This post was written by my 12 year old daughter, as part of a spelling assignment.

I was five years old when my brother was born. I had been born in a hospital in Greenfield, Massachusetts. My mom hadn’t wanted to have me be born there, but she had a bleeding disorder so the midwives had her go there for the birth. She didn’t need an operation, nothing went wrong.

When my brother was born, a year after I turned four and we moved to the house on Barrett Hill, the midwives from Milford decided to participate in my mother’s home birth. We put the birthing tub in the dining room, pushing the table out of the way. I was there with Daddy, my fingers in my ears, calling to Mom over her screams, “You can do it! Push!” That night the coyotes howled back to her.

The midwife and her doula arrived to help and, with their departure, came both new life and new inspiration. The combination of the great care and an old dream moved my mother to imitate the many before her and practice midwifery. She went to an Academy that taught her all about the regulations, rules, and methods of the practice. She passed the academic exams, with no exceptions, and moved quickly up the midwife ranks.

She owns her own birth center now, has delivered hundreds of babies, and has helped hundreds of women. She went to school to be a nurse, too, and she can also work in hospitals.

At parties and other public events in town, Dad and my brother and I have become known as “the midwife’s family.”

She has worked incredibly hard, and is still learning and growing, and helping more families.

It is hard for her. She always seems to be working. It is also hard for us, even though she does her school at home– she used to go to the city. I remember feeling like she spent more time with other people’s kids than her own. I still feel that way sometimes.

At the end of the day, after years of not finding her place in the world, she has found it. I am proud of her — not many people could do that. She is happy and that makes me happy.

Here’s a little piece of my journal. For the past few years I’ve been a midwife… and in nursing school.

 

Tuesday & Wednesday night in the ED. Last semester of nursing school, critical care rotation.

The ED is not like the floors upstairs; it is bright and loud. All doors are open, activity swirls around the glassed-in nurses’ station– the fishbowl– in the middle. The layout is circular, patients roll in from the waiting room, they are delivered by the ambulance, some have driven themselves here. The red phone on the wall is a direct line to the police. “Don’t knock it off the hook,” one of the RNs says, on his way by, “If you knock it down they come find out what’s happening.”  Down here we are street-level. The patients come in dirty, bleeding, shouting; diagnostic mysteries labeled “belly pain,” “short of breath, “chest pain.” Paramedics roll a stretcher down the hall, the patient on it is hidden by a mound of blankets, nurses and aides squeeze by on the sides. My rooms are full and then they’re not, the patients having been shuffled around by the charge nurse, for reasons I don’t yet see. It’s time to dive in.

 

Upstairs is a different world. On the telemetry unit, the dictation room is quiet. The patients are filed away in their rooms, even the call lights illuminate gently. I pass meds and carry blankets, pillows, shaving kits under the “Quiet Please, Hearts Are Healing” sign on the wall. On evening shift vitals are taken at 16:00 and 20:00. I assess my patients at those times. The first assessment is a full assessment, the second is focused. Dinner trays come up between 17:00 and 17:30. Meds are passed as scheduled, everyone’s IV is on a pump, which, if I happen to neglect it, will beep to call me to stop the infusion. A pump alarm is a critical alarm, we are reminded. They should not be left to make noise. Documentation is expected at the time of assessment or action; there is a computer in every room for this purpose. In between patient care duties– the vitals, the assessments, the medicating, the bathing and the feeding– I’m to watch for other nurses who need help, to answer call bells, to stay alert to the hospitalist’s white coat-back disappearing into my patient’s room. I slip in to hear the doctor’s plan, add a comment or two of my own and answer a question. I fuss around the room after she leaves. I rearrange the blankets, tidy the tables. Measure I&O, turn down the TV, and make space for the patient to process what he or she just heard. Inoperable cancer. A pacemaker. A healthy heart or a heart attack. You’re going home, or you will have to make plans, you won’t be able to go home again. Nursing, at the heart, is holistic care. So, I listen and educate, strive for the discipline to keep my mind on the whole patient in front of me. How the tentacles of their illness twine themselves around their home, their family and the community. Sometimes, when the news is particularly dire, we just sit quietly. I’m still sorting out lovenox vs. heparin and how to read an ECG, but companioning is something I know how to do.

 

My rooms in the ED are full again. I have a homeless man with pneumonia, a man with liver failure who came in after gaining 22 lbs– probably fluid– in a week. Across from the nurse’s station, there’s a man with a high fever– he weighs about 350lbs and he needs a catheter. He’s shouting that he’s cold, he needs a blanket. We don’t give it to him– his temp is 104. He moans and argues. There’s an 18-year old, 14 weeks pregnant, with belly pain. A 72 year-old woman with a leg abscess waits down the hall. A woman with chest pain is lying on her stretcher, on the cardiac monitor, waiting for a bed upstairs. Over it all are the shouts of a little girl who took pills (we don’t know what) at daycare. They’re trying to draw blood and she’s screaming, “Don’t hurt me! Please, don’t! I won’t do it again, please don’t!” Her mother charges past us, out of the room, out of the building, “I need a cigarette!” My nurse is a pro, she’s got all the admit times in her head, which labs are drawn and which we’re waiting for. The RN from FastTrack comes over to ask her how to mix rabies IgG for a boy with a dog bite in his stomach. My nurse sends me to do assessments while she explains the dosage. On my way by the computers I see our assignment board pop up with another patient– a 14 year-old is waiting to be evaluated for dizziness and slurred speech. A new belly pain is coming in. And I’m off, going from room to room, choosing who goes first and who can wait, keeping mental track of what’s set in motion and what needs to start.

