Lazy days

I am feeling lazy today.

I'm on days off before a 4 day/night stint from Saturday onwards. I've had a lovely week at work, with some nice women. I saw 35 week twins born on Monday morning - really quickly to a first timer, who I then saw out walking in the corridors later that day! Cigarettes are a powerful motivator!

I then had a young woman on Tuesday afternoon who was a bit depressive, had a really flat affect plus immature petulance on top of it. Now that the epidural was in effect she remained whining and grumpy with her partner, playing one family member attendant off against the other in the matter of who gets to cut the cord. Spare me. Her mother stood around telling about her births, even during contractions. It was a bit intrusive. The young woman birthed really beautifully in the end, had a pretty horrendous and challenging tear internally (with an intact perineum - ironic) and I was fulsome in my praise of her for holding it together when she just shut out all the outside influence crap and just focused with me. I made a subtle point of keeping the young father involved in the birth, he ended up doing the second umbilical cut that actually is the closest to the navel. There's more than one opportunity to cut a cord if there's competition!

When the baby (another 35 weeker) had to go to the nursery, young Dad got the chance to step up as there must be a parent at all times with any visitor to the nursery. The girl's mother had been interacting and answering all the questions the paed asked of the new mother, even standing between the resus cot and the bed so her daughter couldn't quite see what was going on! We kept moving the cot and pointedly turning the baby to a better line of sight for her. Anyway, the young Dad got a bit of status back by accompanying the baby with me to the SCN. Later he also came back to the room when she was being sutured and I asked the others to leave while he stayed by her side, and just quietly kissed her hand and connected with her as she bravely endured the stitching under (pretty solid) epidural cover. He glowed and nodded with pride at my repeated murmurings of praise for her for the way she birthed so calmly, and they both took in the information I gave them about the next few days and what they could expect with a baby in the SCN. They are very young, and I prefer to give them information that allows them to walk through the experience with better knowledge than they may have gained from watching any 'Home and Away' style melodrama. There are much better ways of being.

Once she was stitched up, fed and showered we went to the ward briefly then she walked down to the SCN with me and took her sister in with her to see the little one. He had had a partial lung collapse by this time and was in the higher level nursery with some breathing support, but she was pretty calm, just asking and accepting the reassurance from the doctor, nurse and myself that he would recover and mature well in this supported environment. What he was experiencing was not uncommon with 35 weekers and within a day or so he would off support and continue the task of finishing his growth. He wasn't quite cooked yet. I was really proud of her in the end.

Now I'm on days off I'm engrossed in re-reading a book I haven't read for years from a series and author whose work I just adore.

By Robin Hobb - this book, Fools Errand, is book one of the Tawny Man series - the third trilogy of a three trilogy set about a mythical and mystical place with dragons, telepathic magic, nobility and prophets. I first read them years ago and have recommended them ever since to all and sundry. So absorbing and I just can't put it down. It's nearly noon and I'm still in my PJs. I had all sorts of plans today...sewing, painting, tidying the house for our dinner guests tonight, shopping cooking ... showering!

And here I sit, ass getting broader. Sigh.

Here - enjoy another couple of One Year Ago World Tour flashbacks. The photos are from our last days in San Diego with Lesley and David Z, old Perth friends now living in SD. It was such a thrill to see them in their new environment, and we were so grateful to have a homely like place to start our trip (as you'll see in the links!)

LZ and I are partners in crime from waaaaaay back in 1990 - and in the next few days you will see links that take us from playgroup to Las Vegas and the Grand Canyon Arizona!!!! Yeah baby!

Looking back.

One year ago today my husband and I were flying across the Pacific ocean. It is one year ago today since the final installment of Harry Potter was released - I know because I got the first copy of it from Sydney Airport. Don was standing tapping his foot as our Sydney-LA flight started boarding as the sales embargo lifted! It was all well planned - and there was NO WAY I was flying across the Pacific without it!
I feel nostalgic for our trip....so I will post links to our travel blog from the next 7 weeks. You may click or not. Get jealous or not. But it was the first holiday my husband and I had taken together since 1983, before children. The trip was also a reward for completing my studies, commenced in 2002 to become an RN and then a midwife. I was so excited, I was jealous of myself! I would giggle at the thought of it.

And the reality of being elsewhere with Don, in other countries, with no-one else to please or consider but ourselves was intoxicating.It was such a great trip. The DVD of stuff from the video camera arrived just last week (long story, very dull), so we have been watching it and seeing some bits we'd nearly forgotten already.

The original posts from circa this date are here and here on our World Tour blog. See if you can click somewhere to go to a central page and find the photo albums for the places too, there's some lovely stuff. Natalie may recognise La Jolle from the San Diego stuff...sigh.

Enjoy.

My wordles for the day

I saw this on Twiddletails.

She got it from here.

I wish I could make it bigger....sigh. Another toy to while away my hours.

Blushing now

Ooh, thanks Lesley and Alby.

You have each sent me this honour currently doing the rounds. Forgive me if I don't send it back directly (although you both deserve it).

The only catch is that I have to pass it on to SEVEN others (by making a comment and telling them I've done it, and to come and get the pic from my blog, then pass it on, citing me as their source).

I have 63 feeds on my bloglines (!) and some of them have already received it - but I suppose that doesn't matter really as, if I think they're brillante (brilliant?), then they just are.

