Midwives of the Revolution

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


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Calling on the Saints

I am an atheist. I’m not a person of faith, though I was raised Christian. Despite my parents’ best efforts and wonderful role modeling of spiritual life, god doesn’t make sense to me conceptually or as a foundation for my world view. I have dabbled in Buddhism and attended a Unitarian Universalist congregation, I practice yoga, and there’s some Pagan stuff that speaks to me, but the only philosophy that I have been able to commit to is revolutionary marxism. A smidgen of woo-woo and commitment to personal growth is as spiritual as I think I’m gonna get.

I remain a bit of a black sheep in much of my family for not being part of any church, though I know they love me unconditionally (and pray for me often). My mother, a mystic secular Franciscan who converted to Catholicism when I was in high school, has never given up on me returning to theism. She is quite subtle in her attempts to spark faith back in my scientific mind and heart. She is not an evangelist in any sense, but she knows and works with my soft spots, like the work of Anne Lamott — she gave me that author’s most recent book for Christmas last year (haven’t read it yet).

My mother’s most successful breakthrough in getting me to open up spiritually came when she and my step-father took a trip to Ireland, where my mother discovered this beautiful cross on people’s thresholds and in some of the local shops and churches. They had been to Ireland a few times before, but she had never noticed it before. She asked around about the meaning of the cross and came to find out that it was St. Bridget’s cross.

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St. Bridget’s Cross, traditionally woven

Bridget, whose feast day is my birthday. Bridget, who is a patron saint of midwives, healers, brewers, and poets. Bridget, who by one account, may have brought the miracle of abortion to a woman in need. Bridget, who is recognized by Celtic paganism as goddess of fertility and earthly fire.

When they came back from the trip, I met my mother for lunch. I was having a hard time — I had failed to pass the certification exam for nurse midwives and was feeling a little lost, doubting myself and fearful of not being able to continue to pursue my dreams. My mother was beaming as she slid this small tissue-wrapped gift across the table to me, and as she told me about Bridget while I opened the package. It was perfect.

I have come to adopt a bit of reverence for and connection to saint/goddess Bridget. I may not believe in god, but I do find it useful and calming to call upon the “spirit” of Bridget and to work to embody her legacy when I am struggling. I keep the cross my mother gave me on my desk at work, and I wear her cross on a necklace some days. I may even get a Bridget tattoo one day. It’s not magic, but I began calling upon Bridget as I prepared again to tackle my midwifery board exams, and I continue to do so to help myself get grounded. I have adopted (and adapted ever so slightly) this traditional prayer and find myself reciting it as my mantra when I find myself stressed, worried, or needing to find strength. I’m glad Bridget’s got my back.

Brigid.
You were a woman of peace.
You brought harmony where there was conflict.
You brought light to the darkness.
You brought hope to the downcast.
May the mantle of your peace cover those who are troubled and anxious,

and may peace be firmly rooted in our hearts and in our world.
Inspire us to act justly and to reverence all God has made.
Brigid you were a voice for the wounded and the weary.
Strengthen what is weak within us.
Calm us into a quietness that heals and listens.
May we grow each day into greater wholeness in mind, body and spirit.


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Satisfied Customer

“Excuse me, I just wanted to say: You’re a really good doctor.”

-New patient today, after comprehensive exam, popping into my office while I’m charting

(Not feeling like it was the right time to say I’m not technically a doctor, appreciating the vote of confidence.)


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“Cool, you’re a midwife! So does that mean that you, like go to people’s houses?” Or: What Is a Nurse-Midwife Anyway?

The number one most frequently asked question of midwives in casual conversation or upon doing the whole “what do you do for a living” thing has to be about home birth. This piece is to set the record straight for the less informed readers and friends out there who may have some interesting ideas about what modern midwifery is about. 

International Day of the Midwife is around the corner (May 5), so in preparation, I invite you to learn about midwifery so come the 5th, you can show off your knowledge and love for women and midwives!

