Day 7: No Baby Yet

Apparently I am starting to look like I fit in here because today I had a patient stop and ask me a medically-related question. Although I was flattered, I pointed her in the direction of one of the nurses.

Last week I learned a lot in just a few short days, but I was wondering if at some point most of the information would be a repeat of what I have already learned. However, I am continuing to see, hear, and experience new things every day. This morning I got to see an ultrasound for the first time. The patient was 16 weeks, but Irma tried to find the baby's heartbeat for about five minutes without success, so she decided to bring the ultrasound machine in. I was able to see the tiny heart flapping back and forth on the screen. This picture points out what a baby's heart looks like on an ultrasound:

One of my highlights of today was holding a tiny three-week-old baby while the mom went to get on a scale. So cute!

After waiting on call for three days this weekend, "my" mom still hadn't gone into labor! Today she is 41 weeks, and I have heard from Irma that she is going to the hospital tonight! I will probably be up for most of the night at the hospital, but I am very excited! She came in to the office today to get a biophysical profile (BPP), which I got to see for the first time. It was done to make sure that the baby is still healthy being a week overdue. BPPs check for four things: the amound of amniotic fluid, fetal heartrate and breathing, fetal tone (the ability to flex and use muscles), and fetal movement. Nothing looked worrisome in her BPP, but she is getting worried and doubting her body's ability since with her last birth, her water broke but she never started contracting, so she had to get induced. She is afraid that something like that will happen again, especially since she is already a week overdue, so she got her membranes stripped today to realease the prostaglandins and get more regular and frequent contractions.

Get ready for tomorrow's blog post!

Day 6: I found a mom!

Today was the first time I saw a repeat patient, and in fact she was the very first patient I saw on Tuesday. She is now four days overdue and came back for another NST since it has been three days since her last one. The NST showed that she was having regular contractions every three to five minutes, but they weren't very strong yet, so she is waiting to go to the hospital. During her 20-minute long NST, she was asking me where I go to school and what exactly I am doing with the midwives. I told her all about what I get to do during my intensive, and she sounded very interested by it. The most exciting part is that I asked her if I would be able to attend her birth, and right away she said yes! It will probably happen either tonight or tomorrow, so I am very excited. Jon is on call all weekend, so she will most likely be the one delivering.

I definitely feel like I have accomplished my first goal as of today. Even if something happens and I don't get to see her birth, I got to know her well enough and she got to know me well enough that she felt comfortable saying yes right away when I asked. She not only said yes, but she responded, "Birth is such an amazing thing, and I would really love for you to get to see it." I had a feeling when I met her on Tuesday that she might be the one I would ask if I didn't run out of time.

I set my phone on the loudest, most obnoxious ringtone so that if I get the call in the middle of the night, I will be sure to wake up and get to the hospital!

Day 5: Diabetes and Pregnancy

Today was another very early morning with appointments starting at 7:30 a.m. again. I was with the last of the three midwives, Jonalea, or Jon for short. She was very good about explaining as much as she could to me and always asking if I had any questions. There was also a new RN who started at the office today who will be with the Mercy Midwives for about six months and is working towards graduating from the Frontier Nursing University to become a midwife.

The first patient of the day has two days until her due date, but she is a diabetic (insulin-dependent, not gestational), so it is recommended that the baby be born by the due date or else it runs the risk of getting too big. This is from extra sugar from the mom that gets passed through the placenta to the baby, whereas normally it would exit the body in the urine. She had an NST done to make sure everything was normal, and Jon explained what exactly they look for in the graph to classify the baby as healthy. It is a 20-minute long test, and there should be quite a bit of variability in the heart rate with an average of around 130 BPM. Jon also looks for at least three spikes to around 150 BPM for about 15 seconds within the 20 minutes. The NST also monitors contractions, and the graph showed that she was having small regular contractions every five to seven minutes. Here is an example of what an NST graph looks like:

The top line shows the heart rate, and as can be seen, there are the three spikes that last for a duration of 15 seconds or more, which is a very good sign. There are no major dips, which is also a good sign because it shows that the baby is getting enough oxygen from the placenta. The bottom line records any contractions, but there doesn't seem to be anything significant in this test. 

Jon also explained the Bishop score to me, which is a score that measures the softness of the cervix, how far down the cervix is, and how dialated it is. The patient got a score of eight, which is the most favorable score and shows that she is very close to being in labor. If she does not go into labor tonight, the plan is for her to go to the hospital tomorrow at 9:00 to get induced because of her diabetes and her approaching due date. The Mercy Midwives generally like to stay away from inductions unless medically necessary, but this is a situation in which it could become medically necessary because of the risk that comes with exceeding the due date.

I was able to get a hold of the Mercy Midwives' statistics for births today. Although they are from 2000-2001, I was told that their numbers haven't changed much in 15 years.

