Saturday, July 30, 2011


This week has been all about rounds and rounding.

On the trying to conceive front, Friday was my day 1.  I'm beginning my 4th and last round of IUI treatments.  I pick up my Clomid today to begin taking days 3-7.  I have my US and blood work on Monday, August 8, and then my IUI will probably be 2 days later if all goes well.

This week was my 2nd week in hospital and I did heaps of rounding on postpartum patients.  I saw 4 patients and their teeny, tiny, adorable babies.  Four patients may not seem like a lot, but postpartum rounding takes a long time.  It is the first and only time the patient sees a midwife during the day and they have loads of questions stored up to ask on top of all the questions I need to ask them and the exam I need to complete.  Then there is also time I have to allot for discussion of their birth and fielding any complaints they may have.  The pressure arises as the clock tick-tocks away knowing that I have patients one floor down in labor that I must get back to and round on as well.  It is a great juggling act of time management, to say the least.

This week I caught 3 babies (bringing my total to 4) and they all went so much easier than last week.  I was able to both protect the perineum, provide space for the baby if needed in the vagina, and coach the patient on breathing and pushing.  I really feel like it is coming together so nicely.  All of my babies had nuchal cords - one I lifted over the baby's head and the other two I helped the babies slide through them.  The transition from catching to tummy is going smoothly now too.  No more fuddling and fussing.  We had a few lacerations (or lacs as we call them), and I began to learn how to repair.  I have not yet attempted it on my own, but I experienced a lot of relaxed teaching time.  I look forward to my first hands-on experience.

All in all my clinicals are going quite well.  I am learning heaps every day and growing by leaps and bounds in my practise and knowledge.  I am also working at the same time with the new OB/GYN interns that have just started and that is a neat experience.  It is fun to be "babies" at the same time and grow up together.  My midwife preceptor teaches the interns as well on the low risk side of labor & delivery, so we are learning side by side.  Hopefully one day what these new interns learn from the midwives about normal, low risk births will make an impact in their own practise with women.  I already hear some interns calling what they do catching instead of delivering.  Wow!  So exciting!  The word of midwifery is spreading.

Tuesday, July 26, 2011

First Catch!

Most of this blog has been consumed with our attempts with trying to conceive.  It might make one wonder if I do anything else!  Trying to conceive does seem to overtake almost every waking thought I have, but I am still pursuing my dream of becoming a nurse-midwife.  I am doing about 36-40 clinical hours each week now - 2 clinic days and 1 hospital day.  This past week was my first week in the hospital AND my first official catch!  Wahoo!

As a labor & delivery nurse there have been a handful of times where I have caught a baby due to a precipitous birth where the physician did not make it in time, but those times were usually more of a surprise and panic type situation where I was wondering when the physician was going to arrive while catching the baby and simultaneously calling other nurses and techs into help me.  In contrast, my first official catch happened in a very serene, calm, controlled and beautiful way.  We had a patient who was a G2P1 having a natural birth at 40.4 weeks gestation.  She had a doula and did amazing throughout the whole labor.  She walked and rocked, sat on the birthing ball and tried a variety of positions until she found what worked for her.  But at 0300 and 8 cm she wanted to give up.  She started crying and saying she just could not go on, and that she wanted an epidural or something to make the pain go away.  I encouraged her to get in the bath tub and she did.  She sat in the warm water, pelvis open, rocking side to side and moaning with eyes closed breathing through every contraction.  In 15 minutes time she said she felt like she needed to push.  She walked back to the bed and began her delivery.  Half a dozen pushes later she welcomed her healthy, beautiful baby boy into the world.

For my part, I protected the perineum during the crowning and then supported the head as it birthed.  I then gently pulled traction down to release the anterior shoulder and then the posterior shoulder slid right out along with the rest of the baby.  It was quite easy as the mother did all the work, but I still need more practice with my hand placement and coordination of catching the entire baby with both hands and then placing on mom's tummy.  I am sure though that will all come together in due time with practise.

The birth though was just so magical and beautiful.  I know I have said beautiful several times now, but it really was a picture perfect birth experience. The baby needed a bit of transitional support and the nurse even gave the baby oxygen on the mom's belly.  In the end, the mother got all that she wished for - a natural birth with no interventions, no lacerations and she was not separated from her baby after the delivery.  A perfect birth for the mother and baby, and a wonderful first birthing experience for me!

