Liminal: The State of Betwixt and Between

I was texting with a friend the other day about the state of being almost. Almost done but not quite. She compared it to being at mile 20 of a marathon. You’ve completed so much already and there’s only six miles left. But after 20 aching, limping, unending miles, those last 6 miles might as well be 100 for as far away as the finish line feels.

I use a lot of sports metaphors in my midwifery practice. During IUD insertions I tell women we’re rounding third base after measuring the uterus and there’s just one more step between them and solid birth control for 5-10 years. I tell women who are facing down transition, that state right before pushing their babies into the world, that we’re almost at the top of the mountain. I often use the marathon metaphor to describe pregnancy. I have never run a marathon, but I did bike from Seattle to San Francisco after completing midwifery school. Pregnancy feels about as close to the most physically and mentally demanding thing that I have done short of that nearly 1,000 mile bike ride.

Everything I have experienced in this pregnancy has been absolutely normal, and I feel so incredibly lucky to not have faced significant complications that many women I care for face. My job and ability to support my family has not been threatened by my pregnancy, no matter how much I have whined and complained about the nausea, hip pain, back pain, exhaustion, difficulty sleeping.

I have changed a lot of how I talk to the folks I care for over the past 9 months. I didn’t anticipate my own pregnancy changing my practice so much, but, just like pregnancy, you can’t know it until you’re in it. I feel more deeply, listen more closely, reassure more thoroughly, offer more hugs and grounding touches.

I haven’t written much throughout my pregnancy, and not because I haven’t had anything to say. It’s that there’s too much to say, and I cannot write about it in a public forum. Those who are closest to me know that through much of the spring I carried the weight of bearing witness to incredible traumas in my professional life, which severely impacted my ability to feel deeply the emotions of my own pregnancy, bond with our soon-to-be-born little one, and helped me to recognize that I was suffering from prenatal depression myself.

After a lot of talking with my partner, finding a great counselor, reconnecting with good friends from both within the midwifery world and without, and lots of tears, I am finally starting to feel ready to enter my own birth space while having released and processed the trauma I have seen these past few months.

Up until this week, I used to lightheartedly remind women at the 36 week mark that they should be physically and emotionally prepared to be pregnant for another month at least, possibly closer to 6 weeks. After a full night of crampy on-and-off-not-doing-anything-but-being-annoying contractions, and knowing that I myself, possibly am facing down that much more time of pregnancy, it no longer seems like something I could say lightheartedly. It’s actually possibly the worst thing that I could have been telling women all this time, at least, it feels like it to me.

I feel almost blank. A tabula rasa, only knowing what has lead me to this point and not knowing what lies beyond as I entering this time in between; not yet a parent and not quite not a parent. In anthropology, we refer to this time as being in a liminal state. In my pre-midwifery life, I studied anthropology and was a student of ritual, rites, and was especially interested in the process of social transformation.

Rituals all around the world generally involve three steps: first, separation, then liminality, and finally reintegration. In the separation stage, the initiate, or person undergoing the ritual is in some way separated or made different from his or her peers. The liminal state represents transition, and finally, the initiate is reintegrated into their society or social circle with their new status.

Liminality is a state that is marked by a lack of structure, and often thought of as a powerful or even dangerous time in a person’s life and always temporary. It is a state that is, as the anthropologist Turner described it in the 1960s, as “betwixt and between.”

There are a few other times in my life I have stood in a state of liminality: those first shaky breaths prior to beginning my first reading of the Torah at my Bat Mitzvah, standing under the chuppah at my wedding, and now I feel I have entered yet another intense state of liminality before the birth of our first child.

Bringing a baby into the world is one of the largest rites of passage that we experience as human beings, yet in our modern world, there is little ritual associated with not only the birth of a baby, but also with the birth of the mother. There is little space made for women and families not only to prepare physically, but also mentally for this new journey in life. There are many jokes made about “hormonal” pregnant women who will cry and laugh and act “crazy” at the end of their pregnancies. What I believe we are experiencing is the intense emotional and physical separation from our peers while we enter this liminal, dangerous, and unstructured time at the end of pregnancy but before parenthood. This is what I feel I must now convey to women. That they are feeling on the edge because they are. That this is normal, and that this stage of liminality is essential to their preparation for the next part of this journey.

When we rode our bikes out of the door of our too-tiny apartment and clamored onto the ferry to take us across the water to begin our bicycle journey three years ago, we had no idea what the journey would be like. I imagined that it would be hard, but I couldn’t anticipate the deep fear I felt of failure, the intense physical experience of climbing upwards and upwards, mile after mile, hoping we were strong enough to make it all the way down the coast. Half the time I wished we had never hatched up this insane plan to begin with.

But then the day came, warm and bright as we packed up camp for the last time. We serenely pedaled along the lagoons of Point Reyes Station, entered Marin county, and climbed the steep ramp to the Golden Gate Bridge. The wind made it impossible to hear our whoops and hollers of joy and I had never felt so triumphant.

The best metaphor I can think of for this pregnancy has been that bike trip, as strange as it sounds. At night I would lie of my sleeping bag, stare up at the orange interior of the tent that I had gotten to know all too well and picture what it would feel like to cross that bridge. It is what kept me pedaling through rain and dampness that didn’t go away for days. It’s what kept me pedaling after I had a breakdown on the side of a busy Oregon highway, declaring that I just couldn’t do it anymore.

