Saturday, December 27, 2008
I worked until 7.30ish am and then was picked up and taken straight to my sister's place for breakfast. I had got changed at work into a sensational little black dress with pink sequins, nothing gaudy - just a modest sprinkling suitable for breakfast wear (;p) and I found my second wind after a long night shift.
I had had 5 women and 3 babies - all of whom were a bit antsy. Two were scrawny hungry babies (2.1kg, and 2.9kg), one was already on medically indicated formula top-ups, and the other was on pure breastfeeds, so the littlest one slept well in her room with Mum and the middle sized one sucked for hours before coming out for cuddles and a bath to relax her. She was so sweet in the bath, yelling at first and quite cranky, then suddenly after a minute or so in a deep and warm bath she flopped into a sleep, her head resting sideways in my hand, lower ear in the water, her body cradled on my wrist and forearm, legs stretched out. A different baby with no fight in her. I hardly ever get to bath babies alone, but I do like it. I humm and croon to them that they are safe and its ok to relax and sleep, and then I swaddle them up safe and snug in warm clothes and wraps and rock and pat them off to sleep. This little one, Amelia, ended up sleeping for another 2 hours, Handel's Messiah in the background, waking at dawn to greet her Mum with a hungry breakfast call.
Santa came to the ward too! Just after midnight - with pressies for the midwives and a choccy or two. There were Xmas presents for all the mothers too, gift bags from the Body Shop -( I don't know if they were a sponsored thing or if the hospital purchased them) but it was a lovely treat - specially for many of our Mums who would never have the luxury of Body Shop stuff.
For most mothers our attempted gift was a bit of sleep, even an hour or two. My third baby was a big 4kg fella, with a tongue tie - which means he can't attach properly at the breast. He didn't even seem interested. He would just bite, and couldn't get his tongue under the nipple or finger to suck properly. This will spell disaster for the state of Mum's nipples. His Mum had laboured all the previous night (I had been on LBS the night before so remember his birth occurring near dawn) and he hadn't fed well all day. I assisted his Mum to express by hand - not a huge volume but we did it regularly and put it down his neck with a finger feed, so he was fed and Mum could go straight back to sleep. It will be a difficult few days for them, waiting for her supply to kick in. He sounded a bit mucousy too, so probably needed a chuck before he properly will attack a feed. In the meantime we kept the room quiet, and him fed as well as we could for now. I imagine there will be a BF plan for her quick smart, but the priority that night was to sleep.
Breakfast was yummy, unfortunately my camera was at the bottom of my bag and the screen has been damaged (aaargh) which will need to be fixed. I did take a few pics, but will need to be very tricky to get them off the camera, although the card should be OK....hmm. I hit the wall about 9.15am, so we opened some pressies - including some incorrectly labeled ones - oops- and scarpered home.
Back to our place and open presents again with our family - Santa was goooooooood!!! (photos to follow). The kids (nearly 20 and 23) each got a camera (thumbs up for power shopping) plus assorted other welcome delights. I got a beautiful surprise necklace of semi-precious stones and pearls - just gorgeous! And a book, gorgeous craft supplies, Body Shop White Musk yummies, chocolates, a quilt calendar and a Lighthouse diary (Yay, thanks Lesley!!) plus assorted other delights. Very lucky.
Then off to bed for me until 4pm, while hubby and kids joined his side of the family for lunch, then wake up to prepare for my side coming to ours for dinner. We had a BBQ (Reef and Beef) - very easy with desserts prepared by Steff - a divine sticky date pudding with butterscotch sauce, plus a Tiramisu. Charades, lots of merriment and a growing (up) tribe of teenagers running amok and clicking away on their collective cameras as they posed all over the house. They had a ball. Everyone left around 10pm, whereupon we fell into bed.
A quieter day yesterday, just attending a BBQ at a friend's house with many other choristers from our choir days. Singing was enjoyed in the backyard, along with much catching up on news, then home again and watched a movie on telly.
Cricket and a slow start, with jam-making all morning to use our lovely Santa Rosa plums and a few stray cherries. I now have MANY jars of jam. Along with a savoury apricot sauce from the last of the apricot crop.
Its summer....down time.....bring it on!
Friday, December 19, 2008
They are inconsolable because their mothers are shattered by hours or days of labour. Their mothers are sucked out husks, facing their second or third night without sleep, with tender inexperienced nipples. They are stroppy babies who haven't read the books on normal physiological lacation processes and therefore are really keen for some stomach filling, like, NOW. They suck and suck, and don't feel right unless they are sucking, but until the milk comes in they are not getting full bellies and therefore are driven to keep sucking. They are dry, pass almost no urine, and run a bit warm as is normal in slight dehydration - all normal for babies of around 48 hours of age. And their mothers are so tired they keep falling asleep and are worried they will drop the baby. And their nipples are tender. And they are often a bit sore, or have mobile phones going at all hours of the day and night!
The woman who has a CS is marooned in bed for those first 12 hours or so, unable to lift the baby in or out by herself, with catheters, drips and epidurals to contend with. The CS may have been planned or an emergency, so the woman is often utterly exhausted after an induction of labour, which has not been successful i.e. the door (cervix) did not open so the baby couldn't be born. It is a lot to take in.
The night midwife is a big part of the adjustment process to new parenting, especially for the woman who has had a caesarean. There is an enormous amount of physical care, including monitoring blood loss and fluid balance, full assistance with breastfeeding, teaching as you go, as well as the emotional care of a woman who is adjusting to the first hours of mothering in a (mostly) unexpected way.
These last 3 shifts I have cared for a number of primips (first timers) some with unexpected CS. One had had many miscarriages and was very unsure of every sound the baby made, every whimper in his sleep, how many sucks it took to constitute a breastfeed - she was a bit incredulous that it needed at least 10-15 mins of a consistent sucking pattern to be called a good feed on day 1 of life. She had read all the books, imagined how her first breastfed would be, and planned every aspect of her skin to skin contact with this baby...following a vaginal birth... but had not made a contingency plan for any other outcome. Luckily her baby seemed to have a pretty good idea that the principles were the same - get a good position, line it up, shape the breast/areola and get a good deep mouthful with the tongue under the breast. And suck away! Bliss! He'd read the books too! Mum had so many questions, needed so much reassurance of normality, and rang the bell every 20 minutes! For her water jug to be filled up (it still had 1/3rd left). Give me strength.
I had had similar nights for the last 2 nights, with the woman in the next room sitting on the bell for every mortal thing. Wrap my baby, burp my baby, pour me a drink. Sure sweetie, I'll be right back. (staggers off, gnashing teeth, wondering how the other 6 women in my care are doing as I wear a path to her door). Some nights are just like that.
Last night I had 6 women and 4 babies, three of whom were inconsolable at regular intervals for long periods. They were all really sucky babes, waiting for their Mums' milk to come in.
The other midwives are as helpful as they can be. Any spare pair of hands is cuddling a fractious baby to give Mum a break for an hour's sleep if we can hold baby off for that long. Last night I had a scrawny little chap who could suck for Australia, miserable without a boobie in his mouth, who nearly sucked the meat off the bones of each of my (clean) little fingers in turn. I only managed to get 70 minutes sleep for his young mum, who was knackered, but her breasts were filling well and I think he'll be very satisfied with the offering today!!!