Friday, July 22, 2011

MRI Results

The preliminary results of my MRI came back today.  Report read a "couple" of endometrial invasion islets in the myometrium were noted with only one measurement of 1 cm.  What was seen is consistent with adenomyosis.  I am not sure how many a couple is (2 as seen by US?), and why the others were not measured, but my RE is going to review the films herself and give me a full report in person on August 5.

In the meantime, I am on my 3rd week of acupuncture and have noticed a big difference in my energy, back pain (caused by a previously sprained lower SI joint) and mood.  I am hoping it will have an effect on my cycle this month as well.

I've added 600 IU of vitamin E at bedtime, magnesium 300 mg/d, and vitamin B6 50 mg/d.  I am also drinking a loose chinese herbal tea twice daily that my acupuncturist created for my particular symptoms.

I plan to buy DIM this week as I have read up on it and it says that it speeds excretion of estradiol thereby increasing the metabolism of estradiol and decreasing serum (or circulation of) estradiol levels.  Recommended dose is 600-1200 mg/d.

A variety of websites recommend progesterone cream as well, but I am going to wait to discuss this with my RE as I do not want it to interfere in our pregnancy attempts.

The good news is:  It is NOT cancer (thank god!) and in the end, that we can still go through with our last IUI attempt this August and if that does not work, attempt IVF in October.

The bad news is:  My RE thought we could do the transfer before my husband leaves in October.  However, the lab is closed for most of the month.  So it looks like my husband will have to make several donations, have his sperm frozen and then I go through with the embryo transfer solo.  Not my ideal situation, but it is either that or wait 6 months and watch my age increase by one year and my fertility to decrease even more.

Nope, better to get the good eggs out now before they expire!

Saturday, July 16, 2011

Friday's News - MRI

This day did not go as planned.

It all started off with me driving 50 minutes in moderately heavy traffic (read: people who leisurely drive in the left lane and prevent you from passing) two cities away to have my MRI done. Upon arriving at the facility they tell me that I must be mistaken as they do not do MRIs. They point me towards the hospital up the road and advise me to check there. I call my referring RE's office and I am on hold for 10 minutes, so I hang up and go up the road. The hospital radiology department has no record of my name. My RE's office calls back and says, "Oh sorry. Someone must have given you the wrong information. You are meant to be at the hospital here." What??? I am in the wrong city? I was so hot at this point - literally and figuratively! It was 40 C/104 F already at noon and even with the air con in my car cranked to the max, I was still sweating. I begrudgingly drove another 30 minutes to get to the correct hospital and finally had my MRI.

It took about 45 minutes in total for the pelvic MRI, which I was surprised by. I thought with only having to image a small area that it would take less time than a full body MRI. I was too hot and tired to ask any questions though, and after 45 minutes of lying flat and still on a hard table my lower back was killing me as well (due to a previous SI sprain that flares up from time to time). Luckily I was able to pass the time listening to NPR, which helped with not thinking about the teeny tiny cavity I was in.

After my MRI, I do some yoga stretches (downward dog, padangusthasana) in the changing room to ease my back pain and then side step over to the cafeteria to stock up on some nuts, water and fruit before I hit the road again. It is now 3 hours since I left home, and I have to drive another 30 minutes to my acupuncture appointment which will last another 2 hours. Days like this make me really miss the days of public transit in the EU!

I make it to my acupuncture appointment just in the nick of time. I'm all bothered and irritated, but my practitioner is calming and serene. I quickly shed some of my stress. I hop up on the table and have many needles placed in carefully selected areas all over the front of my body including my head (acupuncturist says it is to lift my mood - ha!). I lie there for 30 minutes having a hard time relaxing. My mind is racing and the halogen lamp is bothering my vision even when my eyes are closed. My acupuncturist then removes all the needles, has me lie on my stomach and then places many more needles along my back including one directly in my SI joint. I practically leap off the table on insertion, but it magically starts to feel better immediately. I lie there for another 30 minutes and this time I am able to fully relax. I can no longer see the halogen light in my eyelids and I drift off to a floating type sleep with vivid images flashing before my eyes. Before I know it my practitioner has returned to remove my needles and I am now happy and buoyant. My stress is gone. How does acupuncture do that? It really is so incredibly amazing to me. I eagerly look forward to my next week's visit.

