I couldn’t have asked for a better sendoff into my new life. Labor was five hours start to finish, hard labor was about 2 of those hours, and it all happened when most families are having dinner and getting kids into bed.

But let’s rewind. I did her visits as home visits after I moved out of my office, so I got to hang out with the now almost seven year old that I helped out. It still messes with my head, really. This former eight pound wonder is now a walking, talking, sentient human being with a will and a personality.

When I got to their house, she handed me a $1 bill. Her dad walked by and said knowingly, “Ah, the tooth fairy money.” She grinned and showed me her four non teeth, two upper and two lower. I asked her, “Sooo….are you showing me this?”

Her absolutely serious reply was, “This is for taking the baby out.”

I tried in seven year old language to tell her I don’t really do anything except make sure mommy and the baby stay safe. Maybe she understood, but later I found TWO $1 bills on the corner of the dresser where the supplies were. I hope it didn’t offend her that I left them there.

Let’s rewind some more and shift to mom. About a month ago she asked me to clear her to return to work at three weeks postpartum. I told her I would do so with great reluctance and only if she swore she’d be in bed as much as possible for those three weeks. She has a relatively sedentary management job that she can mostly do from home, but REALLY. I’m pretty sure she agreed, but maybe I heard what I wanted to hear.

When she was pacing the hall, I distractedly browsed their well-decorated refrigerator. I wonder if any anthropologists have done dissertations on refrigerator art. My eyes fell upon a ticketmaster ticket: Guns n’ Roses, November 15. Actually, not one ticket but FOUR.

As she finished lap # 72 of the hall, I asked, “Um, you aren’t going to this, are you? This is like NEXT WEEK.”

She looked at me like I’d grown a second head and said, “Uh, YEAH?!!!”

Sigh.

No stopping THIS one. I was starting to feel like a scolding mother wagging her finger. I thought about begging her to please not partake of the mosh pit, but I’m afraid she’d just laugh at me.

And the birth? Just beautiful. Remarkable for its unremarkableness. Big baby boy who nurses like he’s been studying.

And with this baby safely earthside, I can turn my full attention to my rapidly unfolding journey. About every twelve to twenty four hours I get new information that dramatically changes….something.

As it looks now, I’m heading to Toronto this Thursday for one month to take a compressed course involving fetal heart rate monitoring, emergency skills drills, exams, observation days. Then back home in mid December.

Providing I pass everything, I begin a clinical placement somewhere in Ontario beginning February 1st. Ideally, I would be done by the end of April but may be there until May. Then boards at the end of May, and returning home for The Big Move.

Then a job, likely starting in July or August-maybe Vancouver, maybe Toronto. I don’t know. Really, thinking that far ahead is somewhat impossible right now.

I continue on a roller coaster, thrilled when the next step is there as I take it, freaked out and convinced I can’t continue a few hours later, confident again a few more hours later. I realized that my biggest source of fear is that I have no financial cushion if anything goes wrong.

Right now, among the things that are keeping me anchored, one is that I don’t need to freak out about what I need six months from now.  Right now, I have enough. I have plans for what to do later, but it can wait until I’ve passed this month long marathon of testing and I know I have a clinical placement.

In the big picture, I know that I have too many people who care about me to have any actual worry about being homeless or starving.

In my fearful moments, I take measure of the many ways I’m feeling supported. So here goes.

THINGS THAT LEAVE ME SHAKING MY HEAD IN WONDERMENT
1)    That the program administrators of the IMPP were willing and able to take me on as a late entry student.
2)    That I got the written exam done in the fashion that I did.
3)    That I was able to do the oral exam with the flexibility of my Planned Parenthood associate medical director and the health center manager where I was working that day.
4)    That I’ve had four people in my life say, “Hey, I know people in Toronto! Here’s their address/phone number/email!”
5)    My fabulous bookend patient had her baby in perfect timing for me to get to Toronto when I need to be there.
6)    Today’s passport photos/chest x ray/medical exam was as smooth as anyone could ask for.
7)    That the program director is willing to work around my Thanksgiving trip to visit my family.
8)    I was genuinely afraid that I might not be able to get a student visa because I need to have evidence of health insurance, which I haven’t had for the better part of seven years. I found out today that I can get international student insurance for an incredibly low rate. (GAWD, that sounds like a commercial.)
9)    That all of this has happened inside two weeks.

OK, I definitely feel better now. Off to bed now. I have a lot to do in the next 48 hours or so.

