Yesterday I shared how my training has caused me to relearn how I think about the term “intervention.” Today I want to share another word that needed to be reframed in my mind – “normal.”

When I first began in the natural childbirth movement, when I heard the word normal I always interpreted it to mean “OK” or “Safe” or “Ideal.” I’m not sure if I had thought of the word that way before my first training, or if I somehow picked up on that meaning through my readings.  It was, perhaps, a combination of both.  I was too young and inexperienced to ever see something bad or dangerous as normal, and the training encouraged me to continue this line of thought.

The most specific example I can recall would be my thinking about newborns.  Perhaps you’ve also had the same mindset about some of these.  ”Physiologic Jaundice is so common, it’s just normal for babies to be jaundiced.  I don’t know why doctors get so hung up about it.”  or “It is normal for the newborn to have really low vitamin K levels at birth.  They increase by the 7th or 8th day, this is no big deal.” or “They get so hung up on blood glucose levels.  It’s normal for glucose levels to be low when you need to eat.  Just give the baby the breast and she’ll be fine.”

Today, I look at the things I used to say and wonder how I could be so confident in my statements when I didn’t have a full understanding of all the issues.  I also wonder how I always assumed “normal” meant good or safe.

You see, a Type 1 diabetic is going to have high blood sugar levels if they don’t take their insulin – this is the normal functioning of their body because a diabetic does not make insulin so the glucose cannot be metabolized. Yes, this is the normal functioning of the diabetic body, but it is not safe.

“But wait!” you say, “The ‘normal’ newborn is not sick, their body is functioning as it should be.”  That is true. But neither is the ‘normal’ newborn body functioning like a one or two week old, an older child, nor an adult.  Their body is in a state of transition, and it is this existence in a state of transition that makes these “normals” something worth watching a little more closely.

Before a baby is born, most of the work of the liver is done by the placenta.  When the baby is born and separated from the placenta, the liver is just a little behind.  It isn’t producing as many of the things needed to help blood coagulate when necessary.  It’s ability to form glucose and store glucose are very immature, as are its production of hormones to regulate carbohydrates.  It’s ability to conjugate bilirubin is limited, as is its ability to break down any medications.

Closely linked to the function of the liver is the function of the kidneys.  Their job of regulating fluids and electrolytes is also done by the placenta before birth.  At birth, blood flow to the kidneys does increase, but the filtration abilities are limited – salt stays in while glucose and amino acids leak out.  The newborn isn’t very good yet at concentrating or diluting urine to regulate body fluids.

The newborn does a poor job of maintaining body temperature.

At the same time the digestive system is starting to gear up for use.  Mucus is being eliminated and the necessary bacteria for vitamin K production are beginning to grow.

What does all this mean?  This means the majority of newborns are going to go through these early transitions without a problem.  But the newborn is in an delicate position – anything that causes additional stress can overload this immature system quickly. This is one of the reasons the highest rates of death in children under five occur in the first year; and the highest rates of death in the first year are among those less than one week old.

As a midwife, I am trained to watch for these things in all my newborns – not with tests but with my eyes and ears.  If something is off, I am trained to investigate quickly to help keep the system in the proper balance during transition. Some of the most common problems look the same or lead to each other in those first hours. For example, if a baby is too cold, the body burns glucose quickly to try to warm the baby which can lead to hypoglycemia. Or a baby who doesn’t feed well may begin to have problems with hypoglycemia, and may also have higher bilirubin levels if they are not stimulating good bowel movements.

While I still accept that this transitional time is normal for a newborn, I no longer pass these first few hours or days off as no big deal.  While the baby is transitioning to extra-uterine life, I watch a little closer because this is one time when early detection of a problem makes a big difference in overall health.

I spent the day at a waterbirth workshop. I’ve been present for and attended waterbirth as a midwife, but there was still things to learn.

What struck me today? In addition to the research questions that alwys swim in my brain, I realized the newborn reflexes have a purpose in birth. How this never clicked for me before is beyond me. It makes the fetal movements make so much more sense. 

See? You never stop learning.