1. The vast majority of midwives who attend birth do so in hospital or out of hospital birth centers.

According to the American College of Nurse Midwives, a 2012 survey showed that only 2.5% of all certified midwife or certified nurse-midwives (CNMs) attended births in the home. Home births comprise a tiny minority of all deliveries — according to the CDC, only 1.36% of all births were not in a hospital setting, and that includes birth centers. 

Now…if you ask me, there are probably loads of people who would do well in out of hospital or even home birth. And I would *love* to attend home births one day when I’m more experienced. But nurse midwives would be in real trouble if we only attended home births, since these are such a small number of the births overall. Now, we capture 10% of the deliveries, which is great and probably will only increase. 

Anyway! Most of us are employed by hospitals or physician practices, and you are likely to find us as an option for prenatal care or delivery if you look. We are often listed as “under” a physician — for instance, if you were to look under your medical insurance for a provider, you might not find us independently listed, but we might be in the office as well. 

Imagemidwifery today is not like this.

 

 

2. Home birth…

Studies have shown that for low-risk healthy women, home birth is as safe as hospital birth. We are not nearly as healthy as a society as we should be, so many women risk out of home birth. But as a feminist, I believe that women’s bodies are capable of normal birth (that’s how we survived as a species) and support the appropriate use of technologies that can help lower risk (like fetal monitoring or c-section when medically indicated). 

But for now, most women have their babies in the hospital, and that has its own risks in this country. But that is where you will find most of us midwives.

3. Labor

Unlike nurses working as RNs, most nurse midwives are not in a good position for collective bargaining. Once you get to the “professional” or health care provider level, you are likely to be in a position to negotiate personally for your working conditions, wages, and benefits. Many midwives do work for themselves in private practice in a physician office or doing home birth, but the question most people ask when they find out I’m a midwife is if I have to drum up my own clientele and run my own business. And the answer is no, that’s why I work for a clinic and not as a homebirth midwife. And even though I’m not in a position for collective bargaining, at least I have coworkers, someone to do billing for me, malpractice insurance, and an office I don’t pay rent on. 

4. One Day

I want to have hundreds of births under my belt before I venture out to be a homebirth midwife. There is so much to see, so many different experiences, good and bad, that I feel I need to be prepared to attend births in patients’ homes. Unfortunately, in this country, we’re not set up to get experience this way unless we want to have our own practice/small business. 

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I love this piece. Can someone please buy this for my office?

5. In the Meantime

What do midwives do? Of course, we attend births. We take care of (usually healthy, low risk) pregnant, postpartum, and lactating mamas. But what most people don’t realize is that we take care of women across the lifespan. Yes, most of us focus on gyne issues — family planning, sexually transmitted infections, menstrual or other reproductive system issues, menopause management, cervical and breast cancer screening and prevention. Others may train to do more advanced stuff like primary care management of chronic health conditions or do more complicated procedures like colposcopy or dilation and curettage or even surgical assistance for c-section surgeries. Much like other advanced practice nurses like our nurse practitioner or physician assistant colleagues, nurse midwives manage many of the same patients our physician colleagues may also attend to. We may consult or co-manage care with physicians for more high risk stuff (diabetes or high blood pressure in pregnancy, or preterm labor), or refer to physicians for surgical care like tubal ligation, fibroid removal, or cesarean section. 

6. Science and Stuff: Or, How We Practice

For historical reasons, “midwife” does conjure up the lay healer, and that experience or association is often degraded, even among midwives. Traditionally, the lay midwife’s science was her knowledge of her own experience and that of her mentors. She learned about the wisdom of the body from attending to women’s reproductive needs from contraception to abortion to birth and postpartum care. The advent of modern medicine and the revolution in obstetric care has in many ways contributed to loss of critical knowledge about normal lifecycle events. Though midwifery wanted during that revolution, it is back and stronger than it has been in decades.