In June I was officially accepted to the bridging program in Vancouver, at that time in its second year as a pilot program for several of Canada’s provinces. Last month I learned that the course slated to begin in January would not be offered, and announcements for the next offering would be made after negotiations with their funders are complete.

FAN-tastic. I’ve closed my private practice and have been working at Planned Parenthood doing family planning exams (which I’ve LOVED) while waiting. I’m fortunate to work in a profession where I have these options.

In a fit of frustration, I sent an email to the parallel program in Toronto, the only other bridging program in the country for international midwives. Their program began in September and won’t run again until next September. I asked if they would be able to accept me into this year’s program, I’m willing to work fast and hard to catch up, beg, plead, etc. After I sent it I felt a little self conscious at how desperate I thought I sounded.

To my absolute shock, they’re willing to work with me, providing I can meet a list of difficult-but-not-impossible demands. A few of this year’s accepted candidates were unable to come at the last minute and they have some openings.

Among these requirements, and the main part of this story, is to do a written and oral prequalifying exam. I talked to the program administrator last Wednesday, did the written exam on Thursday, and did the oral exam on Friday. By the end of Friday I had an acceptance letter and eight modules to complete by November 23rd in my email box.

Dizzy yet? I sure am.

I was told I needed an invigilator for the written exam. It’s not every day I need to look up a word. In fact, that happens about once a year or so. But I had to look this one up, if anything because it sounds naughty. Turns out an invigilator is an exam proctor, someone making sure I’m not cheating. This person also needed to be able to accept the exam and shred it once I was done and it was faxed back.

On Tuesday I turned over in my head who I could ask. They said the invigilator could be a librarian or university professor. (Yes, I am now gratuitiously using the word “invigilator” because it makes me giggle). I decided upon and sent an email to a fellow nurse midwife who I know to be an instructor at UIC and who’s a fellow supplemental clinician at Planned Parenthood. We’ve never actually worked together, but our paths have crossed and we’ve chatted enough for her to come into my head as a possibility. I emailed her, and not only is she happy to help, she’s also from Toronto.

On Wednesday I talked to the program administrator, who set up my oral exam for Friday, and I sent another email to Liz, my Toronto born exam proctor. Thursday morning I called her and asked, “Um, so, that exam I need to do? Can we do it, like, today?”

“Oh! Well, I’m leaving from the school now and going to get my hair cut, then I have a few errands to run, but one can wait until tomorrow,” she said. We stumbled around a bit before deciding I would come to her house later that afternoon.

As I drove out to the suburbs I marveled that she was willing to rearrange her day for me. But wait, it gets better.

I got to her house and we caught up for a bit while waiting to get into contact with the administrative assistant, who would be emailing the test to her. She’d finished her doctorate recently, and I was suitably impressed. I told her of my adventures in the past year or so.

Once she’d printed out the test, she:
Got me some water,
Asked if I wanted some Mozart, and
Lit a candle for me, saying that this very table was where she’d finished her doctorate.

Somewhere in there, she mentioned that her daughter was coming home, and maybe she could give me a shoulder rub afterwards.

About here is when I started pinching myself.

Onward to the test. It was harder than I thought it would be, but I was finished within the prescribed hour. At least, I think I did. When I asked her if I had time to look over my answers again, she said, “Sure!”

Not long after that her daughter came home, and yes, I got a shoulder rub. I asked her if she was a massage therapist and she said, “No, my mom and I were in a car accident a long time ago, and we did this for each other.” More warm fuzzies.

A little bit later, Liz and her daughter had a moment while talking about Toronto and me moving there. They used various intonations of, “Oh!”

Liz to her daughter, covering her mouth and pointing at her, “Oh!” (“What about?…”)

Daughter to Liz: “Oh!” (“Oh my God, yes, how could we have forgotten?!”)

Me: “Oh?” (“Um, what exactly are you guys ohing about?”)

Me again: “Y’know, I think there’s an SNL skit that goes like this, except it’s the word ‘dude’.”

The explanation was that a dear friend of theirs still lives in Toronto, and all I have to do is say I’m friends with Liz and I’m likely to be welcomed into her weekly potluck.

During this time, the sky was turning black, in that way that’s really cool when you’re indoors and warm and dry. After some time it started hailing, and the three of us went outside and giggled as the hail was bouncing off the ground. Then, literally before our eyes, this happens:

It’s a little hard to see, but that’s a double rainbow. The second one is to the right of the more obvious one.