One baby was really loud. I mean REALLY LOUD. I had seen another midwife with her the previous night, squawking the place down as she was bathed to try and calm her. She wanted a burger, with fries and a milkshake and she wanted it NOW NOW NOW. No chance. I tried to talk soothingly to her, I tried joking with her - she was NOT amused, and I was glad i didn't have her in my tribe that night. Oops - guess who I got last night? Her Mum was really patient with her, and fed her well and readily, but was dropping off the perch with exhaustion. There was a small volume of formula in the room when I started the shift, warming, ready to be finger fed (a method of sucking the formula through a straw like device that feeds in next to the pad of a finger in the baby's mouth). We really try hard not to offer formula, and NEVER mention the possibility of using it to mums. However it seemed mum had asked for a top-up in desperation as nothing would console this child other than a continuous boobie fest. The nipples were a bit tender and grazed despite good attachment. We had the talk about breast comes first, second and third. We agreed to try for another hour or so before offering the formula. In the end we offered it just after midnight. Baby scoffed it down, sucking hard. And finally conked out. I tucked the two of them into their beds and turned out the light. In the morning Mum looked like a new woman after a four hour sleep. Baby was just stirring, still no urine but she had pooped, and pooped again as Mum changed her nappy - she was delighted to see it and laughed and laughed! Nothing like a bit of sleep to restore the sense of humour.
Women need the right information to promote and initiate and sustain breastfeeding. Its a difficult phase, those first few days, waiting for the breasts to kick in. I am a passionate breastfeeder, I know alot about it and I am, I believe, a strong advocate for breastfeeding. But I do also believe there is sometimes a place for the use of something else temporarily, especially in the baby who can suck for the national team. Sometimes you see half-assed, can't be bothered semi breastfeeding, where the breast sort of gets the stimulus it needs to kick into gear, but the baby is not encouraged to stay for long feeds, and growth spurts are not factored in. Building of supply is not factored in and 10 minutes a side each 4 hours just won't cut it after three days or so. Some cultures seem to mix and match, offering bottles freely until the milk comes in, and they then establish a long feeding relationship purely breastfed. Some people genuinely don't care if they feed or not, or have always felt it was not likely to be their thing, and that is honestly fine by me. The sky will not fall in. As long as they are sure. But if they want good information on how to do it, just ask me.
In the meantime, my little fingers will be well used!
PS Our friend A has still not been seen the incident, much instability, occasional phonecalls and cancelled plans. Daughter very anxious and worried, send good vibes.
PPS Sister back - Yay! No job offers for her daughter yet, sadly a No from the locals. (Bloody Sydney Dance Company shuffling staff and catapulting others into job queues ahead of talented newly qualified dancer, grumble, grumble)
Tuesday, December 16, 2008
Last weekend (two weekends ago now) I repaired and enlarged a large shadecloth that we attach to the side of the house - This bit belowIts now 7 m long and 3.6m wide, and attaches to various treees and parts of the fascia boards. I got quotes for some fancy schmancy company to make us one, but it was going to be $4000 and ugly as sin, plus we would have had to take it down in a wind or with rain. No thanks. $60 worth of shadecloth, and two hours later- its great!!! Its less droopy now that it has been tightened up.
The plants love it.
Xmas shopping - at least half done, with ideas for the rest. I did some of last weekend with WIDGET!!!! She is in WA for a holiday visit and we caught up on Saturday. She likes our weather (it has been warm and gorgeous all weekend) and approves of my Power Shopping methods. Step 1- Get idea. Step 2 -Buy it, quickly, while praising the customer service skills of young people who appreciate a decisive customer. Step 3 -Walk out, job done. Works for me!(who is very lucky to now have sufficient income to achieve this method)
Plans for Xmas day - now complete.
Work - I commence nightshift again tonight for three nights, with a further two shifts next week on the 23rd and 24th - which means I finish work Xmas morning at 7.30am. Guess what I will be doing for most of Xmas day? Before we host my family for dinner. Go on, guess.
My sister is back from Melbourne! With her lovely daughter, and we hope they will be staying in Perth! yay, bouncing joy on this one! We hope our niece will get snapped up in an audition soon and get a job (hopefully in Perth) but my sis is likely to stay even if her daughter moves elsewhere for work.
Anyway, must dash - the shower is calling and I clock on in 52 minutes time!
Wednesday, December 10, 2008
So, our girl is back from Melbourne and BUSTING to see HSM3 with her bestie, they've been planning it for months, only there is no reply to the phone messages left on Monday.
As I leave for work on Tuesday I call again, and her Mum answers the phone, sounding shattered. Downplaying any problems. Sorry, A is in the shower, we're only just back from the hospital. WTF?
Turns out she has been cutting herself for the last 6 months. Long back-story, not mine to tell. But we see her regularly and care deeply for her. She went further this time and got a vein. No surgery, but sedation and patching up. She will be OK, but the battle for her tranquility goes on.
We are all absolutely gutted. Our daughter is devastated and very fearful. I call work, and hubby (who knew about the cutting but hadn't told me) and he comes home. We send flowers with a big message of "WE LOVE YOU".
I go to work an hour late. To be sent to an area I have never worked in. With a very sick young woman who has just had a stillbirth, and who doesn't speak much English, and whose family oppose many of the practices we commonly do around stillbirth and creating memories. She is very sick, but after a big sleep wakes up feeling a bit better. Her hubby has spent time with the baby while she was sleeping, and has been supported by us to take photos and have them, even if keeping them private from the family.
She is very emotional to hear that her hubby has seen their baby, but is encouraged to think she could see her baby, even in the middle of the night, and the extended family doesn't have to know. Its important that her needs are met. She asks for her immediately. And wants photos, and holds her, and loves her. The couple drink their sweet little one in, and begin to talk about themselves as mother and father to this baby.
Unleashed from restriction the parents want to see her in their favourite outfits, and photographed with things they will keep as mementoes, an urgency to it all. Shuttling back and forth (to the usual area with all the camera, supplies and equipment) and it takes time to dress her and undress her and make her look peaceful, tidy and beautiful, although she is a very pretty baby. All this in a ward area where deceased babies are rarely seen, passing through public areas with a veiled cot. Its a tricky day.
I end my shift handing over the parents and the baby to a night staff member who is quite unused to providing bereavement work, and a bit daunted about the requirements of it all. But I need to get home to see how my own family is.
They are doing OK. They have spoken to A on the phone, the girls had a good long talk, and our daughter is reassured that her friend will recover and they made plans to see the movie when she is feeling up to it.
When I explained what I had been doing at work all day my husband was a bit freaked out. What - a dead baby? You've been dressing up a dead baby? And they've been holding it? And you've been taking photos? He was a bit on edge after dealing with confronting issues all day, and then told me about having the conversation with A, describing it as a conversation with a living person. And how diagnoses of mental illness are all just labels, and this poor kid didn't need more labels, she needed someone to just love and support her.
I slipped quietly into the house, hugged our girl and was grateful to see her reassured and not teary-eyed as she had been when I left. I was in a bit of a daze after a fairly intense day, but realizing that although work was challenging it had kept my mind off the horror and grief of the news of A's hospitalisation. I went to bed early, choosing not to watch the ridiculousness of Brad Pitt and Angelina Jolie trying to kill each other in the "Smith" movie - it just didn't appeal somehow.
And now I should get off the computer and get myself ready for another day at work.
What will it bring?
Thursday, December 4, 2008
We got talking..as you do, and he mentioned his son's full name. With a familiar and pretty unusual surname. I punched lightly him on the arm, and laughed. He looked a bit intimidated, but not for long....
Turns out, the Dad was my first boyfriend at high school. No waay! Yes way! 1974 flashback!
Now featuring baby number seven from wife number three.
Its a small world.
Monday, December 1, 2008
No pics yet, I hope I feel able to show you when I finish it. But with Steff away and only 3 more days not working til she comes back I feel I should push on. I did discover the value of painting over a crappy bit! Nothing is permanent, it can always be embellished over!
Many stories. Sorry it takes so long to bash them out, but I have limited time with hubby and yesterday was the first day in AGES when I didn't even turn the computer on. It was a temptingly creative day! I should do more of it!
Saturday, November 22, 2008
I had a day in the assessment unit - where it is frowned upon to catch babies unless you genuinely have ZERO time to whizz them around the corner.
