Midwives of the Revolution

Explorations, analysis, and reflections on women's health, midwifery, and politics from a feminist, marxist lens


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Tears

Some days, I come home on the verge of tears. This is my body’s way of telling me that I am soaking up a bit of secondary trauma. I am good at being an emotional sponge, but that is not going to work for me long term. Here is a short list of some things my patients shared with me, that made me tear up at work and once away from work in the last two weeks:*

  • Partner being incarcerated during her entire pregnancy
  • Being set up and attacked by a group of people that she thought were her friends
  • Being intentionally burned as a small child
  • Child sexual abuse
  • Partner sabotaging her birth control
  • Being told that since she had two abortions, she wouldn’t be able to have healthy pregnancies

There is a choice that caregivers must make when witnessing others’ trauma — we can absorb others’ trauma/let it overwhelm our own emotions, we can distance ourselves from it/numb ourselves, or we can find a middle way, to walk with the trauma.

I aim to walk that middle way.

And it’s really not taught in nursing or midwifery school. If we are lucky, a friend, classmate, or colleague tells us about theoretical and practical work around secondary trauma, compassion fatigue, vicarious traumatization, and trauma stewardship. These are all different ways to say that people who take care of people that experience trauma also need to be taken care of. I am lucky that I learned about this field of research/practice among caregivers some years ago.

…Because if you don’t realize how bearing witness to others’ trauma impacts you, and work on it, it can take over. One who was once empathic, laughing easily, and finding meaning in life and work can fade into someone cynical and burnt out…someone who is ultimately not only unhappy in life but also an ineffective caregiver. In other words, it should be taught in nursing/midwifery/medical/PA/education/PT/OT etc. school — and supported by healthcare (and other) institutions.

I’m glad I’m tuning into this two weeks into seeing patients, and not, say, two months or two years. Because I have my emotional work cut out for me, not to mention clinically, as I develop competencies as a new provider — and I’m ready for it.

And that’s why I love and am honored to be a midwife. 

*I also laughed and smiled with loads of patients, and many told me they hoped I’d be there to catch their baby or to see them in clinic next time. So it’s gratifying in fun ways too!


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Condoms. The Why.

I am working in a part of the city where bacterial sexually transmitted infections (STIs) are unfortunately endemic. They are easily prevented by condom use, yet for a wide variety of social reasons, the majority of my patients who are at risk for STIs report to me that they use condoms sometimes or never. These same patients often present to the office not only to be tested for STIs but also to report bothersome vaginal discharge that may or may not be related to STIs. Condoms are readily available in my office — in a basket in each exam room, or in paper bags of 15 of them that we can give out, or even by prescription at the pharmacy on site.

I want to share my top five reasons I encourage condom use for my patients and others who are at risk for either STIs like chlamydia or gonorrhea but also for this bothersome discharge known as bacterial vaginosis.

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1. Safety

Starting with the most obvious/boring/basic/duh. If you have sex with someone who has one of these infections, or HIV, or even HPV, you greatly reduce your risk of being exposed to their infections by correctly and consistently using condoms with those partners. Great for casual encounters, someone you don’t want to or can’t talk to about their risk factors for STIs, or someone known to have these infections. 

2. Less Mess!

Let’s face it, male-bodied people are messy when it comes to sex. Their ejaculate can get all over you if they pull out or if they come in you or during other sexual play. It’s nice when you wrap it up that if you/he removes the condom appropriately after coming, that mess stays put in that condom and not all over you/your sheets/car/bathroom/couch/wherever you are.

3. (Added) Contraception

If you are trying to avoid pregnancy and have sex with a male bodied person, using condoms for penis-in-vagina sex is a great primary or secondary family planning/contraceptive method. If you *always* use condoms correctly, this method is 98% effective — meaning that if 100 women are using this method correctly all of the time, only 2 of them will get pregnant. Of course, not using it correctly every time is less effective — but still 82% effective. This is great added protection from pregnancy if you use another method, like the pill, the patch, the ring, or the shot. 

4. Fewer vaginal infections

That thin, white, fishy smelling discharge known as bacterial vaginosis can be prevented with good vaginal hygiene and by using condoms. This helps keep the environment of the vagina nice and acidic. Your vagina has this lovely acid-producing bacteria (the “good” bacteria) that can get disrupted by semen/cum, which is very basic (going back to some chemistry here…). If the semen isn’t hanging out in the vagina, it doesn’t have a chance to change the vaginal environment, so you can keep it acidic in there. (Then, don’t douche or use those other “feminine” products…more on that later!)

5. It involves your dude!

Unlike most birth control methods or things women/female bodied people do to keep ourselves safe and free from pregnancy, etc., condom use directly involves your guy. This may not always be possible, if he hurts you or wants you to get pregnant when you don’t, or he wants to have other control over you. But in a safe and healthy relationship, talking about condom use and safety can add intimacy and a shared commitment to your safety. 

Now…the HOW of condom use is another thing. If it were as easy as telling people WHY we probably wouldn’t have such high rates of STIs and unplanned pregnancies. So, that’s for another day.


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“[Knock on wood]…So if I got pregnant and you took care of me, you would come to my house for the delivery?”

#1 myth about midwives:

We only/always attend birth at home.