Lets start in Oz then. I've been having fun and making plans with Frogdancer and Widget this week - teacher tag x 2.

I received a package from the generous Victoria this week. She was kindly giving away prints of her insightful and quirky collage art. My loyalty can't be bought, but I'm really thrilled to receive these pieces from her. Tagged!

Next - the wicked and awesome Kelley, who tells it like it is. I laugh and I cry reading her blog. She won't be surprised...it is all due to her awesomeness.

Hmm, three to go. Jess has already received it, but tough. I'm a fan.

As a nod in the direction of midwifery I will nominate my friend in Alaska - Lisa. She is a terrific midwife and knitter - I'm so jealous of her knitting ability, and I dream of being such an accomplished health professional as she is. Brilliant (and tagged).

Finally, I also really enjoy the gentleness of Jenny's blog. Her sweet little dolls are just amazing. And I am nostalgic for her stay at home life - I didn't fully appreciate it when I had it. And although my house could never be that tidy, I hope it is as much a home as hers clearly is.

Speaking of tidy houses, sigh. Mine is definitely not tidy currently, much to my husband's annoyance. I had some fun late last week preparing a package for a friend who just needed one. I had a great time, and rediscovered stuff I hadn't seen in ages. But in terms of denting the stash...it didn't go close!

I have been having a clothes blitz lately, and threw out quite ruthlessly. I can now fit (nearly) all of my clothes in the drawers and cupboards. I should take a leaf out of Widget's book and get organised. Unfortunately op-shops have been calling quite loudly lately -and boy have we scored! I have found some really sweet pieces of moulded glass, sugar bowls and the like that I have been happy to adopt. Some great shirts for craft fabric, some vintage dresses with beautiful English lawn. And Stephanie found some great pieces of clothing including 2 jackets, a sassy skirt and a sweet top.

I am trying to get better at throwing out something everytime something begs to come home with me. And I will get better at it, or be smothered in the attempt.

I have a social week coming up. It is a year this week since our class finished the midwifery course. I have been a midwife for a year!!! Yay!! A bunch of us are going out for dinner on Thursday night to catch up. Some have had babies, some have new jobs, some are working as midwives, some not. It will be great to see them, especially the ones I haven't seen for a while.

Happy 1st Anniversary Curtin Midwives 2006-2007!

Hubby and I are going to an art show on Friday night, and then away for a grown-up night on Saturday night. Can't wait!

See ya!

The battle for VBAC

I've been thinking alot this week about vaginal birth after caesarean (VBAC).

I had the care of a woman early this week who was keen for a VBAC after her first labour ended in a CS for non-dilation in first stage. Her cervix had not dilated past 4cm 6 hours after reaching that stage. She wanted a VBAC because she had found recovery from the CS to be very difficult, understandably, and was keen to avoid the same again.

She had presented to the assessment area of LBS, a day or so past her due date, contracting strongly but irregularly and was keen for an epidural. Her cervix was dilated about 1.5cm, but was fully effaced- a bit early for an epidural. She was given a shot of opiate - which knocked off the contractions and had a sleep. When she woke up she started contracting strongly again, and was very anxious to get an epidural. This was not a method of pain relief she had used with her previous labour. She was transferred around to the labour room where she tried to settle in and get the contractions started again, as they had died away. I was assigned her care and after an initial chat it was clear she felt under the pump to labour that day as there was a CS scheduled for her the following day. She was also quite cross that she had been given the opiate earlieras she felt it had dampened down a happening thing. I spoke quietly to her, encouraging her to set aside everything else that was going through her head, and to give herself time and space to just be in the room, in this moment. We worked together quietly to create a space where she could feel safe, dark and quiet.

After a while, and a rupture of membranes by a doctor(2cm), she recommenced contracting. They were strong and lasted for 45 secs or so, but were irregular in their pattern. 2-3:10, then a gap, then 5-6:20. The baby was lying in a posterior position, which does cause an irregular pattern, but something just wasn't convincing as the pattern was too easily disturbed.

When planning a labour after CS the accepted wisdom is to avoid the use of artificial hormone stimulation i.e. syntocinon/pitocin, as this is technically contraindicated as a use of the drug when there is a uterine scar. The big scary bugaboo is uterine rupture along the previous scar. The incidence in natural labour is quoted at 1:80 - 1:200. That's 79:80 and 199:200 where it doesn't occur (if you're thinking positively). Under syntocinon augmentation/induction the incidence rises significantly. This woman had done some reading and consulted some people in the lead-up to this labour and her understanding was quite clear. Avoid use of synto.

Four hours after the ARM I examined her again, very little change (2.5-3cm). There was a different doctor hovering outside the door, who demanded the information and ordered an epidural and another examination in an hour. Then synto was to be started if there was no change. AN HOUR! She hadn't even met the woman, felt the contractions, heard her fears. The next shift came on as this occured and we collectively decided that this was not in her interests and she could decline this plan if she wanted. She declined, I documented it.

I was torn in many directions. I felt psychologically that this woman needed to do something different in this current labour to change the script from her previous labour. Her first labour had been induced from scratch, building up to maximum synto use, with a stalled dilation under a theoretically adequate pattern of contractions. She herself had little faith in the ability of synto to cause cervical change in her. We had been keeping upright or on all fours to encourage rotation of the baby to a more favourable position. She had been off for walks. She was trying nipple stimulation to encourage contractions.