Yesterday I talked about studying with the Mnemosyne digital flashcards.  I did like the program, but had to change for a semester due to a class flashcard making project that was being based on another program, StudyBlue.

Study Blue is digital online flashcards that can be accessed from any computer, tablet or smart phone.  This was nice, because I could open my flashcards anywhere I had an internet connection.

The flashcards use a simple yes/no answer system to categorize your cards, meaning you mark each card as correct or incorrect as you move through them. If you pay for the premium service, you are able to target your studying to only the most difficult (most often gotten wrong) flashcards.

You can share your flashcards with others, and even use groups of flashcards made by other users. Because it is fully online, you can make flashcards from any device that gives you access to the site, including smart phones.  You also have the option of uploading your cards as an excel spreadsheet (this is how my class shared cards – each student created a group of cards as an excel spreadsheet and then you deleted any you did not personally want).

To review your cards, you select the group of cards and then select 5, 10, 20 or all the cards.  You can also specify if you want to go through the cards in order, randomly shuffle or (with a premium package) target more difficult cards. You can also view your cards as a review sheet – seeing the front and back of all cards, or take quizzes made from your cards.

I liked the easy access to all my cards from any device, but found that not having good cell service in some buildings frustrating limited the usability (like being on call in a hospital late at night). I wanted the ability to put some cards on my phone so I always had cards to work with. I couldn’t access my online cards while in Honduras – when I had  internet I downloaded important card groups and then imported them to another flashcard program.

The quizes were a nice additional way to test my knowledge, but I found that making them work took planning on my part.  Basically you chose between multiple choice, true false or fill in the blank and the quiz gives you the front of the card and you have to identify the back.  This worked well for some topics, but not others (it is frustrating if you have the same answer for more than one card, or if the answers are obviously for only one card – so not the best with medication doses, etc.).

The correct/incorrect scoring and no intuitive way to select less than all the cards was also frustrating. With random selection, I was just as likely to get a card I had well memorized as a card I hadn’t seen before. This didn’t work for me and I decided to pay for the premium package – but was still limited to 5, 10, 20 or all the cards in a grouping.

There are other digital flashcard programs available, and hopefully understanding what worked and didn’t work from my experience will help you make a good decision about which program will work the best for you.

I don’t have a terrible memory, but I do struggle to memorize information.  My brain works better with systems than small bits.  This is a problem for many of the types of information one needs to be familiar with to be a midwife (or other birth worker).

To help me memorize, I have started to use some digital flashcards.  I have found there is truth to the theory that repetition is the key to memorizing information.  So I make my flashcards and go through them over and over and over.

I have two programs I have used, they work a bit differently and each has some advantages.  I can’t say one is better than the other, but one might work better for you.

Mnemosyne

The first I tried was Mnemosyne. This is a free program that allows you to make flashcards that you rate as you work through them.  For example, a flashcard that completely stumps you would be rated a “0″ and would be shown more frequently than a flashcard you remember pretty well and rate a “4″. In all there are five levels to rate a card.  The other trick to Mnemosyne is that it sets the cards up to give you a specific number to work on each day – so you can have the daily repetition without being overwhelmed, and there is an emphasis on the cards you do not know well.

Mnemosyne is compatible with smart phones, but the connection is through sync. You make a selection about what groups of cards to send to your phone, and then send them.  While the cards are on your phone, they continue to be tracked in terms of your proficiency. You can also export your groups of cards to share with others.

I loved the way Mnemosyne knew how often I needed to see cards – it really helped me to master information to see difficult cards over and over.  I also loved that the cards were always available to me, so if I was waiting to pick up my kids I could work on my cards.

I did not like the way Mnemosyne couldn’t handle having the cards on the computer and the phone at the same time.  If I had cards on my phone, I couldn’t make flashcards in class without breaking the sync and losing some of the mastery data associated with the cards on my phone. I also couldn’t go through the flashcards on the computer if I had some on my phone without losing some of the mastery data.