I spent a shift with a delightful young primip who spoke minimal English (my French was fairly rusty, oui, c'est vrai). Her trace looked like crap (she was on the trace due to augmentation of labour) and the baby heartrate kept bottoming out, so needed to go for CS. Bummer. Near perfect gases. Cord only around the kid once, but had been in a spot that got squashed a lot and made the trace look crappy. The heartrate did take time to recover, more each time, and can only do that for so long, but it was disappointing for everyone. Baby came out squawking. Happy Maman and Papa. (Hopefully happier than this Maman below, Michaelangelo's finest work, the Pieta. Forget the Sistine chapel. This is it. Oh, and his David - who is also utterly magnificent.)
Today I came on to two delivered women. One was asking about circumcision for her new son - she wasn't too fussed whether it happened or not, just thought it was what you did. "In the olden days: we know better now, why cut something off when you can just wash it?" I told her. Thats the way God makes 'em, might as well leave them alone! Besids - he'll be the odd one out, it is so rare to find a circumcised boy under the age of 20 in Australia. (and thats a good thing) She was most relieved, it was one less thing to accomplish, and once I gave her the script to brush off enquiries from old-style pressure groups she was very happy to leave him as nature intended. We had a brief discussion about how to care for it (self-cleaning mostly, or just a swish until it pulls back fully and needs to be gently attended to by the fella himself) and then talked about Sci-fi fantasy books! (these look a bit like bookends to me)I was then sent to collect a multip who was a sure thing for a catch. A nice couple with a good history of spontaneous easy birth, including a multiple birth. Nix. Nada. Bupkiss. I even stayed behind nearly two hours after everyone else from my shift,but she went off the boil, even after rupture of membranes. I have just phoned - she had her son two hours after I left. I'm pleased for her, but sheesh. What does a midwife have to do? No-one else was scoring any babies either today, it was uncharacteristically slow, and two rooms were closed for water leaks! But I will be heading to the ward this week, and not be rostered back on LBS for a long few months. My catches remain at 45!
My perineal repairs remain at zero. No catches, no repairs. Easy equation. Not much call for it on the ward either (one hopes). Even less in clinics or VMS!
K2 CTG training remains unfinished - I have had no time to complete it at work this week, but can access it from home and will apparently be paid for the time I take from home. It is very interesting to do, I am refreshing and building on my knowledge. Its great.
The mentoring is all sytems go. We will meet soon, but had a brief catch-up at work, during which she beamed when I said Yes. A good sign. I have a few things planned to start with already. She is an interesting woman and its a good challenge for me professionally.
I have had a pretty definitive NO about getting some temporary work in the birth centre, more's the pity. Ah well, when one door opens another may open. I'll keep my ear to the ground for suitable continuum opportunities.
At home - I have been struggling a bit with a sore throat this week, along with an unwell hubby with a viral illness. Its not like him to take time off work, let alone go to the doctor and he has done both this week. He's not sleeping well, but I think it is starting to lift, and he is finally accepting that pain relief IS a necessary part of coping with sinus pain. He does allow a bit of cossetting every now and then.
I saw my Mum - who was not terribly cheerful or positive following her trip. We went out to a rose nursery near her place to get some rose bushes struck from a cutting I had taken of a stunning climbing rose 'Chrysler Imperial' with a heady fragrance. It was a favourite of my Dad's - I'm sure I've posted about it before. However the nurserywoman was most blunt - nuh, wrong time of year. Nuh, got no root stock to graft it onto. We finally dragged the month of January out of her as a good time to try again. Customer service training surely can't cost too much can it? Heavens above, at least be forthcoming with information - we were the only customers in the whole enormous place - it can't be too hard. To top off our frustration the nursery cafe where we had planned to have lunch was also not open on the day of our visit. I could feel a Mum-shaped meltdown coming on, so we wandered out to distract her and bought some new roses instead. Sigh. They also had some very pretty decorator pots which made a lovely advance birthday gift for Mum. Another gift off the pressie list.
Oh yeah, make a list, check it twice....that was on my to-do list. DONE!!!! Yay! Now to get to the shops and achieve the purchasing, or do the making......
Minimal crafting achieved this week, apart from... oooh I lie! I made two little button bracelets on Wed night at swimming. And I altered a polo shirt for work by appliqueing some pretty bright rose print cutouts over a very unattractive logo on the breast of a new white polo shirt, and adding a matching trim around the collar to cover up an orange stripe. I don't do orange. It doesn't suit me. But the alteration worked out well, and I wore it to work successfully (successful in the fashion stakes, not the baby-catching stakes, sigh). I even sold a bag this week! Which inspired me to stitch a few more. I may join Calamity Kim and make a craft pledge to make 3 small items a week in 2009. Just competing with myself, but also for etsy stock. (shop still empty, I'll blow the horn when its open). Its not like I don't have the stash!
Speaking of which...House still a tip? Check!
Purchased Xmas tree? Nope. The hunt continues, I seek them everywhere I go.
(BTW - we have absolutely NO idea what this item above is. They were fixed to the walls at regular intervals in many places in Rome, Siena and Florence and are at about head height to me. But we took a photo, and I love it 'cos it shows Don's hand. I love his hands)
More op-shopping. I found a blue cowgirl + tiara hat! I need it. Truly. The theme for our staff Xmas party is Country and Western! See - I DO need it. And the matching shirt, which hubby will claim when I'm finished with it. We also found some gorgeous Bally shoes for Steff. $10. Worn once. Very stylish black and cream loafers with sedate tassles. Di-vine. Italian leather designer shoes. We were suitably stoked (I bet Kelley is very jealous - do you have teeny-tiny micro feet? Cos Steff does!) And a sassy tote bag for fun. It is a rare day when our local Vinnies doesn't give some sugar!
Enough rambling on .... Be good.
Sunday, November 16, 2008
I have so much on my to-do list!
- Catch more babies myself. (myself, do you hear?) It has been very noble of me to find and foster 25 catches for a very nice resident doctor in the last 2 months. She got her 25th last night - 3 in one night. Good thing she runs fast. She owes me chocolate. And LOTS of it.
- Stitch more perineums (current total = 0)
- Sort out whether I can be a mentor to someone who has asked for me (I am pretty junior, and I'm moving on, and around. Alot. But am flattered to be asked. And it may just work despite all that. Stay tuned)
- Finish my K2 CTG training (item one may interfere with this notion, decisions, decisions)
- Finishing said K2 training may make me more defensive in my practice. I hope not. Its all about perspective, people. Small percentages. (Do I sound like I had a frustrating shift last night? How could you tell? What were the signs?)
- Swap a shift so I can attend a meeting on Thursday night, seeing as I am the secretary and all, and I was an apology last time. And I am rostered to work a late shift on that day. And if item one happens, there is fat chance of me getting away for an extended meal break to attend.
- Did I tell you I have seen TWO true knots in the cord in two shifts running? Wow? One born vaginally, no worries, one who went for CS not even in established labour. Rats. I've been seconding a lot, so I've seen lots of births, but I'm missing the hands on (poised, actually) (thanks to Google images for this pic)
- Enjoy my last week (for now) with a great team, who have made me very welcome. I have spent 7 1/2 months with them in the last year- the longest I have ever worked in one place.
- Make a Xmas list, start shopping/making/planning. 5 weeks you say? Eeek!
- Figure out the family meal arrangements for Xmas - given that I have just agreed to work night shift on the 23rd and 24th into Xmas morning. And will therefore be asleep until lunchtime. Oops.
- See my Mum, who is back from gallivanting (in an unrelaxed fashion) around Europe.
- Make some more stuff, to clear my decks a little, and just for fun.