Now, as I lie awake at night, little feet adorably jamming themselves into my ribs, I picture what this new little life will look like. Will they have my hazel eyes and olive skin? Will they have the bright blue eyes of my partner, his laugh and wide smile? What will it feel like to pull this baby onto my chest, triumphant, at the end of one incredible journey, my liminality ending, and integration into the world of motherhood beginning?

Just like all the women who have stood at this place before me, I don’t know what lies ahead, but having intimately watched the strength of birthing women for years, I can only trust in my body and this little body inside me to know what to do when we pedal up to the bridge.

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Baby Blues

I could feel myself backing up into the corner of the room as a newly postpartum family sat sprawled out on the bed talking with my mentor and sage midwife, Ciska. I was trying to shrink, make myself as small as possible; I was an alien observing the overwhelming and unfamiliar emotions flooding the room.

Everyone was crying. The new mother was sore, exhausted, milk just starting to come in. The new dad was gingerly holding his baby with the sweetness and unfamiliarity of not knowing exactly how to hold on to this squirming new creature. The baby was wailing and hated the scratchy velcro straps around her hips and legs, a common sling used to help rectify newborn hip dysplasia.

“Oh sweetie,” said Mom through tears, glancing over in my direction, “Everything’s fine. Just normal stuff.” I tried to tamper the surely wide-eyed, terrified look in my eyes and scooted a few feet closer. I watched with awe as Ciska skillfully and easily asked about aches and pains, breastfeeding, sleep deprivation, and navigating splitting baby care between the new parents. These parents were three days postpartum, right when the “baby blues” can really start to hit. Everyone’s exhausted, no one has slept in at least the last three or four days, and the reality of life with a new baby is starting to sink in.

Roughly 80% of new parents experience the Baby Blues, periods of feeling overwhelmed, completely out of your element, and having immense emotional highs and lows. Most of these feelings resolve by about the two week mark, but its when they don’t that we see the Baby Blues morph into postpartum depression or anxiety. All the studies we have tell us that we do a terrible job of taking care of postpartum families–medically, emotionally, socially.

Up to 20% of birthing parents experience postpartum depression, and roughly only 15% of those ever receive treatment. Most large practices see women for postpartum rounds at the hospital, which,  even in the best case, last about 15 minutes and are focused mostly on the birthing parent’s physical well-being. We then release new parents with their tiny cargo into the world until their six week visit with some loose guidelines on when to call and some big red flag warning signs.

I sat with a woman four weeks postpartum last week, other young children running around her ankles, pulling things out of drawers, her postpartum screening score (a tool with which we use to diagnose postpartum depression) through the roof. The lines under her eyes were almost as deep as the folds of the blanket surrounding her month-old infant.

“I don’t know about that, I really think I’m fine. I’m just tired, that’s all,” she kept insisting to me again and again. Her insurance doesn’t cover counseling. She isn’t open to using medication. Her support network lives on the other side of the country. I have a thirty minute visit to discuss the benefits and risks of starting medication and common misconceptions about postpartum depression, while also assessing her stitches,  discuss breastfeeding problems, bleeding, figure out a birth control method, conduct a full exam and a pap smear if she needs one.

We are letting our postpartum parents out of the plane without a parachute. Not to mention the sparse care we give to new parents, I often have patients calling my office for notes to go back to work 10 days, two weeks, three weeks after giving birth because we live in the only industrialized nation not to provide any paid parental leave to new parents. It almost seems like a cruel joke that we wonder why our postpartum depression rates are so high and our breastfeeding rates are so low when we, as a society, do absolutely nothing to support new families in one of the greatest transitions that they will experience.

I take all this in, hold it close, and think about what my own postpartum experience will be like. I have the incredible luxury of a partner who is willing, able, and excited to care for our baby once I go back to work.  I will be honest though. Most days I am completely terrified of missing out on my budding family’s life, the little milestones and small joys, and I think of the long days and nights I will spend with a breast pump instead of feeding my baby while I care for other people’s families.

So how do we fix this? Below is my Postpartum Wish List. Some of them feel pie-in-the-sky unrealistic, some would simply be expansions of current programs that I see offered to (or can be afforded by) some, but only those with means.

  1. Fully paid parental leave for the gestational parent and their partner (if they have one) like every other industrial nation (compare to other country’s policies here)
  2. Postpartum doula support for the first few weeks to help with laundry, cooking, cleaning, and errands
  3. In-home postpartum visits by a nurse or midwife at 3 days, 1-2 weeks, 3-4 weeks, and 6-8 weeks.
  4. Universal, free access to groups like PEPS (Program for Early Parent Support), which, according to their website is “a session of 12 weekly PEPS meetings brings parents together to share the joys and challenges of parenthood and develop confidence in their own abilities. PEPS stands apart from other new moms groups or dad groups by providing ongoing neighborhood-based resources and peer education, facilitated by trained volunteers. During one of the most vulnerable periods for new parents, PEPS provides immediate and accessible support, creating “extended families” that often last a lifetime.
  5. Single-payer insurance which would fully cover counseling services for parents needing counseling for either postpartum depression or anxiety or for the transition into parenthood.
  6. Once parents return to work, in-office, free childcare that can continue to nurture breastfeeding relationships and family bonding.
  7. Comprehensive sex-education, universally available and accessible contraception and abortion services to help ensure that every child is born to parents who are ready, willing, and able to care for them.

I imagine a world in which I get my wish list fulfilled and think of all the joyful, strong, and confident families I would see at my six week visits instead of so many where I feel as though I am sticking my finger in a dike.

