Friday, October 31, 2008

Yesterday's 24 hour call

So I paid bigtime for all the wonderful and simple births I have had this month. Yesterday's call was stressful :p

I had a lady being induced - she begged in the office to be induced because she was driving three hours one way for her prenatal care. She had some of her previous babies with us and still wanted to see us. Wow, talk about dedication :) Well, we all said no but the doc she saw for a tubal consult had his heart strings tugged from her story so I decided to go along with it. I went and met her for the first time to explain the process and then scheduled her for the next day. That's lady #1.

Lady #2 came in for induction as well, however when I had seen her in the office previously she was already contracting and 3-4/80/-1. She was a primip wanting to go natural. So the plan was just to break her water and see if she would just get going (which she did).

Lady#3 came in during the afternoon - a VBAC attempt with 4 previous vaginal deliveries, she showed up 8cm (according to the nurse).

I had just gone over to the office to see a few patients when I got the call about lady #3. I dumped my patients on the other midwife and headed over to the hospital. I sat at the hospital for about 10 hours before I had the first delivery...grrr. The VBAC attempt was successful after a few hours of watching an occasionally crappy strip with no or little cervical progress...she was really more like 6cm when she arrived. Too high to rupture so I waited and waited for the head to come down. By the time it did she was about 8cm for real. So I rupture her and guess what? Her cervix shrinks back to 6cm...grrr. I leave her alone for a couple more hours...she doesn't change. So we decide to use some 'gentle' pitocin - we started at one mu/min and never got past that. In fact, when she finally kicked in with her contractions we cut the pit off. Well, and not to mention the big decels. That had something to do with it too :p She finally delivered shortly before midnight. I was so glad because the doc I was on with has a low tolerance for 'abnormalitites' during VBAC attempts. He would have had an absolute shitfit had he come in and found out she was there for 10 hours!

Oh, I have to go for now - gotta start getting costumized - I am a zombie midwife :) I will post again tomorrow to finish the tale!


Friday, October 17, 2008

Interesting placenta

I had a fabulous lady who VBAC'ed recently. No fetal issues at all throughout the labor - baby looked beautiful. No unusual history with mom. But this placenta appears to have an infarcted lobe...I thought it was cool having never seen such a thing so got permission to take pictures. The lobe is black almost to the base. Check this out...


An older, tired-looking dog wandered into my yard;
I could tell from his collar and well-fed belly that he had a home and was well taken care of.
He calmly came over to me, I gave him a few pats on his head; He then followed me into my house, slowly walked down the hall, curled up in the corner and fell asleep. An hour later, he went to the door, and I let him out. The next day he was back, greeted me in my yard, walked inside and resumed his spot in the hall and again slept for about an hour. This continued off and on for several weeks. Curious I pinned a note to his collar: 'I would like to find out who the owner of this wonderful sweet dog is and ask if you are aware that almost every afternoon your dog comes to my house for a nap.' The next day he arrived for his nap, with a different note pinned to his collar: 'He lives in a home with 6 children, 2 under the age of 3 - he's trying to catch up on his sleep. Can I come with him tomorrow?'

Grey's Anatomy - doh!

Who wants to go to the hospital where the cardiologist does both adult and pediatric cardiothoracic surgery? After all, we know children are nothing more than mini-adults...not.

Who wants to go to the hospital where the residents...and it's not their speciality even...are starting IVs on children? After all, I see residents start IVs all the time...not.

It isn't about us...'s about them.

If I hear that phrase one more time, I am going to puke. What it means is, midwives do this for the women we's all about the women.

Ok, yes, I care a great deal about the women I provide care for. I want them to have a wonderful, fulfilling pregnancy and birth. I want them to have the journey they envision. These things are the top priority when providing care for women.

But I am a midwife, a mother, a wife, a daughter. Those women are not my top priority in the rest of my life...and yes, I think I have a life outside of midwifery. Granted, midwifery is still a very large part of my life.