Here’s where I started crying.

I left not too long after that. I think Liz was tired of hearing “thank you”.

This entire day was a marvel. Other than the fact that she’s a nice person, Liz had no real reason to bend over backwards for me the way she did. Maybe it’s good karma coming back to me. I dunno. I DO know that I’ll pay it forward someday.

This story is one of a few in the past few weeks when I’ve felt a friendly cosmic shove in the direction of Toronto. Each step I’ve taken has materialized before me as I’ve taken that step. This, truly, has been the story of my life, but for some reason I’m feeling more fear this time, despite all the neon signs saying “GO!” Maybe it’s that I have no freakin’ idea where the money is going to come from to do this. Maybe it’s because this time, I’m moving into uncertainty, whereas in my other major relocations-from home to Cleveland and from Cleveland to Chicago-were for college and for a job I already had. I’m not afraid that I won’t get a job, I’m just afraid of the number of unknowns in my near future.

A less tangible reason, but a reasonable one, is that last year I made a conscious choice to be less magical in my thinking. A few years ago I would have charged forward with the confidence and certainty that this is where God wants me to go. I have lots of examples in my life of feeling divinely protected and guided. But I’ve also had some experiences of charging forward with that same certainty, and retrospectively, realizing that my intuitive and emotional side really needed to be balanced with some rational and pragmatic thinking before making the leap.

For right now, the most rational thing to do is to keep taking the next step. I have these modules to tackle, and if things keep clicking into place, I may be in Toronto at this time next week, doing prerequisites before my clinical placement. Which will likely start in February, somewhere in Ontario.

As my rational side does what it needs to do, I want to comfort my emotional side and generate more anticipation, to allow myself to be excited instead of cautioning myself to not get my hopes up. Encouraging gratitude and reflecting on the other examples in my life of things just falling into place will help a lot with this.

Thanks for reading-you’ve helped more than you know.

First, go back here.

And here’s a comment from today:

Dear Urban Midwife:

I am the woman who left the Starbucks card on the eL in Chicago. I actually just heard the story of how you got in contact with HappyAnne’s mother today, through the woman who originally had the idea of placing Starbucks cards around Richmond, Virginia (http://kindnessgirl.com/2008/02/19/guerrilla-goodness-2/). I did a bit of Googling and stumbled onto this blog entry. I wanted to let you know how happy it makes me that the card turned into something more than a cup of coffee. Thanks for passing along the guerilla goodness and for making my day.Sincerely,
Christina Couch

I’m gonna do another one today. Just because.

I have no idea what step four through nine might be.

Anyway, it was kind of fun once I got rolling. The interviewers were a midwife from BC and another from Alberta. The BC midwife has a three month old and actually ASKED if I minded if she nursed during the interview. I hope my uproarious laughter and “Of COURSE not!” was taken in the good humor in which it was intended.

I answered a lot of questions about GBS management, largely with it as an example of my informed consent process. Generally speaking, I follow CDC standards, and for the occasional mom who wants to avoid antibiotics, I’m OK with risk factor treatment-for prolonged rupture of membranes, meaning more than 18 hours. The other indications are being less than 37 weeks and maternal fever during labor, whereupon we’re going to the hospital anyway.

My only absolute is that I can’t/won’t deliberately not treat a positive result. I picked that up from an OB who is also a lawyer (raise your hand if THAT breaks your head), who said in a specific situation, “If you weren’t gonna treat it, you shouldn’t have tested for it!”, and went on to explain that it’s legally very difficult to defend that course of action. The scenario I want to avoid now is for a mom to blithely accept the GBS screen, to be shocked and surprised by a positive result, and then try to argue me out of antibiotics. That being said, I HAVE become more accepting of alternative treatments.

Interestingly, my practice will be limited compared to what I can do now. I can do contraceptive counseling but not the actual prescription, and won’t put in IUDs. The BC midwife said that it’s an opportunity for midwives to pursue in the future. I offered, if and when that happens, I can be a resource for that. Even if I don’t put in an IUD for years, it’s a little like riding a bike. For the medical types reading this, the CNM who taught me the most about IUDs said, “It’s like putting in IV’s. You do about ten and you’re good to go.”

I also won’t be able to manage postpartum mood disorders. I may actually miss that; it’s a particular area of interest for me, and it’s quite satisfying when the lowest dose of Zoloft works effectively and we wean off in three to six months. I should hasten to add that I don’t just throw Zoloft at any and all depressed and/or anxious moms, but when it’s clearly indicated, it’s a great thing. Much like most interventions. They’re great when they’re indicated.

