No Updates in 4 Months???

Where have I been? What have I been doing?

Good questions! I will try to fill in the 4 month gap with this post.

Since the start of 2012, I have been swamped with finishing my Master's in Nurse Midwifery and preparing for my husband's return in April from a 6 month deployment.  I have also been quite busy growing a little baby.  While this does not take much effort on my part, it is quite exhausting!  

So just a quick run down of what has happened since I fell off of blogging in late January...

January

Found out the sex of the baby at 11 weeks (hard not to find out when you know what you are looking at and ultrasound machines abound at your work place!) and shared with husband and sister (having a gender reveal baby shower, so keeping it a surprise until then); had a great scan at 12.1 weeks; announced on FB and to friends that we were expecting a baby in August.

12.1 wks

FB Announcement - our dogs wearing "I'm Going to Be a Big Brother/Sister" shirts

February

Shopped at my first Just Between Friends (JBF) sale with my sister and bought heaps of baby clothes and other supplies for such great deals; finished my last full month of midwifery clinicals - feeling more and more confident by the day; felt the baby move for the first time (so exciting!); had a 16.1 weeks scan that we skyped with my husband in Afghanistan, the baby is still growing well and doing great!

16.1 wks

March

Caught my 59th baby (wahoo!) and completed over 1000 clinical hours including seeing 637 patients; graduated magna cum laude with my Master's in Nurse Midwifery; spent a week interviewing with a physician/midwifery group for a prospective job; began to work on all the house projects and baby's room; purchased the remainder of large baby needs and created two registries; had a 22.1 week scan and all was still normal with great growth (due to IVF with ICSI and AMA, there are concerns for IUGR - intrauterine growth restriction and fetal demise or stillbirth).

22.1 wks

22.1 wks - look at those lips!

April

Completed all of the organising/purging/cleaning of every room in the house; painted both the baby's room and master bedroom; completed the baby's room (yay!); welcomed my husband home from a 6 month deployment (so nice to have my best friend back); received the job I had interviewed for in March and they agreed to allow me to work part time/2 days a week + call (such great news!); went on a reunion spa holiday with my husband for the weekend and was upgraded to a top floor, 3 room suite due to his deployment (a wonderfully rejuvenating and lovely time); began Bradley Method Childbirthing classes for my husband to learn about birthing and how to support me in labor (he has no clue what to expect!); began studying for my boards.

May

Passed my boards!!!! (what a relief - I am beyond excited!), now officially a Certified Nurse Midwife (CNM); had a 28.1 wks scan - first one my husband could be present for and the lovely techs threw in some 3D views for us which were amazing - it's finally all becoming real for my husband since he missed out on the 1st half of the pregnancy; all is still going well with the baby weighing in at about 3#/1360g/67th percentile and everything else (amniotic fluid, anatomy, etc.) is all looking good; working on getting credentialed at the hospital which involves a lengthy contract and application process and getting a NPI (national provider identification) and DEA number in order to be reimbursed by medicaid/care and be able to write prescriptions respectively (the process typically takes up to 3 months, which puts me at the birth of our first child and then I am taking 12 weeks off for maternity leave, so it looks like at this point I will not start working until November.  Hopefully I can keep my knowledge and skills up in the meantime!); trying to find things to do for the next three months with no job and no studies to keep me occupied (maybe I will be better with keeping up with the blog?); started knitting a baby blanket; beginning prenatal yoga classes next week.

28.1 wks 3D profile

28.1 wks hand moving across face, yawning

Looking forward at June

Finishing the house; meeting with our doula to prepare for birth; finishing our Bradley Method Childbirthing class; another growth scan; going to the annual ACNM (American College of Nurse Midwifery) conference in Long Beach, CA (our babymoon!); husband having surgery to fix his varicocele in hope that we can get pregnant spontaneously in the future; maternity pictures; gender reveal baby shower!

A Disappointing Day

I had a hard day at my hospital clinicals yesterday.

We had a patient that wanted a natural, unmedicated birth.  With her previous birth, she was induced with pitocin, had a very difficult labor, and subsequently has a very negative image ingrained in her memory about her birth experience.  This time she wanted to have a simple, serene birth - the one we all dream of.  She presented to the hospital already dilated to a 7 as a G2P1.  My midwife and I thought that this would be perfect for her, and that she'd easily give birth in the next few hours.

After 5 hours of hands and knees, walking, birth ball, rocking, squatting, in and out of the bath tub, lighting candles, and listening to soothing music there was relatively little change in her cervical dilation, and yet she was experiencing increasingly worse contraction pain.  She was beginning to give up; thinking she would not be able to carry on with her plan.  We were not checking her, so I was encouraging her to continue - telling her soothingly that she was almost there, that she could surely make it.  At the 6 hour point, we finally checked her to see if she was close.