- Find a nice plastic Xmas tree - why are they all scratchy, dull and spiky? WTF? Our previous tree - which I bought in 1983- had semi-glossy authentic looking cypress branches. I paid $21 for it. It was terrific. Last year I was determined to replace it (getting a bit shabby), and spent $85 on a truly horrible tree (dull, scratchy, too dense). Which we all hated so much I didn't bat an eyelid when hubby tossed it this year. Even a silver tinsel tree would be better than some of the ones I have seen recently.
Please - don't write too much of interest on your blogs, dear friends. I spend way too much time attached to this Bloglines. The above lists will take time to achieve. Take pity on me.
Now how do you spell s-e-l-f d-i-s-c-i-p-l-i-n-e?
Wednesday, November 12, 2008
She is my manager. I sent her a balanced, insightful, self-deprecating (and only slightly whiny) email about my plight. And how I love my job, and want to further my career. About how it wasn't fair to move me to the ward just to get holiday out of them.
"Don't be ridiculous!" she said. "Everyone does it. So...first two weeks of February? Done. Sign here. We'll use the same method for June - you're first in line. Tell us when your dates are sorted."
Sheesh. (insert pic of blushing, sheepish and relieved look here)
Thanks for your sympathy and tolerance for my inexperienced whining. I wonder when I will be a real grown-up and understand the workplace better?
Now ... I wonder if Eagle Bay is available?
Tuesday, November 11, 2008
Apart from one year in 1985 I have not worked full time in a regular job until I started work as an RN in mid 2005. I have had the utter luxury of being a stay-at-home wife and mother (albeit with considerable voluntary commitments by choice) for most of my children's lives. I worked one day per week for money from 1996. It was pretty good.
Since I gained my qualifications as a registered nurse I have been employed at the hospital nearest to my house. Because its easy and I'm a bit lazy. And we only have one car. Besides, parking is appalling and I walk to work. And my husband and I prefer to be near to our places of employment and we were able to buy into the area in 1984 (when we still paid 2-3 x what people were paying to live in suburbs further away). My employer is also a specialist in women's health and maternity care. My field.
I relish my work. I find it very absorbing. I think about it alot. I have plans to experience a wide range of areas, with my eye on a longer term goal of being community based. I like to see people in their own environments. That's where health (or a lack of) impacts on people. With respect to maternity care, childbearing is not an illness for most people but it can be a challenge to the health systems of some with underlying conditions, or poor health and nutrition. I like to understand how a pregnancy fits into someone's LIFE.
So I am working about 3/4 time. And fitting work into MY life. I still feel I am a beginner at this. Because of the way I work I move around between areas, 2 months here, 6 weeks there. Mostly with around 2-3 months notice of where I am going, in broad terms.
I am coming to understand that while this is intellectually and professionally stimulating, it has a downside. Namely that my family gets the leftovers. Of me. I am frequently not home for evening meals, weekends, sporting events. Or if I am at home I am sleeping. Or wishing I was asleep. Or mentally exhausted and needing to unwind in front of the TV. Or at the computer. I spend more time communicating with YOU, readers, and others whose blogs I read even if they are unaware of my attention to their whimsy, than with those I live with. This is not always ideal, or appreciated by others in the house.
So to get some time to spend with said others in the house I apply for leave. That I have accumulated. That I am theoretically entitled to. That must fit in with the needs of the organisation. That comes on a first in best-dressed fashion. With advance notice an advantage. Major planning required. Others always ahead of me in a queue. Because I don't (can't, not always) get much notice. Do you see where I'm heading with this?
I am becoming frustrated in my attempts to achieve a better work/life balance because of planning. I am not used to planning this way. The problem is largely mine. I chose to work in this way, to gain experience across a lot of areas. I hadn't anticipated the pitfall of leave planning. And major short-staffing issues - which means that the employer has need of labour and doesn't have the capacity to replace any more staff if they are on leave. Which sucks for the employer as much as the leave-deprived staff. Morale drops because people are not able to recharge their batteries. They feel flogged and overworked, constantly taking extra shifts to meet the shortfall of staffing. I am by no means an island in feeling advance planning pressure. It must be dreadful for the managers to try and fill the rosters with a decreasing number of staff. Almost no-one works full time. Days off are breathing space for the weary. For the sleep deprived with constant body-clock changes.
I don't know how systems can be sustained in this environment. I've only been working for 3 years and I'm getting frustrated. There is no leave available in one of my key areas until mid-2009. And there are others ahead of me in the queue. I can't apply unless I know where I'm going to be. By which time I am never near the top of the queue with a chance of 'getting' the leave.
Many have resigned permanent contracts over the leave issue, and now work as casuals - picking and choosing the days and shifts they want to work. They have to be organised, but it seems to work for them. Of course they rarely want to work night shift, so the bulk of night duty falls to permanent night staff, supplemented by other permanent staff taking turns to work night shift. 2 weeks on nights, 4 weeks on days. It is not easy. I can't see that managers have much choice. But it would be nice to think it will change for the better sometime soon. I could always follow suit and resign and go casual - but that would mean that I lose access to some of the areas I have yet to gain experience in (i.e. I have NO chance of being rotated through those areas if I am a casual) and hence I will never get those brownie points on my CV. Which I'm not building just to take to heaven. I need those experiences to move into the community. Therefore casual = serious career limitations.
My family are resigned to my shift work. They, of course, don't get the rewards that each particular shift gives me in terms of my contact with people, the buzz of a birth, or the camaraderie with work colleagues. I do love my work. But I don't think my family are finding my absence endearing, for all that they are pleased that I love my work. My husband works really hard, and our kids are not the most forthcoming houseworkers or cooks. He is entitled to be somewhat cross when he comes home at 6-45 to a wife still asleep after an interrupted day of catnaps and another night shift ahead, and a dinner not even underway, and adult kids lounging around waiting for the fairies to pop dinner in front of them.
The reality of life as a midwife, being on call (not yet but one day), shift work including lots of night shifts will continue to take me out of their sphere. And return me tired and in need of space and solitude to recharge myself. Which is clearly lacking currently.
As I have alluded to before, this is the first year that I haven't had a kid in school. A reliable 9-3 timeslot where I can have the house to myself. For creating, thinking, reading, sewing, playing bingo - whatever! Where I can just pick up my keys and go out without answering to anyone, or stay in my jammies if I want to. No-one draping themselves over my neck and hassling me to 'do that thing [insert needs of others here]'.
However loved or needed I am by others, I need myself too.
I suppose I am also struggling with the idea of ambition. Of ego. Of stepping deliberately (a little) away from family ties that have been so strong, and at a time when children are usually becoming more independent, ours are not. (For various reasons. Some of them too difficult to go into.)
But I want to strengthen my professional self now. I work hard and happily, in a high-ish pressure environment, and need to re-charge to sustain this. Some regular hours alone, and definitely some time with just my husband would be just what I need. I am planning and applying to all and sundry, while taking my place in the queue (sigh).
Pray for a solution from this seemingly insoluble mess, that will continue to provide the range of experiences I need to build a career doing the work I love.
In other news...
I do apologise, in the public domain, to all those behind me in the queue at a large office supplies outlet yesterday while I insisted, implacably, on a refund of the $50 difference between the price of a new laptop and the slightly higher price of the laptop LEMON that my daughter purchased only 3 months ago, which was being replaced after 2 lengthy delays for major and unsatisfactory repairs. It was the least they (the company) owed us after all the inconvenience. Bastards. We received the refund. Only after I assured him I was quite happy to stand there for the next hour and explain the principles of customer service obligations to him while his potential customers streamed out without their purchases. I am a largish woman and can block an aisle quite effectively. His junior staff were all hissing at him to do the right thing, don't be ridiculous, pay her because it truly is an absolute dud. I even insisted on it being recorded on the electronic comment section for the register "Product exchange - DUD". Take that large corporation whose after sales service sucks.
And finally, I am overwhelmed with joy at the wisdom of the majority of American voters. Intelligence and integrity is welcomed back to the White House.