Another difference in practice is that because midwives ARE so well integrated into the system, they are more bound by their standards of care; ie, the list of reasons for consultation is clearly spelled out.

I’m more than willing to give up these things to be able to do home and hospital birth.

They asked a few questions about how my management style of postpartum hemorrhage has changed, something I addressed in the narratives. For about three years I had this crazy retained placenta/postpartum hemorrhage karma. I was seriously ready to hire a witch doctor to rid me of it. Turns out I didn’t need to, I just made a conscious decision to begin offering Pitocin if the placenta hadn’t delivered by 30 minutes, and haven’t had one since.

I DID have a few occasions of planning for active 3rd stage management, most commonly in women who were anemic. In each of these cases, well, we ended up sorta forgetting. Baby came, placenta came, recovery proceeded. An hour later I (or someone) say, “Wait a minute. Weren’t we supposed to give you Pitocin?” Whereupon we all shrug our shoulders and marvel at the minimal blood loss. Interventions are great when they’re indicated. And only when they’re indicated.

An interesting series of questions had to do with how I would handle moms who flatly refuse a clearly indicated transfer. I took a while to actually answer their question; those of you who know me know that I tend to give long winded answers. They wanted to know what I would do here, not what I’ve done in the past, which seems like an odd question. I won’t know until I’m there and faced with the situation. I said I’d need to know what the guidelines are, and the degree of support I’d receive from my colleagues and collaborators. Also, at the end of the interview, I asked pointed questions about malpractice risk, because that’s a consideration. More on that later.

I concluded with saying that most women with that degree of resistance to needed medical care tend to self select out of my care. Before that happens, ideally, I’ve had a chance to ask the mom, “Under what conditions ARE you willing to go to the hospital?” Because everyone has a line somewhere, and it’s usually sometime before death or disability. The nuances of this kind of decision making are part of the reason that I’m hired. If I’m too conservative for her, well, there are other midwives out there whose limits are more liberal than mine. Fortunately, my journey has taught me to let go of pejoratives. My feelings aren’t hurt if someone chooses another midwife or leaves my care, nor do I feel like a smug hero if someone comes to me from another midwife because my standards are more liberal.

I ended with a question of my own: In the US, 89% of obstetricians have been sued. I’d wager that the other 11% have been in practice for less than 10 years and will eventually be sued. About 15% of midwives have been sued. Did they have numbers of the frequency of lawsuits in Canada?

No, they didn’t, just that their number is WAY less than that. And I heard much the same thing that happens here: sometimes a midwife can follow standards to the letter, but if a bad outcome occurs, sometimes the parents sue because they need the money for long term care. I suspect that some of the reason they have fewer lawsuits is because there is a universal health care system.

At the end of the interview I talked for a few minutes to the program director about time lines. Much to my befuddlement, NOW I may not be moving until March of next year. The program starts in January, but I can do it online; I actually have to physically be there to begin a six week intensive in April, which will be followed by taking the board exam.

*sigh* Not sure what I’ll do yet. I’ll likely ponder various possibilities in another post.

And yes, I was pantsless.

Let me try to do this without sounding like a used car salesman:

Are you upset about me leaving?

Do you live in Illinois?

If so, please go here, type in your address, and find out who your Senator and Representative are. Bookmark them, write them down, whatever.

Then write THIS down somewhere: SB 1616 and HB 1682. These are identical bills, one for the Senate and one for the House, and they will eliminate written collaborative agreements.

One of my reasons for moving is because Illinois requires me to have a written collaborative agreement (hereafter called the WCA) with a physician in order to work as an advanced practice nurse (hereafter called an APN). If I don’t have this agreement, and I work without one, I am in violation of the Nurse Practice Act and could lose my license.

So why is this a problem? Shouldn’t I have a doctor in my back pocket in case a patient has a problem?

OF COURSE I should. As should every other health care provider. The problem here is that it needs to be WRITTEN. As in, SIGNED. As in, a doctor needs to sign his/her name to something, which then implies responsibility for my actions as a CNM, which is NOT TRUE.

Just a minute, guys…..

Palms up. Touch middle finger to thumb. Breathe deeply. Repeat as necessary.

OK, better now.

