The summer project is completed and I am finally home. It feels good to be in my own surroundings. It feels good to not be surrounded by people all day. It feels good not to have exhausting hours. It feels good not to have to rethink what I am saying in Spanish or to struggle through exams with a translator. But now I must return to my regular life of studying and paper writing, which can be equally difficult.

Two papers I will write today are reflections on the experience. The instructors assign us a topic or a question, and we write about that topic as it relates to our experiences on the project. As an example, one reflection I must write is about the disclosive (the trust that happens that allows patients to disclose information) space that occurs between a nurse and her patients – did it happen during my time at the foot care area and what helped or hindered it. I must conclude the paper with discussion of how this will affect my future practice.

I wish I could say that being a midwife means I will work with healthy women, not individuals with health problems.  I wish I could say the disclosive space for me will only be about fear of giving birth or becoming a mother. But to say “only” belittles the effect such fear has on a pregnancy, a birth and the first few days to months of parenting. And to assume that just because pregnancy is a normal healthy condition that every woman who becomes pregnant is healthy is nieve.

Not all women follow a healthy diet. Not all women exercise daily. Not all women get adequate rest. Not all women are able to stop their medications during pregnancy. Not all women have a supportive family. Not all women feel safe in their home. Not all women feel they have control over their circumstances. Not all women are comfortable with their sexuality when pregnant. Not all women enter pregnancy excited about being a mother – again. Not all women are willing to cut off smokers from their lives. When you think of all the things that affect a woman’s health, suddenly the opportunities for disclosure of important information can seem overwhelming.

The difficulty comes in the fact that the woman may not realize how important the things that affect her life are to her health – so the woman probably will not come to the visit planning to share such information. Instead, I must learn to create a space that helps the woman understand not only that everything matters – but that I am willing to help her through whatever struggle she may have. She must know I can be trusted with her shame or her fear or her anger. She must know I can help without removing her autonomy. I must counsel and educate and assess her total  health very quickly so I do not take up too much of her time.

All of this with the “normal, healthy, young women.”

In the fall I start more intense family nurse practitioner clinicals – and I will have to do all that with individuals who are sick.

My husband needed to run to a store today.  He selected a store in a large mall in a trendy part of town.  The mall has beautiful furniture, enticing little cafes and sushi shops, every popular chain you can imagine.  He likes the freedom to look at other things that interest him when he goes to the mall.  He doesn’t mind the traffic congestion near this mall or the large amounts of people who are always inside.  If he can get the item he wants and spend time at this mall, he feels satisfied and successful with his shopping trip.

When I need to pick something up from a mall I choose the small mall on the edge of town that has the major stores and a few little shops.  Traffic is easy in and out, I am not fighting with hoards of customers and I have space to relax if I want to sit and have a coffee or a snack. As a bonus, several other stores I frequent are right outside the mall so I can get several errands done at once.  If I can get an item from this mall I a feel satisfied and successful.

My husband asked me to go to that mall with him once.  I hated every minute of it.  The trip took longer than it needed to, the shops were too loud and too crowded, the cute little cafes were more expensive than I am willing to pay for.  When I ask him to stop at my mall he is bored and annoyed at how many errands I try to do.

I mention this, because I think it is important to understand that even something as “simple” as stopping at the mall to purchase an item can be a hit or miss based on individual philosophies of shopping. Imagine then how difficult it can be to help a family be successful at birth.

It is important to take the time to understand what it takes (besides having the baby) for a family and its individual members to be satisfied with their birthing experience.  Not only does this mean you need to understand where your philosphies differ from theirs, but also where their philosophies differ from each other.

It is also important to remember that different people will make decisions based on different priorities.  It is not that my husband or I “know” more about mall shopping than the other.  In fact, we both have the knowledge and use that to ensure satisfying shopping.  It is the same with birth, your goal can never be to ensure everyone has what you consider to be the perfect birth.  Instead it should be to ensure every family has access to services that allow them to make the decisions about how to manage birth that will work best for them.

I’m spending time this week (spring break) to work through the postpartum study guide I need to complete for school.  In the process I found an interesting list in Varney’s of reasons a woman may be experiencing inadequate milk supply.  How timely, someone had just asked this on the Facebook fan page last week.

So what does Varney list?

