Waiting

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.”

BUT:

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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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Crash

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.

Relief.

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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Here I Stand

I have experienced a huge mental upheaval in the past month, which is mostly the reason for my lack of writing.

I have sat down many times on post-call days reflecting on my growth, my new experiences, and my newfound voice and independence as a midwife. Much as I imagine new parenthood, no one can prepare you for the feeling of responsibility that comes with this shift.
For many days, I have not really known what to write, because I sometimes don’t know exactly what I feel, or how to express it.

I have forged relationships with my new colleagues, bridged gaps in practice styles, and pushed myself to be the best, most caring, vigilant midwife I can be. In the depths of the night, I have found a voice and a surety and a confidence that I always knew I could bring if it was needed but at the same time have surprised myself with the words coming from my mouth.

I feel raw. Not in a bad sense; this rawness feels like freshness, like soft newborn skin instead of pain. I feel humbled and awed, frustrated and timid, wild with passion for my patients and their families and their births.

Yesterday was my first day of solo call. I have a back-up physician also on call should I need to consult, but the midwifing was all mine.

I spent the night before that call reflecting on this journey that I have undergone in the last five years, and feel like a bit of a pheonix. It has been hard, heartbreakingly hard at times. The self-doubt and fear was numbing. I felt broken down and built back up again, made anew with each reflection, each mistake, each birth.

I went back to my old, leather-bound journal and read my account of the first birth I witnessed. I thought about all the advice and guidance that Ciska and Susan gave me, and how true it has all come to be. I think of myself, five years ago, almost too timid to touch another person, squeezing myself into corners, terrified of saying the wrong thing and think of how much I have grown, and how much growing I have yet to do.

I had a beautiful birth last night, the kind that make everyone in the room cry the sweetest tears, lights down low,  guiding a woman through the pain to the end. It felt so normal, so right. And then the cord was wrapped so tight around the neck, and the nurse looked at me and said, “Which way are we going?” Meaning, could I slip the cord over, or would we have to somersault through?

No extra set of hands to help. There I stood. Midwife, decision-maker. “We’re going to somersault.” Firm. Clear. Confident. Hoping not to look and sound like I had actually never done that before by myself. But there I stood. No one to help this babe out but myself.
There is something so deeply terrifying about being the only one standing there at the foot of the birthing bed. In a way, it feels exactly like what I had told this very brave laboring woman, and in the coming months I will try to apply the same advice to myself: “Dont back away from the pain,” I told her, “The only way is through it.”

There is only one way through that sinking feeling, I think, and that is to catch babies again and again and again, and to do the right thing and see that I am capable.

The meaning of the word obstetrician is “to stand before,” which I had always despised in contrast with the meaning of “midwife,” which is “with woman.” Although I am not an OB, I do have more sympathy to the meaning now more than ever.

So now, here I stand, in the Ring of Fire, the only way through it is to dive right in.

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