EVERY health care professional collaborates. If the patient of a family practice doctor has a massive heart attack, that doctor will collaborate with a cardiologist. If an internist diagnoses someone with cancer, he/she sends that someone to an oncologist. If a garden variety obstetrician has a diabetic hypertensive pregnant patient with lupus and twins, that obstetrician will consult with a maternal fetal medicine specialist.

The point being: no health care practitioner is an island. The difference between APNs and all of the above examples is that none of those relationships have to be formalized in a written agreement that is required for the referring doctor to work.

The hand waving done by the Illinois State Medical Society is to the effect of, “WHAT? We can’t let APNs work without an agreement! There will be chaos! Mayhem! Blood will run in the streets!”

Um, no. One thing is accomplished by requiring the agreement to be signed: all APNs remain dependent on the good will and signature of a doctor(s) who let(s) them work. Seriously, how many other professions require the support of their competition?

Sixteen states do not require a written agreement for APNs. There is no federal mandate requiring that the agreement be written. Not only is there no evidence that the WCA ensures safety, states that do NOT have this requirement have better health outcomes on several measures, not just maternal & infant health care.

On the runway level, I am leaving because as long as I stay here, I remain in a position of dependence in which I’m no longer willing to stay. Dr. James Gomez is and has been FANTASTIC, but he is one of three doctors willing to sign his name to helping home birth midwives. What if he moves? Or retires? Or dies? Or decides he doesn’t like me anymore?

There are a handful of obstetricians that are willing to help off the record-ie, as long as they don’t have to sign their name to a legal document.

Let’s pause for a quick count. Three doctors willing to sign their names to a document. Somewhere between 5 and 10 more willing to help off the record. HOW many obstetricians are there in Chicago?

Never mind, I don’t want to know.

I’ll spare you details of midwifery in The Great North, I’ll just say that midwives are an independent profession. They still have prejudices to overcome and stakeholders to win over, but they are protected by legislation from what could happen to APNs in Illinois.

OK, enough raging. So here’s what to do:

1) Find out who your senator and rep is. Illinois, NOT US.

2) CALL, WRITE, or VISIT. This is in ascending order of effectiveness, but do SOMETHING. The Illinois Society for Advanced Practice Nursing says NO LATER THAN TUESDAY.

3) If you’re one of the awesome people writing me a letter to help me get to Canada, put it aside for now-it’s not due until April 8th.

4) This may sound strange, but DON’T mention that I’m a home birth midwife. This is a much bigger issue that applies to all APNs in Illinois, not just CNMs, and not just home birth CNMs. Bringing home birth into the conversation confuses the actual issue.

5) Below is my sample letter, but I have an easy one-Senator Steans introduced the bill, and Representative Osterman supports it. Find where YOUR senator and rep stand on this issue, and tailor your letter accordingly.

6) REMEMBER: Your senator and rep work for YOU. You put them in office, you can take them out.

Here is my letter to Senator Steans; my letter to Rep. Osterman will be modified a little. I have a PS at the bottom; please read all the way down.

DEAR SENATOR STEANS:
As one of your constituents, I would like to thank you for your support of Advanced Practice Nurses (APNs), specifically for your introduction of SB1616, to eliminate the Written Collaborative Agreement (WCA) requirement for APNs.

I am a certified nurse midwife with a private practice. While most APNs agree that the WCA is a barrier to practice, those that are employed by hospitals or large multispecialty groups are, relatively speaking, safer than a private practitioner. I, and all private APNs with small practices, am particularly vulnerable to losing the support of my collaborating physician: if he pulls his support, I need to immediately close, or work at the risk of being disciplined (ie, losing my license) by the Illinois Board of Nursing.

For this reason, I have chosen to close my otherwise successful practice and move somewhere where this requirement doesn’t exist. Needing a doctor’s signature in order to do my work is to keep myself in a position of dependence in which I’m no longer willing to stay.

While I am looking forward to my move, I will be closing my six year old practice and leaving behind over 300 satisfied customers, many of whom would return to me should they choose to have another baby. Some of them are your constituents.

Last year my business won the Mindful Metropolis Reader’s Choice Award for “Best Midwife Agency”. On this basis, it is accurate to say that Chicago’s best midwife is leaving. The written collaborative agreement is one of my major reasons.

Again, I appreciate the important work that you do, and for your support of my APN colleagues. I hope that my story will serve as an example of why this requirement has to be changed.