Reproductive justice has many points it addresses, but encompassed in its definition is the full care of families when they do chose to have a child. We have yet to see paid parental leave and many of the other things on my wish-list emerge into reality, or even to be discussed in most spheres. So for now, I’ll keep dreaming, talking, and agitating for a world in which my wish-list is a reality.


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On the other side of the exam table

Well, the cat is out of the bag with our friends and family that I’m pregnant!

Half the reason the blog has been so quiet lately is that this pregnancy has been affecting every waking moment of my life, and if I were to write, I couldn’t not write about it. Even in this short time it has affected how I think about my profession and changed the way I practice and discuss things with the folks I care for.

From the day I found out we were pregnant, I began my long (and on-going road of) constant, daily nausea. I’m talking every-single-minute-of-every-single-day-and-even-when-I-wake-up-at-night kind of nausea. I write about this not to complain, or garner sympathy, but to underscore exactly how difficult pregnancy can be physically and emotionally. To be completely honest, I have been humbled at the feet of this great unknown in the past 11 weeks or so.

When I think about the way I used to think about or recommend remedies to the women I cared for, I think, “I would have slapped me If I had been my midwife. Just stay hydrated? Oh, have you tried ginger, and saltines before you get out of bed in the morning? Try eating small frequent meals. Try all of that first before we jump to the bigger guns of prescription medications.” Yeah.

None of these things has worked for me. None of these things tend to work for pregnant people who have severe, unrelenting nausea. Even zofran, which is a prescription medication that is given to chemotherapy patients, has not been helpful. I have had to step out of exam rooms, delivery rooms and operating rooms to try and control my nausea before re-entering.

I discuss these unpleasantries with such frankness because I know that what I am experiencing is normal and common. Close to 80% of pregnant people experience nausea and vomiting. What this knowledge has left me with is an unrelenting awe at the power and strength of pregnant and birthing people.

In some ways, I already felt this reverence and awe, but truly knowing the physical and emotional toll such illness can have has further increased that feeling. For the first time in my life, I can empathize with the people I am taking care of, not just sympathize.

Most people’s early pregnancy symptoms dissipate by 12-14 weeks of pregnancy, coincidentally when it is conventional for couples to share their good news. So what does this mean? That we, as a society, by convention, leave pregnant people to keep their suffering to themselves. Many pregnancy apps and blogs have “helpful pointers” on how to hide the fact that you’re not drinking or how to keep your needed trips to the bathroom at work concealed from the suspicion of co-workers and bosses.

Not only does that mean that we are leaving women to suffer in silence and without support, but it also means that we are leaving people to miscarry in silence and alone. Most miscarriages occur prior to 12 weeks of pregnancy, and this woman’s devastating tale of grief  and her thoughts of feminism following her miscarriage was deeply moving to me. She writes:

For us (in American culture), miscarriage is a solo and secretive happening. Women miscarry alone, isolated by the 12-week rule: Don’t announce your pregnancy until the second trimester. The thinking here is sensible. One in four pregnancies ends in miscarriage; most in the first three months. A woman who does not announce her early pregnancy will not have to announce its loss. She can move on in privacy, as if it never happened…

The more I considered it, the more I became convinced that the silence around miscarriage was connected to feminism’s work around abortion. How could I grieve a thing that didn’t exist? If a fetus is not meaningfully alive, if it is just a collection of cells – the cornerstone claim of the pro-choice movement – what does it mean to miscarry one? Admitting my grief meant seeing myself as a bereft mother, and my fetus as a dead child – which meant adopting exactly the language that the anti-choice movement uses to claim abortion is murder.

While the feminist circles that I run in definitely don’t take such a hard line that would leave people to believe that the grief people feel after miscarriages is unjustified because a “fetus is not a person,” I do believe that this author is scratching the surface of battles that are not often fought by the feminist movement.

This rough first trimester has made me an even more staunch advocate for reproductive justice and free abortion access than I ever was before. It has also made me deeply ponder the purgatory that couples who are facing fertility issues, or for whom a wanted pregnancy does not come quickly or easily experience. I know so many kind, wonderful people who have desired parenthood for a long time, and have had to try so hard, that it almost makes me feel guilty that this thing came so easily to us.

The beginning of this journey has also changed how I talk with people about their fears or lack of knowledge surrounding their own bodies or their pregnancies. I have always tried to convey empathy for those who are scared or who have seemingly infinite questions, but even through my best intentions I sometimes think to myself, “Can’t they google this?”

Being on the other side of this journey, being the one going through it has given me fresh eyes with with I view all the pregnant people I care for. I had one day of light spotting a few weeks ago and my heart raced and panic set in before I could remind myself that this was absolutely normal. I have found myself re-googling which fish are safe to eat and in what quantities, and I still worry when I forget a day or two of prenatal vitamins. I am awash constantly with these feelings, and I am the so-called expert on these things! In a world where so few people know the ins and outs of their own bodies, let alone what is normal or not normal for a pregnancy, I have tried to reset my mind. Hear my own, panicked voice on the other end of the phone.

So now I speak slower. I listen deeper. I make sure to ask how my patient is feeling and offer condolences, understanding, before the advice. Because sometimes everyone’s had enough of advice. Eat this. Don’t eat that. Have you tried this? What about that?

What about just listening? Just connecting with another human being who will take in your frustrations, all your fears and your feelings and has known them herself?