1. Infrequent or scheduled feedings, not on cue
2. Replacing or spacing breastfeeding with pacifier
3. Replacing breastfeedings with formula or baby foods
4. Compression of milk-making cells (too tight bra, engorgement)
5. Use of nipple shields
6. Stopping night feedings too soon
7. Poor letdown
8. Prematurity, dysmaturity
9. Retained placental fragments
10. Inadequate glandular tissue (ofeten presents with breasts of markedly discrepant size)
11. Class 2 or 3 inverted nipples
12. Poor milk transfer by the infant
13. Breast surgery or injury
14. Cigarette smoking by the mother
15. Drugs or medications that could negatively impact milk supply
16. Endocrine (especially thyroid) problem

This was a few more reasons than I would have quickly listed, and a good reminder that not every woman who is experiencing poor milk supply is having the same problem. So what was the issue with last week’s reader?  Let’s try to figure it out.

We know a few things about this mother.  She was breastfeeding post cesarean surgery but with a poor latch.  She utilized the services of a lactation consultant and a nipple shield and within about two months was feeling successful at nursing. Around three months the milk stopped flowing.  She attempted to increase her supply by using supplements (for mom), increasing fluids, pumping before and after feedings to stimulate more milk production but the flow continued to decrease and ultimately her breasts were dry.

From her description we can rule out several items on the list, specifically 5 (she is no longer using nipple shields), 8 (the baby was already 3 months old), 9 (this would have already been resolved), 10 and 11 (which the lactation consultant would have helped her discover and manage).  She was previously successful with breastfeeding, so we can guess that  7 and 12 do not apply to her case.

This leaves us with a few possibilities.   Since she was working with a lactation consultant, we can guess that she already knew about 1, 2 and 3 and 6 so would have avoided those, but we should still ask her anyway. We would need more history to assess the possibility of  13, 14 or 15, but the mother should be able to give us information about those relatively easily.  15 (medications) is quite likely since she may have been prescribed hormonal birth control at her six week postpartum visit and recently began using it.  If it was birth control related, changing the method should help restore supply.

Though I would NOT have come up with this without this list to work through, the next most likely cause would be 4 – her bra had become too tight. Around three months most babies will go through a growth spurt and will increase the mother’s milk supply.  This mother had already successfully passed through two growth spurts, so I doubt she would have failed to move through this one successfully.  But if we believe the signs in dressing rooms, most women wear the wrong sized bra anyway, and if her bra was too small before the increase in milk supply (perhaps she bought it during pregnancy) it could have been very restrictive after. This would be easy to check, all we have to do is ask her and look at her bra.

If her bra did fit well, we could consider 16 (thyroid problems) and may recommend she get a test.  But chances are her problem will be resolved before we get to this step.

What a good reminder that every breastfeeding couple is unique, and we need to work through all possible problems with the mother to understand what is causing her supply to decrease.

I’m not really an herb person.  It’s not that I am against herbs, I’ve just never really felt the pull to learn much about them. Honestly, I feel sort of strange about it because I personally have integrated herbs with midwifery in my brain.  It seems natural to me to hear about women whose midwives have prescribed herbal treatments.  So it seems natural to me that I should have knowledge about herbs.  But I can never get myself to actually study any of it.

What I do have a pull towards is aromatherapy, which really is herbs but in a oil form. It makes absolutely no logical sense to me what-so-ever, but if you give me oils I’ll read for hours, give me herbs and I’ll stash them in the cupboard until I cook with them. It gets even weirder when I confess that I’m actually quite chemically sensitive, so much so that I have been known to get headaches from hair gels and liquid soap. How can a girl who cannot stand the smell of perfume feel so drawn to rubbing aromatic oils on her skin?!?

The best explanation I can give for the chemical aversion paradox is that the plant oils are pure plant extracts.  They are more intense than the plant itself because they are concentrated, but they do not have the chemical base that perfumes, hair products, cleaning products and even soaps have. I’m not an allergic person, so the oils don’t bother me.  I have no explanation for why I can only get myself to study oils.

So now that I have confessed all that, here is the reason for talking about oils.  I’ve had the first cross-over of “medical” and “traditional” knowledge. It comes from all the pharmacology studying I’ve been doing and focuses on topical treatments. There are basic principles you must know about any drug before you prescribe it, and one of the things is how quickly the medicine is absorbed.  Topical treatments are the lotions, powders, creams and oils that are put on the skin and absorbed through the skin.  But skin is more unpredictable than absorbing drugs through the gastrointestinal system, because the skin is so highly affected by the environment. Moist skin absorbs the medicine better than dry skin.  Skin covered with a bandage or dressing will absorb more than uncovered skin. Skin on different parts of the body will absorb the same medicine at different rates. The ability of the skin to absorb changes with age.