Tuesday, November 4, 2008
I worked last weekend and had two very different days!
On Saturday I met a young couple having their first child. In spontaneous labour, not wanting any pain relief, very private, from a non-English speaking country but they spoke very good English, which is always a help because my Arabic sucks (I have three words). She declined the opportunity to have her baby caught by a male resident doctor, so I was actually in with a chance at catching this baby myself!
She laboured really well, steadily and stoically. It was such a breath of fresh air to see her. No drips, no CTG, no drugs, just massage and movement. Gripping our hands and calling to God to help her. Membranes intact, walking well. I offered the shower, or a bath for pain relief, she chose the shower, but she didn't seem to want to be away from me for too long. So I stayed, and talked soothingly to her, encouraging her, applying counter-pressure to her back with the pains. The room was fairly quiet, the day drifted away.
Earlier we had talked about the usual progress of labour, how she was smiling now at 3-4 cms dilation, contracting 3-4:10, but things would heat up and get intense and she may feel desperate and out of control and restless. That was all normal, I would welcome those signs and she should trust her body and allow it to function in this way. She looked a bit nervous but secretly determined, and a bit excited at the prospect. Sometimes I will explain that the intensity feels a bit sexual, and this is when they can reach for their partner and focus together, as they complete the activity that started 9 months ago. It is really intimate, and often noisy in a similar way. My job is to hold that space for them, and help establish their confidence to get through that intensity together.
And so it unfolded. She did so well. He did so well. In the last 2 hours or so I barely left the room, as she entered transition, trying a bit of gas briefly, then throwing up and getting back in the shower. She was just beautiful, unveiled, naked at times, breathing hard, reaching for us and accepting our assurance that this was exactly right, prevailing, pushing through, napping between contractions then rousing to focus again.
At 8pm her waters broke in a gush. Could she feel a baby in there? Have a feel! No, she wouldn't but I could if I wanted to. I could feel him quite close. I guided Dad's finger gently in, he gasped in delight, his jaw dropped! Go ahead and push. By 8.10pm there was suddenly a head well on view, and I laughed and scrambled to another pair of gloves. Their son was born at 8.16pm, with one hand tucked up under his chin, and a full head of hair, and an intact perineum for Mum. What a triumph for her, what a delight all round. All 3kg of him. Just beautiful. So clever. Baby Mohammed tucked in for a feed quite quickly, Mum lying on her side and resting after her efforts, both of them relaxed and sleepy after a big day. What a natural she was, she should definitely do that again!
Noting his birth later at home I realised that he was the first baby I had caught all by myself (no midwifery or medical student, doctors, intruments by docs, or gone to CS) since 12th August. There was a second midwife present, but I was the only one to lay hands on him to birth him. I am quite fussy about calling a baby 'mine'. I must be the primary accoucheur. There are many, many babies that I suppose I could call half mine, where I was gloved up and guided hands, then someone else 'got the catch', with me as secondary accoucheur. Even for the babies I have seen through to CS lately after long labours, where I am listed as witness to the birth and I have signed the birth certificate forms. But there is something pretty special about seeing and feeling their wrinkled scalp appear, watching the face emerge and blowing bubbles or mewing a bit on the perineum. I love that bit the best I think, when they are just head out - poised between worlds, a soul hovering in transit. Then to guide a baby's shoulders out after waiting for their dear little head to turn, then placing them in their mother's arms, or helping Mum or Dad to bring them the rest of the way out that is, oh, just sooooooo amazing. There were 3 people in the room, and now there's 4 people in the room. Yay!
So full of the joys of Spring I waltzed into work on Sunday morning. It looked like I was going to get another one, a young primip at 8cm, labouring all night, but no. Her progress was really slow, really slow, and she was unwell, febrile, tricky epidural, offensive smelling liquor. She was a big girl, and quite immobile, a bit passive. She ended up having a CS mid-morning, baby a bit flat, needed some resus, really whiffy, probably with sepsis, but not doing too badly really. Poor love. Lovely family, that little baby boy P, will be well loved and cared for. He was a big'un too! When we took him down to SCN he weighed 4.220kg (9lbs 5oz). I saw his Mum in recovery and she was just relieved it was all over, and couldn't wait to get down to see her son.
I returned to LBS gasping for a cuppa (11am) but no - I was sent straight back to theatre with another woman who was opting for a CS due to a big baby. She was another really big girl, we used special lifting equipment to move her safely onto the table. There were delays for one reason or another and by the time the baby was born at 1301 I was getting really cranky for some nourishment! Further delays in the ward receiving the baby, and I finally took baby S to the ward where she weighed in at 4530g - (10 lbs) with an enormous head - 40cm (av. = 34-36) - the biggest I have ever seen on a baby - her head looked like a bowling ball. Good decision on the CS! No wonder that head hadn't entered the pelvis!
By this time I was feeling quite vague and trying not to cry (I really ache when I'm standing in theatre, and being hungry and thirsty too, boo hoo, woe is me). I got back to LBS at 1355. I fell on the nearest spare meal from the patient trays and wolfed it down, with my feet up on a chair. I couldn't even talk, but after 20 mins rest I was feeling more human. I finished my paperwork as quickly as I could, weighing the smelly placenta with a student to show her the probable chorioamnioitis, and tracking down small details from the two births I had witnessed that day, plus a form from the previous day that the ward had lost (I found it, they had been having a 'boy's look' It was there all the time). By 3.25 I was off home, I actually walked home after my earlier exhaustion! The exercise will do me good.
So now I am starting 4 nights tonight. I have a social weekend planned in between sleeping, and hope to catch up with the girls for a pseudo-camp weekend. It should be great.
I look forward to hearing about an Obama win in the USA elections - the alternative is just unthinkable!
Wednesday, October 29, 2008
I have made an actual list of things to excuse my absence, well...more like things that happened when I was away from the keyboard and I feel I might tell you about.
I have been op-shopping (clearly I desperately need more stuff in this house). Buttons galore, some cast glass pieces (imitating cut glass) that I seem to be collecting. Do they have a name as a style? Please let me know.I wonder why I like them? They remind me of my Nanna's sugar bowl which I have and use daily. I'm sure that the sugar bowl is absolutely nothing special in terms of value, probably a fancier looking piece from a department or chain store, but it has always been in use with the Sydney Harbour Bridge spoon from my earliest memories (at least the mid-60s). It has the lovely quality of looking beautiful (esp when freshly washed) but as solid as a rock...let me take a picture (oh bugger, now I'll have to wash it....might as well photograph the rest of the haul....semi-prepared blogging...grumble...grumble). They were all as cheap as chips to buy, but I do like them.Here ya go. I use this one as a pin dish (it may very well be exactly that).
More Wild Women have been crafted, including some brown ones. I am not a brown person. It looks hideous on me. Its not 'my colour'. So I used to naturally shy away from it as a craft choice....but lately I have realised that it was cutting out a whole range of palette for me to play with, and it does combine well as a neutral with all sorts of colours. I don't have to wear it to use it. I'm pleased with these women. I haven't named them yet...But they please me inordinately.
I went to an Enjo party last week (sigh, don't get me started on party plan selling). To be sociable, and because I love the party holder dearly. I knew her late mother, and now the daughter, M and I have ended up doing nursing together (sort of, she was the semester ahead) and midwifery in the same class. When her mum died in 1997 some friends were asked to make quilt squares for a memory quilt for the family. I hadn't started quilting then and I am embarassed to recall my efforts, but I made two blocks for the quilt and sent them off, but never saw the finished quilt. M showed me the quilt at the party. Its huge! And I was relieved that my squares weren't as badly finished off as I recalled.