Midwife means “with woman,” which I have always loved, always held so dear to my practice. As I enter my third year of midwifing, I’m excited to experience the childbearing year along with the families I take care of and bring new meaning to being “with woman.”

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How I learned to get over my social anxiety and love group prenatal visits

One might ask, how is it possible to have social anxiety and work in a field where you are constantly meeting new people,asking them to tell you about the most intimate details of their lives, and form meaningful, trusting relationships in 15 minute visits?

Excellent question, dear readers. It has taken many years, lots of self-talk, and lots of practice.

There is a myth that seems to exist that those who go into the health professions and midwifery especially must inherently be outgoing and comfortable in social situations. Rewind to the night before my first midwifery clinicals:

I am sitting on my bed, rocking back and forth, terrified about being in a room alone with a patient come the next morning. I was a nervous wreck, envisioning myself stumbling over my words, unable to explain basic concepts, dreading forgetting to ask important questions because I was so nervous. But above all else, I was scared that my patients would see me as scared, awkward, and stupid.

Spoiler alert: midwifery students are often scared, awkward, and stupid. And they are supposed to be. They are full of knowledge and passion, but maybe haven’t figured out how to not slime themselves with ultrasound goo all day long. Instead of dreading this very reality, it took nearly the whole of my first year through school to stop comparing myself to people who have been practicing for years to embrace the awkwardness that comes with learning this profession.

Through school my biggest help was role play with classmates, practicing little shpeils in my car on the way to clinical, running scenarios in my head, and attempting to find ways to make myself comfortable so that I could make the women and the families that I cared for comfortable (hint: fake it ’till you make it is a real strategy).

There was no easy fix and I felt awkward (and still do sometimes) well into my first year of practice. Why do I tell this story? Because just as I was beginning to feel comfortable and competent after moving from the GYN world back to working in OB, I was asked to do something no one with social anxiety likes to do: facilitate group prenatal visits.

My practice recently began a Centering Prenatal Care program, as described from the CenteringPregnancy website:

 Centering is a multifaceted model of group care that integrates the three major components of care: health assessment, education, and support, into a unified program within a group setting. Eight to twelve women with similar gestational ages meet together, learning care skills, participating in a facilitated discussion, and developing a support network with other group members…

Through this unique model of care, women are empowered to choose health-promoting behaviors. Health outcomes for pregnancies, specifically increased birth weight and gestational age of mothers that deliver preterm, and the satisfaction expressed by both the women and their providers, support the effectiveness of this model for the delivery of care.

I first learned about Centering while still a student and loved the idea that prenatal care could not only be something that women engage in individually, but that provides for a social connection that is so often lost regarding pregnancy in our society. Gone are the days of elder mothers and grandmothers who guide us through this vulnerable time, leaving most women to feel like they are in a singular journey.

Not only did I love that prenatal care could occur in a group setting, the entire philosophy of this care is focused around the notion that instead of having the “Expert” (midwife or doctor) give all the answers to the questions of the “learner” (patient), this model recognized the diverse life experiences of women and their families. In Centering it is not my job to provide answers and make sure that the question gets answered in the most quick and correct way, but instead to elicit the knowledge and experience of the women that I am in the group with.

Furthermore, women take their own blood pressure, weigh themselves, keep their own shadow-chart so they can track their pregnancies. Not only does this de-mystify what we do on our end, but also gives women a greater sense of control and engagement in their care. It very much embraces the Montessori model of “teach me to do it for myself,” which is another philosophy that I have come to love.

The Centering model mirrors a radical pedagogy of education that I hold dear and that is put forward by the Marxist philosopher Vygostky. His theories are mostly related to child cognition and development, but profess that social interaction and culture are large parts of how people learn and also emphasizes a group, facilitation-style learning model. This is starkly different than the “banking” model of education, which assumes that knowledge can simply be explained by an expert and “banked” into the knowledge bank of the learner. If you’re feeling industrious, I definitely recommend reading this article on Vygotsky’s revolutionary theory of psychological development  

So, as we have established, in theory, I could not be more excited to participate in this model of care. In reality? I was nearly nauseous during the Centering facilitator training I did a few months back, envisioning awkward group conversations, groups spinning out of control, and yet again, ended up rocking back and forth on my bed basically trying to figure out how not to feel like this:


I have now had two group sessions using this new model. I can wholeheartedly say that, while mildly awkward the first night, the vibrance, excitement , and diversity of experience the women and families that are in my group bring far outstripped my fears.

In the first two nights I learned more about these women, their families, and their pregnancies than I often do after working with folks for the entirety of their pregnancies. Everyone laughs, brings food, and even though the folks in my group come from very different backgrounds, watching them bond over their shared experience brings me so much joy.

It is easy to see now why this model has so many positive outcomes, including fewer preterm births and higher breastfeeding initiation and continuation rates. My patients bring so much insight and excitement into each group that it is easy to see how women become more empowered and feel more in control of their own care and their pregnancies.

I’ll keep you all updated over the coming months working with this new model of care, but for now, this is how I’m feeling about our blossoming Centering practice:


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Taking a family history is a huge part of what I do as a midwife. Certain themes seem to run through families clearly; other far-flung and seemingly unrelated diseases and cancers lurk just under the surface. Most commonly I find strings of diabetes and heart disease, advise my patients to exercise regularly and follow up with their primary providers and move on.