The area-wide rate for cesarean sections has gone up to about 33% since 2001, but the Mercy Midwives' rate has stayed very similar. 

Irma came into the office today for a little bit even though she was not seeing patients, and she said that she was at the hospital most of the night delivering the baby that was due yesterday and had come in for an NST! She said that it was a very healthy, beautiful baby. We are still working on finding a mom who will allow me to be at her birth, but I'm learning that there will be no shortage of births in the next two weeks, so there is plenty of time at this point.

Day 4: 6:00 Alarm

Today was a very early morning, as I was on my way to the office by 6:45. It was my first day with Irma, and she had an even earlier morning since she was at the hospital by 2:00 a.m. to deliver a baby!

I got to see a wide variety of things today, including everything from pregnancy comfirmations to postpartum visits. I also heard and saw several of the things I read about in Ina May Gaskin's books; it was fun to be able to connect my knowledge to my experience.

The first appointment was a comfirmation of pregnancy, so she was only eight weeks in. She was complaining that she was having a lot of cramps, which I learned was because of the placenta burrowing in to the wall of the uterus, and the placenta starts functioning at about ten to twelve weeks. The mom wanted to know if she could listen to a heartbeat yet, but at eight weeks, the uterus is still behind the pubic bone, so we wouldn't be able to hear it if we tried.

Another patient came in who was about 33 weeks along, and she said that previously her baby was in breech position (the head up instead of down), but now it was transverse (sideways). This connected to the chapter I read on determining the relation of the baby to the mother's pelvis. If the baby doesn't turn into a longitudinal position before 37 weeks, the attendant tries what is called an external version where he or she manually turns the baby from the outside. Here is a picture from Ina May's book on external version:

Irma explained this to the patient today, and I knew exactly what she was talking about because I read about it earlier this week! Irma also asked the patient if she was planning on taking flu and whooping cough vaccines, which are recommended for pregnant women because their immune systems are compromised. When Irma was checking the heartbeat, the baby was very active, but the mom was saying that she could barely feel it, and it worried her that she doesn't feel the baby moving much, but apparently when the placenta is in the front, the mother can't feel as much movement from the baby. I also learned that the minimum movement for the baby is ten movements in two hours, and anything less than that causes some concerns.

The next patient was 40 weeks, and her due date is today! We did a non-stress test for her, and the baby seemed to be very active with a good heartbeat. One of Irma's questions for the mom was if she wanted to get stripped. I didn't know what this meant and neither did the mom, so Irma explained that it is when they separate the amniotic sac from the cervix, which releases prostaglandins and sometimes helps initiate and encourage labor. The mom decided she did not want that done at this point.

Irma let me use the gel and monitor to check the baby's heartbeat for the second to last patient we saw! She also let me measure her belly, and I didn't realize before that the measurement should be the same as the number of weeks along the pregnancy is. How convenient! This mom was a little small because she measured 29 centimeters and is 33 weeks in.

I learned a lot today in each of the appointments, and I am excited to see what the next two and a half weeks bring!

Day 3: My First Day in the Office

Today was finally my first day in the midwives' office! Everyone I have met so far–staff and patients–has been very nice. My mentor Irma was not in the office today because it was her day off, so I spent the day with another midwife, Kim. Although I hadn't previously talked to her, she knew exactly who I was because she knew my mom and remembered when I was born! She even remembered I was the only girl in the family. Small world!

It was a pretty laid back day of normal appointments. Since Kim was the only midwife there today, there weren't very many patients, but I still got to see quite a bit. The nurse Carrie would ask each patient before Kim came in if it was ok to have a student in the room too, so she would put a little card outside each door that either said "student ok" or "student not ok." Most people were very willing to let me be in the room and were very surprised when they learned I am only in high school.

The first patient to come in was one day over her due date, so it could be any day for her at this point! Kim did a bunch of regular procedures, such as measuring the belly, listening to the baby's heartbeat, feeling the baby and its position, and checking the cervix to make sure it was soft and thin. After that, the patient was taken to the NST room to do a non-stress test, which monitors the baby's movement and heart rate for an extended period of time to make sure that the placenta is giving the baby enough oxygen and nutrients; the heart rate should go up when the baby moves, which is exactly what happened during this non-stress test! When getting very close to birth, I learned they recommend a non-stress test every three days to make sure the baby is normal and healthy.  Here is a panorama of the NST room (the patient gets a nice, comfy recliner to sit in):

The machine to the right of the recliner is what slowly prints out the graph of the baby's movement and heart rate.

The second patient was another regular visit, but she was only 20 weeks along, so she has another 20 weeks to go. Like the first patient, Kim measured the belly and listened to the baby's heartbeat. During this visit I learned that starting next week at St. Vincent's (where the Mercy midwives deliver the babies), Nitrous Oxide will be available during births as a relaxer for the mom. St. Vincent's will be the first hospital in Ohio to begin using Nitrous Oxide, but it has been used for decades in Europe. In fact, in the show "Call the Midwife," which I named my blog after, the midwives in England used Nitrous Oxide–back in the 1950s and 1960s!

