Ilana Stanger-Ross

After a flurry of births we don’t have any more women due until June 30th, which means that, although I’m on-call another 24 hrs, it’s unlikely I’ll attend another birth in Stony Plain.

So I’ve been doing some exploring: chowed down on gravy & fries at the local diner; hunted for junk as a massive antique/garage-sale store (bought the juice glasses of my dreams, though they still have to survive 4 flights before they’ll be tucked into my kitchen cabinet); and have a date with Gillian to lay in the sun at Alberta Beach and tour the Spruce Grove Grain Elevator:

I’ve also been reflecting a bit, thinking through what I’ve learned these last 6 weeks. I take it for granted now that I’ll manage a birth on my own, consulting with a midwife when I think it’s in order.  I also call the midwife when the woman is close to pushing, but generally she’ll just lurk in the background, there if I need her but otherwise out of the way.

I know where I still need to improve. For instance, I feel comfortable with the actual manuevers of suturing, but still struggle to visualize that post-partum perineum: what goes where, and how.

(Did you just unconsciously cross your legs reading that? I did writing it.)

A less cringe-worthy skill: navigating fetal position from the suture line & fontanelles. Definitely still a serious work-on.

Then there are the emergencies.

As frightening as the post-partum hemmorhage was, the drugs stopped it fast. 

 (“Get me the misoprostal!” my preceptor called out, and thank goodness I’d noted where it was stored, and knew the dose. What I hadn’t noticed: each 200mcg pill was sealed tight in its own plastic baggie. We needed 800mcg, so that was 4 tiny and seemingly rip-resistant plastic bags to pry open while this woman bled. My feedback from that episode: keep an 800mcg dose ready. I heard yesterday that they now had tiny envelopes with 4 pills each. So look at that, I’ve even changed hospital protocal.)

But shoulder dystocia can’t be stopped with a drug. And even more than PPH, it flat-out terrifies me.

Of course emergencies are frightening for a reason, and it’d be fool-hardy for any practicioner, no matter how experienced, to feel bold about them. (Have I ever said ‘fool-hardy’ before?)

But then there are those gray areas. Ruptured membranes with a GBS- woman: do you wait for labour to begin, or crank up the oxy, and if the former, is your limit 12 hrs? 18hrs? 24hrs?  Labour dystocia: do you augment? Rupture membranes? Will positions help, and, if so, which ones? Post-dates: do we wait or get labour going? Fetal heart rate decelerations in 2nd stage (pushing): is it just the baby coming around the pelvic bones, or is it time to demand aggressive pushing and call for a vaccuum?

Perhaps it all boils down to: When should we be hands-off and when should we be hands-on? When do we watch, and when do we act?

In some ways, gaining confidence managing those gray areas is the most difficult. We look to the research literature to guide our recommendations, but quality research isn’t always available or applicable. At those times,  a practicioner needs to act on her own experience and intuition. And experience & intuition is just what we newbies lack.

So that’s where I’m at right now. But I’ll end this post with a great birth story, which happens, conveniently enough, to be about the last birth I attended.

Gillian was the primary on-call midwife, and I was playing the role of nurse/”2nd midwife.” (At a home birth, there are always 2 midwives.) The 2nd midwife takes fetal heart tones after every contraction or every 5 minutes (whichever is more frequent) during the 2nd stage of labour, documents, notes the time of delivery, gives the oxytocin injection if active management is chosen, assesses the baby and initiates resuscitation if necessary, notes the time of delivery of the placenta, assesses the placenta to ensure it’s intact, and just generally assists the primary midwife–following orders as needed.

(Any questions? Everything mentioned there is explained elsewhere on the blog. So, if you’ve been reading closely….)

So. We had two women in labour: a multip and a nullip, both at 6cm when I arrived.

15 minutes after I arrived, the multip reported an urge to push. Gillian and I got into our respective roles, but after a few contractions Gillian checked her and found her to be just 7cm dilated with a posterior babe. Meantime, our nullip was getting pushy. So we left the multip with the nurse and headed into the other room.

Nearly 2 hours later, our lovely first time mom was getting very close to delivering her baby when the nurse knocked on our door to say that our other mom was now wanting to push. I had gotten so involved in my role as 2nd attendant at the nullip labour that my preceptor had to say, “Ilana, aren’t you going?” before I realized that I should go take the primary role next door.

I walked in to find the client in the tub, with her husband, sister, mother-in-law, and mother gathered around.

Remember my first birth in Stony Plain, when I was told the dad would catch and had to pull aside another student to ask how I was supposed to make that happen?