What’s so important about knowing all that?  Because the same things that help or hinder absorption of medications on the skin will help or hinder absorption of aromatherapy oils on the skin. The treatment principle is the same. This means depending on the state of the woman’s skin in labor, I may need to increase or decrease the amount of aromatherapy I use. If a woman has been laboring in a tub, her skin will absorb much more oil than a woman who has been laboring outside.  If I use an oil to massage a woman’s feet I may need to use a higher concentration of oil to get the same effect I would have gotten by massaging her back. Absorption matters.

I wish I had specific drop to carrier oil numbers to give you, but since I’ve really only just started putting the pieces together myself I’m not quite that far yet. I’ll let you know if I get a chance to look it up.

I have been forgetting to tell the blog to accept posts from my phone. But I have it set up now and this can make it easier to keep everything updated. Well, except I hate typing on a phone.

“my phone will take dictation. but it seems I have to go back and change the punctuation, figures.

I have been trying to get ready for final exams to begin next week.  Not terribly traumatic for me, just time consuming.  Anyway, I had to take a quiz tonight – and I had studied, dutifully prepared.  I even spent 45 minutes reviewing the material before I took the quiz and told myself I understood the material on every slide.  Yet, 20 questions later I found myself wondering how many I actually got right.

I am not a fan of test anxiety, so sorry if you experience that.  But I am a fan of testing yourself – using the information you have learned in a different way to ensure you really understand it.  Because the truth is my recognition of the information in my notes was great–as soon as I read it I remembered it all and could explain it.  But my recall of the information was not as good, without the notes for prompts I found myself working hard to remember which secretions are hormones and which are not.

The same thing happens with birth.  When you watch a video or read a book what you see makes sense, it is natural to think you understand how to manage birth.  But when you are given a test – the scenario without the answer, you begin to realize just how much you do (or do not) really understand about managing birth. This is the reason my classes are full of labor rehearsals – both “act it out” and “what would you do?” types.  This is why I give my doula clients homework.  I want them to work through the problems and build not just their confidence that they are prepared, but also their ability to use the new labor tools they are learning.

This was originally posted on Jun 6, 2010 on the blog I destroyed.  This is the article I was talking about yesterday.

I still don’t feel like it is “home,” but my family has survived the move and is settled into our new apartment.  Over the last week I have been reflecting on the lack of privacy afforded by apartment buildings and the necessity of apartment dwellings in urban areas.  Which made me wonder, are apartment dwellers less likely to give birth at home?

As I type this it is late, and I am only up because the young men who moved-in upstairs seem to be having a housewarming party.  So I am not going to take the time to find out if there is any research on this.  Instead, I’m going to consider all the factors that go into the decision to give birth at home.

You see, as a house-owning natural and home birth advocate my argument for birthing at home revolved around the ability of the mother to relax in her own environment; the privacy of her own home; the control she had and how all that works to create a better birth experience with at least as good of outcomes as the hospital.  But this week my eyes have been opened to a few holes in that argument.

My apartment may be my home, but my ability to relax in my own environment depends on what is happening in the homes above and around me.  Could I feel comfortably relaxed laboring at home tonight?  I doubt it.

My apartment is private to an extent – I can close the doors and shades to prevent people seeing in.  But I can tell what is happening upstairs right now, which leads me to believe if I were to use my birthing voice my neighbors would hear me.

And so, although I could control who was in the room with me and to some extent what they did, I could not control who would be home and be aware (or hear) what was happening.

Now, the catch to this is that I do not gain a relaxing environment, privacy or control by moving my labor to a hospital.  Far from it, I lose parts of each of those. But what I might gain is anonymity. The nurses won’t care and I will never see the people in the next room again – so there are no long-term consequences if I am loud or  walk out of the room naked.  I can only imagine the months of discomfort that would result from wandering out to my “private deck” naked during labor – I have to see my neighbors every day.

So if I were to become pregnant today, what would I chose?  A birth center may be a good option – except there is not one here.  While I dislike the idea of birthing in a hospital, I just might decide it is a better, more relaxing option for me than trying to not disturb the neighbors here.

While I accept there are many reasons birth should be a normal part of everyday life, I can also accept that many women live in a world where it is not.  Recognizing the challenges women face as they make decisions about where and how to birth can only make me a stronger advocate for the women I serve.

This was originally posted on Jul 8, 2010, it is from the blog I accidentally killed. I have been thinking about this topic lately because of an experience I had volunteering at a free clinic.  Enjoy!

Last week I received my enrollment information from Emory, the school that is going to train me to be a baby catcher.  Nursing and medical schools are a bit different than other schools because in addition to classroom lectures, we work with people.  People in healthcare settings.  People depending on us for health care.  This means, we need to not only provide all the information to successfully enroll in classes, we need to provide all the information to be able to work in a health care setting.  Hospitals are required by law to have this information on file, and the school must ensure we have it before we are allowed to work/learn there.