We're taught that there are often mental blocks to cervical dilation related to fear of pain, anxiety of other nature, insecurities of all sorts. One of the challenges for the midwife is to identify and work with the woman to push through, allay or dissolve these factors, making the conditions right for relaxation and cervical dilation will follow. It so happened that the next shift midwife was one who had cared for this same woman in her first labour! I was unsure whether this was a positive or negative factor for the woman. Was this to be a re-living of the script?

The next midwife was having a quiet and assertive advocacy argument with the doctor in the corridor outside. I was very grateful to see it, as I don't have a lot of experience in caring for VBAC candidates and felt a little shocked and out of my depth at this challenge. There are practical factors to be faced either way.

I can see the doctor's point of view - no amount of standing around watching and creating a nurturing environment is going to establish a truly effective trial of contractions. Except that I felt we had been getting somewhere psychologically up until the point of that examination at the time of shift change. If the cervix had been dilated 5cm at that point I felt we would have been home and hosed. But honestly, there had been very little change in nearly 4 hours of strong but not always regular contractions. Her body clearly wasn't quite ready to do this.

There was the question of pain relief. This was a back labour, and was pretty painful. The afternoon midwife felt an epidural was not the way to go, as it often knocks off contractions a bit if used too early - which this was on the borderline of being. Her recommendation was for a shot of opiate - which the woman herself didn't want because it had diminished the labour 12 hours earlier. The doctor didn't care which method was used as long as the synto went up, sooner rather than later so the woman and the baby were less tired than they would be if we held off for a further two hours, which was the general preference in the room. Tick tock tick tock. Bloody hell, we felt we were getting nowhere.

The doctor entered the room for the first time (uninvited). It felt like an ambush. There was a lot of 'baby getting tired' language (the trace was excellent), contractions have to be effective (she hadn't palpated a single one), the pattern isn't established yet (well, I'd pay that one). She asked who had done the last assessment and insisted that I repeat it now (2 hours later) and a plan would become clear if there had been any change with the spontaneous (under pressure, very disturbed, doubt creeping in) contractions.

The woman agreed. The doctor left the room, her views and orders were clear. I did the deed. There was very little change.

What I know is that to achieve any vaginal birth, whether the first or the seventeenth, for VBAC or not, the cervix must dilate. The baby cannot be born through a closed or semi-opened door. End of story. No matter what one believes, or what the environment one creates. Babies are born with their mothers clinging in trees to avoid being swept away in floodwaters. Does that desperately unfavourable and exposed environment inhibit cervical dilatation? Clearly not.

My emotions were swirling. I would not lie to this woman. I felt her crumbling hopes acutely, her self-belief, her visualisations for cervical opening evaporating by degrees. I felt she had spent the last two hours being undermined by a series of factors, but was that really true? What if her cervix was one of those that just didn't dilate? Sure she was anxious and a bit nervy, but I would be in her place too. Was it my belief in her that was wavering? Or was it a growing acceptance of reality?

I saw the logic of the doc's plan. Let's have this labour declare itself one way or another sooner rather than later. Was I being pie in the sky waiting for spontaneous labour to 'win'? As much as I wanted nature to take over if I could protect the environment and sing Kumbayah sincerely enough, was it always going to be a losing battle in this woman? I have seen VBACs achieved before, with and without the use of synto. I just wish it didn't have the reek of 'doctor getting all her ducks in a row by knock-off time' about it.

I stayed for the discussion about synto Vs pain relief. They looked to me for guidance and I felt like a traitor discussing the benefits of a compromise, with a trial of synto under controlled conditions, yes, start with an opiate for pain relief (not my first preference for this woman, an epidural may have been the psychological script change she needed), you can always move up to epidural (oh God, that trace is going to suffer with morphine and an epi, hope the baby is alright when he/she is born around 8-10pm - my estimate - probably by repeat CS). It was time for me to leave.

I phoned later that night and she ended up with a repeat CS at 8-ish pm. A little girl. They already had a boy at home. They would be really pleased to meet her, I know. I confess I had a bit of a tear about the outcome.

I have been troubled for days about this 'failure'. Was the failure mine for not creating the environment appropriately? Did I do her a disservice by holding on to her birth plan too solidly - trying to create a safe space for her with time to get into labour. I wasn't convinced she was in established labour except for maybe the last hour before the lunchtime assessment. The contractions were sneakily irrregular. Yet only days before I had seen a woman give birth to her 7th child with a similar pattern of contractions. Through a cervix that had dilated. Was this woman doomed to a repeat CS by a physiological anomaly of her own body, regardless of my supportive touch and words? Kumbayah humbug! Did this anomaly cause a script re-run?