Midwife means: “with woman.” We are present with the woman (or female bodied or female identified person) for everything. Midwifery means respecting the body and helping the body and mind be healthy. Midwifery draws on traditional knowledge of women’s bodies, and modern nurse midwifery is demands evidence based practice to wed experience with science.

Midwives, like providers in any care field, practice with a wide variety of styles. Wherever we practice, whatever our style, being a midwife is not about where we deliver care to women or their babies — the hospital, public health clinic, private practice, home — but about bringing our knowledge about and respect for women’s experiences and choices. Wherever we are, whatever our job title, we should be found working with women to achieve general, reproductive, and sexual wellness goals.

No, I don’t do homebirth (yet). Most of my day is not that glamorous…I’m usually in the office assessing women’s health needs and trying to help them manage issues like unplanned pregnancy, menstrual disorders, STIs, sad vaginas (see earlier post), alcoholism and smoking too much weed, parenting while father of the baby or boyfriend is incarcerated, depression, overweight and obesity, family planning goals, and pregnancy. Promoting breastfeeding, teaching about the menstrual cycle, and most of all, trying to get women to understand and love their own vaginas–and yes, the smell that comes with it!

And sex. Mostly, my day is spent talking about sex. That’s why midwifery is awesome. 

 


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Healing to the test?

In this day of Common Core and mandatory ACTs for high school graduation, it should not be surprising that patients are obsessed about getting all the lab tests they can to make sure “everything is alright.” Luckily, unlike my teacher friends being measured by their students’ test results, my patients’ performance on tests or other health measures does not directly impact my pay or job standing. But this preoccupation with testing does impact  how I work.

What tests matter?

Don’t get me wrong. The miracles of modern medicine include such wonderful innovations as cultures and blood tests for herpes, liquid based pap and HPV tests, vaginitis cultures, gonorrhea and chlamydia DNA tests, and sophisticated tests for syphilis and HIV. You don’t have to just rely on the patient’s history and the exam findings to make a diagnosis when such tests are available. I am ever so grateful to have these tests, as I like to compare my clinical diagnosis to the test findings to learn more about what I’m seeing, especially as a new provider. And duh, there are many infections and diseases you can’t diagnose from an exam alone, like HIV.

Someone that has high risk sexual practices, like multiple sex partners or a non-monogamous partner, or who doesn’t practice safer sex with new partners needs to be screened. Luckily, our scientist friends over at CDC have figured out based on evidence that such folks should be screened for common STIs even if they don’t have symptoms, based on such risk factors. In a healthy clinic environment, we can educate patients about what health practices put them at risk and for which screening is indicated. We can point to evidence based guidelines to shape our practices, and we can counsel patients about what we recommend they get screened for. We can also educate patients on reducing risk and promote prevention.

It’s also usually indicated to offer HIV testing to all patients at least annually and three months following a positive test for other sexually transmitted infections like gonorrhea, chlamydia, trichomoniasis, or herpes.

Why isn’t it all about the test though?

I know why we’re all obsessed about getting tested for everything. It’s widely promoted as the be all and end all of healthcare. And it probably has a lot to do with the fact that lab testing companies make money every time providers order tests. They have put a lot of work into convincing the healthcare world that tests are better than anything for most diagnoses. This contributes to the the move away from physical examination as an essential skill in health provision. How many times have you been to see a physician for care and they have not laid hands on you at all? Not listened to your heart, lungs, and bowel sounds, not measured your abdominal girth, not palpated your tummy, not inspected your legs or feet? I hear frequently from friends that their doctors don’t even touch them.

We have been trained to think that the test says everything. And when it comes to women’s health, our bodies are so often the site of something wrong, something that could be wrong, and we want that test that says “everything is alright.” But we are not test subjects, we are human bodies. I hate that my patients think they need to hold themselves up to be examined like that: alright or not alright based on a test. Even if a physical exam appears to be normal or not normal, there are also other elements of the clinic visit to be taken into consideration — the patient’s history or symptomatology, for instance. Technology cannot replace the wise hands or critical thinking skills of an experienced practitioner.