 

I’m so busy it takes an hour to realize that this state of controlled chaos is somehow familiar. For the past 5 years I’ve worked as a New Hampshire Certified Midwife, delivering babies at home and in my freestanding birth center. I am on call almost all the time, I leave home at all hours of the day and night to evaluate problems, rule out labor, confirm ruptured membranes, check on babies who aren’t feeding well and to attend deliveries. The first similarity I notice is the pacing; the routines of both community-based midwifery and the ED are determined largely by the patient. Babies come when they come and people get sick and crash their cars without consulting the clock. I don’t round the hall in the ED to do vitals at a particular time; instead I keep track of who came in when and plan forward from that time. Each arrival time and complaint sets a new schedule in motion; the art of nursing in the ED involves intertwining all of these individual progressions of patient care into an achievable series of tasks for the nurse who is responsible for all of them. That the parameters are constantly changing makes it an exciting puzzle to work. I discover that I love this– the constant adjustment, no time to sit. I know how this works; crises happen when they happen, just like women bleed, break their water, and start labor after clinic hours.  

 

Halfway through the night, another similarity becomes clear. They way an ED nurse needs to approach and read her patient is very similar to how a midwife works with a woman in labor. All of the mothers I deliver are unmedicated. They are in pain, sometimes panicky, and the limbic system rules the day. The neocortex is far in the background; so we omit needless words, keep our questions short, simple and clear, and make eye contact. My nurse and I walk in to evaluate a woman who just arrived with a PE. She sits straight up on the stretcher, gripping the rails, sobbing. My nurse makes eye contact first, “Tell me why you’re crying,” she says. “Am I going to die?” the woman stammers. “No, no, what you have going on is serious. But you’re here in the hospital and this is where you need to be.” We tell her what a PE is and about the heparin we’ve started. She is relieved, but I make a mental note to come back in 20 minutes and do the teaching again– she is still tearful and too upset right now to take anything in. I read women in labor by their body language, piecing the picture together using what they say and what they don’t say. I know that the number of questions, the complexity of verbal communication, is strictly rationed in labor. I save my words for what is most important. It turns out that people in pain or crisis have similar needs. An ED nurse needs to make constant visual assessment, pick up on the subtle clues and have a finely tuned sense of whether a patient can absorb teaching or instruction—or even answer questions–  at any particular moment.  My ability to talk to patients simply and directly was learned in thousands of hours spent at a laboring woman’s side, and I am grateful for it every time I knock on the wall and twitch the curtain back in the ED.

 

Our second belly pain case pulls it all together. She’s a 38 year-old woman and I go in to assess her. She’s curled on the stretcher, right side, guarding her belly. Her eyes are squeezed shut and her neck is arched. I introduce myself and check her belly right away– a big, tender mass in her RLQ. She moans softly, “they gave me morphine and it isn’t working at all.” I quickly run through the rest of her assessment, tell her she’ll probably have an ultrasound and more morphine soon, and step into the hall. My nurse and the PA are there. The PA is questioning peritonitis, but she and the nurse know this woman’s hGC quant was positive, and that she’s 4 years post tubal-ligation. I tell them about my assessment (suspected ruptured ectopic) we talk through her differential diagnosis– the PA says, “tubal or not, she must be pregnant. Why else would we have this quant?”– and quickly get her down the hall to ultrasound. I stay with her during the ultrasound, the wand pressing on her belly hurts. The technician is quiet, but I know enough to see the black masses of fluid, a tiny bubble of yolk sac, but not in the uterus. We bring her back into her room, give her more morphine, and page the surgeon. The patient opens a sliver of one eye and fixes it on me, “What kind of a nurse are you going to be?” A midwife, I answer. “Ah,” she says, “this will be good for you.” We’ve just told her, that despite her history of 6 failed cycles of IVF, a tubal ligation and a uterine ablation, she has an etopic pregnancy. What was left of her fallopian tube is probably ruptured, and she is bleeding internally. She’ll go in to the OR as soon as it’s open. She and her partner are amazed that this is happening, they are even chuckling a little. It’s ironic, he says. Not what we expected at all. Of all the things it could be.