I am trying hard to love this question. I suspect there are different answers in each woman. I was always taught that the CS to avoid is the first one. With the syrocketing CS rate in this country, state and the facility I work in I am certainly keen to work to avoid the first in all women in my care. Have I seen any soft decisions for CS? Hell yeah. I have also seen many vaginal births that may have not been achieved in other facilities. Some women have one CS for breech and then just never think about not having a VBAC with the next. In some countries it is the same, one just assumes she will have a VBAC unless there is another really good reason (placenta praevia, severely bad trace, placental abruption - which can give a subtly bad trace, cord presentations, delayed progress in first stage of labour). Breech presentation in first-timers is another common reason for a first CS- I am in two minds about this one. One school of thought says that this leads to de-skilling of midwives and obstetric staff as they never get to manage a breech birth, so never develop confidence in it. Others think that the consequences of a bad breech birth for the baby and woman can be catastrophic, e.g. with a trapped head. I know of a recent case of this, the staff still pale at the memory, the baby was not good (i.e. nearly died) but is coming good now apparently.

So,VBAC is quite a fraught issue in my profession. It is not the case that all vaginal birth is better than birth by CS. They say that recovery from a good CS is much better than from a bad vaginal birth (i.e. instrumental births with minimal analgesia and 3rd or 4th degree tears). There is definitely a place for the use of CS. The World Health Organisation accepts that CS is appropriate for births in about 10-15% of women, and women die daily for lack of skilled surgeons to support the needs of these women. Would the woman of this story be one of those who falls into this category? Whose cervix hasn't fully dilated with either an induction of labour or a spontaneous and augmented labour? Would she be the mother of two living children? Albeit recovering from a second non-elective CS? We'll never know.

Teaching tools

It had to happen one day.

On each of the last two night shifts I have been assigned a senior medical student. One hopes these students witness an easy, natural, spontaneous labour and birth, with no dramas, bells or whistles. Sigh. You want to make God laugh, just tell him your plans.

Night ONE. Enter the room to a very young woman, unaccompanied, in spontaneous labour with first baby. Progressing well, has an epidural in place, which means there needs to be fetal monitoring. The fetal heartbeat is a bit fast, just above the normal range, but Mum has a slight temp and this is often the cause. I was still taking handover when the heart sounds took a dive. And kept diving. From 170 beats per minute to 55 bpm. Roll over, take pressure off the cord, roll the other way, no recovery, its been a minute, call for urgent assistance, warn the Mum, the team comes flying in, after another minute it starts to pick up and ticks along to its usual merry rate. Phew. Wide awake now and well on our toes. Explain to the med student that that is NOT a normal pattern.

Twenty minutes later it does the same thing. Stormtroopers re-enter, this time the recovery is a little quicker, hmm, little tricker baby. Where is that cord? Are you holding it? Is it wrapped around an arm? The cervix is dilating well, its nearly fully dilated now, it won't be long until this little one can be pushed out if necessary. Keep watch.

Dive three. Reposition and watch and wait, call the coordinator, ah yes, here comes the recovery, and the cervix is now fully dilated. Good, lets hope she can get some descent with just the contractions in the next half-hour or so, don't want to push too early with a primip. We top up her epidural as the pain was breaking through again and I'm sent to tea with another midwife covering in the room. I get a banana and half a cuppa into me when I am called back for another deceleration. It is recovering by the time I get there, but the coordinator is a bit concerned as the docs are all in theatre for emergencies, and this baby is still playing tricks that may need some urgent assistance. Bugger! We start her pushing just as a relative arrives, an aunt who looks as though she has had plenty of experience in childbirth. Yep, 9 babies, she tells us proudly. Oh, we are so glad to see you, you're just the tonic and company your niece needs right now. After 4 contractions worth of pushing the fetal heartrate takes another dive, and stays down this time. Get a senior-ish doctor out of bed as all the rest are still in theatre, and she decides to do a forceps birth there and then. We quickly get a strong top-up into the epidural, while the heart rate crawls back up. The medical student got an eyeful of a very confronting birth over the next 6 contractions, as we all worked together with the young woman, her aunt and the doc to bring the baby suddenly into the world. She, the baby, was not impressed! She was born in great condition and squawked loudly for the next hour. My back-up midwife was fantastic, very supportive and on the ball, encouraging me to stay with the girl and keep her on track and accepting all the delegation really efficiently. It was my first time seeing forceps in the room (instead of transferring to theatre) and it was not pretty. Somehow the draping of the operating environment seems neater, or something. There was a lot of blood, and flesh, and stitching required. Poor kid. She was pretty shocked. I think I was too. The med student told me later she was surprised you could pull so hard with forceps, but didn't seem particularly phased by the experience. She was called to theatre a little later to witness an emergency CS, so had a fairly full night of viewing!

From my perspective I was disappointed she saw such a violent emergency with so much drama preceding it. One aims to show a woman moving and coping well with contractions, with minimal monitoring, as a role model of a normal physiological process. It is too easy for the medical model to be seen as the norm, and there is such limited opportunity for them to see a normal birth, so they may never know the difference between the physiological and the managed. They will rarely see the way it can be. As an advocate for normal birth it is frustrating. But the vicissitudes of working in a large high risk hospital mean that it can be weeks between us midwives seeing one of those too. Sigh.

So, night TWO. Assigned another student, pick up a woman from the assessment area in early labour with baby number 3. Waters broken 12 hours ago, meconium stained fluid draining. Needs monitoring and a drip to get things established as the baby may be compromised. She had had two previous vaginal births with minimal analgesia, both over 9lbs and this one was a similar size. Should be a straight forward labour and birth with continuous monitoring required and a paediatrician at birth due to the meconium. Do you hear God starting to chuckle?