“Any family history of breast, ovarian, colon, or pancreatic cancers on either side of your family?” This is often my lead-in question once I get a general lay of the land for a person’s overall family history. Most women can recall an aunt, a grandmother, a great-aunt with breast cancer. One in eight women will develop breast cancer over the course of her lifetime, most of it related to age and environmental exposures over time.

However, sometimes a person’s family history will be much clearer. Two aunts and a cousin with breast cancer. Mothers diagnosed in their 30’s. This is when we start to talk about the hereditary breast cancers, and the genes most commonly related to them, the BRCA-1 and BRCA-2 genes.

Less than 10% of all breast cancers are related to genetics, but those who have them are at close to a 79-90% lifetime risk of one of the related cancers, which, for women, is most often breast or ovarian cancer.

“Has anyone ever told you that you are most likely a candidate for genetic screening?” I always ask, because the topic is often an emotional one.

“You know, it’s a very personal decision to be tested or not.”

I know this because I have made this decision.

This is an extremely personal topic, but one I feel passionate about writing about because once you start looking for resources on whether or not to test, what the process is like, and what most people do, there is almost no information. The best information I could find was from the American Cancer Society, which bluntly lays out risk factors, general guidelines for screening, and preventative measures that can be taken once someone tests positive.

I had my blood drawn last Monday, and the heaviness of waiting has been surreal.

I probably never would have considered myself at risk if I was not a women’s health care provider myself. None of my providers have ever seen my father’s pancreatic cancer as a link in this chain of risk.

I remember being a new graduate, sitting in my very first office completing the requisite online trainings and orientation materials and hit my required breast cancer screening module. I was half listening as the slides scrolled by, the grainy audio lagging a half second behind.

“Women with family histories of not only breast and ovarian cancers, but colon and pancreatic cancers may also be at risk. These women should be referred to see a genetic counselor.”

Then the slide moved on.

A bolt of lightning ran down my spine. Breast and pancreatic cancers. My grandmother had breast cancer when my dad was in college. And then my dad was diagnosed with pancreatic cancer at 53. We had always just talked about it as an unlucky, random occurrence. I didn’t know much else of my family’s medical history on that side; it had been paired down through a combination of long-deceased great-aunts and great-uncles, distance, and similar to most modern Jewish families, by the Holocaust.

I sat with the knowledge of my risk for a little under two years, paralyzed by fear, indecision, and rage at the universe for putting me in such a position.

Never one to be comfortable with uncertainty, I sat with the decision for an unusually long time. The factor that pushed me over the edge was that the vague idea of “children someday,” was starting to become a more definite, “children soon.” I knew that I couldn’t head into that phase of my life without knowing if, or what I was at risk for. The way that these genes function is that if one parent is positive (and I have no idea if my dad had the gene, and my elderly grandmother probably could not get tested), there is a 50/50 chance of the child having the gene. A coin toss.

I stared at my wavy dark hair in the mirror, remembering my grandmother telling me that her hair had started to get curly in her early 20’s, just as mine had. My olive skin and hazel green eyes, those for sure are from my mother’s side, I reasoned. My just-above-average stature? Definitely from Dad, I mused, laughing at my mother’s telling of their wedding, “It looked like the wedding from Munchinland!” she would always laugh as I looked up at her nearly six-foot frame. I could stare at the mirror all I liked, but knew that there was only way to discern who I took after in the respect that mattered most to me at the moment.

So one sunny Friday, my hand shaking as I filled out the forms, I met with a genetic counselor who talked me through my risks, the tests available, and the sticky wicket of figuring out insurance coverage. Without insurance, or if my insurance decided to decline covering the test, we were looking at the possibility of an out of pocket cost in the realm of $5,000-$7,000.

It took me another month past my appointment to work up the courage to go to the lab and actually have my blood drawn. It’s still going to take about another month before the results come back.

So now I wait. I would be lying if I said that I didn’t think about it every day. I would be lying if I said that I have only dealt with my fear in completely healthy ways that do not involve a little too much ice cream or one more beer than a responsible adult should have on a weeknight.

Instead of abject fear this month, I have been trying to think about the meaning that I derive from all the things I love about the life I have built. The joy, difficulty, and challenge that comes with being a midwife. The trusting, honest, and passionate relationship my husband and I work at every day. My deep friendships with friends both far and near. Watching now not one, but two of my Godchildren grow and change constantly as they begin to explore the world. Exploring the great outdoors by hiking, biking, and climbing everything I can get my hands on.

In about three weeks I’m going to get a call. I have no idea what the result will be or how it will change my plans, or how I think about life. Ever the nerd that I am, all I do know is that Gandalf can often be consulted for life advice, and this quote, which I hold dear:

Frodo: “I wish none of this had ever happened”

Gandalf: “So do all who see such times. But that is not for them to decide. All we can do is decide what to do with the time that we have.”

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Anatomy of a 48-hour Call

Day 1

0700: Ok. Cool, there’s not too much going on. I’ll do my postpartum rounds, finish my coffee and maybe get back to bed for a little bit

0804: “An ambulance just arrived and she says she has to push, can you come quick please?”

0954: Page from answering service: “Can I take a hot bath while pregnant? How hot is too hot?”

0955: Page from answering service: “I’m having a miscarriage and I don’t know what to do.”

1147: “This baby is having a hard time with labor and we’re concerned that if we wait longer the baby might get into serious trouble. We think it’s best if we proceed with a cesarean birth now.”