Then what is it all about?

Heart disease is the number one killer of women in the United States. It drives me crazy that I have many patients who are not at risk for gonorrhea and chlamydia, who don’t even get bacterial vaginosis, but demand to be tested for these infections as though the results to those tests will be the major determinant of whether or not “everything is alright” for them. The far bigger impact on their health is not something that may or may not be wrong specifically with their vaginas but that they have sedentary lives, eat no fruits and vegetables, and eat a ton of fast food and junk food. Somewhere down the line, when they begin to develop diabetes or high blood pressure, there will be tests they can demand, and those tests may reveal whether or not everything is alright. Maybe everything is “alright” until the tests say otherwise. Maybe these test-hungry patients are trying to buy time until there will be a simple solution like a blood pressure pill or diabetes medicine to take, something far less complicated than trying to change a lifestyle when there’s nothing “wrong” except for…well, their whole lifestyle. And who can blame them? Pretty much nothing about how this society is organized facilitates healthy lifestyles for any but the few, and that’s why we are mostly an unhealthy society. If it were easy to be healthy, most of us would be.

What is it all about? Making the clinic a welcoming environment in which the normal and healthy are celebrated and explained, and the provider and patient can be partners in moving toward healthier habits and reducing risks. Demystifying the office visit and the technology we sometimes use to aid our assessments. Patiently explaining. And hopefully winning patients’ trust to lean on the exam and not just the tests.


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Sad Vaginas

Vaginal infection is a major reason that women visit the gynecology office (Brown, Hess, Brown, Murphy, Waldman, & Hezareh 2013; Overman 1993). I knew that going into midwifery. But my god, I never thought I would see so many sad vaginas every clinic day. My patients have a lot of vaginal infections. I spend a lot of time with patients talking about why for optimum vaginal health, less is more. Many have heard before that they “shouldn’t” douche, from other healthcare providers — but even among those patients for whom this is not a new idea, they continue intravaginal practices and don’t necessarily know why they shouldn’t.

This raises two issues for me as a nurse midwife and a feminist — the social roots of intravaginal hygiene practices (IVHP) and how providers educate –or don’t- — their patients about their own health.

Why do women douche? 

Many women tell me they feel they need to get clean after menses. They don’t like the residual menses they feel might be hanging around when the bleeding stops, and in particular they worry about the smell. They also think it will help them prevent infections. Commonly, my patients douche because their mothers, sisters, and grandmothers had and taught them these practices. But as one patient asked me this week, “why would they sell all that stuff if it’s so bad for you?” Good question.

And since Summers Eve re-vamped and expanded their product line beyond simple douche products to an impressive array of “yoni” personal products, these commodities are hipper and more attractive to consumers than they have been in a long time. Image

In a small (141 participants) prospective cohort study of sexually active women 18-65 years old in Los Angeles, researchers found that 66% reported IVHP, 49% of whom admitted using an intravaginal product (other than tampons) and 45% of whom reported intravaginal washing (Brown et. al 2013). This washing could include vinegar, water, soap and water, or commercially available products (Brown et. al 2013). One 2004 pharmacy journal reports that the reasons for these IVHP vary according to geography, racial background, age group, and rates of sexual activity (Pray & Pray 2004). According to Pray and Pray, African American women inherit IVHP from their mothers, while white women learn these habits more from advertising.

There is nothing wrong with your vagina

Wherever women get the specific idea that they need to use special products and habits to keep the vagina clean, smelling like roses (or lilies or citrus or island splash!), no one who lives in a wretchedly sexist society should be surprised that any woman would get the general idea that there is something wrong with how her normal healthy vagina smells, tastes, etc. But if women in modern capitalism can’t be trusted to decide if, when, and under what circumstances she gets pregnant, labors/births babies, and parents — wherein, for instance abortion is expensive, unavailable, often provided under non-compassionate conditions, and women are shamed for considering or choosing abortion (and even using birth control, these days!) — why could they be trusted to take care of their own vagina they way nature made it?