She was attended by her teenage sister, and her hubby was on his way back to the hospital. The woman herself was really cheerful and positive, a short round young woman who had complete confidence in her ability to just get on with it. And so we started. The baby was initially in a posterior position and a bit tricky to monitor with that lovely plump tummy. Bub was really active, and turning to a more favourable position for descent, and unfortunately the need for monitoring meant she had to be near or on the bed with me holding the heart thingy all the time. She didn't complain, and I gave her frequent toilet breaks to apply gravity and some hula dancing to shake things up. Hubby was back by midnight and sat dozing in a chair, but could be encouraged to apply sacral pressure as long as he didn't have to see anything gory. He wasn't good with body fluids or hospitals. At one stage he threw up in the bathroom, and stayed a bit pale, but came back to do his bit with the back pressure. He was full of praise for his wife's talent at labour and birthing, and was most assured things would be well over by dawn. The sister was soundly asleep.

By 2am things were getting pretty full on with contractions. Gas was being used and she was really hilarious under the influence, but it helped immensely. We encouraged her to position herself for comfort, and examined her for the first time. 5cm dilated. Hmm, a little less than we expected but steady and not that surprising given the non engagement yet of the head. The fluid was getting a bit thicker and I asked a more senior midwife to come and check my abdominal palpation. She agreed with my assessment, and confirmed the fluid was thicker. The trace was good, heart-rate good. Just as she was leaving the dad tried to cross the room to go to the bathroom. I heard a thump. He had fainted. It was a bit busy in there for a while as I organised oxygen and some staff to attend him, and the woman was pretty desperate and calling for me to apply back pressure with each contraction as the sister slept on. My hands were full. Hubby was taken away and not keen to come back, and I was under pressure to take a tea break, but she pleaded with me to not go. I felt sure she would start pushing very soon, in fact she had a lot of involuntary pushing with contractions, and was shaking in a transitional way. Another assessment showed 7cm so we got her up again for another plie and hula dance, and had her climb up on a higher than normal bed, and kneel up and down repeatedly to encourage the last bit of rotation and engagement of the head. Finally another midwife came in and insisted I leave for a meal break at 3.55am. I reluctantly agreed, assuring the woman I would come straight back if called.

My backside had just hit the toilet seat when I heard the phone ring - Laura - get back right now! I finished my wee and ran.

I entered the room to find a green head between her legs and a wide-eyed look of shock on her face. Clever girl, that was quick! I pulled some sterile gloves on as others called the paeds and I eased the rest of the head out. The face was slow to emerge and people were passing me suction to suck the meconium from his mouth and nose. It all seemed to happen in slow motion. I could sense the activity behind me. His head slowly rotated to Mum's left thigh and I got her to push but he wouldn't come out. No cord around his neck, but he was stuck pretty tight. Call for assistance. Legs went up, knees to nipples, more pushing, normal traction, no progress. His head was turning a deep shade of violet, and I could see his white neck. I called for supra-pubic pressure which was applied, and I carefully kept the traction on. After about 15 seconds he started to budge and slowly corkscrewed in stages from his mother's body. It was nearly two minutes from head to body delivery and I was very relieved to guide him out in a rush of fluid and meconium and blood. Clamp and cut, hand him to the paeds and he started gurgling and crying within 20 secs. Phew.

It was my first shoulder dystocia birth, and I had anticipated it as a possibility with this birth. He was a really big baby 4720g - or 10lbs 6 ozs plus change, and really long too. The placenta was pretty tricky as well and Mum lost a bit of blood initially, but was soon well contracted. A doctor had arrived with the assist call and helped get the membranes out and confirmed the bleeding had stopped. We were shocked to see that the perineum was intact! OMG! After hauling that toddler out of her! Holy crap!

There was a lot of mess, which we just threw a sheet over, as the sister was taken from the room in a wheelchair as she had almost fainted. It was quite some 10 minutes really. And once again my medical student had got more drama than we bargained for! Oh dear.

After 15 minutes and a quick cover-up of the mess, Dad was brought in to meet his son, and praise his sweet little wife who was recovering from the shock of it all. Baby JJ was a bit pale and shocked, but admired by all. He was so big he was almost hanging over the edge of the warming cot, and the wraps seemed tiny. They were all pretty pleased with themselves and he got stuck in to a feed fairly soon, and pinked up nicely, even if he did have green hair!

I got to have some dinner about 5am while bub was at the breast. They were up on the ward by 6.15am, after we had photos together to celebrate our joint achievement. The sister and the med student were de-briefed about the events, and assured that although the last 2 minutes had been a bit hairy for all concerned we were pleased with the outcomes, and were they OK? The sister was pretty freaked out by the green head appearing so suddenly, but was reassured that it was fairly normal when a baby had done a poo before birth. She had a cuddle alone with the baby while Mum was in the shower and was interacting well with him and telling him all about it. The med student was going off to learn more about shoulder dystocia and emergency drills!

It had been a real effort, that labour and birth. It was the first time a woman had really leant on me so heavily during labour, and called my name so repeatedly. There was a lot to balance - the positioning, the trace, the meconium, the fainting family, the documentation, the assessments, the being with woman in a tight spot. I was grateful to be very well backed up by other staff who supported everything I was doing, and without whom I would have felt a bit scared. It was a challenging shift and I learned heaps.