I should hear back from RE in about a week's time. Fingers crossed for good news and that we can proceed with our last IUI, and then IVF in October if not successful.

Post script: I'm on day 9 of my juice detox and it is going well. I feel like I have heaps of energy and have even lost 4 kg/8#. These past few days I have not lost anything more, so I have been a bit worried. I hope I can lose more weight while continuing to feel great.

Saturday, July 9, 2011

Friday's News - HSG

I had a hysterosalpingogram (HSG) with saline in my doctor's office on Friday. The procedure is initiated with a small catheter that is inserted through the cervix, then a small balloon is inflated to keep the catheter in place within the uterus and to prevent the saline from leaking out. It is similar to a foley balloon used for dilation of the cervix and induction in labor, but much smaller.

Saline (100 cc or more) is then injected via the catheter into the uterine cavity in order to examine the uterus and surrounding structures via ultrasound.

The procedure itself is not painful - felt like a typical pelvic exam. However, upon first insertion, the catheter was not staying in place and they had to use a tenaculum on my cervix in order to insert the catheter further inside the uterus.

While medicine and science say there are no nerve endings in the cervix, the pain experienced when the tenaculum was placed was intense (you can see here it pierces the cervix in order to hold on to it). It was a searing, tugging pain that felt like my whole uterus was going to be pulled out. I became overly hot, sweaty and nauseous. At one point I even thought I was going to pass out. The nurse gave me a magazine to fan myself, and I began to feel better. Thankfully the tenaculum was only in place for a few minutes until the catheter was inserted further and the balloon was re-inflated. Then they proceeded with injecting the saline.

As an aside: Even though the tenaculum was only in place for mere minutes, I am still having cramping, soreness and an achy discomfort in my uterus a day later. Many practitioners use tenaculums to place IUDs, but after yesterday's experience, I am definitely going to ensure I learn how to insert them without a tenaculum. Hands down, that was the worst gynaecological experience of my life.

My US revealed a few nabothian cysts on my cervix, but nothing to be concerned about there. They are small and benign and typically disappear on their own.

The spot in my myometrium was reviewed. Last time it was fluid filled, possibly blood, but this time it was empty. A second area was also noted with this US. Both appear to be adenomyosis. On one hand, this is a relief as it is not cancer, but on the other, it is still somewhat concerning for me due to the possible effects on fertility and the increasing menstrual cycle pain I have been experiencing. I am also quite stressed by the fact that this has shown up only after commencing with fertility treatments.

Adenomyosis is when endometrial tissue that lines the uterine cavity grows into and within the myometrial (muscle) tissue of the uterus. This endometrial tissue is a glandular tissue that secretes essential nutrients for implantation and growth, as well as blood during menses thereby essentially causing bleeding within the walls of the uterine muscle. This is what causes the extreme pain during the menstrual cycle.

My two spots on US, however, appear to be isolated islets (like these spots on far right) instead of endometrial tissue growing into the muscle (as seen by the arrows here). This is why my RE is not 100% sure of the diagnosis, although she says she is quite confident that what she is seeing is not going to affect our chances of conceiving.

Adenomyosis can cause menorrhagia - heavy or prolonged menstrual bleeding (yes to heavy, no to prolonged), dysmenorrhea - severe cramping or sharp, knife-like pelvic pain during menstruation (yes, definitely - began with fertility treatments and became increasingly worse with each month), menstrual cramps that last throughout period and worsen as one ages (no, only first 2 days), pain during intercourse (no, thankfully), bleeding between periods (no, hopefully never), and passing blood clots during menses (yes - has increased with fertility treatments). The uterus can also increase to double or triple its normal size (don't know yet). Adenomyosis can cause a bearing down feeling (yes) along with pressure on the bladder (no).

I have not asked for my measurements of my uterus, but plan to at my MRI. I have been feeling rectal pressure and lower back pain more and more frequently of late and am wondering if this is due to the increasing size of my uterus. Previously my RE told me my uterus was anteflexed, but I have always been told previously that it was retroverted. We shall see and confirm on both counts with the MRI.

Adenomyosis is mostly found in women over the age 35 (that's me!), typically between ages 40-50. Adenomyosis is dependent on estrogen and grows with an increase in unopposed estrogen or in the presence of an estrogen imbalance. Due to this, adenomyosis often goes away with menopause.