I get tired of hearing "you don't go into midwifery to get rich", you don't become a midwife if you want to make money". SCREW YOU! I became a midwife because I love it and couldn't imagine doing anything else. But why can't I make enough money to support myself and my family without struggling paycheck to paycheck? I can't help it if my husband has a horrible heart condition and can either work or can go to school but not both. I think it sucks that we midwives are so willing to suffer and forsake what we deserve because we are so friggin' 'altruistic'. Check out this post Rambling part 2

I realize that others have it far worse - I try to remind myself when I get frustrated, aggravated...

Thursday, October 16, 2008

Happy Trails Dr Induction

Happy Trails Dr Induction!

He was actually supposed to work until the end of the month before he takes off for a job elsewhere. However, he insisted on taking his full break even with several patients waiting. Sooooo, to make a long story short - Dr Boss said don't come back.

Guess who got to see his afternoon schedule?

One of the midwives had to leave sick while this was going on.

Guess who got to see her afternoon schedule.

Another doctor had to leave to go do a delivery.

Guess who didn't have to see his schedule thank god!?

So, yes, I had a light schedule with only 4 patients. they added the other two providers' schedules onto mine. I saw (with the help of the student - I would have been majorly sunk without her help) 17 patients in 3 and a half hours - 2 of which were new OB appointments (which are slotted 40 minutes each). Agggghhhhh! But I did good :) And three of Dr Induction's patients have switched to the midwifery service :)

Tuesday, October 14, 2008

Rectal pressure

There's nothing like a woman saying she feels like she needs to poop that warms an OB nurses' heart.


I spent my whole three day weekend off at home, in the bed a lot. That sucks. But starting to feel better now. Surprisingly so since I am finishing 24 hours of call. Nothing too exciting...caught one baby, or actually the student did. And another in for cervical ripening. Just sitting here waiting to report off to the oncoming midwife so I can go back to bed.

Cochrane Review regarding midwifery care

This was just released a couple days ago from the Cochrane review on the midwifery model of care...just more evidence supporting midwifery care!!!

Midwife-led versus other models of care for childbearing women

Midwife-led care confers benefits for pregnant women and their babies and is recommended.
In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called 'team' midwifery. Another model is 'caseload midwifery', where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects. The main benefits were a reduced risk of losing a baby before 24 weeks. Also during labour, there was a reduced use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman's chance of being cared for in labour by a midwife she had got to know. It also increased the chance of a spontaneous vaginal birth and initiation of breastfeeding. In addition, midwife-led care led to more women feeling they were in control during labour. There was no difference in risk of a mother losing her baby after 24 weeks. The review concluded that all women should be offered midwife-led models of care.

Saturday, October 11, 2008

National Midwifery Week

It's National Midwifery Week - actually today is the last day - it was October 5-11th. I just want to say thank you to all midwives fighting the good fight, for all that you do.

My boss didn't do a darn thing for us. Wait until doctor's day comes around...

I was going to post a bunch of funny, sad, and crazy things midwives do but am just too sick right now (got a real nasty cold - trying hard not to sneeze snot all over the computer screen - especially since it is my mother's laptop I am using - she gets upset about that). So maybe later I'll give it a try.

Thursday, October 9, 2008

Call today/tonight

Had a couple nice deliveries with the student today - hung out with some fun patients in the office who are ready to go anytime now (hopefully when I am on call!).

Had two pages from patients this evening - one while I was attending my daughter's 2nd grade concert. Both early first trimester and both spotting.

I understand the worry...really I do - I've had a miscarriage and then bleeding off and on for the first 15 weeks of one pregnancy...but that doesn't mean it can't be monotonous. It's like telling patients they need to drink more water...we live in Arizona for crissakes! It's a cool 90's during the day :p I must tell them to drink more water a minimum of 10 times each day I am in the office.

They come in complaining of urinary symptoms but the urinalysis is completely drink more water...

Anyway, one of the women sound irritated after I spoke to her. I don't think I told her what she wanted to hear...perhaps I was supposed to tell her to rush to the nearest ER? I'm sure Nurse K would appreciate that!


1. I get Bladder infections every week for the past two years.

2. I get yeast infections every month for the past year.

3. I have migraines although I have never seen a doctor and been diagnosed with that - and Tylenol makes them better.

That was off a H&P recently from a very sweet little girl. I should have gotten an academy award for best acting performance in that visit. I kept a straight face the entire time.