I'm getting the hang of this.

Great beginnings

I had a beautiful night shift this week.

I was assigned to a couple having their first baby, 10 days overdue, and being induced. I took handover from a lovely midwife who assured me the cervix was really soft and favourable, the head was low and now the waters were broken. They were really excited and smiley and chatty.

"So, this is the kick-off, eh?" the husband asked. I assured him they would not be getting out of this labour suite without a baby, and I planned to catch it before morning. She was having a few niggly contractions before I started the drip, but as I turned it up gradually over the next 2 hours the contractions started to get her attention and she became restless. She moved really instinctively, circling and rocking her hips, remaining upright, alternating standing with sitting and moving on the birth ball. He was a bit unsure of himself at first, and she kept assuring him she was fine, and there's nothing I need you to do yet, thanks hon. He settled into a chair and dozed briefly, but kept getting up and walking over to her. I encouraged him to stand behind her at the back of the ball in case it scooted out from under her, and to touch her between contractions.

We had discussed their birth plan, and they were really not keen for any analgesia other than a shot of opiate perhaps, and really didn't want an epidural at all. I asked her how many times she was allowed to beg me for one before I gave in. "Five" she stated very firmly. OK its a deal. We talked about how things were going to get hot, heavy and pretty intense at various points with smiles wiped off faces. Thats fine, they said. I told them I would do my level best to encourage her through the tough bits, and would let them know about the next bits as they approached. There would be a phase where she was gonna lose the plot for a bit, and swear and beg, feel shaky and sick and want to go home, but that it was normal and that I would be glad to see it, because it would mean she was progressing well. OK? Yep, that's OK, we agreed.

It was beautiful to behold. The only downer was that she had to be monitored due to the induction and drip and post-dates, but she was just marvellous, and didn't complain once about the monitoring. It was my problem, and my shoulder was pretty sore from reaching out to keep contact but it was worth it.

About 2.30am she started drawing within. By 3.30am she started saying that it really hurt and that she may need some analgesia. At 3.45 she asked for an epidural. "That's once" I said. She was starting to really dread the next contraction. We went into drawing her out mode, lots of praise and encouragement as she was starting to lose the plot. To hold her off I got all the equipment out for an epidural insertion. She had asked 3 times by now. It was becoming more difficult to monitor the baby with her movement and agitation, and the coordinator was hovering wanting to know why there were big areas of poor trace. As soon as she entered she could see why.

"I don't know yet if I can offer you an opiate shot or epidural - how about we examine you and see where we're at?" She readily agreed. Onto the bed for the first time. A quick examination and I attached a scalp clip to reduce the number of belts she needed - 5cm dilated - slightly less then I had expected behaviourally, but I really felt she was cracking on. Get up and go to the loo, keep that bladder empty, yes do a poo if you need to, make room for the baby. Hmm electrode not reading too well, and there's a lot of fetal heart changes with contractions. A passing middle rank doctor was called to review the trace and the electrode positioning on baby's head.

"Ahh, you're almost there" he smiled. 9cm now, 30 mins after the previous examination! Sorry hon, I grinned, no epidural - you'd be sitting on the baby's head before we could get it in! She was not quite amused, and was quite frowny for the next 10 minutes.

Then she started holding her breath and involuntarily pushing with contractions. It is quite something to witness, and to experience. You know how when you need to throw up and you have a few dry retches first? It is just like that. Irresistible. We had talked about this sensation, and I assured her she would know when it was time to push. Go ahead hon.

It didn't take long before there was bulging and twitching and unfolding occurring. It's wonderful to see. She was less impressed. Its often quite hard to push effectively at first, and to get into the pattern of understanding the downward/forward progress of the head within you. And she was still feeling pretty ripped off about having asked for analgesia and not getting any. So as the unfolding occurred she was not sure she liked it at all! We changed position regularly, encouraging her by reminding her that it was all in their birth plan to push in these positions! She found it hard to coordinate her breathing with pushing, and would let her energy go between pushes, which meant the head would slip back and she covered the same ground 3 times each contraction! Finally she got the hang of it, and asked how it could be speeded up. "By doing the scariest-feeling thing, and then going further!" I replied. "I'll tell you each step of the way what to expect next." Within the next two contractions we had head staying on view between bouts of pushing.

"OK," I said "this next bit is going to sting and burn. It will feel pretty crappy, but I'll talk you through it, so try to work with me and stick it out. It won't last long. And then there'll be this really great bit where the head is out and the relief is sensational. And then there's this fantastic bit where the rest slips out and it is the best feeling in the world. Ready?"

And it was just like that. God- she was wonderful. What a champ. At 5.29am her baby surfed out on a wave of amniotic fluid, to her gasp of triumph. I helped her lift him to her chest where she welcomed him with an introduction of "Hello my darling baby, I am your Mummy". After a minute or so she and her husband thought to ask, "Oh - is it a boy or a girl?" I helped her to reposition the babe so she could see his beautiful rosy scrotum. "Its a boy!" they cried to each other.

She needed a few stitches, which another midwife performed, and after an hour or so we weighed him - 3.670kg - 8lbs 1oz. She was as high as a kite, the baby was alert and calm, and they were all so proud of each other for making and birthing such a beautiful baby. A triumph all round.

