my bike anyway.

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On Being a Bi/Queer Midwife

“When you become sexually active, do you think your partners will be men, women, or both?”

The shy teenager shrinks down in her chair a little farther, scared to make eye contact with me, but manages to squeak out, “I think….maybe….both”

A huge grin hits my face and I (at the total dismay of this teenager who would like to be doing literally anything else in the world) launch into my spiel about safer, pleasure-based sex with men, women, and people of all genders. It’s not 20 seconds until I’m drawing a diagram of how to make a dental dam out of a condom and my patient looks simultaneously horrified and intrigued.

I talk to so many people about how to have better sex every day, their identities, and some of the most intimate details that someone could know about a person and I feel so humbled and honored to be a part of my patients’ lives in that way.

I have written about so many parts of who I am as a midwife over the years, and, although I’m a little late for this to be a Pride-related blog entry, I figured it was high time for me to write about being a bi midwife.

Its difficult to be out at work, and as most bi folks know, no matter who our partners are, our identity tends to be erased. I wish I couldn’t recount the number of times I have had to tell people, “nope, still bi even though I’m married to dude!” And even though it’s difficult to explain to my co-workers, I still have a Pride flag that sits in my pen-holder and a big button that says “total Bi visibility” on my corkboard along with all my guidelines and resources I use on a daily basis.

But what about being out with my patients? I have always struggled for the best way to do this, without also divulging information that might make the visit seem like it’s about me or my identity. I know lots of bisexual, queer and gay providers struggle with this, and luckily over the years, most of us become known as “the queer NP” as word travels through the community that we are safe and competent and understanding health care providers.

One of the more visible things that is deeply a part of how I present my identity is that I don’t shave my armpits or my legs, and hope that this acts as a small signal to my queer patients that their health and identities are safe and respected in my hands. I try to use language like, “we,” when explaining concepts, like, “when we are dating men bacterial vaginosis isn’t considered a sexually transmitted infection and I wouldn’t treat you both, but when we’re dating women/vagina owners, I would treat you both.”

When taking a sexual history I always ask if my patients are sexually active with men, women, or both/all genders, even though there’s a check box on the history form. So many times the answer I receive after building rapport with someone and ask in a non-judgmental, kind way changes from what’s on the form. This was the case especially when I was seeing men at Planned Parenthood due to the increased shame around men having sex with other men.

In midwifery school our education about queer health was laughable. We had one lecture for our whole cohort essentially giving the basics of language and how not to be or act like a bigotted asshole to your patients. What we really needed was a whole course on how to talk about sexuality, pleasure and consent-focused sex, and the different health needs of men who have sex with men and women who have sex with women. Instead, I was left woefully underprepared for giving my patients the best sexual health education I could give when I entered practice.

As a queer midwife myself, who has so long felt like I don’t belong in the gay community because my partners have been (up until this point) primarily cis-men, I felt like I was failing my siblings by not knowing what I should. Luckily, my first job out of school was at Planned Parenthood where I got a crash course in just about everything I needed to know from increased risk factors to what everyone needed to be screened for and how often, Pre-Exposure Prophylaxis (PrEP) counseling and how to tell someone they have HIV.

Unfortunately, many folks view bi and queer people as the “most privileged” of the LGBT community because our sexualities are often hidden, but this actually makes us higher risk for things like depression, suicide and self-harm, drug and alcohol addiction. What that actually feels like is that we don’t belong in the gay or straight worlds, and both places tell us we don’t quite belong in either place.

I try to share as much of myself with my patients as possible (and professional!) insofar as it will help them with their journeys and struggles with depression, loss, parenting, and discovering and exploring their sexuality. It is my favorite thing in the world when I can hear a big exhale from a young queer patient when they know they don’t have to explain themselves to me. That I get it and I get them.

To all my queer, bi, and not quite straight friends, family, patients, coworkers, and fellow midwives, I see you and I know I am seen, and happy (belated) Pride to you all

 

 

 

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Our Bodies Our Doctors

A few weeks ago during the Seattle International Film Festival I had the absolute honor of seeing a film featuring some well-loved abortion docs that I know and deeply admire. Directed by Jan Haaken, the film follows four doctors in three different cities through their lives and work as parents, community members, partners, and abortion providers. Some of the doctors are OB/GYNs or family medicine physicians who travel to rural areas or cities across the South and Southwest. Some, like the physicians based in Seattle, do abortion work as their main day to day job and teach others to become abortion providers.

As the film unfolded, I saw an instrument prominently featured that I am learning to use for miscarriage management, and hopefully someday soon, for terminations: the MVA, or manual vacuum aspirator. It’s incredibly low tech and functions through a self-created vacuum. It essentially looks like a bulbous cylinder with a straw on the end.

Not only did the film feature this beautifully simple device, but it actually showed women having abortions. As someone who has seen hundreds of abortions performed I was struck at how much of my normal life was being seen by most people in the audience for the first time. Two of the docs, Sarah Prager and Deb Oyer, our two hometown heroes, talked about how small and relatively isolated the abortion provider world is. As I excitedly leaned over to my partner to tell them that the MVAs they were using in the procedure rooms were what I am learning to use I felt so strongly like my world was being seen and understood by a much broader layer of people.