Well, this time I asked, “Whose catching this baby?”

There was a moment of surprised silence, and then the mother of the labouring woman stepped forward.

“I would love to,” she whispered.

I had her sit beside me, and told her what we’d be doing. 

“Do I need gloves?” she asked, motioning towards mine.

“Nope,” I said. “It’s your grandchild.”

A few contractions later (and 7 minutes after a boy was born next door), I placed my hands over the grandmother’s and together we guided the baby out and up onto its mother’s chest.

There was a collective cry of joy & relief. Then the mother asked, “What is it?” pawing at the blanket to see what make & model of babe she had.

I peeled back the blanket and she took a look. A girl.

Everyone screamed and shrieked and laughed and stomped and hollered. The dad’s face was wet–actually wet–with tears.

It was the first girl to be born to his side of the family in 50 years.

What a priviledge to share in that moment.

So, so long Stony Plain, and thank you to the women who let me into their lives & labours.

One final local picture:

Who knew, but the first sheriff of Stony Plain, commemorated on the mural above and by a statue outside the old railway station, was none other than a Mr. Israel Umbach.  I’m thinking he was MOT, for sure.

It’s been quiet here. Eerily quiet. We’re talking browsing strip-malls/getting up-to-date on Jon & Kate/trusting that there’s something I’m learning in exchange for being in Northern Alberta far from my family with no births/ quiet.

Quiet enough that I watched The Proposal at the West Edmonton Mall. A famous (infamous?) mall which has a pirate ship, submarines, sea lions, an amusement park, a casino, and a hotel. 

Did I mention the submarines?

The Proposal was entertaining in a pre-feminist-movement kind of way, especially since it gave me insight into the life of my book editor.

(“We’re dying to know–what does a book editor do?” two fawning guests ask at the mock-engagement party. Hmmm. Wouldn’t it be relatively obvious what a book editor does?)

It has got me thinking, however, about career. Every job has its lines, the things we say over and over. Like “Please take a number” or “We take visa or mastercard” or “Use APA formatting next time.”

This is what I say, over and over:

“Okay, now bring your ankles together and let your knees fall to the side. That’s right. Now you’re going to feel my touch, and some coolness from the gel, and then a bit of downward pressure–”

It’s an odd job.

In my first year at UBC I read I knew a Woman , an account of the caregiver-patient relationship by Courtney Davis, a nurse practitioner in a women’s health clinic in Connecticut. At one point in the book Davis’s friend is marveling that she performs pelvic exams routinely, “touching women like it’s nothing.”

“Not like it’s nothing,” Davis replies.

In my 2nd year at UBC, we attended a pelvic-exam workshop where a group of incredible women taught us how to perform pelvic exams and paps.

On them.

The women knew their bodies, told us where we’d find their cervixes. They handed us mirrors and pointed out features of their anatomy. They breathed a sigh of relief we were midwifery students –”the medical students, they shake so much the speculums hum”–but were fast to reprimand us if our touch was anything less than gentle.

At the time, I compared it to Halloween as a kid at school: the mystery bags you were made to plunge your hand into while blindfolded, told it was filled with eyeballs. Without vision you had to rely on touch, using your fingers to see, processing through touch until you thought: peeled grapes.

It’s the same with a vaginal exam. Using two fingertips we feel and try to interpret: Where is the cervix and how open and how thin? How low is the baby, and in what position? Do we feel the amntiotic sac? The fetal head? The posterior or the anterior fontanelle?

I try to remember what Davis wrote, and so while pelvic examinations have become routine for me (though I’m no expert on navigating a baby’s exact GIS location from a suture line), I try to remind myself they’re not routine for the woman.

And more than that: given the stats on sexual assualt in our society, it’s very possible that the woman lying before me has been touched in terrible ways in the past.  I can’t control that, but I can ensure that my touch is thoughtful, deliberate, gentle. Like our teachers say: sensitive & skilled.

Some days I feel like I’m there.

Other days…

Midwifery is a profession where one grows & learns over a lifetime. Those are the lucky professions. But as an adult learner, it can be tough to feel that distance between theoretical knowledge & actual practice skill.

Yesterday I palpated my first breech. I called an experienced midwife over, not yet confident enough to declare the baby breech on my own. She felt the mother’s belly and couldn’t be sure, so we used ultrasound (the midwives here have ultrasound) to confirm the presentation.

Yup, breech.

“That’s my first breech palpation!” I exclaimed. And then remembered the mother on the examining table, the anxiety on her face as she worried over whether her operating room date was about to be booked.