I was at my daughter's swimming competition last weekend and for some reason (anticipated boredom?) as I ran out of the door I grabbed something to do while sitting for hours. It was knitting. KNITTING!!!! Good Lord! What possessed me? Anyhoo....Using op-shop chunky wool and 9mm needles an elf hat emerged. Quite randomly. For a creamy-beige elf. No pattern, no clue, made it up as I went along. The daughter came third in her race too. I continued the illusion of knitting the next day and attempted to make a headband for the wild-haired son - either his head is gonna have to shrink or a cold, smaller child will find herself with an ear warmer. I suspect the latter. See I can actually knit, just randomly. I even knitted the headband in the round on DPNs!! Double Pointed Needles. Are you impressed? It was a complete pain in the ass, but I'm stubborn. I thought about unpicking it, but instead I got it off the needles ASAP. It's not completely finished, but meh, what's a few buttons. I even crocheted the flower thingy, with the last of the wool. Oy veh. I am NOT dedicated to knitting. Can you tell?
I caught up with a long-lost sister on Sunday (well, not quite lost, but you know...). She is doing well at this end of a very stressful and difficult year, and is enthralled with her new puppy, a pedigree Shi-tszu with a very long name, Poppy for short. Very cute. Sooooooooo cute. Did I mention that she is cute? No photo, sorry, but she is cream, gold and sable saddled with symmetrical markings. She matches the long-haired Burmese cat. And the furnishings. Deliberately. She is just what my sister needed, and I am so pleased to see her looking content.
We saw a movie 'Burn After Reading' on the weekend too. It was really good, hilarious and wicked. Are people really as completely and relentlessly unfaithful to their spouses as depicted in the movies? Or just in Washington? I know, I know, its just a movie, but it did strike me as weird. There was only one sympathetic character in the film. Brad Pitt was so funny as a bonehead gym worker. Frances McDormand was brave and wonderful in her role. George Clooney was as adorable, but despicable as the sex-obsessed public servant. John Malkovich played the uptight, pernickety husband to perfection and Tilda Swinton was revoltingly good and believable as the cold wife of Malkovich's character. Recommended if you like quirky, off the wall plots.
Work has been good too, absorbing and challenging. My baby drought has continued, I haven't caught a baby myself for about 5-6 weeks. I cared for 2 families with stillborns last weekend, they were so sweet and tiny, their parents were devastated to see the end of their hopes for those children. The memories we make for them to keep are so important, and I'm always delighted to work with midwives with great photography skills, or presentation skills who will help create worthy records and mementos of that short precious time with the baby. Parents are always so touched to receive the gifts of quilts, clothes, teddies etc that are provided for their little ones, often by families who experienced such a loss themselves and in memory of their own baby. Grandparents who provided teeny little teddy bears 4" high can keep a photo of their grandchild's perfect little hand on teddy's tummy, just the right size for a tiny 23 weeker. Its a privilege to care for them.
I'm starting to make plans for next year at work. I'm talking to my manager about rotations to a birth centre on-site, that provides care across the continuum for low-risk women in a team or group practice model. They work shifts and regular on-call, do their own education sessions, and provide short-term postnatal care on-site (<24hrs) and do their own visiting home postnatal care. I am looking forward to seeing more spontaneously labouring women. Fingers crossed for my rotations!
Last thing! I went to craft today with all my old friends. They are all besotted with my Wild Women (what's not to like?) and want me to lead a class in making them, so I will find a date in early December for that. We made some silk 'paper' with silk 'topping' and added threads. I'm quite pleased with it. It should be a cover for a new small journal, or maybe something else. As I said at craft this morning - I may use it straight away, or I may find it again when I am 72 and I hope I remember the day when I made it and the company of such dear friends. And the friends I shared it with online.
Right! Consider yourselves caught up!
Thursday, October 23, 2008
Am still reading blogs x 103. (updated 105, hello William Horner)
Lots of work.
Child 'round neck constantly.
Re-reading Harry Potter 7 (still sooking about it 4 reads later). Updated -Finished AGAIN
House is a (garbage) tip. (updated - get real, still a tip)
Must. Do. Tax. (updated - Done! for two!)
Thursday, October 16, 2008
Well, I know that keeping labour normal is not always a job for which one will receive thanks. Not that I expect any in particular. But in the case I'm thinking of, should I have done so?
The unit was crazy, like....Crazy! There had been 10 inductions started the night before and they were all coming home to roost, so to speak.
I had already seen the couple I had been caring for the previous evening (one of the inductions), who had just had their baby at lunchtime, an hour or so before I started. He was a whopper! 9lbs 14oz (4.485kg - the same as my son!) it was a pretty yukky birth in the end (he had a REALLY big head!) and she was being stitched up pretty extensively. I spent an hour or so in their room, cleaning up the chaos post-birth, and organising some solid pain relief for her immediately and planning the next few days worth of it too! There was pressure to get her up to the ward quickly as labouring women were piling up in the corridors and there was a room crisis.
So I was removed from the first couple (their morning midwife took them up to the ward) while I was allocated to another room - their third midwife of the day in all the shuffling around. There was a young woman of 25, labouring spontaneously, hot and heavy. Just holding it together with the use of gas. Oh, and she'd had a shot of morphine too. The husband was in and out of the room, and was clearly quite anxious and unsure of his role. She was attended by her Mum and sister, who were in a great rythm with her, and she sought them as each wave came. She was really focused, eyes open and intense with each contraction, membranes intact. Just how we midwives would expect it to be. Woo-hoo I thought, another spontaneously labouring primip! I know normal birth! I can keep birth normal! I can do this!
I introduced myself softly between contractions, watching quietly as the labour continued thick and fast. Checked the room quietly, gathered a few things ready to meet a baby in the next hour or so. She was so in the zone, sitting cross-legged on the bed. I was just in awe, in fact at one point I was moved to tears by her beauty and strength, she was that amazing. I almost never cry at births, and this is certainly the first time I had cried watching someone labour! Her mother and sister were a little surprised, but I decided to be unashamed about my damp face and silently pointed to her and gave a pat of my heart, acknowledging her effect upon me. They whispered to me "are you always like this?" to which I shook my head- but she is that good.
Every now and then she would rouse and speak, I took her BP every 2 hours, someone came and took the CTG machine (we weren't using it, I could use the Doppler). At one point she asked for an epidural, and her Mum asked her to wait another half-hour, which she agreed to. She sailed through that and on and didn't ask too hard again. Her husband was worried, will she be strong enough to push the baby out after all this pain now? I can't stand seeing her in pain like this. I told him that women were so much tougher than they looked, that's the way God made 'em and that his wife was an absolute Goddess and doing it all superbly.
The madness outside was not getting much better. I was asked to 'prang her' (i.e. rupture the membranes) and get her going and out of there! Well, no! I decided. She was in spontaneous labour, the cervix was dilating steadily (I was watching the line), the waters were intact and she was only just coping with the pattern of contractions now, without bringing them harder and faster, not to mention the effects on the baby - who may need those waters to help him turn to a good position for birth. There was no indication that an ARM was necessary. I regretted performing a belated ARM on staff request on a 34 weeker a few weeks ago who shot into a less than favourable position and ended up being born abdominally via CS. I was not keen to go back there again. I felt I would make the decision for the preservation of normal. So I ignored the request.
The woman refused to reposition, or get up for a wee. When she asked again for an epidural I offered to examine her and see if she was near the finishing line and that may help her decide if she wanted one or not, if the birth was going to be soon. After a wait of a few really intense contractions, she was 7cm dilated. There was a brief discussion of pros and cons of epidural, and I stated that of course she could have one if she wanted one, but that it would be a shame to turn a normal labour into an abnormal one - with a monitor and bells and whistles etc. She was doing so well. The contractions were so powerful, she was so focused .... she lost herself in the next one and kinda never brought the subject up again for a while.
I went for a meal break, ex-HB midwife relieved me and persuaded her up for a wee. Hooray! I was expecting her to report feeling pushy any time. She did report rectal pressure with the peak, but not overwhelming. There was a bunch of mucous - a good sign. It was all really intense, but 7pm came and no baby.