WARM REGARDS-
JENNIFER GAGNON, CNM, MSN, APN

PS to my readers: If being in letter writing mode makes this easy, kindly do a quick thank you note to Dr. Gomez. He’s kind of awesome. Here’s his info: 675 W North Ave # 416, Melrose Park, IL 60160-1626.

She writes:

I’m a student midwife writing a paper about midwives assisting OBs at sections. I am discussing the positive and negative sides and looking for your stories. I would especially like to hear from you are a midwife who assists in surgery, but I would also like opinions from those who did not. I am particularly examining the issues of continuity (is it better preserved by the mw being involved in the delivery or not), professional relations (how do the midwife and doctors work together, or not), and the promotion of natural childbirth (does it go against the midwifery ideals and goals, or not).

I wrote:

I’m a CNM and have first assisted at c sections. Most of my patients appreciated knowing I was on the other side of the curtain. For some scheduled sections (placenta previa, breech), we actually bantered back and forth from over the curtain.

I can’t speak much more to the experience of the patients, but I can speak for me. I was a CNM employee in an MD owned practice, and my boss sent me to a c section workshop. A year later I got let go, and another year after THAT I started a private home and hospital birth practice with another CNM.

I ABSOLUTELY loved being able to “do it all”. I could help someone have her baby at home; if she needed a transfer I could continue to care for her and catch her baby; and if she needed a c section I could STILL help her baby out.

Speaking to a previous poster*, I did some advocating as the first assistant. During one c section, the doctor was going to close her uterus with a single layer, which increases the risk of uterine rupture in future pregnancies. It was a little tense, but the doctor did a double layer when I mentioned that she wanted more children.

Another piece of advocacy that may be a bit less “important” than a double layer uterine closure is that I ALWAYS asked the doctor to close the skin with a suture/technique that would minimize scarring.

Finally, once the surgeon told anesthesia to give an antibiotic after the baby was out, and I said, “She’s allergic to that one”. Chances are quite good that the anesthesia doctor would have noticed it, but wow, it’s SO GREAT to know my patients as well as I do.

I understand another previous poster that it seems “wrong” and “against midwifery philosophy” to be a surgical first assistant. CNMs make complicated decisions for complicated reasons. In some academic medical center somewhere, CNMs learned how to do circumcisions because the residents were screwing them up. I’m ethically opposed to circs, so I don’t see myself expanding my skill set in that way. In rural areas some CNMs do vacuum assisted births. I’d consider learning how if it were truly needed wherever I was working.

I’ll admit, though, that I like first assisting because I like it. My former midwife partner teased me that I’d be going to med school soon. I think my wretching noises convinced her otherwise.

Oh, another thing: I’m a reiki master, so when we were closing I would sneak in some reiki during pauses. Who knows if the reiki energy could make it through the surgical gloves, but I like to think that that helped the healing process to some degree.

Adding here: As with anyone, I respect another midwife’s choice to NOT first assist. I’m a little puzzled by the blanket statement, “It’s WRONG for midwives to first assist!” Whatevs. I’m a midwife and I like first assisting. It’s one of my many contradictions, unless one expands the meaning of “midwife” to be a verb. I can midwife a baby into the world through a surgical incision, and likely do it more consciously than most surgeons.

Does first assisting go against midwifery ideals and goals? Well, it depends on what those goals are. If it’s to have a 0% c section rate, sure. But some women need c sections. Specifically, 7% of the women I’ve cared for in the past five years needed one.

If, however, midwifery goals include caring for the whole woman, for honoring her transformation into a mother, and for helping a new being into our world in the safest, most loving manner possible-midwives assisting in surgery actually supports midwifery ideals and goals.

So, MY summary-For me, first assisting at c sections and being a midwife comfortably coexist. Not every midwife would agree, and (s)he is free to not first assist at c sections. To anyone philosophically opposed to midwives participating in surgery-well, go find another blog. Being true to myself has made my life remarkably easier.

* Another poster said that a midwife is more appropriately in the OR as an advocate for the mother, NOT as the surgeon’s assitant. Here I’m saying the two are not mutually exclusive.

As Lynne squatted by the pool getting ready to listen to the baby’s heart tones, he ran up, smacked Lynne on the back, and ran down the hall. Lynne looked at me a little dumbfounded as mom finished up her contraction and said, “Oh my God, did my son just hit you? I’m SO SORRY!”

A few hours later, after the baby was out, we were piled onto the bed while I examined Mom to see if she needed stitches. The same little guy ran into the bedroom with a MagLite approximately as big as his arm saying, “I’m gonna help!”