1312: Alright, well, maybe I’ll take my book outside and read for a little bit and eat lunch. There’s only two folks in labor now and they’re remote from delivery

1320: “She went from 4 cm to 8-9 pretty fast, are you close by?”

1430: Ok, now lunch, for real this time.

1433: Page from answering service: “Can I get my pap on Monday if I have my period?”

1556: Alright, things have calmed a little bit. A nap is in order. Who knows what’s coming in later.

1630: Why do I always have such a hard time sleeping here? Maybe should I have closed that tear with one more interrupted stitch? It was hemostatic. It totally was. But maybe I could have…….zzzzzzzzz

1748: “Can the mom in 206 have some tums? She’s got some pretty bad heartburn.”

1810: Ahhhhh my favorite call treat, conveyor belt sushi. I should have time to pop away from the hospital for a few minutes. Huh. It’s nice out today. Is this the first time I’ve seen sunlight today? Oh god, don’t think about it like that.

1826: Page from answering service: “I’m having cramping, but not like deep cramping? Like tightening. And back pain. Is my baby ok?”

2003: “We have a patient’s of Dr. Rose’s in. She thinks her water is broken. She left a puddle in the wheelchair, so I’ll save the amniotic fluid test. Can you come admit her?”

2155: Ok, everyone’s admitted. Perfect. All my charting is done. I need some down time. Maybe I’ll indulge in some Grey’s Anatomy for a bit.

2236: OMG. STOP. STAAAAAHHHHP. You are doing a crash c-section and somehow this show never has an OB on staff, and you use a VERTICAL INCISION? Oh, and that baby you just pulled out is definitely a 3-month old. Not a preemie. God, why do I watch this show?

2311: “We have a present for you! One of your patients is in active labor! Come say hi and admit her!”

0302: You’re almost there! One more contraction and we’ll have a baby. I know it hurts. Don’t back away from it. So close, so close!

0306: Happy birthday, sweet girl!

0334: Bed. Where is my bed.

0615: “Can you just come out? Lisa has a triage patient and Molly wants to talk to you about a patient of Dr. S’s that just came up.”

Day 2:

0703: Ok, Dr M gets to sign out. Don’t look like you’re jealous or anything. Oh crap. I forgot to brush my teeth before coming to report. Well, at least you have clean scrubs on? And at least you’re on with Dr. L today. He’ll help you if you need it. Look alive, look alive!

1002: Are you serious? Literally all the rooms are full. How is this possible? Is it a full moon already? And the cafeteria just closed, so you either have to wait until 11 to get coffee or go to the provider’s lounge and get the see-through coffee that comes out of their “coffee machine” down there. Yeah. I’ll wait.

1049: Oh I feel bad I was a little curt with that nurse. I hope she knows that I’m just uncaffeinated.

1101: Sweet, sweet coffee, my dear friend.

1113: “We need you in Birthing Room 3. Now. Just put gloves on.” Is this coffee too hot to chug? Kind of. Oh well.

1245: Nothing looks good in the cafeteria. Do I have time to run out and grab something?

1247: Page from answering service: “I think I’m in labor”

1252: There aren’t any open rooms right now, but I just invited someone in for a labor check. She really sounds like she’s in labor, guys.

1450: I know these contractions hurt, but they’re just not changing your cervix, at least not yet. At home take a hot bath, try to relax, and you can always come back if they get stronger and closer together.

1520: Why do they always show doctors on Grey’s Anatomy pushing meds, placing catheters, and starting IVs? I could write a whole article on the erasure of nurses in modern media. Yeah. In all my spare time.

1650: I think my body is pretty sure it’s never going to get more than 2 hours of sleep at once ever again and it just reset itself. I feel great! Only 14 hours to go!

1823: Welcome into the world, baby! Great job mamma! You’re so strong. Woah, I really do feel great. Nothing like a smooth birth to keep you energized heading into the night.

1947: Oh no. I’m crashing. It’s happening. Ok. Just go lay down for a bit. Just 11 hours to go. You can do this. You have to do this. You literally have no choice but to do this. Has anyone ever died from being on call for so long?

1949: Page from answering service: “I think I have a yeast infection. What can I take for it?”

1954: I think I’m having homicidal fantasies about killing my phone? I need a nap. I’m just going to lay down for a little bit. Oh no. It’s ringing again. I think I need to change my ringtone periodically so that I don’t have nightmares about that specific sound.

2104: Hooray, a normal, healthy multip admitted in active labor! That’s always a great way to end a shift. And maybe I’ll get a nap before she gets too active

0200: Yes, you can check her cervix. I know I said I’d be back to check but….getting out of bed is too hard right this second. Call me back if it isn’t changed.

0402: “We’re ready for you for delivery!”

0446: Man, those are the births I live for. Happy baby, happy mamma!

0516: Well, change of shift is in less than two hours. Should I just stay up? Maybe I’ll try the coffee in the provider’s lounge again. Maybe I caught the machine on a bad day.

0520: Nope. It’s really as bad as I remember. How is it even possible to have coffee that bad? Never mind. I don’t want the answer to that.

0538: I’m just going to put my feet up in the nurse’s lounge for a minute. Just for a little….zzzzzz

0649: “Go home, it’s been a long weekend, I’ll report out to the oncoming doc.”


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Caring for Women Who Do Not Seek Out Midwifery Care

“But….when’s the doctor coming?” An exasperated first-time mom howled at me as I rushed into the room, introduced myself as the midwife on call today, saw the baby’s head beginning to crown and hastily threw on a gown and gloves.