The rest of the day I was in and out of appointments. I was curious to see how many appointments would be obstetrics-related and how many would be gynecology-related, and today it seemed that most of the visits were regular OB appointments. Tomorrow is an early day with appointments starting at 7:30! 

Day 2: Another Day with Ina May

Today was an unexpected day to do some more reading instead of starting my time shadowing the midwives. I came down with a cold on Saturday, and I didn't feel well enough to start my experience today. Hopefully I will begin tomorrow morning!

I continued reading one of the books by Ina May Gaskin called Spiritual Midwifery. Today's focus was learning about getting ready for the birth itself–the essental anatomy of the mother, the baby and its life-support system, and determining the relation of the baby to the mother's pelvis. The section I found amazing and extremely fascinating was the weekly development of the baby inside the womb. It is really incredible to read about how something so complex quickly comes into creation.

One of the things that struck me the most was how small the baby could be while having all the basic structures and systems. For example, by the fourth week, the back bones, spinal cord, and brain begin to take shape, as well as the beginnings of a face, throat, eyes, ears, nose, stomach, intestines, liver, kidneys, blood vessels, blood, and a heart! But can you guess how big it is by the end of the fourth week? The baby is only one-fifth of an inch long from head to tail! It could fit on my pinky fingernail, yet it has all these amazing systems starting to form, grow, and specialize. Here is a diagram of what the baby looks like at this stage:

By the sixth week, the baby is only half of an inch long, but the brain already controls the functioning of the other organs. There is also a complete skeleton of cartilage, which later hardens and turns to bone. By this time, everything the baby needs is there, and the rest is all growth and specialization–everything is packed into half an inch of length...wow!

To give more perspective, here is a life-size model of a baby at eight weeks:

Although it is important and fascinating reading, I am excited to connect some of this knowledge to the patients I meet.

Day 1: Overview, Goals, and Research

My first intensive is focused on hospital-based midwifery with the Mercy Sylvania Physicians and Midwives practice. I will be able to shadow several different Certified Nurse Midwives (CNMs), attend regular appointments, and ideally see a birth! Most of the time I will be with my primary mentor, Irma Cobian, following her into appointments and doing things such as listening to babies' movements and heartbeats, measuring mothers' bellies, and assisting in other small tasks that won't interfere with liability restrictions. Near the beginning of my Independent Study, I will be paired with a woman who agrees to have me in the room while she gives birth, which will hopefully be within the three weeks I am in my intensive.

I currently have five goals for my Independent Study, but some new goals could be formed depending on what happens throughout my experience:
1) To develop a relationship with at least one mother so that she is comfortable allowing me witness the birth of her child
2) To be present at the birth of at least one baby
3) To determine if I want to pursue midwifery as a career
4) To research, analyze, and compare statistics of infant mortality rates in other countries around the world versus the United States and understand some of the causes
5) To better understand the differences between physicians and midwives

Today was a research day, mostly focused on the the last two goals, in addition to learning the basics of what happens during pregnancy and what midwives are equipped to do.

One recurring theme that came up in many of the articles I read today was that infant deaths are consistently lower for births attended by CNMs than physicians. For example, the National Center for Health Statistics (NCHS) and Centers for Disease Control and Prevention (CDC) determined through research that in the United States, infant mortality was 19% lower for births with CNMs, neonatal mortality was 33% lower, and the risk of delivering low birthweight infants was 31% lower. This can partially be explained by differences in prenatal, labor, and delivery care practices. For example, CNMs generally spend more time with patients during prenatal visits, putting more emphasis on patient education and providing emotional support, as well as focusing on non-interventionist methods. One chart that I read showed statistics on this, highlighting the difference between home births with midwives and hospital births with physicians:

Another common theme found in the articles today was that European countries utilize midwives much more than physicians and have found great success with them, an area in which the US is still struggling. In fact, all European countries have lower perinatal mortality rates than the US, which is not surprising when considering the fact that the percent of births in the US attended by midwives is 4%, whereas the percent of births in Europe attended by midwives is 75%. This also goes along with CIA Factbook's study showing that the US is the 50th safest country for the baby in birth and the 47th safest country for the mother giving birth, which are scary facts considering the US should be at the top or at least in the top ten. However, in the countries with the best outcomes, midwives are the primary providers of care for pregnant women.

After reading these articles comparing practices within different countries, I read some excerpts from books written by Ina May Gaskin, who is a very well-respected midwife and author. I learned what the mother's body goes through during each of the four stages of labor and the different hormones involved. This will help prepare me for understanding the process while watching a birth in the upcoming weeks. I also read about basic nursing skills such as taking blood pressure.

Starting on Monday I will be in the office with my mentor! I am excited to see what the next three weeks will bring.