I did not know this before, but someone experiencing uterine surgery, i.e., cesarean section, is at higher risk for adenomyosis due to the cutting through the uterine layers of myometrium and endometrium. However, I have had no uterine surgeries, and am not sure why I would be predisposed to this.

Treatment for adenomyosis is via hormone suppression and balance with oral contractive pills, IUD with progesterone (Mirena), or Depo-Provera. I have also read online about the use of natural progesterone cream as a way to balance the estrogen dominance. Heavy menstrual flow and pain can be controlled with around the clock ibuprofen (decreases blood flow by 25-30% and cramping pain due to anti-prostaglandin action). Lupron can also be used, but it causes a menopausal state with complete cessation of ovarian function and menses, eliciting many menopausal type side effects like hot flashes and can only be used for 6 months. Typically all symptoms of adenomyosis resume after medication cessation. Sadly, at this point in medicine, an hysterectomy is the only permanent cure outside of menopause.

Next Friday, I will have a pelvic MRI to determine a definitive diagnosis as well as to see if the adenomyosis is diffuse - throughout the myometrium - or only localised to the two spots seen on US. I will have the results a week from next Friday. I am hoping my RE is right and that this will cause no impediment to our chances of conceiving and having a healthy baby. I definitely do not want to have a hysterectomy.

My theory is that I have an estrogen dominance issue due to:
  1. Drastic increase in weight gain since moving back to US (up 9 kg/20# in 10 months).
  2. Fertility treatments.
  3. Not practicing Ashtanga/working out regularly.
  4. Age - over age 35 estrogen levels rise and progesterone levels fall, progesterone levels are lower due to less consistent ovulation and short luteal phases, the latter which I have. Unopposed estrogen (without progesterone) leads to estrogen dominance symptoms and diseases.
So my personal plan now is to:
  1. Return to my acupuncturist (I stopped going when I found out that our fertility issues were due to my husband's low sperm count).
  2. Make an enquiry to the acupuncturist regarding DIM and Myomin - I read online both can reduce and balance excess estrogen thereby reducing adenomyosis symptoms.
  3. Add supplementation - vitamin E 600 IU at bedtime, magnesium 300 mg/day and B6 50 mg/day - along with my prenatal vitamins.
  4. Take a month break from fertility medications to clean out my system.
  5. Do a juice fast for 20 days to detox, rebalance and lose the excess weight - I will be following the Reboot plan.
  6. Return to practicing Ashtanga 5-6x a week for de-stressing, fitness, health, detoxing and re-balancing. Many asanas in Ashtanga also work to increase blood flow (prana) to the reproductive organs and mula bandha helps strengthen the pelvic floor.
  7. Feel better in 30 days!

Tuesday, July 5, 2011

To Do List

  1. Read 333 pages in Varney's Midwifery and Williams Obstetrics about prenatal care and normal pregnancy.
  2. Finish laundry - only 4-5 loads left!
  3. Reschedule hair appointment that I missed today - knew my appointment was Tuesday, but thought today was Monday. I blame the holiday.
  4. Enter 21 patients into Typhon* system. This term I am bound and determined to keep on top of my logging instead of leaving it to the last minute and then scrambling to enter 200+ patients at once.
  5. As per #4, leave the last-minute-Laura days behind.
  6. Return to practising Ashtanga tomorrow if my ladies holiday^ is over.
  7. Life insurance physical and grocery shop Wednesday.
  8. HSG with saline Friday.
  9. Study, study, study this week due to no clinic/hospital days (preceptor is on holiday).
  10. Sleep, sleep, sleep this week due to #9.
  11. Complete antepartum case study and worksheet, and write a SOAP note on an unique patient by next Friday.
  12. Find a unique patient by next Friday.
  13. Prepare for garage sale - price, organise, set-up - must sell many things!
  14. Hopefully some time in the next 2 weeks: have some fun!

*Typhon is a patient tracking log for nurse midwives and nurse practitioners in order to account for all the types of patients one sees as a student along with how many births one attends.

^In Ashtanga yoga, female practitioners are meant to abstain from practice during their monthly menstrual cycle.