We had just changed over shifts, and, evidently, the physician that I took over for did not mention that a midwife would be taking over her care. I sighed. I usually like to have this conversation a little earlier than say, well, when there’s literally a baby’s head emerging.

I quickly explain that as a midwife, I take care of healthy, low-risk women with normal pregnancies and births, so the fact that I was there meant things were just fine. (Note to self: midwifery humor is usually lost on women pushing a baby out their vaginas.)

“….but….when are you going to cut me?” She was in a break between pushing, and had some more questions.

I rarely cut episiotomies, the cutting of the perineum to allow a baby’s head to emerge faster. I have cut exactly two in my life, both when extremely worried about the baby’s well-being. Up until recently, episiotomies were routine practice, and many of my patients expect to have one cut, or have had them cut in previous deliveries (with or without their consent or knowledge).

“Oh, honey, this baby is doing just great, we don’t have to do that, he’ll come when he’s good and ready. All this skin and muscle stretches to let babies through.” A look of relief passes over her face but quickly returns to a grimace that starts in her brow and I can sense her beginning to gather her strength to push again. A few big pushes later, we have a squealing, pink, and gooey infant directly on her skin.

I work in an environment where very few women seek out midwives for their care. The midwifery program at my hospital is just over a year old, and the word that there are midwives at our hospital is still making its way through the community. This is far different from the image that many people have of midwifery. We have to be honest, midwifery has a class problem and sure enough, midwifery also has a race problem.

I have many friends that work in the large metropolitan city that I live in, which has been increasingly gentrified. Poverty has been suburbanized in my area, and most of the poorest people have been pushed to suburbs south of the city. All of the midwives in her practice are white. Nearly 100% of her clients are white and have very good private insurance. All of them have sought out midwives, desire unmedicated childbirth, and most have not heard of the concept of food deserts.

The community I, and many other midwives work in looks very different. 80% of our patients are on state-sponsored insurance or medicaid.  I am surprised when I don’t need to explain to a new patient what midwives are and what makes us different than physicians. There are multifaceted reasons for this,  mostly having to do with the fact that many midwifery practices don’t function out of major hospitals that accept medicaid, or at least they didn’t until recently. The practice I trained with did not accept medicaid, and was in the same city that I am currently working in and our populations are extremely different even though the clinics are just miles apart.

Working with women who are facing pregnancy and childbearing while also facing poverty, low-wage labor, and many other struggles that the working class deals with is an honor, and listed below are some things that I have learned to help me be the best midwife I can be for low-income women and women who have not gone looking for midwives, but have ended up in my office because we are the only office that takes their insurance:

  1. Don’t be offended if you explain who you are and what you do and your patients still want to see a physician. Like with birth, if women aren’t comfortable in a certain environment, they just won’t labor well there. Don’t take it personally.
  2. Be versatile. Women need their midwife to be many things for them, sometimes you will need to know the local doulas and natural childbirth education classes and have good recommendations and then in the next visit need to be able to clearly explain labor law and what types of accommodations women’s employers are obliged to give them.
  3. Get to know your local WIC office, eligibility criteria, and familiarize yourself with the paperwork so that you don’t make the process any more difficult.
  4. Discuss food security with every patient at their new OB visit. Oftentimes this gets me quizzical looks, but for the patient that is experiencing food insecurity and is ashamed or scared to discuss it with you it will mean the world
  5. Be gentle in discussing breastfeeding. By this point we all know that breast is best. But when a women tells you they can’t do it because the idea of bringing a breast pump to work, asking for the breaks, and having somewhere to store the milk is too overwhelming (even though she is legally allowed all these things), believe her. Gently encourage her, but never shame or tell her “Don’t worry, you can do it!” and brush off her concerns. Have you ever tried to take a hospital-grade breast pump and all your milk home with you on a crowded bus?
  6. Know your labor law. Know your labor law. Repeat: know your labor law. Many pregnant women need some form of accommodation during their pregnancies and the way in which you phrase your notes and the specifics you write on FMLA paperwork can mean the difference between a women receiving the accommodations she needs and not. If you have a question, contact your local Labor and Industries office and encourage your patients to contact them as well.
  7. Advocate for in-person interpreters instead of the phones and for double the time in visits. Using interpretation services well means that it takes time. Women who don’t speak English as their first language often have significant barriers to good health care, don’t let short appointment times or low-quality interpreter services add to that stress. I know this is easier said than done, as the clinic I used to work for never had in-person interpretation because it is exceptionally expensive. I feel incredibly lucky to have in-person interpretation where I’m at now, it makes a huge difference in the visit.
  8. Finally, don’t assume who needs what services. I take it to the lowest common denominator for everyone and then work upwards. I ask everyone if they need referrals to get on WIC, need a prescription for a breast pump, or need a prescription for prenatal vitamins. If they don’t need it, fantastic, but I consider myself having failed if someone ever needs to sheepishly ask me for these services.

Midwifery care looks different in every practice. In mine, it tends to look more like talking about food and housing security than about prenatal yoga. All women deserve midwives, but each midwife needs to be able to give the kind of care her patients need and be familiar enough with her local resources to provide what we all strive for in midwifery: the true care of the whole person.

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Getting Back on the Horse

This past month has been hard. I’m going to be very, very honest. I had a difficult birth last month  and everything that I have done since then feels like just going through the motions until I feel normal again. I’m not sure if or when I will ever feel “normal” again. This month I’ve celebrated small victories, which is pretty much all I can ask for now.