The other thing that always bothered me was the small volume of cards Mnemosyne would assign for each day. I usually had a week to memorize the information for a quiz, and couldn’t take the amount of time Mnemosyne recommended to get through the hundreds of cards I made.  This was a problem when I was using the phone, because the only cards sent to the phone are the cards scheduled for the next few days.  To get more I needed to connect to the computer and resync.

Overall, Mnemosyne worked well for me.  I did adjust to having to deal with getting new cards frequently, and didn’t have a problem only making cards on my computer.

Tomorrow, I’ll share about the other digital flash card program I used.

Yesterday I was introduced as superwoman to a fellow student.  The speaker, an undergraduate student nurse, had remembered me from a scholarship meet and greet I attended in the spring and had been impressed with my line of study.  But superwoman?  I have to disagree.

I’m not doing anything different than any of the other students.  I study, attend class and work on projects.  I’m learning.  The only difference is in the degree of scale – by working on two programs at once I am doing more studying, attending more classes and working on more projects.  My difference is not one of ability (superhuman or otherwise) but of scheduling.

What she doesn’t see when she judges me by my completed coursework is all the things I let go to successfully learn the material. This, again, is no different than any other student because taking classes takes time.  Taking 20 credit hours of classes in one semester takes more time (usually) than taking 12 credit hours in a semester.  To make room for all that time and still have relationships with my husband and kids I don’t do some things I would like to do.  For the most part I don’t have friends except for the friendships I have that exist within the confines of the classroom.  I don’t watch TV, movies or other forms of entertainment except when it is something done with my family.  I often don’t cook or shop for groceries.  I don’t have a paying job and have let many of the things I wish I could do for Birthing Naturally go until I finish school.

The secret is to be organized and to prioritize.  To me, coursework and travel are my big priorities because I will never have so much ability to learn this volume of material this quickly after I leave school.  I don’t want to have to come back and restudy things later – I want to know them know. I don’t want to be working on my degrees for years, so I put the work into it now.  Getting six weeks off to volunteer in Honduras probably isn’t realistic when I get a job, but I can do it now so I let go of other things and do it.  It isn’t easy to let go of all the other fun stuff in life, but it is temporary – and it is only one way this can be done.

Some people think you can learn to be a midwife easier by doing the self-study method, but that isn’t necessarily true. The only thing you gain with self-study over classroom learning is the control over the speed you learn the material.  You still need to learn the same things. You still need to put in the same work.  This works for some women because they are willing to do several years of slow self-study while working at something else. For some women this method becomes harder because they don’t have enough variety in their sources of information – they do not end up with as wide a variety of skills as they would like to have.

Distance learning can work as a nice balance between the two, but don’t be fooled into thinking it is somehow easier than sitting in a traditional classroom.  For some women it makes study possible because there are no programs available locally and they cannot move. For some women it is actually harder – I had one friend who tried distance learning for a year only to find it would not work for her family because she was too easily pulled away from her studies.

The point is, regardless of how you do it – or how long it takes you to do it – you will be doing the same amount of work.  Once you accept that no matter how you approach it you will be working at learning, you can begin to make decisions based on what fits your family, time frame or finances best – not on what you think will be the “easiest” in terms of actual work.

One thing that has always amazed me about working in the birth world, and life in general, is how much more I learn every year.  I have had the unique privilege of watching my knowledge expand through my website; as I understood more, I put more information up for others.

I’m doing another set of updates to the website.  I have anticipated this for a while; after all, I do have four years of nursing classes worth of knowledge to integrate.  So here I am, updating the website–not even to the nursing school parts yet–and I have so much I want to add. I know more complementary and alternative therapies. I’ve learned more tools to use during labor.  I even know more about the questions women have when they are pregnant for the first time.

Not that this surprises me, I knew there would be a lot of non-book learning–how could I work with so many women and families and not learn new things.  It was just that I don’t tend to think about these things.  I don’t get tested on them, they simply become background information for the way I work with women. The only reason I am getting a glimpse of how much I have grown is because my website acts like a journal, making an interactive representation of everything I know about birth.  The way I approach subjects, the things I link them to and even the subjects I address are all recorded for me. Which means this week, as I work to further improve the section on techniques for natural birth, I am able to see how much I’ve grown.

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.