Back to sitting on the loo, listening in to the fetal heart regularly, noticing that the rate is always in a similar range - definitely fetal, but not widely varying, during or after a contraction. I encouraged her to drink fluids, which she did. She was getting really exhausted and desperate and whiny (its typical transitional behaviour) and I was pretty sure she was fully or close to. She agreed to be examined - I thought it was 8-9cm dilated, but there was a pulsating bit off to one side that i was sure was a front fontanelle, and a gap at the left back - bugger! She nearly hit the roof during the exam, which I apologised for, but it was important that I rule out the pulsation as NOT being due to a cord presentation. She stayed on her back, gasping as the next contraction hit, and just lay there. It was horrible to watch. I did that to her. She was coping before and now, for this one, she wasn't. When it passed I helped her immediately to a sitting position and reminded her that she was comfortable in this spot and she would be again, lets regain that working formula.
At this point I had some decisions to make. I felt that with a deflexed or neutral positioned head, even with membranes still intact, it may be a bit longer yet until she was ready to push this baby out. As I had tried to tuck the baby's head down to chin on chest, it had almost risen away from me - yet on abdo palp it felt well down, although in the pelvis it was barely at spines. Her blood pressure had also crept up, not startling, but a sign of prolonged pain/stress. The fetal heart rate variability told me that the baby was either asleep or starting to get stressed. I was getting concerned about her and felt that with all these factors I should have her reviewed. I had kept her normal, but I also recognised that this was deviating from the norm and starting to add up to needing a second opinion. The first step before any further assessment would be possible was to get her out of pain, so as not to cause her trauma.
I apologised again for the stressful VE. Then I suggested she have an epidural, as although she was progressing well, I felt it may be a while yet due to the baby's position and she may need break from pain before the effort of pushing (funny how we can couch the same words as the husband in our favour when we have to, eh?). She readily agreed. Gratefully agreed. Almost kissed my feet agreed!
So then we waited for an anaesthetist. And waited. Finally after 45 minutes (the longest 45 mins in her life I bet) a consultant comes in from home. He is fast and good, considering we don't even have IV access yet. I had everything assembled, the machine, the epidural stuff, the IV stuff. It is in quite quickly, just in time for the night shift staff member to come on. I was attaching the trace as she entered, doing BPs, the woman was smiling, hubby smiling, the intensity was all altered. We were saying that we had waited for a while to meet this baby and the night midwife was going to catch him instead of me - yet I would have bet good money that I would see this baby before the end of my shift! Oh well.
And then we saw the trace. Gulp. It was pretty awful. Late dips all over, pretty crappy variability. Still contracting frequently but oh my, that baby was not coping well. It was the first time we had put a trace on him - there was no reason to - this woman was normal, low risk, and now look at it! The night shift midwife scooted me out the door as I had a morning shift the next day. She is a very capable new midwife with ICU experience, and loves a challenge. So I went home.
I slept really badly. I woke up at midnight and couldn't get back to sleep until 2-ish, and then only fitfully. My alarm was going off at 6, and so when I woke up and started tossing again at 5.30 I gave up and got up.
I dragged my yawning butt into work, where I found out that the baby was born by vacuum extraction at 1.26am, and needed a bit of resus with Apgars of 4 and 9. They had ruptured membranes not long after I left (when she was comfy and in no pain) and there was thickish meconium. Followed by fetal blood samples every hour or so, which weren't too dire, so she was allowed to push for a while before they dragged that 4kg baby out of her when the trace got too terrible to watch any more. Baby was sent to nursery for a while due to respiratory distress. I saw them briefly the next day, still with the whole entourage in tow, and trying to breast feed the baby with 6 people in the room. Sigh - what are their chances of establishing that?
So, in terms of normal childbirth, what did I preserve? Was I all misty eyed about my ideals for her birth? Everything I did was on her birth plan. Should I have said YES, Certainly! when she first asked for an epidural? Which wasn't on her birth plan, and of course she can change her mind, although could she have known that she would cope so beautifully that her midwife would see such beauty and cry, for fuck's sake? Was I so busy singing Kumbayah and reassuring the husband that 'this is all normal' that I ignored danger signs? Was it that dangerous? If I had blindly followed orders and 'pranged her' at 3.45pm and given her an epidural at that time would the mec have been picked up earlier? Was it there then? Did she actually care about having a normal birth? Or does her idea of a normal birth include an epidural? Cos it technically isn't...and introduces all sorts of interventions that can start the cascade of interventions that lead to CS ...oh for God sakes...you KNOW all this!
I'm a bit frustrated and bewildered. Is this a win some/lose some situation? Cos if it is, I could have just saved her all the trouble and pain and got her an epidural 5 hours earlier - even though it would have meant finding a spare CTG machine in a full LBS with all the women on all the monitors already...sigh. Has anyone been done a favour here? Answers on a postcard please.
In other news - something else I know now, that I didn't know last week, is how to suture perineums. I did a workshop yesterday. It was fun! Yes, really. I can now be Really Useful. I took to those knots like a duck to water. It was fun having a trial run on a piece of mutton. It took a while, but I think I am willing to do it under supervision this weekend when I am working 5 shifts in a stretch. (We then had to undo all the stitches so the demonstrator could take it home for her dog! )
Thursday, October 9, 2008
I had 2 lovely shifts with a student midwife earlier this week. Yes, really, and no drama was attracted! It was such a wonderful change (for us both). We were both just delighted with our birth together on Monday.
We entered for an afternoon shift to an 18 year old primip who had just achieved full dilation about 30-ish minutes ago. Her morning midwife was gentle and very low-key and non-interventionist, and has recently returned to the hospital after a long stint working with homebirths, so I knew she had really good assessment skills and faith in the natural process. It was a spontaneous labour and the room was calm, and the only attachments were the CTG because the woman had opted for an epidural. She was standing at the foot of the bed as we entered and the bed was arranged as a big low armchair for her to sit upright in if she wanted to. It was good to see it like that, I had forgotten that it could be put in that arrangement.
We were waiting for the contractions to do the work of inching the baby closer to the exit for the next hour before starting any active pushing. So we just encouraged her to stay upright and rest as she was comfortable with her epidural and quite mobile as well. Its a good combination when you can get it. She had her Mum and a sister-in-law with her, her partner was quite squeamish and was waiting outside by mutual consent. This was women's work.
After a while it was time to start having a push. It often takes a long time to get the hang of pushing a baby out, especially in a woman with an epidural. They don't get the same sensations of the baby within that an undrugged woman does, nor do they get the expulsive reflex that is just irresistible and almost pleasurable. The midwife uses words to guide her pushing efforts, or gives feedback as she can see the progress (or lack of it) of the push. It is a tricky process. I usually start by describing what I'm looking for - a flowering open of all the bits that are usually tucked up, as they expand in the way Nature designed. I will see an expansion of the perineal area, a parting of the labia, a pouting of the bottom, a tiny bit of stool pushed out in advance of a descending head - these are the signs we look for that tell us descent is happening. Most women are (understandably) reluctant to think of the appearance of poop as a 'good thing' but we midwives are very encouraged by it.
At 1.45 she started pushing. Her contractions were quite short, and it was difficult to get much momentum going with the pushes as they would die away just as she got to full push power. There was nothing visible after half an hour of pushing. One of the docs came in and suggested a bit of synto to help strengthen and lengthen the contractions, as she was well covered by the epidural and it shouldn't distress her. So we all agreed on that, and stopped pushing for 45 minutes to let them build up and for more descent. She walked to the toilet, remained upright, and saved her energy while we went to tea.