I found myself a great therapist. She is a certified postpartum international counselor, and talks to lots and lots of people about birth trauma. It feels good to have a space, twice a month to let out my feelings related to my work instead of a constant, diffuse feeling that is overwhelming.

I’m sleeping through the night again, and most of the dreams and intrusive thoughts that I was having have dissipated.

I have talked to fellow colleagues, former professors, and close friends outside the midwifery world who have loved me, supported me, and hugged me.

I have caught close to 15 babies in the month since my traumatic experience, and it has felt good to start to trust normal birth again.

I caught my 50th baby since midwifery school this past weekend, and measured up all my stats, and even though its a small sample size, I am extremely proud of my 9% c-section rate.

I have been really honest with myself and others about my needs, and a lot of this involved eating ice cream and cupcakes and going to the gym more often (I know, it sounds like these things are counter-posed, but really they are complimentary, I swear. Also, carrot cake for breakfast on a post-call day is totally fine, right?).

I found a continuing education conference for Nurse Practitioners in Women’s Health that I’ll be attending in October and can’t wait to make connections with other women’s health NPs and midwives who are passionate about primary and reproductive health care.

I’ve celebrated all these small victories and have recognized that healing is a process. I have learned a lot about myself, my resilience, and how deep my love for this profession goes in the past month, even if it is capable of breaking my heart wide open.

More to come, and maybe even a humorous post sometime in the near future. But for now, cheers to the small victories and my amazing support network of family, friends, and colleagues who have stuck it out with me this past month.

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Everything Was Fine Until It Wasn’t

**Note: This post contains thoughts and feelings about birth trauma. As always, no protected patient information will be shared and this writing is comprised solely of my own reflections**

Everything was fine until it wasn’t. Those are the words that everyone keeps telling me. Insisting to me. The nurses. Other midwives. My consulting physicians. My own voice.

We all know that the weight of the work we do can crop up at any minute and the joy and ease with which I help many newborns into the world can be erased in an instant. But knowing that intellectually is not the same as experiencing this feeling. Not the same as the bottom dropping out of your stomach and the mind-numbing fear; crippling your ability to breathe and put words into sentences.

“You must be ready. This is life. If you cannot be ready, go into dermatology.” Harsh, but true words from one of my back-up physicians that ring in my ears as I try to fall asleep each night. You must be ready.

I don’t know what to say. I am having a hard time relating to those outside of the birth world and have shrouded myself into a self-protective cocoon. I don’t know how to be ready for this to happen again someday. I looked up the statistics. It’s rare. I’m hoping the stats hold true, and that 10 years of busy practice goes by before I see another case like it.

It feels unfair. I have been doing this for such a short amount of time. I wasn’t ready to have my soul crushed. Doubt, fear, and sadness enmeshed into who I am as a midwife so early. To fear the shadows creeping into every birthing room.

I have spoken to the midwife elders. Poured out my heart like a river running over its banks and in return have been ushered into a seemingly secret club. Me too. This is what I saw. This is what I felt. It’s like miscarriage in that way. It seems rare and shaming; bringing you unstuck in place and time, until you meet others like you.

Each birth I have attended since this day lacks the same joy, ease, laughter that I had brought with me before. I am hypervigilant.  My heart pounds in my chest as I pull on my sterile gloves. I ask for the fetal heart rate monitor to be turned up. And up. And up. I put on the mask, but I do not feel the same way inside. Like with grief, each progressive day holds slightly more light. Two steps forward, one step backwards, but I am constantly glancing over my shoulder, waiting for the darkness to follow.

Like with grief, I know it will not always be like this. I know I will survive because I have to. I know that I will thrive because I must. I know that one day I will stop glancing over my shoulder, paralyzed with fear. But I cannot un-know the darkness that lives there.

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In school they tell you you’ll know a “crash” c-section when you see one.

I had thought I had seen them. I had moved briskly to the OR, helped get things set up, waited impatiently for the prep to dry while holding my sterile, gloved hands clasped, as close to prayer as I can get.

Then you have a true emergency.

The bed is hurtling down the hall, and I quickly scrubbed. Cursed because I had forgotten to take my wedding ring off before I started and had to have a nurse remove it, tuck it safely into her pocket, and re-scrub.

“Just copy what I do,” the surgeon said to me. “I know you’re new. Just follow my lead. Do exactly as I say and do it quickly.”

I expected to feel adrenaline rising. My heart pumping in my ears. But instead we just flew.

There were too many hands and not enough. Betadine flew everywhere as we prepped. Had we called the nursery? Questions echoed into the room and I couldn’t answer. We flew down the layers of tissue. Skin. Sub-q. Facia. Muscle. Peritoneum. Uterus.

Sweat beads ran down my spine, my glasses fogged up as I exhaled. Retract retract. Pull. Push.

Finally, a green-stained, squirming baby.


Tears under the mask and finally time for deep breaths I didn’t realize I had been holding.

This was my first emergency since beginning practice on my own. I like to think I rose to the occasion. The OR was hectic, everyone moving, performing their job and that of at least two others. I stepped out of the OR and pulled off my gown and mask bent over the sink. I took a minute to breathe. To shake. To let the delayed release of adrenaline shoot a wave of nausea through me.

Breathe In. Out. In. Out.

I put my wedding ring back on, a grounding ritual, and went to help my other patients. Labor waits for no midwife.

They tell you, you’ll know a crash section when you see one.

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