"So ... you never did get to asking me five times" I said to her with a hug. "You are very good at this birthing business, you should do it again!" She laughed and said that the head just out, and the slipping out bits were just as I had described them! Fantastic!

It was such a delight to look after them, and I saw them again on the postnatal ward the next night. Baby was starting to feed quite well, and she was really calm and confident, and still on a high after the birth.

And so was I. I am starting to feel like I can function as a midwife now. I've seen 7 births since my return to LBS, 5 x CS (! - although 4 of those were when I was working on the section list) and 2 normal vaginal births with no analgesia. Plus my friend's homebirth. I know which births I prefer.

I really am keen to work in the community, or at least in a model of care that offers continuity of carer/midwife. I was chuffed that morning to have the coordinator ask me if I could see myself working as a community midwife. When I readily answered yes, she said I would be good at it, and that it had been a lovely birth. I couldn't help but feel all warm inside. A beautiful labour and birth, and a compliment. I have been qualified a year, and working for 9 months now, and I really feel like I am finding my feet as a midwife. There are now 2 groups of midwives who are less experienced than me. I am sucking it up and getting on with it more, but still very ready to ask for guidance.

Of course as a rotational midwife I don't stay in one area for too long, but move around every 2 months or so. The next shift I was sent unexpectedly to the postnatal ward, where I had the care of 6 women including 3 women less than 24hrs postpartum, 5 babies including a 36 weeker twin, a withdrawing 37 weeker under phototherapy and a 3 week old baby whose Mum was very ill and was unable to care for it safely. The other staff were very kind and helpful, and cuddled and fed and answered my bells when I had my hands full, but it was a bit of a rude shock after the idyllic previous shift!!

They were both good shifts (in the end) and made me realise how much I have learned as a midwife in a short space of time. Two more night shifts to go in this stretch.

I still love it.

Picture diary

Thanks for the comments. I read and appreciate every one. When I asked if anyone was still there it meant I hoped you hadn't stopped visiting because there was nothing new to read! I must say since I started using bloglines my blog reading has been greatly simplified. Instead of rabidly going to every site just in case I missed something new, now I can see instantly who has posted and I can relax about all the rest. I am spending less time on the computer, but am still in touch and up-to-date. Phew.

Which leaves more time for sewing!!!! I have been going a bit mad lately and loving it!

OK I promised photos. First - from my birthday. Here is the cake. Black Forest Cake. YUM.

And my oldest friend called late in the day and came by to join us for dinner. We hardly ever get to see each other any more - she lives an hour or so away and now I work shifts with less holidays its too easy to let time slip by. But we manage 1-2 visits per year and it is always such a hoot to see her.

We met when she moved to our area at the start of year 5. For the only time in my childhood or since I was picked to choose a softball team. Such a responsibility! I was always picked last so I knew the anguish of waiting to hear your name spoken. So I chose all the kids who usually waited and waited, including all the interesting kids who were new or who had accents or different coloured skins. It is a decision I have never regretted, least of all because it brought Bobbie into my life. We were inseparable from that moment on. It still feels like that. Can you tell?

I was her bridesmaid at her first wedding. The first quilts I owned were made by her for each of my children - I still have them and treasure them. She is such an inspiration to me. She went back to uni to complete her high school, and became an environmental scientist. She is a grandmother now, and still her own self. I just love her. It was so good to see her.

Here is a very bad shot of the Michael Buble concert, which is badly out of focus but conveys something of the atmosphere. Jeez it was a great concert.

Here is a quick excited photo of my sister and I in the audience. Even though its crooked, I like this shot. She is not usually so pale, she's been unwell. Yep, that is the favourite pink cardigan of the moment getting another outing!

Something else exciting happened last week. I received my labels. See? Its a name that a family friend used to call me (my family call me by my middle name) I accidentally ordered iron-on ones (sigh) which don't necessarily suit every fabric I use to make a bag, but they still look very satisfying to have on my products. Even if sewn a little rustically.

Speaking of rustic, here is the bag I just had to make on Friday instead of doing housework (I don't recall making an active choice - was the housework ever a realistic option? ;P )

I had found the orange embroidered jeans in a favourite op-shop on Thursday. They fitted Steff but she felt she wouldn't wear them. Ditto the black chunky cord Diesel jeans we had found a few weeks ago. So....she requested a shopping bag. Et voila!

I was very brave and even put in an internal zipped pocket - my first time - piece of cake. Everything on this bag was chosen for recycledness (is that a word?). The outer fabric, the lining fabrics, the zip, everything had been used before. I'm really pleased with it. It wears my label outside and hers inside!

Which brings me to the weekend....sigh. It was an oasis. I took a healing doll that I had started back in February sometime, that I got stuck on. It was meant to be my inner child, but she looked so vulnerable that I just couldn't move forward with her alone. She needed longer arms to reach out to people. I was a long lanky kid (snort), and while the hair colour was about right, and she had big brown eyes I felt stuck. I knew that if I took her with me to a safe place she would be able to evolve into herself.

We chose messages from a set that spoke to us. Mine were about not believing and living old, negative messages, and how I could create new beliefs about myself, about how I am alright NOW. These tapped into some thought patterns I needed to change. Remember don't believe everything you think ..... So I set to work.