So…more on this later. But (for better or worse) the vast majority of midwives (particularly nurse-midwives) in the US attend births in the hospital–including me. We can take care of low risk pregnant women — meaning, we need to consult or co-manage your care with a physician if you have an issue like gestational (or pre-existing) diabetes, hypertension in pregnancy, twins/multiples pregnancy, preterm birth, or need an instrument (vacuum or forceps) or surgical (c-section) birth. Otherwise, we are all yours for the normal stuff!  

One day, women will be healthier, birth will be less risky for many women, we will have single payer or nationalized healthcare, and birth can again commonly take place in the home, for women who want it. And then or perhaps before that day (but when I have lots more experience under my belt), I will attend home birth. Until then, my nurse-midwife sisters (and a few brothers!) will take care of you in the clinic/office for your gynecology and prenatal care needs and in the hospital or out of hospital birth center when you need to deliver your baby. 


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Orientation Time: The Cervix!

I’m on orientation for two weeks — I get 4 patients in the morning, and 4 in the afternoon. That’s supposed to give me lots of time to get to know my patients, the charting system, and how things work in the organization with patient flow and all.

It’s been a year and a half since I graduated. The only other times I’ve laid hands on “patients” is when I have been doula to the friends and family that asked for pregnancy, birth, and postpartum support. So here I am, getting the hang of using the speculum again, and I’m having to figure out simple things like how to best help a patient sit up on the table after a bout in the stirrups. Other things, like listening to women, talk before touch, and explaining what I’m doing, haven’t changed.

As I am getting oriented to the organization and to my patients, and getting used to being in charge (not a student any more!), I am trying to also orient my patients to their own bodies.

Today, I found Nabothian cysts on two patients. I actually had not seen any on any patients while a student, so both times, they threw me off — sending me to investigate first with my heavy edition of Varney’s Midwifery and then to consult with my collaborating physician (OB). 

First, you have to get a good view of the cervix. The cervix is at the “back” of the vagina. In some women, it may be tilted down (toward the back) or tilted up (toward the abdomen). In many people, it can be found “midline,” or straight to the back if you are looking into the vagina head-on. The cervix is the mouth to the uterus — it’s where the sperm has to travel to get into the uterus in order to pass to the fallopian tubes for fertilization to occur. Most of us think about the cervix because of the pap smear, HPV, and cervical cancer. It’s also the opening that will dilate when a pregnant woman is in labor, so the baby can pass through the uterus to the vagina and out into the world. 

So…to find the cervix on an exam. We usually do the speculum exam before anything else, so as not to mess anything up first by stirring the pot. This has a disadvantage, however. If you haven’t done a digital (finger) exam first, you don’t necessarily know where to look for the cervix. It could be in any of the three positions I mentioned, and you really can’t tell from looking at a patient where her cervix might be found. You also may not know what size speculum she may need. 

“M’am, please place your feet on the stirrups here. Good! Now, keep your feet here, and try to flop your knees out toward the wall. Wiggle your toes to relax your bottom. Great! Now, here is my hand [touches back of left hand to patient’s inner right thigh]. I’m going to place the speculum now. Lots of pressure.”

Placing the speculum at a 30* angle to the floor of the vagina and pressing down ensures you aren’t putting pressure on the bladder or clit. From there…you have to kind of wiggle the speculum toward the back of the vagina, then open slowly while trying to visualize the round shiny part with the little opening. Flat if she’s had babies; small and round if she has not.

Then: what is that? You want it to be round, shiny, and pink. Some might have an area of pink around the os (inner hole) — “ectropian.” Cervicitis, or inflammation of the cervix, can be seen with sexually transmitted infections chlamydia or gonorrhea, and usually comes with discharge escaping from the os. 

What I wasn’t expecting today was present for two women I cared for: 1-2 centimeter bumps on the cervix; round to more ovoid, white with pink/reddish edges, and non-tender when touched with the fox swab (giant Q-tip). To give you a visual, here is a “normal” versus a cervix where there are Nabothian cysts:

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Of course, these are cartoon drawings…but you get the idea. After I took samples from the os for a pap test, STI screen, and a culture of the bump, I did a “bimanual” exam — meaning, I checked her pelvic organs using both hands. Internally, I found her cervix with my right hand. There was a hardened area on her lower cervix, but it was not tender or painful for her as I moved the cervix with one hand internally and then pressed the uterus down with my other hand. 

Nabothian cysts usually resolve on their own, and are considered a benign condition. You can read more about them on this delightful website: http://www.beautifulcervix.com/nabothian-cyst/

I had the pleasure of learning alongside my patients today…and now have the pleasure of sharing with you, dear reader. Now: tell your friends! Get to know your cervix. Find out what size speculum works best for finding your cervix, so you can tell future health care providers which size they should reach for when doing your exam. 

And…be nice to your cervix! Protect it from possible exposure to HPV by getting the HPV vaccine; by using condoms if you are at risk for STIs; and by following pap guidelines for prevention of cervical cancer. Talk to your partner(s) about it, and ask your health care provider for more information or for help navigating your sexual health and safety. 


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Another Beginning

I started seeing patients today…on my own. 

I have been through many beginnings, from deciding to become a nurse, to attending community college for my prerequisites, to moving to a new city for nursing school, to deciding to become a midwife, to being a student midwife, to working as a nurse, and now, beginning my new practice. 

I am thanking all my life midwives as I transition…my mother, my teachers, my mentors, my patients. 

I hope to use this space as my professional life grows to share my journey and my own and others’ analyses and thoughts about the world of women’s health.