As a matter of fact, the vagina has its own beautiful environment that does all the work you think a douche might do for you — keeping your vagina clean — all on its own, when you are healthy. The vagina likes to be nice and acidic, which is made possible by a wide variety of anaerobic and aerobic gena and species (Overman 1993). Acid-producing bacteria like Lactobacillus keep in check the more basic bacteria that cause the common infection bacterial vaginosis (Overman 1993).

When you douche, you are likely to wipe or wash away the “good” bacteria, leaving lots of room for the “bad” bacteria to take over, causing you bacterial vaginosis (BV). Studies have not shown a direct correlation between douching and BV — for instance, infrequent douching may not directly cause BV (Brown et. al 2013). Overall, however, douching may increase a woman’s risk of contracting a sexually transmitted infection, or HIV if she is exposed to those pathogens, developing pelvic inflammatory disease, or be associated with preterm labor and birth when performed during the second and third trimester of pregnancy (Brown et. al 2013; Pray & Pray 2004).

Then there are all the products designed to make the vagina smell like something it’s not. All the deodorants, sprays, wipes, external washes, creams, and powders designed for vulvar application may place you at risk for yeast infections or irritation, but even if they don’t, their very existence and success on the market contributes to the cultural perception that there is something wrong with your vagina in its natural state. And it makes individual women feel bad about their bodies in a very particular way. As this wonderful columnist for Essence wrote: “There is nothing wrong with the totally natural, completely unaltered smell of your va-jay-jay in its normal state. (Our “down under” isn’t supposed to smell like summer linen, fruits, or fresh mint)” (Lucas, D. L. 2011).

Well, society doesn’t really value anything “natural” about women except for our bodies’ ability to 1. sexually excite men and 2. bear and mother children. So, we are meant to buy cosmetics, sexy clothes, enjoy pole dancing for exercise, be ok with making less money than our male counterparts, do more housework, assume primary responsibility for childcare, etc.

So if we do everything else to bend to society’s desires for who we are as women, why shouldn’t our vaginas be part of that package? As the “EVEangelist” over at Summer’s Eve reminds us, ”It’s time for a shower inventory. If you’ve got a cleanser for everything but your vaginal area, it’s time to make room for our pH-balanced Cleansing Wash.” Products for everything! You are not good enough as you are!

(As an aside, a simple, non-scented soap to cleanse the vulva should do the trick! Avoid body washes and avoid washing in the vagina itself.)

Don’t get me started about the pseudoscience and fake pro-vagina crap over at that website…Barf.

…Until there is

Not all vaginas are going to be happy all the time. And vaginal health isn’t just about products you do or don’t put in them or any sexual pleasure/stimulation a vagina might be party to. Vaginas are part of the female body, which may have lots of experiences that can enhance or hurt vaginal healthy: like diet, exercise, sexual consent, history of abuse or assault, body size, and emotional stress.

But none of those things can be rapidly fixed with an over-the-counter product that makes claims that it will fix up your vagina, unless it is medicine designed to treat a real infection, like intravaginal treatment for yeast infections. And I am all for trying things yourself, DIY, and taking care of yourself using health knowledge grounded in non-commercially biased information like that which is found in, say, Our Bodies, Ourselves and Guide to Getting It On. But douching and using these so-called yoni products that are making some CEOs rich over at Hate Your Vagina, Inc. isn’t gonna help.

Where the provider comes in

I’m glad when patients come into the clinic for evaluation of vaginal discharge because it allows for patient education. I like talking to patients about the difference between healthy and abnormal vaginal discharge, and what a healthy vagina might look/smell like, versus what could put it at risk for infection.