Wow, kids are smarter than we give them credit for. Maybe he heard me commenting that more light would be helpful. But somehow he put together what he thought I needed and went and got it. And he was right.

His protectiveness of Mommy didn’t end there. At her six week checkup my office, I was in the middle of taking Mommy’s blood pressure and heard a muffled, “NnnnnnnOOOO!” and he ran up and shoved me.

New story:

At the office I have a cloth pelvis/amniotic sac/baby model. I bought it to demonstrate how the baby’s head position can affect how easily (or not) it can come through the pelvis, among other things. Sometimes I even use it for this purpose. Most of the time, however, the baby doll gets held and carried around the office and otherwise becomes a plaything of the short set.

One morning a three year old orthodox boy was busily putting blocks together and in his concentration took off his yamulke. Some time later he came across the cloth pelvis and put it on his head, looking very proudly at his mother. She said, nonplussed, “Honey, that’s not a yamulke. It’s a pelvis.”

File THAT under sentences you never thought you’d hear.

New story:

A mom and I were talking while her two year old looked into the back room. He held up his hand and wagged his finger back and forth saying, “No, no no!!” while looking into the back room. She said, “That’s right, don’t go back there,” then explained to me, “He tells on himself. When he’s thinking about doing something that he thinks he maybe shouldn’t do, he says, ‘No, no, no!’”

I didn’t know toddlers came with that feature. Like, anywhere in the universe.

A mother came in with her 4 and 2 year old daughters. The 2 year old approached the toy bin with a shiny grin in her face. I said, “Hi, buddy!” She looked at me with consternation and said, “I’m not buddy, I’m KAIA!”, not only perturbed that I had interrupted her trek to the toys, but wondering how on earth I got a master’s degree without knowing her name was Kaia.

New story (well, not exactly a story, just funny):

A mom came to a visit without her two year old son, an unusual occurrence. She said he was at Grandma’s. He had informed her he didn’t like going to see the midwife because he didn’t like the bellyphone. To the uninitiated, that would be the doppler used to listen to the baby’s hearbeat.

I have like a MILLION of these kinds of stories. More to come!

Onward with my story-

From April 1995 until I started grad school in 1998 I worked as a labor and delivery nurse, first at Cleveland’s county hospital for about two years, then University Hospitals of Cleveland.

I’m probably going to contradict myself a lot. I needed to put a part of myself to sleep in order to function in these high risk settings, but I also learned how to handle emergencies. The term “county hospital” conjures images of dark hallways and outdated equipment, but Metro was in many ways nicer than some other hospitals I’ve seen since then. I saw technology overused, but I also saw many occassions when judiciously using technology very likely averted a c section.

I could spend several postings on various stories from those days, and I’m certain some will surface now and again. The big picture, though, is that the fishhook in my mind persisted. For as battered as I sometimes felt to work where I was working, I kept in touch with my midwife side by reading a lot and, for whatever reason, not losing sight of what I ultimately wanted to do.

And I’ll leave the stories at that for now. What I want to convey now is the theme of my life and career: when it’s time for me to go into a certain direction, my path is not just clear but lit with neon lights and flashing arrows.

One of the reasons I wanted to work at University Hospitals (UH) is that I felt like it would get me one step closer to grad school. UH is affiliated with Case Western Reserve University, where I got my BSN and where I wanted to go for my Master’s.

Well, whaddaya know, on Day One of corporate orientation who should sit next to me but a CNM, new to UH but not to midwifery. She would be working half with the hospital and half with the nursing school, restructuring the midwifery program. I introduced myself with the subtlety of a sledgehammer: “HI!! I’m SO GLAD to be sitting next to you!! I want to be a midwife!!”, and eagerly dove into how excited I was to be working at UH. Her reception of me was, let’s say, RESTRAINED. Which is more a reflection on my degree of enthusiasm than her reservedness. It isn’t hard to be less enthusiastic than me, the way it isn’t hard to be taller than me.

(Spoiler: Gretchen ended up being my graduate program advisor, and we still talk every so often.)

I didn’t see her for quite some time, but not long after I started I worked with another midwife, Cheryl, and her student at a lovely birth. Karen, the student, was from CNEP, a distance learning program that’s affiliated with Case but is otherwise its own entity. When I saw her again a few weeks later she said, “You know, the regional CNEP coordinator is in town for a social we’re having. You might want to see if she’s available and chat her up a bit.”

