I heard it again today, “They won’t let me….” Whenever I hear someone talking about “they” or “them,” my ears begin to perk up because I know there is more to the story than I am being told.  Here are the things that go through my mind.

1. Does this woman understand what she was told and why? I don’t ask that to be smug, but out of real concern about miscommunication.  It can be easy to believe everything you hear, even if what you heard was not what was said.  It is also easy to believe things you hear from individuals who are not in a position to be decision makers.  If a friend tells you the hospital doesn’t do water birth, you are much less likely to ask about the option on a tour. If you don’t ask, you won’t find out that they only have two water birth rooms so if you are interested in a water birth you need to tell someone on admission.

2. Is this woman making assumptions due to misinformation? If you were to believe everything you read, every doctor, nurse and midwife is out to make sure you have a terrible birth experience that hinders your breastfeeding and bonding. The good news is that most health care providers are NOT like the stories you hear.  In fact, each health care provider is a unique individual, just like every mother.  Individuals have strengths and weaknesses, good days and bad days, get tired and will even have opinions. Sometimes the opinions of other individuals will be different from yours.  But you cannot know this unless you ask.  Making sweeping generalizations about everyone within a profession is stereotyping. Not only is it unfair, accepting your assumptions based on stereotypes means you are less likely to ask the questions you need to ask to prepare for the kind of birth you want.

3. Is this woman feeling judged about choices she made and just trying to get out of the conversation? For those with a passion for helping mothers have natural births, it can sometimes be difficult to understand why a woman wouldn’t choose a natural birth – and this can come across as judgmental in conversation. Some women politely smile and nod as you continue explaining the perils of epidural, some will get angry and tell you it is none of your business, and some will blame the decision on someone else so you will leave them alone.

How do I handle these situations?  First, I never assume the mother and I are “on the same side.”  I don’t make assumptions about who she is or what she wanted from birth or how she feels about not having an option.  I don’t argue against the medical establishment, medical techniques or individual caregivers.  Instead, I listen. I let her talk, sharing what she feels is important.  If she needs to know I am listening and not judging I might ask if she can “Tell me more about that?” Instead of deciding for myself how she is feeling, I ask her, “how do you feel about that decision?” Then, I listen.  Because she might be angry the option is gone, but she might be relieved.

I’m preparing for two upcoming conferences where I will be presenting.  The first is a conference for Christian midwives where I will be providing a clinical update on menopause.  The second is a conference for nurse midwives where I will present a poster of my original research. As I finalize my work for these two events, I can’t help but notice the similarities between educating my clients, and educating my peers.

You see, the natural instinct is to basically vomit out all the information you have.  Everything you’ve ever read or heard is weighted equally without any regard to who the audience is.  This tends to be very long and boring for the listener (trust me, I’ve sat through many really bad student presentations over the last four years).

If you want to really do the best job of sharing information, you need to do a lot of work to determine what needs to be shared, and when.  What do I mean?

For example, in the clinical update on menopause I could go deep into the endocrine changes and types of testing available.  But since this is a group of midwives who are not infertility specialists, this information is only relevant enough for them to understand that if a client says they had a particular test they know how to find out what that test is.  What is relevant is the information women will want from the midwives, and the ways the midwives can help them get that information.  For example, we’ll be spending a lot of time talking about menstrual cycles and how they can be used to track progress through the menopause transition.  his information help women determine how much longer they probably have to achieve a pregnancy, when they can expect symptoms to subside, and when they can expect that final period.

Next time you are working with your clients, think about what information they really are looking for to make decisions.  Make a list of the key things to share and don’t bring up the rest unless they ask.  It will save time on your visit and make the clients more likely to listen to everything you have to share with them.

I am in the process of reviewing for my certification exam – the test that will prove I can be trusted by the community to be safe and competent as I work with families to maintain their optimal health.  This is such an interesting experience for me as I realize how much I have learned in the past two and a half years, and continue to realize how much more I have to learn.  This has also caused me to reflect on my clinical experiences and the things I have learned about being a good health care provider.

I find myself continually pausing at the importance of a physical exam. The sheer amount of information I can obtain about a person’s health by looking and touching.  But I live in a society that seems uncomfortable with both looking and touching. These most basic of human interactions are reserved for only the most intimately connected to each of us.  Yet, somehow, I must look and touch if I am to participate.

On the one hand, I think of the importance of the midwife being willing to look and to touch.  My very fist semester of nursing school I was struck with how difficult it was for some of my fellow students to walk into a hospital room and introduce themselves to a stranger.  This seemed such a simple act, but at the same time was felt as such an invasion of privacy.  The first clinical learning was to be comfortable taking a step into someone’s private world, to risk being rejected.  As a midwife, this step into the private world is even steeper.  I ask her to tell me about her most intimate details of her life.  How is her menstrual bleeding?  Does she have any discharge? Does she have a new sexual partner? The physical exam is also more intimate – STD testing, PAP smear, assessment of uterine enlargement.

On the other hand, I think of the willingness of the woman to be looked at and touched.  On some level she is ready for the intimate exchange that is about to happen because she made the appointment, she is here.  But at the same time I am most likely a stranger to her.  I have only a short time to allow her to trust I will help her achieve her health goal.  I have only a few minutes to make or break this opportunity to be invited into her private world – her fears and her brokenness.  If I am invited in, she may share things she’s never revealed to anyone.  If I am unsuccessful, even my best advice will seem unimportant to her.

As I reflect on the importance of the first few moments of the first visit, part of me wonders if this exchange is easier for homebirth midwives.  Does it not seem logical that having more time for that first visit allows for more building of trust?  Some of my homebirth midwife friends feel the longer visits are key to establishing a relationship with the mother.  But is this relationship built because more time allows for the building of trust; or because the trust is successfully established in the first moments of the first visit, the time allows for a more broad relationship with the woman.

And I begin to wonder how it works when things do not go as planned on that first homebirth visit. When a relationship of trust is not able to be established in the first minutes of the visit, is it then less likely trust will be developed at all? Does more time without this trust cause the woman to feel she cannot be connected, or does it allow the woman the time she needs to be connected. My best guess is that it is different for every woman and every midwife.  Personalities are so hard to categorize and people are never “average.”

So then my thoughts return to the world of the nurse-midwife and abbreviated visits. What can I do to be ready to enter her world and be willing to touch…and to help her be willing to be touched.

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.