Nope.

She was the same.

Upon further inspection, her baby's posterior fontanel was extremely posterior, which is not typical, and we could not 100% decipher what the presenting part was.  It felt like a face.  We had the attending come and confirm for us, and she said it was definitely a face presentation with mentum transverse (MT).

MA or mentum anterior is the only one able to delivered vaginally.  It is done by placing a finger in the woman's rectum and flexing (or tucking) the head forward so the baby can still go through the cardinal movements of delivery.  Unfortunately, this is not possible for MT or MP (mentum posterior) presentation.

Oh sigh.  It was a such a heart wrenching moment to tell her she was not going to be able to physically birth from below.

When I came to get her husband to bring him back for the cesarean section, I asked him if he wanted to bring his camera and he said quietly, "No, I think we'd rather not remember this part."  My eyes welled up with tears and I had to look away.  How absolutely crushing.

Thankfully the baby was born easily and did not need any resuscitation efforts.  Both of the baby's eyes were swollen shut, but there was only minimal bruising over the right brow.  The mom, dad and baby spent the rest of the surgery time trying to bond with their new baby in the OR.  The mother was shaking uncontrollably (due to the spinal anesthesia) and despondent.  The father was quite sad.  It was a bittersweet moment for them.

The attending ensured a triple layer closure so that should they decide to have another baby they could attempt again to have the birth they so desperately desired.  She made sure they knew this, but I am not sure how much comfort it provided in the moment.

I am sure the healing both physically and emotionally will take some time, but my hope for today is that they are enjoying their baby much more and are able to let go of their negative perception of this birth bit by bit over time.

Rounds

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.

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!

Ghana bound

I have decided to do an elective in Ghana via Work the World in September when I am on my 3 week break between summer and fall terms. There I will be working in a hospital in Takoradi - a 4 hour drive west of Accra along the coast of the Gulf of Guinea. The experiences other midwives and students have had sound phenomenal. I am quite excited to go, albeit a bit nervous as I have never been to Africa and do not know what to expect of the country or the healthcare. I imagine it will be quite shocking at first and not at all what we are use to in our Western industrialised nations.

To enter Ghana I had to have a pre-travel appointment with the travel clinic and found I needed both Typhoid (only good for 5 years and my last was in 1991) and Yellow Fever, which certification of receipt is required to enter Ghana. Upon receiving the news that I was not pregnant (again) I quickly secured my vaccinations since you cannot take either whilst pregnant due to the live viruses they contain.

This now delays my next IUI since I need to wait a month before trying to conceive after taking these vaccinations. I was a bit skeptical about trying another round of IUI in May though, as both Malaria meds are pregnancy C category and if pregnant, I cannot take Doxycycline at all. I also read that mosquitos are more attracted to pregnant women (hence why many pregnant women in Ghana also have malaria), so I am a bit leery about that. I am following up with my physician to ensure it will be okay to be pregnant and go to Ghana. I definitely do not want to work so hard to get pregnant to then put my baby or myself at risk of being infected with a disease.

I have asked for a consultation with my physician, but it seems that all appointments are booked up for consults until May. That is a bit disappointing. I am hoping to get in before we do our next round as I would like to discuss our short term and long term options. Obviously I know we can do another 2 rounds of IUI, but there are further issues to contemplate. I will be gone to Ghana for 3 weeks in September, and sometime around September my husband will also be leaving on business for 4+ months. We hope to inquire about sperm freezing as well as speak about our options with IVF to include how it would work if my husband is gone, financing, risks, etc. I never thought I would consider IVF, but it looks like we are heading that way. I just do not know how it will work with me being out of country most of September and my husband leaving the same month. Possibly we have to do egg retrieval and insemination before he leaves with implantation after I return? These are the questions I would like to learn answers to.

I will be 39 this November. I feel like my time is running out. I want to be pregnant before I turn 40 as success rates after 40 drastically decrease while risks of Down's Syndrome and other age related issues increase.

Gosh. Hoping for a miracle!

Adoption

Last week I had a teenage patient who was gang raped and decided to give her baby up for adoption. She was not sure what race the baby would be, but found a lovely couple who was happy to have a baby regardless of circumstance. The mother of the baby and the adoptive couple were both Caucasian, but the baby had a chance of being Caucasian, or a mixed African American or Hispanic race. The adoptive parents were fully aware of not only this but also that the birth mother could see her baby and change her mind about the adoption at any time leaving the adoptive parents bereft and emotionally spent.

Upon the birth of a beautiful Caucasian/African American baby girl, the mother held her baby close, smelled her, kissed her and then asked the adopting parents, "Do you want to hold your baby?" There was not a dry eye in the room.

