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Difficult Decisions

Jul 24th, 2012 Training

In my first semester of attending births in my program I had something devastating happen – I had to send a woman for a cesarean surgery.  It was her first baby, I labored with her at the birth center and we pushed in every position and used every trick I knew to get the baby to move, but that head was stuck. When I spoke to the midwife at the hospital after the surgery she described the oddly swollen head and confirmed what my instinct and exams had told me, that head was stuck in a very bad position.

So here is the weird thing, it didn’t feel awful to send her for surgery – that part wasn’t devastating at all.  I expected it to be. In ten years as a doula I had yet to have a woman I couldn’t labor.  It didn’t feel bad, in fact, I knew it was the right decision and I was proud that I knew when to suggest it. I was only frustrated that I didn’t have student privileges at that hospital so would not be with her.

What was devastating was that I felt like I couldn’t share my experience with my natural birth community. I have been part of this community for years, and knew what responses I would get.  There would be a few supportive remarks from the people that really know me, or who have been through the same thing in their training.  But most responses would be about what I should have done, what else I should have tried or how this only happened because of the type of midwife I am training to be – a nurse midwife.

I know this because I used to think this way myself – that every cesarean is avoidable. Even though I would comment that a small percentage are really needed, the reality was that I had never heard a birth story in which I couldn’t find a way the cesarean could have been, and should have been avoided. I wouldn’t say anything to the mother out of respect, but I always knew she had been lied to or tricked and had an unnecessary surgery.

Somehow, it never felt like I was being unfair when I was on the other side of the laboring woman. I felt justified in my judgments, but I’m not really sure why.  I’m not sure why I felt I could have a better understanding of what was happening by hearing a story after the fact than the midwife had at the birth.   I am not sure why I believed my experience as a doula and the few books I had read made me a better judge of labor than the experience of a midwife who studied things in much more detail and attended births much more regularly than I. I am not sure why I felt any use of technology was always evidence that the midwife didn’t really understand labor.

This was a real growing point for me, a specific instance in time where I made the first step into the shoes of a midwife. I knew that as a midwife my job would be to recognize and address any problems during pregnancy and birth. To help mothers stay safe and healthy.  I think in a way, I knew that would mean sometimes having to make difficult decisions, but I didn’t really expect it to happen.  Here it was, it happened, and suddenly I was on the wrong side of the laboring woman.   Suddenly I was the midwife whose actions would be judged by others, becoming a story of why nurse-midwives didn’t really understand labor.

It was a devastating moment that separated me from my natural birth community. It shouldn’t have been, but it was.  Along the way I’ve had other moments, things that I did or decisions I made that I knew would bring snarls from the crowds. These moments, learning to make these decisions, has kept me from being able to be honest about how difficult this journey to becoming a midwife really is. How can I describe the discomfort of working with a midwife group that induces regularly so I can learn the skill of managing induction?   How can I talk about my struggles as I learn to read labor with an epidural? How could I ever mention that I actually performed an episiotomy?  Or what about the mistakes I’ve made while learning?  Like the time I pulled just a little too hard on the cord, the time I thought a woman was ready to push when she still needed to labor down, or how difficult it is for me to assess effacement?

This learning is hard. And not just hard because there are so many skills to master.  It is difficult because I have to learn when to use the very tools I have convinced other women to avoid. I need to know how to use them safely, and when the right time is to use them.  I really think this part would be easier if I didn’t come from such a strong natural birth background, but I am struggling through it and learning that I can make good decisions.

Here it is, a year and a half after that labor that ended in cesarean, and I finally feel confident in my self to talk to you about these things. I am finally ready to talk about what it is really like to learn to be a midwife.

 

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