The “chatting her up” ended up being an impromptu interview. I started filling out the application. Not long after THAT, I interviewed for Case’s program with Gretchen and her then co director, Marsha.

The confidence of knowing I was a good candidate allowed me the luxury of looking at the curricula of each program. I had to humbly admit that I may not have the discipline to do the CNEP program, which requires boatloads of self direction. I JUST KNEW I would do better with the structure afforded by classrooms and human interaction.

Throughout this process, I was working full time, and blossoming like a poppy. Since Metro, the county hospital, is where I “grew up” as a nurse, I was never quite able to shake the image the old school nurses had of me, the new grad who was all mouth about wanting to be a midwife but fell apart in emergencies. I used to denigrate myself a lot for that, but more than a few nurses since then have told me I sounded like a normal new grad. When I got to UH and jumped right in, I started thinking, “Wow. Maybe I DO know what I’m doing.”

And then I got accepted to grad school.

Such is the journey. I couldn’t see my own progression from new grad to competent nurse-it happened when I wasn’t looking. Too bad it has to be accompanied by such self doubt. At least it did for me. I read over my old journals and feel a little sad for the nurse I once was. I’d like to go back in time and tell her how great it’s going to be in the future.

But, knowing me, I wouldn’t have listened anyway.

I hope I’ve learned my lesson this time about overcommitment. Back in June a dear friend of mine who’s doing awesome stuff with her career-like writing questions for nursing board exams-asked me to contribute to a basic maternity nursing textbook she’s editing. Since I don’t have enough to do, I eagerly accepted.

OK, OK. I’ll just be honest. I realize there’s a certain degree of ego in my unconsidered “yes” to her request. One, who doesn’t want to see their name in print? Two, only ego could allow me to think that I’d POSSIBLY be able to shoehorn one more thing into my life.

My paralysis over how HUGE this project is has been a forbidding shadow lurking in the corner. For the past week I’ve happened upon a new strategy: when I come home in the evening, I open my computer. When that little voice pipes up, “I DON’T WANNA!”, I just tell her, “Fine. You can write ONE SENTENCE. THEN you can go on Facebook or The Oatmeal or College Humor.”

And that’s how books get written. Because of course I end up doing a few paragraphs.

Too bad I didn’t figure this out until two weeks before the final draft due date.

So I figured I’d repost something I’ve already written.

See you guys after December 1st!

Back in 2008 I was on my way home on the El late one night. The woman in front of me got up the stop before mine. As she walked out and passed the window she glanced back at where she’d been sitting with a bit of a smirk.

When I got up I saw an envelope that read, “Open me!”. If I’d been a more suspicious person I may have just left it, but I’m not. Trusting is my default setting and has generally served me well. Especially now that my life is populated with nothing but trustworthy people. But I digress.

The envelope contained a card that spilled a Starbucks gift card on my lap and read, “Enjoy! This random act of kindness has been brought to you in memory of Happyanne Kuhn, 1980-2006.”

It took me a few days, but googling her name led me to a newsletter of the Virginia chapter of the International Cesarean Awareness Network (ICAN). Happyanne was the daughter of Teresa Hak-Kuhn, a doula trainer and childbirth activist in Virginia.

Seriously-what are the odds? That this random act of kindness should land into the hands of one of Chicago’s two home birth midwives?

I made a few phone calls and eventually talked to Teresa. We had quite a conversation. It’s been long enough that I don’t remember details, but Teresa marvelled that something that no doubt got started in Virginia ended up in Chicago. And of course it didn’t “end” with me, I’ve since passed it on. I got to hear about Happyanne’s incredibly interesting life and her untimely death at the age of 25.

Teresa came to Chicago about six months or a year later for a doula training weekend course, and I met her in person when I was moving into the same building that the doula training was being held in.

Some would call this a miracle. I’d stop short of calling it a miracle and just consider it God saying hi, and possibly chuckling a little bit. That being said, all of us can find magic and miracles where we choose to see them.

barry.straube@cms.hhs.gov
Dr. Barry Straube, Director of Clinical Standards and Quality & CMS Medical Officer

donald.berwick@cms.hhs.gov
Dr. Donald Berwick, CMS director

jking@acnm.org
Joanna King, Director of Government Relations, ACNM

patrick@federalgrp.com
Patrick Cooney, ACNM Federal Lobbyist

tjohnson@acnm.org
Tina Johnson, Professional Practice and Health Policy Director

Not quite done with my letter yet, but it’s coming!