And that’s why I’m glad I’m a midwife (do I say that in every post?). Midwifery is about meeting women where they’re at, and working with them to achieve desired health outcome. Women really are the best expert in their own body/experience, and I am just there to facilitate her reaching her optimum health. When women tell me anything about their health habits that I may think is unhealthy or possibly harmful, my first question is “tell me more about that.” If you want to help a patient/client change a health habit, you need to know what motivates her to either continue or change. This is what we do for smoking cessation, nutrition or exercise promotion, and especially for sexual health risk reduction.

This gets back to my initial observation that many patients know they “shouldn’t” douche (or do lots of other health behaviors deemed unsafe/unhealthy, but I digress), but most don’t know why. When I explain to a woman how wonderful her vagina is and how douching disturbs that beautiful environment, she is more likely to understand her own anatomy and how to promote her own health. My hope is that instilling pro-vagina sentiment can also clear the way for greater acceptance of vaginal delivery of medication and contraception and to an increased motivation to use condoms/protect the goods from more dangerous infections and disease. We shall see.

Really sad vaginas

 

A much riskier health habit than douching, though douching may compound the risk, is practicing unprotected sex with someone whose infection status you don’t know, or having multiple sexual partners, having a partner who has multiple partners, anonymous sex or sex when high or drunk. (You can look forward to my forthcoming Condoms, Part II post for more on that.)

Actually sad vaginas have infections like trichomonas, chlamydia, gonorrhea, herpes, warts, and syphilis. Many of these have no symptoms or barely noticeable symptoms, but none of those can be treated with douching, and all of them require diagnosis and treatment in clinic. And someone who gets one of those infections is at higher risk for sexual transmission of HIV and hepatitis.

I guess a part of me understands that when my patients who are at risk for STIs douche, they may be trying to cleanse themselves of STI risk. (Fortunately, the old myth that douching can prevent pregnancy is much less prevalent these days.) And even here, I can find a good instinct. Douching may not get the desired results (a healthier, happier vagina), but it is a health habit, and I think providers need to recognize that patients do want to be healthy.

Toward a world with happier vaginas

I don’t blame individual women for buying into the crap that the vaginal hygiene industry sells them, any more than I blame women for using makeup, enjoying fashion, partaking in gossip and petty shit among women, or being in abusive relationships, for instance. These are all symptoms of a sexist society, and individual women who make these “choices” are operating in a false set of choices we are allowed to make in capitalism. Sexual liberation (or for the sake of this post, happier vaginas belonging to happier female bodied people) is about a lot more than lack of vaginal infection/STIs, but I do think that would be a good start.

Health care providers–not just midwives–can play a role in that by promoting and practicing in line with Dr. George Tiller’s call to trust women. We need to stop blaming women when they make “poor” choices about their health in a society full of so much sexism, racism, and class inequality. And we can take part in every social movement that confronts sexism, misogyny, and inequality, because health isn’t just about what happens in the exam room — it is determined by the world we live in, and we have to fight for a world that values women and allows for people to make the best possible real choices about our lives and our health.

References:

Brown, J. M., Hess, K. L., Brown, S., Murphy, C., Waldman, A. L. & Hezareh, M. (April 2013). Intravaginal practices & risk of bacterial vaginosis & candidiasis infection among of cohort of women in the United States. Obstetrics & Gynecology 121(4), 773-780. doi: 10.1097/AOG.0b013e31828786f8

Lucas, D. L. (July 21, 2011). Real talk: feminine care 101. Essence. Retrieved 04/14/2014 http://www.essence.com/2011/07/20/real-talk-feminine-care-101/

Overman, B. A. (May-June 1993). The vaginal as an ecologic system. Journal of Midwifery & Women’s Health 38(3), 146-151. doi : 10.1016/0091-2182(93)90038-I

Pray, W. S., & Pray, J. J. (2004). Douching: perceived benefits but real hazards. US Pharmacist 29(1). http://www.medscape.com/viewarticle/490338


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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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“[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:

Image

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.