Really, as a midwife you have to be supreme at maintaining a straight face. The things we hear and see are sometimes insanely crazy, or sad, or just plan funny. But....straight face.

Monday, October 6, 2008


Did you know smoking decreases the risk for preeclampsia? And keeps those pesky babies from getting too big?

By gosh, I'm handing out the Marlboros along with the prenatal vits at all my new OB visits.

All kidding aside...smoking is bad for momma and for baby. I can totally relate to how hard it is to give it up - been there done that three times. But you know what made to easier?

Smoking during pregnancy versus placental abruption, previa, fetal death, growth restriction...

Hmmm, tough choice.


Come on momma - you can do it.


It was a busy weekend followed by a conference today...I'm so tired I could.......zzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzzz.................

Oh, sorry! Well you know how it is. I made up in one weekend for the awful slow month I had last month. I did 9 deliveries last month which is pitiful. I did five this past weekend....course my student caught four of those :(

Baby number 3 arrived in the wee hours of the morning (don't they all?). The student talked her out of an epidural at 7cm...I disagreed with this decision but went along with it. Her theory was that the patient was going quickly and she wouldn't get much benefit from it. My theory was that the woman had no desire to go natural because she wanted that experience. She was going natural because she was scared she would be paralyzed by the epidural (a common misperception among many of our Hispanic women). I therefore felt it was a little unethical to withhold the epidural. I don't know - tough call there.

Baby number 4 was my lady that I sent home after the failed induction...she prodromaled...came in the day before with no change. Naturally I was getting ready to go home to bed when she called to say she was on her way. Fortunately this looked like the real deal - 5/100/-2. She labored fantastically and we had a mild shoulder dystocia that lasted to the belly button! The baby was 10-2. Great apgars and no problems... later she tells the student she had the same problem with her last one (which was close to 10 pounds). Um, ok, that would have been nice to know prior to delivery - not that we weren't prepared as I knew this was a big baby and she had a history of big babies (smallest was 9-7 I believe) but that kinda info should have been all over the chart. It wasn't. I looked to see who had done her initial OB visit - one of the WHNPs - and not the one I think highly of if you get my meaning. Figures.

Baby number 5 was actually a doctor patient but when she was informed that her doc was not on call and that it was Dr Greedy from another practice covering...she promptly said she would take the midwife (me of course). Apparently she had started prenatal care with Dr Greedy and transfered to our practice. She had a great delivery. I had the student watch me do this one because I wanted her to check out the differences in our styles. Her style is ok but just not what I had envisioned a homebirth midwife to be doing. I don't know what I expected....maybe zen mantras being chanted and incense burned, etc....:)

There was actaully another baby I caught...Dr Greedy had a patient there who was a gravida 4 para 3. She went from 7 to complete +2 in maybe 10 minutes. The nurse asked me to come in for delivery as Dr Greedy was not going to make it. The patient was fine with this - she didn't care who caught she just wanted to push! Delivery went smoothly, even with the triple nuchal cord! I was going to grab a billing sheet when the doctor who had since arrived saw me with it and flipped out. There was no yelling but the atmosphere was tense as Dr greedy told me he wouldn't bill for doing a favor...blah blah blah. I informed him in polite words that he was full of sh*t and had done it to me a few weeks previously. He said he didn't ask me to do the delivery...I said that a resident would never have made it, the other doctors would all prefer a midwife to having the resident or nurse attend the delivery (no offense intended to either parties btw). Not to mention the hospital policy states the nurses should make every attempt to have a provider present if the attending MD can't get there. You see, Dr Greedy is...well...greedy. He will try to take deliveries from other docs and bill for them...he gets to bill if a nurse or resident catches the baby. I told him that I would never catch another baby for him. I feel bad for the patient who gets burned for his greedy selfish behavior...

Saturday, October 4, 2008

This weekend

This weekend is kind of interesting yet stressful. The doctor (from another practice) on call this weekend never has midwives on call with him except Sunday night. Now that we have gone back to a midwifery service, we are covering for his weekend starting this weekend. After all, you can't tell patients "oh yes, you can have a midwife anytime now....except for this one weekend every 6 weeks".