At 3pm we started again. The woman was really mobile and I was confident that she could position quite freely to assist descent. The baby wasn't huge, but the other midwife felt the head was sitting a little tilted off to one side instead of presenting the central back of her head to the exit. I hadn't examined her at all, but trusted the assessment, and the slow progress with pushing backed it up. The answer in this situation is positioning. Keep moving. Have three contractions in that position - if no progress - CHANGE something. Free mobility is really so useful in second stage - e.g. walking up stairs, crawling up or down stairs, lunging or clambering like a bear up on the bed or over a chair can shift the angles of the head in relation to the pelvis and provide that 'give' that gets things moving. So in this case, with a young fit, mobile young woman I was determined to give it a go, and keep birth normal!
I can't do it, its not working she cried. Nonsense - it just hasn't worked yet sweetie. You're doing so well, you're really actively giving birth here, not having it taken from you. Pull it out, suck it out! she moaned. No, we may need to ask for a hand in a while, but first we need to know you have tried everything! Leave no stone unturned for you to give birth unassisted and push this baby out on your own. She agreed that was worth doing.
By this time I had her standing on one leg with her other leg kneeling up on the bed at near right angles. I was kneeling behind her, gently stroking the base of her spine and hips, encouraging her to rock in wide circles while I spoke soothingly to her, encouraging her to sway her pelvis to shake that baby loose. She was in a bit of a trance. With each push she would strain, and then hold back as she sensed something shift. She didn't want to poop or fart. I told her quite plainly that I would cheer if she farted in my face! It would mean something was moving. We all had a laugh and with the next contraction a teeny bit of poop came out - hooray we were on the move!
The morning midwife was due off shift, but was keen to see a bit of this baby's head. Alas that bit of poop was all we could manage for the next 15 minutes. She went off after giving a top-up of the epidural as the woman was feeling the contractions again and we felt the relaxation of less pain for her would help us all out if it was going to be a long process, and frankly, with such slow progress it was likely she would end up with an assisted birth. She left at 3.35pm.
A bit more poop. Change position. Back onto the bed to push sitting back a bit, on the side now. More poop. Finally we had some labial parting, but then she would hold back when it moved forward - it does feel a bit freaky, but I remind women that if it feels scary you're doing it right! I encouraged her to feel inside and tell me what she could feel. She was reluctant, but I could do it if I wanted to. There was a little head about an inch inside. Swollen on top but finally close to the world. With the next contraction she had a go and felt it too. Eee-ew! she said and wiped her finger- but her eyes lit up a bit - it was real. There really was a baby coming! It was 3.45pm.
The contractions were still quite short, but I would get her to do 'one more push for luck' as it was easing off, which unless I asked for it she would try and get away without doing it. 18 year-olds are so cheeky! It became a running joke. At 3.47 there was enough labial parting to get a peek of the head with pushes. Head on view. At last. The trace never looks good with pushing especially at this late stage. It is physiologically normal for the heartrate to reduce with the contraction and expulsive effort, and to recover between contractions as the squeeze is off, but it is watched nervously nonetheless and with central monitoring there are often many people watching. This means that there will frequently be someone at the door asking if things are alright, or actually entering the room and tempted to intervene if they don't quite trust that things are well or moving fast enough.
That little head stayed elusively away from the exit. She just wouldn't crown. I started to mentally prepare for a shoulder dystocia (as is often preceded by slow descent) and quietly communicated this to the student, planning which side we would apply suprapubic pressure from and getting the bed controller at the ready for fast maneuvring in case of emergency.
I heard the door open as she was pushing again. I spoke more loudly than I usually do and said "good girl, yes, thats much more head than we've seen so far, ooh look at that hair! Good pushing, nearly there" as the feet at the curtain identified themselves as the consultant. A quick peep around the curtain to glimpse the vertex for himself and he melted away again with encouraging noises. It was 4pm.
With the next contraction there was a little more head to see, but still not too much. I examined her to see if there was a band of tight tissue, considering an episiotomy, and feeling only a smallish band of the hymenal ring, but a lot of moulding of the head and it was still a bit tilted. It was a tightish fit (what you would expect really) but I could slide my finger all around the head and couldn't feel a hand as well or anything, so we would just wait. Maybe consider legs pulled right back, and recline back a bit more. Ah there we go, thats the best we've seen, we are nearly crowning now. The shortish contractions inched along but came frequently enough. The woman was getting desperate despite our encouragement - can't you suck it out? No honey - its honestly not worth opening the sterile packs - baby is right there. Don't give up, she'll be here any minute. She could shoot out like a pea with the next contraction. It was 4.15.
I heard the sound of the vacuum trolley being wheeled outside the door. At 4.17 the door opened again. It was the young female doctor who started the synto. Ah very clever, she cried as she could see the almost crowning head. Our eyes met and we were thinking the same thing. She came in for backup- we both prepared for a shoulder dystocia by dropping the head of the bed, with legs pulled back. Finally the head crowned, followed slowly by the face and then the chin. We waited for a turtle sign, where the chin pulls back into the vagina as the shoulders hook up on the pelvis. No turtle sign, feel around for a cord at the neck, no, no cord, ready student? Its all yours, OK hon one last push now - here she comes! It was 4.20pm and cheers erupted in the room, the young Mum was sobbing with relief and joy, her Mum was misting up and SIL too, and she came forward to cut the cord. Little Aliyah was a bit stunned but soon had a brief yell and then lay frowning and blinking on her mother's chest in the afternoon light as she was cuddled and wiped.
What an effort! A three hour fifty minute second stage. Admittedly with an hour and a bit for descent initially, followed by another 45 minute rest, but it was still pretty prolonged for a hospital birth and she still managed to push her baby out. We were all absolutely rapt. I felt like a Midwife! It was rare to get the space to conduct such an active second stage, with minimal intervention from docs or others, and the woman herself was just terrific. She tried so hard, and pushed so hard, and cooperated, and hung in there despite collywobbles at times. It was such a group effort. We were all just thrilled to bits. And an intact perineum with minimal blood loss. Baby number ten for the student midwife, who was just tickled pink. She too felt we had dodged a bullet, no assisted delivery, a truly active second stage even with the epidural. She said she learned so much about positioning, and moulding and understanding the principles of descent and pushing with an asynclitic presentation (the tilted head). It was just great.
Dad came in within minutes and was suitably delighted and misty to meet his daughter. Baby Aliyah saddled up for a feed promptly, and boy could she suck! What a talent. Her mother had great nipple shape too so it was easy to put it all together with minimal assistance from us. We couldn't praise them enough.
I saw them again the next day and they were doing just great, all smiles, very comfortable and pleased with themselves. What a lovely start for this little family. I'm so pleased for them.
The morning midwife saw me the next day and was skipping that we had achieved a spontaneous birth. I was still grinning too! I swear I must have had the Jedi mind control that day - to talk soothingly to all the docs and others, reassuring them and having them melt away while we had that head on view for so long. It was fascinating, and I suppose that they must have had confidence in me to call them if we needed help. I was completely fine with the backup of the doc at the last minute, in cases of shoulder dystocia you don't want to muck around, but the student midwife got the catch after all her hard work that afternoon. It was win-win.
Our next shift together was also terrific, a lovely woman and her husband and Mum, where she had had a shoulder dystocia with her previous birth, so it was certainly the flavour of the week! She laboured really intensely with us all shift, and we were sure we would get to see her little one, but she went on to birth an hour or so after the end of our shift. The birth was straightforward with no emergency, so we were pleased to hear that even though we didn't get to see her baby.
Achieving that birth on Monday has boosted my confidence in my 'normal birthing' skills, that are easy to lose in a tertiary hospital environment. I do recognise normal. I can model the normal to my student midwife. I can keep birth normal. I can recognise if things deviate from normal and am trained to respond appropriately, but all the time I am shaping my care and responding to the needs of the woman at the centre. It is good to have this experience after a few weeks of turmoil and drama (which is still playing out).
I love being a midwife.