At discharge the birth mother hugged the adoptive parents and said, "Thank you for adopting my baby. I know you love her and will give her a good home."

This epic event gave me pause and much to contemplate. If 4 rounds of IUIs do not work, would I be able to give up my dream of having my own biological child and adopt? Would I be able to love another person's child as my own? Would I fall instantaneously in love with a baby as this couple did?

After much soul searching into the deep abyss of hidden feelings, I came to the conclusion that I could not.

I really, truly want to experience it all - conception, pregnancy, labor and delivery, breastfeeding, sleepless nights - the whole kit and caboodle. I know I would be giving up my entire dream if I adopted.

I also cannot imagine that I could love a stranger's child as my own. I see babies born on a daily basis and whilst they are sweet, cuddly and precious, I am not in love with them nor do I feel an emotional connection to any of them. It is hard for me to imagine feeling that same unconditional love and joy for an adopted baby as I see parents express for their own children. There is something to be said about that bond that is formed during pregnancy and the emotions experienced at birth - all of those mechanisms, hormones and emotions link the mother to the child intuitively. I know a bond can be created with an adoptive relationship, I just do not know how it is formed.

I do know that I would not love a child instantaneously. Maybe it would grow over time, but I do not see in myself the same characteristics that this couple had. I have several friends and patients who have adopted and I admire them greatly. They love their adopted children unconditionally and as their own, and for those that also have their own biological children, there is no difference between how they love and treat the children. In my family, I have seen several family members treat their adoptive children and step children differently, and in the case of the step children, horrifically. I know I could never treat a child cruelly but I worry that I would not love an adopted child enough, completely.

My heart does hurt for all those children waiting to be adopted, especially in countries like Russia and Romania where they are failing to thrive due to a lack of love and human touch and solely existing on boiled fruit juice and a couple spoonfuls of food a day. I wish I could love and help them all, but realistically this is not possible.

After looking at countless pages of babies and children waiting to be adopted, I started to wonder why there were not more people willing to adopt. But after looking into the costs for adoption, I understand a bit better. I found that the cost for adopting vs IVF is virtually the same (oftentimes adoption fees are even higher than IVF), and with IVF, parents are given the chance to go through pregnancy and have their own biological child for the same price, if not less. It is no wonder more people opt for IVF over adoption.

This was definitely a challenging soul searching journey that brought up many ugly realities that I was saddened to face. In the end it left me feeling morose and worried that we may not be able to have our own biological children.

If only we could see what the future holds!

Primary Clinicals

This blog was started to document both my last year in my Nurse Midwifery program as well as the ups and downs of infertility and trying to conceive and I have yet to post anything regarding the midwifery portion of my life.

Currently I am in my primary care rotation, but my preceptor (also a Certified Nurse Midwife - CNM) sees only OB and the occasional GYN patients, but no primary care and not very many GYNs. So, I have been farmed out to a inner city clinic where I am working with 3 Nurse Practitioners and 1 CNM and am seeing about 20 family planning, pre-conception counseling and GYN patients a day. This clinic also predominantly sees Spanish only speaking clients, so it has been good to not only be able to meet all my GYN patient goals but also to be able to speak Spanish all day and help an underserved, mostly uninsured, population.

Most of my day this past week was spent doing annual well woman exams, i.e., pap smears, and doing heaps of family planning and education. I learnt some new pelvic exam techniques that have been really helpful and useful to both me and my patients, and I also learnt how to identify yeast and bacterial vaginosis infections under the microscope. I also am becoming highly proficient in my speculum exams - I am aiming to do them gently and with as little discomfort for the patient as possible. I will be returning to this same clinic for 2 more weeks, 2 days a week, and then winter quarter will end and the spring term will begin bringing on a full 10 weeks of GYN focus. Luckily, since I am knocking out my primary, family planning and GYN now, I will not have to worry about my numbers for next term.

I have an exam and a research article to finish by Sunday whilst I also have to work Sunday and Monday nights. I will be dreaming of spring break tonight, that is for sure!

Where to begin?

In the beginning, I presume.

Just a bit of background: I am 38 years old. Happily married for 6 years, together for 10. We have 2 dogs and enjoy them immensely. We love to travel and see the world and have been spending most of our marriage doing so. We decided this last year in March that we would start trying for a family. So far we have not had any success. We are both vegans and we both practice Ashtanga yoga. I am also in my last year of my Master's in Nurse Midwifery - working towards a DNP (Doctor of Nurse Practitioner) in Midwifery degree.

This blog will be my (hopefully) daily diary of the ups and downs of trying to conceive and the trials and tribulations of being molded into a midwife.

Looking forward to the journey.