(I’m not a total lout–she was only 33 weeks and a 3rd time mom, which, I quickly assured her, means plenty of time & space for the baby to turn. And: The SOGC [Canada's ACOG] has recently called for a return to vaginal breech birth.)

Of course, touch isn’t only about assessment. As midwives we also wipe foreheads & rub backs, bend to help a woman slip on her socks, stand tall to wrap a warm blanket around wet shoulders.  

A friend in Edmonton referred to herself as a “doomer.” As in: doomsdayer. I’d never heard the term before, but told her that, since we’d been on the subject, the approaching apocolypse was a reason to like midwifery. While in our current practices we depend on all sorts of technological bells & whistles –from ultrasound to functional ORs–midwifery at its heart is about respecting –even guarding–a natural process and assisting it with touch, words, support.

The Doomer is a Nephrologist.  “Take away my machines,” she said, “and I couldn’t do anything. Anything.”

But sometimes, touch is one of the most important things we can offer.

When I worked at a women’s clinic I followed the nurse’s lead by taking a woman’s hand in my own as an abortion began.

“Squeeze as hard as you want,” I’d tell them, “it won’t hurt me.”

There was one woman whose hand I was reluctant to take–she was so gathered into herself, I didn’t want to violate her privacy. At the same time, I had found that asking only made it difficult for women to say, yes. Better to take her hand, I decided, and judge from her hold whether she needed someone to hang on to or not.

She gripped my hand back. And said to me afterwards: “I was so hoping someone would hold my hand.”

What did this have to do with The Proposal? I can’t remember. I’m just biding my time here, learning from some very wise midwives, hanging around pregnant mothers, occassionally practice-suturing placentas (okay, once, but that’s one date I plan to repeat) and trying to remember as I wait for births to forget about the numbers (we students need to count them, and it can be hard to silence that count) and remember instead that 4 births = 4 wonderful babies.

And it’s the stories behind those numbers that make the caregiver.

There are several UBC Midwifery students on far-flung adventures this summer, and their blogs are absolutely riveting to read. You can hear from the students in Uganda here and The Netherlands (departure quickly forthcoming) here.

Meantime, I’m continuing to adjust to Alberta. After the rush of the first day it’s been quiet, and I’ve had a lot of time on my hands. So: I’ve gone for 2 runs. (And in doing so discovered horses & donkeys three blocks away, where the edge of town gives way to fields. “It’s like a kibbutz,” I told Jordan. Pretty sure I am the first visitor to compare Stony Plain, AB to a kibbutz, but there you go.)

I’ve also begun researching for my midwifery thesis paper (actually, I find it appalling that in addition to full-time clinical work & weekly research assignments a thesis is also expected. Far be it from me to normally whine about writing & research, because I tend to get all nerdy-excited about such stuff, but WHINE) and working on developing pharmocology note cards–something that’s been on my to-do list since February.

And the next novel. Starting to think through that.

Which somehow all still leaves time to relax with wine in the back yard after dinner, talking till late because the sun stays in the sky so long it’s easy to lose track of time.

This is what happens when you leave your kids behind. The days grow looooong.

Long enough too to worry that I misled y’all with my multip vs primip comments the other day. See, here’s how it works:

Gravida = Number of pregnancies

Para= Number of births after 20 weeks

So a woman might be G4P2, which means she’s had four pregnancies and two births.

A more detailed description might be G4T1P1A1L2, which means 4 pregnancies, 1 Term birth, 1 Preterm birth, 1 Abortion (spontaneous or terminated–there’s no clear distinction drawn), and 2 living children.

So back to this gravida/para thing.

A Primigravida does mean first pregnancy. But Primiparous actually means one birth. See the difference?

So we say “primip” for first-time moms, but really it should be “primig.” Or Nullip, for nulliparous. Other than that, you can say multiparous or multigravida, Grand Multipara or Grand Multigravida. It starts sounding like a Starbucks drink, doesn’t it?

“I’ll have an iced Grand Multipara with caramel, please.”

 Meantime: got paged today while on a run. (Not the horse/donkey run, the other run). A woman had come in hoping for an induction. Only she didn’t have any medical indictation for an induction, she just was sick & tired of being pregnant.

There’s a distinction drawn between medical inductions (for a clinical reason) and social inductions (no clinical indictation), and this one would be termed social.

And in Canada, we don’t do social. Or at least otuside the major urban centres. Or at least with midwives. Or–you get the idea.

(Far as I can tell, in the US a woman can have an induction anytime she wants for any purpose. And if she doesn’t want one, she’s likely to get one anyway. But I digress.)