This doctor doesn't particularly care for midwives - I think he believes we are a liability to him and he says his malpractice insurance doesn't cover us. Well, gee, you're right. Your malpractice insurance doesn't cover us...but ours does. I think the deeper issue is greed. He was making a pretty penny on his weekend covering our practice. We are substantially larger than his practice (he's by himself) so he was enjoying all that extra money.

Greed + dislikes midwives = pain in the a$$

So last night I had two ladies come in for post dates cytotec induction (both multips wanting induction but as little intervention as possible...hmmm). They were both multips so I hoped the cytotec would knock them into labor and we (we being the student and I) wouldn't need to do anything else. Well, naturally...the best laid plans and all that. I was a little stressed about doing it because we normally avoid inductions on the weekend and because this particular doctor was on. I had hoped I wouldn't see him but he came by for a delivery and naturally wanted to know what I had going on. *sigh*

I told him I had the two ladies here for post dates cytotec induction. He promptly mentions that he thought we weren't doing weekend inductions. Well, I say "mostly not, however one came to the office and wanted induction while the other came to triage for antenatal testing and decided she wanted to give it a try". I told him I can't send home anyone 41 weeks and beyond if they are requesting induction. In our awful litigious society, you send them home and tell them to wait and they come back with a dead baby...guess will become close and personal friends with a lawyer. So anyway, he just gave me this condescending smile and that was pretty much the end of it. Whew.

Now, having this scenario, I just knew that nothing had better go wrong or I would never hear the end of it. So it was a stressful night for this reason.

So what happened, you ask....

The first lady had some response to cytotec and ambulation then kinda stalled out. She wanted to continue though so we started pitocin....then she decided that she was so tired she wanted to try an epidural so she could sleep (she had never had one with any of her previous babies). So she gets the epidural. (this is starting to sound like the children's book "If you give a Mouse a Cookie"). She sleeps, we break water at 7cm and she delivers her baby 20 minutes. What a sigh of relief. There were times when the strip didn't look all that great, and she just took quite a while to get going. Her and the FOB were quite content with their little one.

The other lady had pretty much the exact same response...went from 2-3/40/-2, a little firm, to 4/60/-2 and softer. She walked as was kinda funny to see these two ladies out walking at the same time doing the exact same thing (the other one was 4cm by this time but a lot thinner). Well, this lady opted to go home after she stalled out.

In the meantime another lady came in who I had sent home earlier due to barely being dilated and not really contracting a whole lot. Well, she called me just as I was drifting off to sleep about 1am. She was really picking up the pace and sounded pretty uncomfy. She showed about an hour and a half later in active labor - woohoo! Did a beautiful and rapid labor and birth with nary a tear.

So both births were really nice although it's really hard to stand back and watch while the student does the catching. After having such a sh*tty month last month I really need some beautiful births :p Especially when one of these ladies was someone who I had been seeing in the office regularly. *sigh*

So, just waiting to see if the other one shows up sometime this weekend...oh, and back on call tonight at 1am for 18 hours...don't ask - there was a little scheduling snafu so the medwife and myself are covering the whole weekend.

Oh, and am excited - I start my first assist course on Monday as well as having a conference to attend.

My son't birthday is next week - 14 years!

More later...

Friday, October 3, 2008

Funnily (is this a word?) enough...

I had a patient who showed up for a new OB visit wanting an abortion. Sad stuff. So I counsel her, explain that we don't do abortions, blah blah blah. I felt like crying. I just find it hard to imagine being in such a difficult position. Anyway, after she left, I was trying to decide what codes to put on her superbill so asked the doctor (one of the ones I like and respect) what he would put. He then proceeds to tell me I should have sent her for an ultrasound. I guess the reasoning being that she would see the baby, and then decide to keep it.

Umm...I didn't say anything to him...yes I am a chickenshit but I am probably the only pro-choice provider in the office. Makes for a wee bit of awkwardness (sp). However, this practice of sending women for ultrasounds to convince them to keep a baby....makes me's hard to put into words. It's just not right for me to do. It seems very unfair and low-handed. So I just said she was already gone and left it at that. I know it's not just him...others in the practice have told me they do this. Crap, I felt like I was sleeping with the enemy!