We learned about the orphan archetype and the pros and cons of examining the orphan within us all. We heard the story of "the Ugly Duckling". We journalled. The opening sentence was "I want..." A very powerful tool. We danced through a guided meditation through a four part garden with gates dividing the areas. We experienced the long hard winter that precedes transformation and growth. Rocks for grief, sticks for anger, water for despair, and sand for feeling depleted. We then went for a silent meditative walk about the bush. It was the winter solstice and people all over the world were also engaging in that exercise simultaneously. We were encouraged to see if anything called to us on our nature walk and to collect them for inclusion in our dolls or journalling. The sticks of anger had called me during the meditation. It was time to examine their purpose.

The other women had mostly not made the dolls before and we all had kits in front of us for a new doll. So did I. So I made a new one as well as working on my inner child doll. She had come with me as plain Jane. I was called that a lot as a child. This weekend I made her/myself blossom.

I used the sturdy sticks I collected to first of all give plain Jane a backbone. Next I entwined some curved sticks to her to give her longer arms to reach out for help and comfort. Next she needed to stand taller, so some very strong branches were bound to her short legs. These new limbs were bound in a tartan that reminded me of the little tartan pinafores I wore as a child - with a plain cotton top and a beautiful pleated skirt. They were worn with a pretty white blouse and a cardigan over the top. My new doll seemed more confident already. She had been mousy and brown before, and I look hideous in brown. She wasn't happy being brown. As the dove-grey and green tartan strengthened her she seemed happier. Suddenly I knew she needed more green. A scrap of sequinned green spoke to me. I bound this across her heart. There were some leaves that filled a gap or two, then she sighed contentedly. At last, you are getting to the heart of me. Returning to the treasure chest I found a small sculpted baby, painted gold. This touched a very deep chord. The little one was immediately tucked next to her heart. Scraps of green gingham, more layers of beautiful dyed green cotton with leaf prints, a few more sequins, a tie or two, more hair, a flower for blossoming happiness, a jewel or two, a few pearls, following our instincts. Then someone brought me an amazing gift. There, in a small velvet covered matchbox, was a tiny baby with a message in the box that read "I love you just the way you are". It was just the message she/we needed to hear. She held a stick to acknowledge the rage at her mistreatment, but it was softened by a growth of green, as she didn't want it to define her. It now looks like a wand to achieve transformation. A friend across the table said, you realize, don't you, that she is Mother Earth. A bell rang somewhere. Many people call me an Earth Mother midwife. Others have called me a Demeter figure. But of course. My inner child had blossomed into a manifestation of something that feels very natural to me. An earth mother. I was profoundly moved by the whole experience and can barely take my eyes off her. She is just right. I had never imagined that I would create something as beautiful as she is. As green as she is. But she is "No More Plain Jane" now. And I love her just the way she is.

The white doll I am holding is my midwife warrior I made in the first healing doll workshop I attended. She is full of symbolism and has a long story too. Her new red sister is also related to the meditation. She is a goddess of rage, who trails her anger behind her and has no problem expressing it. I think her story is one for another day....

Here is our group with their dolls at the end of the weekend. We all found it a very powerful and symbolic exercise, an oasis in our busy lives as mothers of children with special needs, some bereaved mothers. We had danced, including a belly dancing session, journalled, ate great food, talked, laughed, cried, discovered, meditated, slept and relaxed and shared an incredibly intimate weekend.

I am very lucky to have access to this type of workshop. It is a lifeline for me, a tool to have an inner life that allows my inside to match my outside. This doll making is a stunning exercise when taken as a whole 30 hour journey in a supported psychotherapeutic environment with trusted friends. And now I entrust the sharing of it with you, dear reader.

Peace and love.

Busy busy

Is anyone still there?

Its hard to maintain a blog on night shift, my bed is sooooo appealing.

I've had a busy week on re-entry.

I've caught ONE baby (very cute).

I've made ONE super bag (pics to follow)

I've seen ONE movie (Sex and the City - I liked it immensely)

I've been op-shopping (pics to follow)

I've got people coming for dinner in 4 minutes.

I haven't packed for journal, belly dancing and doll-making camp - and I leave at 6.30 tomorrow morning! YIKES!!

Later, friends!!!

Hubba hubba Buble

Oh. My. God.

The Michael Buble concert was BRILLIANT!!!

I was a fan before, but now I am completely smitten. What a voice.

Truth be told, he was singing just for me. I don't know who the rest of the people were at the venue tonight, but their intrusion did add a concert atmosphere. Nice of them to turn up really.

And the support act, Naturally 7? Also very, very good. Not a hardship to listen to at all. Here's a clip of them with an impromptu (?) performance on a Paris subway train.

Three hours of pure entertainment. Just a great night.

The hotel on Saturday night was a great idea. We haven't been so relaxed for months. The room was really comfortable. We had a 2-person spa, and a walk through the evening streets and a browse in a bookshop before a delicious dinner for two in a swish restaurant up the road. Slept like logs. Plans for another wander in search of breakfast was somewhat curtailed by pouring rain and wind, so we breakfasted at the hotel instead, which was pretty average.

And then back to the real world. It was such a lovely oasis. I think we'll make it a regular date. Sigh, contented sigh.

I start night shift tonight. It should be OK. I haven't done any for a few months. I might get to see a baby born (well, duh).

I'll catch you when I can.