I examined her and broke the news, and she was not pleased. But I also gave her verbena, an essential oil from Germany that has long been used to hasten labour but has never been studied in a clinical trial. Okay, so a typical midwifery move, albeit not one I’d ever done before.  What was interesting here, however, was that the nurses guard the verbena at the hospital, and keep along with it a recipe for the verbena cocktail (almond butter & apricot juice….not for the weak of stomach) and a form to fill out if she goes into labour, so that data can be collected.

In the hospital.

In the maternity ward.

Astounding.

I’ll let you know if it works.

So….

At 5:30 am yesterday morning I kissed Jordan goodbye, gave one last, long look at my sleeping daughters, and took off for the airport. Destination: Edmonton, Alberta. Within a few hours I was at a friend’s place, and then driving another friend’s truck through the outskirts of Edmonton, on my way to Stony Plain, where a legendary birth centre has been attracting BC student midwives for years.

Sometimes a voice in my head says something along the lines of: “How did a kid from Brooklyn end up here?”

Driving an unknown truck — did I mention the cracked windshield, apparently de rigour for Northern Canada?— through an unknown city was one of those moments.

But then: I pressed ‘play’ on a mystery tape in the tape-player, and at once was comforted by the reassuring lyrics of Uncle John’s Band–a song I haven’t heard in years but apparently still know by heart:

Oh, the first days are the hardest days don’t you worry anymore

‘Cause when life feels like easy street there is danger at your door….

And so I arrived in Stony Plain.

I’m staying with one of the midwives here, and came prepared with 3 bottles of wine–midwives are notorious lushes when we’re off-call, after all. I got a big hug for the gift, and an invite to a fabulous family dinner. Two other student midwives–Roz and Gillian– joined me, and we talked NSVDS –normal spontaneous vaginal deliveries, as if it isn’t obvious–to our heart’s content.

The first page came at 5:30 the next morning.

There must be something in the water here, because when I left the birth centre 12 hours later I’d witnessed not one but three NSVDs. The first I simply observed. Another student, Roz, motioned me in, telling me the baby was on its way. 

Impossible, I thought, entering the room. That woman still has her underwear on.

Well, she got it off. And the baby came 3 minutes later.

I then returned to ”my” labouring woman, who spent the next several hours swapping stories and laughing, only occassionally pausing to gaze somewhat distractedly off into the distance.  If you’d asked me to guess her progress based on her demeanor, I would’ve said 2 cm dilated, early labour, go back to sleep. But I knew from examining her that was 9cm dilated, with a history of laughing her babies out. Eventually she birthed a beautiful boy in the birthing tub –such a simple thing, a tub, and such incredible pain relief, yet so many hospitals, mine included, don’t have them for labouring women–her husband catching while I coached him through it.

(“How do you coach a husband through it?” I’d asked Roz earlier. I’d never done it before, and wasn’t sure when to step back. In the end it was easy, because he was a natural. But I did provide one key interference: his wife was on all fours, and I had to guide his hands not back –it’s an instinct, to bring the baby towards you–but under and up to where the woman herself  can reach down and take hold. Because otherwise you have a woman on all fours with a newborn wailing from behind her bum. Which isn’t what she wants, trust me.)

And then those adorable, laughing, story-tellers –well, they wept. Which is always the best part.

The last birth was a doozy, and make note that this is the first time I’ve used the word “doozy.”  With every room filled, a client (or as we say, a “multip”***)   arrived with fluid leaking. She was Group B Strep positive, which to make a long story short means IV antibiotics. So I inserted the IV on the couch in the hallway, then brought her into an assessment room while we waited for housekeeping to clean out a Labour & Delivery room.

“My water broke an hour ago and I’m just starting to get contractions,” she told me. “Watch me be, like, 1 cm dilated.”

Well, she was 8 cm dilated. 

Do you see what I’m saying about the water?

20 minutes later she reported pressure with contractions. I checked her again: fully dilated with a bulging bag of waters. I ruptured her membranes, which soaked my arm, and so turned around to wash up. When I turned back around she was crowning. Roz was ready & gloved, but technically off-call. Not one to give up a catch, I cracked open a new pair of sterile gloves and caught her baby 2 minutes later.

9 lbs.

Well, that’s been my welcome to Alberta. And now: to sleep and shower.

*** multip = multiparous = previous delivery; primiparous =first time mom. Except actually these terms are misused, because techincally nulliparous =first time, primiparous =2nd time, and multiparous connotes 3rd and up to 5th, at which point you’re a Grand Multipara.

How’s that for a prestigious title?