So tomorrow I will be getting my token physical and my drug test.  Yes I said drug test…like I said, I have to follow the hospital employment requirements.  To make it even more interesting as a student you work at several hospitals and must have the mandatory paperwork for each hospital in place before the semester begins. Remember a few posts ago when I became painfully aware that many things contribute to the decision of where to give birth? (hmmm, I guess I need to add this post for you too?  How about tomorrow). This week I became painfully aware that many things contribute to the decision of who to attend a birth.

After a week of trying to become a patient in a family practice so I could get these forms filled out and submitted before August 1st, I really don’t care anymore who I see. I like this visit to be the first in a  partnership with a physician or nurse practitioner for the few years we will be here, but since my state sponsored program from New York (which runs out soon anyway) won’t cover non-emergent health care in Atlanta; and because my school mandated health insurance does not begin until August/September; and because I cannot become a patient at the student health center until I am “in school,” but will be expected to use their services as primary care once I am (because I will have the school insurance program)’; and because my last physical with my doctor was now over a year ago; and because the paperwork is due August 1st, I am stopping by the cheapest walk in clinic I can find to have the paperwork completed and signed.  After a week of trying to get what I expected and wanted, I give up.  The deadline is too close.  I simply ran out of time and options.

As I said, tomorrow I will have my token physical.  Token because I don’t have a doctor here in Atlanta yet so whomever I see will have meet me about seven minutes before they fill out the form.  Most of the information will be based on my answers to questions because they have no access to my health history except that I provide. Yes, I still care that I will have to meet this doctor for the first time while essentially naked; that I will probably never see him/her again; that this visit is really only the illusion of  health care; that true health problems are not likely to be discovered because of this appointment.  I am still me, I still wish I could have the highest quality care with a practitioner who partners with me.  But I am stuck in a system that makes it almost impossible to make this visit any more than a shadow of what health care should be.

And herein lies the dilemma for many expectant moms.  Not enough time to explore options before the appointment must be set.

Let’s assume a mom knew she was pregnant pretty early, maybe she tested as soon as she was “late.”  She is now about two weeks gestation, which is four weeks pregnant.  Her first visit with her chosen health care provider will be when she is ten weeks pregnant.  That leaves six weeks to:

Get an appointment to verify the pregnancy (if necessary for her insurance);

Review the list of care providers covered by her insurance;

Get recommendations, check locations and if she is lucky what hospitals different providers will go to;

Set an appointment for that tenth week…wait, that means she doesn’t really have six weeks to do all this.  Because she has to have the appointment set for the tenth week – she probably needs to have her decision made so she can schedule an appointment by the eighth week.

Four weeks – she has four weeks to pick her doctor/midwife to be on the right “schedule” according to the standards of care. And for many women these are not the best four weeks of pregnancy.  She has to stay motivated to do her research and make a decision while tired and sick to her stomach.

I gave up after 10 days, in perfect health and without the common symptoms of pregnancy.  While I might suggest the birth of her baby should induce her to put a little more care into her choice, shouldn’t the care of my family induce a little more care in mine?  I set out to find a family practice whose philosophy of  health aligns with mine.  I was supposed to choose the family practice who would partner with us for the next four years.  I settled for a one-appointment-stand with a doctor whose name I don’t even know yet.  Frustration and feeling pressed for time will do that to you.

Today we have thoughts from two guest mentors that really highlight the things that helped them labor.

Thank you to guest mentor Leah for this thought about preparation.

My natural childbirth experience with Bradley method 9 years ago was the most amazing moment of my life. I was very lucky to have a doula at my side and a partner who was supportive and caring. I did not need any pain medicine, because I tapped into the Bradley breathing and meditation techniques. It was a more healthy way for my child to enter this world than the way I did – lethargic because of doses of Demerol to my mother. I immediately got to interact with my girl. My doula helped with my slight postpartum depression as well in a natural way, which helped my child again not receive unnecessary medication.

Thank you to Darby for this thought about labor support.

I am a mom with three kids, all birthed naturally. My last one was at home, and happened so fast only my midwife was present as the second didn’t make it. My hubbie was the second and I loved it. There is more of a story there. I have also helped at a friends hospital/natural birth which was amazing. I think the key that birth professionals need to know (or at least one of them) is when your in it, and the panic sets in, that they get you to look at them, tell you your doing a great job, and that you can do it! I know it sounds basic but hearing that when I was starting to panic made all the difference. Calmed me down and let me know this is normal, and I am almost there!