The deep empathy and compassion that the abortion providers, nurses and clinic staff  showcased the world that I found my bearing in as a new midwife. There are lots of reassuring touches, hugs, and warmth. It transported me back to my first few weeks as a new grad midwife at Planned Parenthood. I was working out in a small clinic in Bremerton and did a now-seemingly insane combination of a bike/hour long ferry/bike commute to the clinic in whatever weather the Northwest winter would through at me.

I shadowed our medical director, Laurel, while she performed abortions. I wasn’t sure what to expect, but abortion care certainly didn’t look like what I thought it would. Laurel was confident, soft-spoken, sure, carefully and effortlessly moving back and forth between chatting about kids’ soccer schedules and what time the patient had to be at work the next day to letting her know what she might feel next.

Laurel didn’t shy away from being fully present with the folks who were struggling, always calmly and empathetically listening and nodding. I saw her ease and seriousness, occasionally mixed with little anecdotes and jokes and saw the kind of provider I hoped to someday be; the kind of provider I hope I’ve become.

The film also takes on an issue that I came far too familiar with as a midwife working at a Catholic Hospital. In Washington state, nearly half of hospital beds are in facilities with a religious affiliation, and not a small number of times I found my hands tied with what I could or couldn’t do for a patient because of the presence of a fetal heartbeat. Cienna Madrid wrote this excellent long-form piece about the creep of Catholic hospitals into Washington’s health care matrix in 2013 that’s always worth going back to.

While it was invigorating to be in a packed-out theater surrounded by friends, fellow abortion and reproductive health providers and abortion rights activists, I couldn’t ignore my nagging feeling that the film was leaving out the people who provide, numbers-wise, the majority of abortions in this country: nurse practitioners and nurse-midwives. The film was overall physician-centric, and didn’t acknowledge at all the huge role that we as advanced practice clinicians take in abortion care and advocacy.

I hate to complain too much about one of the only films in existence that showcase some true abortion heroes and advocates, especially because the Seattle-based physicians featured in the film are the ones helping me to expand my own skills so I can be a part of training other ARNPs to use manual vacuum aspirators.

It feels so fulfilling to see a film portray mostly women physicians as specialists in abortion care as the gentle, beautiful humans that I have come to know and look up to as mentors. There is a fear among older abortion providers, many of whom began providing abortion care in the years immediately after the passage of Roe v. Wade that there will be fewer and fewer providers choosing to become abortionists. This film shows dozens of eager med students involved in the national organization Med Students for Choice hanging on Sarah and Deb’s every word, and while most of them won’t become abortion providers, they’ll at least have the empathy to know who to refer to, and how to talk to their patients about their abortions.

For more information on the film, trailers, and more about the abortion docs featured in the film check out: https://ourbodiesourdoctors.com/

 

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Day of the Midwife

Today is International Day of the Midwife, and after a truly trying week I started reflecting on what this day means for me and my colleagues.

Much of the work we do as midwives is completely invisible and this international celebration of midwives brings to light who we are and what we do. It makes me feel connected to the long and beautiful history of all people who have helped women and pregnant people bring forth new life, acted as confidants and advisers as the wise women of their communities.

“We’re going back to the OR. Now.” I hear my voice get slow. Calmer and calmer as my heart starts to race. I’m not allowed to show my distress, not until later when I can have a few solitary moments of nausea, retroactive fear and the grounding ritual of slipping my wedding band back on after tearing off my face mask and surgical cap. I stare down at my booties, splattered in blood, amniotic fluid, and God knows what else. I hate nights like these, I think to myself.

Unfortunately on this night, I don’t have the luxury of wallowing in my occasional regret of choosing a profession with the infrequent instances of terror that punctuate my shifts. I move on to the next crisis, quickly scrubbing some blood off my shoe and hurtle down the half-way lit hallway.

We midwives are often the first to see women through crisis worldwide. We were sorely needed in the immediate aftermath of Hurricane Katrina. We are being called to the U.S.-Mexico border to help care for women and babies in one of the greatest refugee crises North America has seen. We’re on the shores of the Mediterranean ushering new life into the world amidst such turmoil and political upheaval and pain.

I burst into the room, parents terrified, nurses moving in every direction as I thrust my clammy hands into gloves. The slow dum-dum of a distressed baby’s heartbeat slowly returning to normal prompts me to let out a breath I didn’t know I was holding. There are tears, long discussions about risks and benefits. Everyone stumbling over words. It’s 4 a.m.

By the time I return to my call room to lay down for a few minutes and collect my thoughts before starting to write down the last several hours of the care I have provided the sky has turned the grey, dusky, pre-dawn glow that midwives everywhere know so well.

Lots of posts today about International Day of the Midwife are optimistic, warm, glowey and proud. I am all of those things, but as I also stare down the growing crisis of maternal mortality in my own country and the almost complete lack of progress in reducing maternal mortality world-wide I am ashamed to admit that I feel helpless and rootless. The vast majority of maternal deaths are completely preventable but because women everywhere are valued so little, and midwives valued so little along with them we’re barely scratching the surface of what can and needs to be done.

I try to bring to light the more invisible work of midwives everywhere. We catch babies, yes, but at least for me, that’s probably the smallest part of what I do. We’re primary care providers, abortionists, and experts in family planning and birth control. We’re experts in sex and sexuality, helping women and people through all the transitions of life: menarche, parenthood, menopause, and increasingly, midwives are branching out into death work.

So, dear midwife siblings, know that while the romantic notion of what we do is mostly being celebrated today, your darkest times, your hardest times are seen and known.

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