Monday, July 4, 2011

A Dangerous Lie

A few weeks back now, I had a new OB patient (G5P3013) that was a transfer of care from a physician who she said, "did not listen" and would not allow her to VBAC. Since our hospital is one of the few hospitals in the state that VBACs and has midwives, she decided to switch to our care. Upon taking her history, though, things just did not seem right. She could not recall much about her first 2 vaginal births and focused solely on her last birth which was a cesarean section. She was dismissive of medical history questions and kept interjecting her horror stories about her previous obstetrician. Her children were also the most unruly children I have ever experienced in an exam room. The patient had no control over them and they screamed, physically fought and clamoured up and down the walls and on anything else they could climb in the tiny 8x10 exam room. Ten minutes into our visit, I had a raging headache. I left the room to retrieve the US machine and conveyed my misgivings of the patient and her history to my preceptor. I also warned her about the screaming, but there was no need. She heard them from down the hallway. We both re-entered the room, US machine trailing us.

The appointment ends with the patient thanking my preceptor saying, "You are a wonderful doctor. I am so glad I switched." To which my preceptor corrected her yet again explaining that she was a Nurse Midwife. Ignoring my midwife, she then said, "And your assistant is wonderful too." Ha!

We were not sure what would become of her. We left the consultation taxed, harried, overwhelmed and not even sure if we even wanted her to remain our patient.

Today, a month later, her medical records came in from her previous physician. Lo' and behold, she has had not one, but three c-sections! We were shocked. What if we had never received her records? What if we had helped her to VBAC? The possibilities of what could have gone wrong are both unsettling and frightening!

Sunday, July 3, 2011

BFN #3

Another disappointing negative. Number 3 that is.

Luckily this time, due to not getting my hopes up, I have not been sobbing in my bed for 2 days. Instead, last night my husband and I took a midnight swim with a bottle of Pinot Noir and The Gotan Project playing in the background. It was a nice, romantic time to reconnect and discuss our dreams, hopes and fears.

Hopefully one day we will have a child, but it was not meant to begin today.

I again have had raging dysmenorrhea (cramping, nausea and vomiting) and had to take 2 percocets and 4 ibuprofen liquid caps. I rarely take medicine and tried to just get by on 1 percocet, but I was up at 0500 retching and doubled over in pain sobbing. I have never, ever in my life felt so horribly during my periods and am a bit concerned, but my RE seems to think it is solely due to the Clomid.

Today, due to the medicine and pain, I have slept most of the day away, recovering. Luckily now the pain is manageable with ibuprofen. My mind remains unfocused and cloudy though, which does not bode well for my studies that I have to do today.

On my scan this cycle, the fluid filled sac was seen again in my myometrium, so since I am not pregnant, this month will be focused on diagnosing the mass. I go for a MRI on the 15th of July, and will schedule another HSG this week, but this time it will be with saline. I heard from a nurse-midwife colleague of mine who got pregnant both times after a saline flush, so fingers crossed that will work for me as well.

And so the journey continues.

Saturday, July 2, 2011

Ready, Set, Ghana

I booked my airline tickets about a month ago and today I finalised my balance payment.

It is official!

I am going to Accra, Ghana, Takoradi more specifically, in September. I am so excited I can barely contain myself!

I am going to be working with Work the World - a UK based company that provides medical, dental, nursing, midwifery and physiotherapy electives and placements in Africa, Asia and South America.

In the UK, unlike the US, nursing students and midwifery students do electives abroad during their training and some even do gap year placements. My university had nothing on offer for a study abroad program, so I have decided to create my own experience via Work the World, a company I had heard about from other midwives and nurses when I worked at Guy's and St Thomas' NHS Foundation Trust.

As I have never been to anywhere in Africa, I was not sure where to go, but chose Ghana as it is a placement that allows for direct and highly involved care. There are 3 other locations in Africa - Dar es Salaam, Mwanza and Arusha, Tanzania, but for some reason Takoradi, Ghana spoke to me. The testimonials from other midwives in Ghana are quite inspiring as well and are what helped confirm my choice.

I am quite excited to go... a bit nervous, as always when I travel to a new country and do not know what to expect, but more agog and breathless than anything. I feel assured that Work the World will take good care of me and provide an easy and engaging experience. The process thus far as been worry-free. Work the World provides a 'My Trip' webpage for each candidate and it has easy hyperlinks to click through to learn everything possible about your upcoming trip along with what to do and when. My last 'to-do' is to secure my visa and pick up my malaria tabs.

Easy peasy.