 

The urgency of this case– and the many like it– creates a culture of collaboration in the ED. The nurse, the PA and the surgeon all worked together to make a plan. Everyone’s input was taken in to consideration– even mine. And it happened fast. I’m not sure if the need to limit reaction time created this culture of collaboration or the other way around, but it is markedly different from what I’ve experienced on the units.  I entered nursing school as a means to study Midwifery in graduate school, not really expecting to work as a nurse, or even to enjoy it much. During the past three semesters I’ve learned so many things and, through learning, my perspective has changed.  I may always be more comfortable working independently in the community. The closest I’ve come to “charge nurse” is to serve as clinic coordinator on our school’s medical mission trip. Standing in the middle or a re-purposed, open air disco in the Dominican Republic and deciding where to put triage, which translators we need in crowd control, and how to clear the area of dogs and roosters is a far cry from nursing on the quiet, controlled units. But I loved it. The units may not be my country, but I am proud that I understand them now, that I can probably pass for a native. My experience in the ED was an amazing convergence; what I knew as a midwife and what I learned as a student nurse all came together. For 16 hours I was a nurse. 

 

Medical Mission Team from Manchester Community College, Catholic Medical Center, and the greater Manchester area.

This is the story of what happens at homebirth. Not of the birth, of a baby’s eyes opening, for the first time, in his parents’ bedroom.  It isn’t about the labor, even though this one, a third baby born with his arm raised after a long, dark night of work was “the hardest.” And it isn’t about the baby’s father, his murmured words of encouragement, the contraction-timer app that, over hours, became a running joke, his strong hand to hold. On the first day of the new flower moon, I attended my dear friend’s homebirth. Her big, healthy son was born an hour and a half before dawn, his brother and sister sound asleep in the guest bedroom.  He came into this life, into his body, held tightly in his mother’s arms and surrounded by joy. When the sun rose, his brother and sister bounded up the stairs and burst into the bedroom. They knew he would be there. He knew their noise and their voices. They loved him right away; he had always been theirs.

And that is the last I am going to say about mother and baby, because this is the story of what happens at homebirth, but outside the bedroom. In the early evening, early in labor, my apprentice and I arrived at the house, as we arrive to every house: sideways through the door, calling out greetings, bags bumping over the threshold. There was unpacking, talking, looking and listening.  A plan was hatched. We went our separate ways, we to town for supper and they on a walk, through the neighborhood, at the close of the day. Later, after supper, after driving around the city on other business, we returned to the home. This time we enter quietly, climb the stairs in stocking feet, conjure a quick and ancient heartbeat, and slip back down into the kitchen.  The table is ours now; we unpack our textbooks, articles, needles and balls of wool.  The lights are low, a huge pot of soup simmers on the stove. We wait.

But not for the birth, not yet. Headlights shine through the window, we hear a car in the driveway, the engine cuts out. The women arrive, through the side-door.  Two good friends, neat-handed helpers who drove from nearby towns. We are glad to see them again. The baby’s grandmother, who had been putting the big children to bed, comes upstairs to join us in the kitchen. We have the table covered: books, ipad, mugs of tea, a colorworked hat streaming yarn. Hours go by. We talk of travel, births we have attended, our children, both babies and mothers. A daughter’s sweet sixteen party, a son’s christening. A new house, and packing the old one. Past days spent in far away places, plans and schemes for days to come. As the night winds on, with one ear listening to the floor above, we weave the story of who we are and what we know. We take turns going upstairs, slipping into the darkened bedroom to listen to a tiny, beating heart, to bring ice, to lay out clothes, pressed and perfect, and wrap them in the heating pad. A tray of supplies is organized silently and  by touch: gauze, flashlight, Kelly clamps, cord scissors, Berman airway, syringe, the tiny vials of pitocin. I leave it on the bureau, walk out of the room and close the door.

And then, downstairs in the kitchen, we start to hear footfalls above, voices, a moan. A friend goes up, carrying a bowl of ice. The door is opened and not shut again, we hear the mother’s voice. “Don’t go.” The kitchen quietens, we drift upstairs one by one and take our places. A circle of women, surrounding a family. In a white house in Concord, a dirt yard in the Caribbean, a drafty cave at Lascaux, before we watched the clock. This pattern is inside us, always and ancient, sleeping in our brains and cells. The baby is coming. We know what to do and what to leave alone. We know it will be soon.

The circle is born at home, it is the other birth, the one that happens in the kitchen, or on the porch, or in the family room. It is initially a patchwork of personalities and experience that meld, during the labor-watch into a cohesive, if changeable, whole.  This is community-building at its most primitive, and most enduring. Forever after, there will be five women, who can say to this little one, I was there when you were born. I saw your mother’s work, your father’s joy, your first breath. When we tell him his birth story, we will tell him how his mother baked muffins and bread, enough to feed an army, and left it all piled on the counter. That we picked out his clothes, matched hats, and smoothed them on the bed. That his dog kept sentinel on the landing outside the bedroom door, head up, eyes watching. If he is sixteen and belligerent, we will all remember, behind our wry smiles, when he pooped unholy chaos all over the blankets, his father and the scale. This baby will know, and knows already, that he was born with a place in the world: into a home, into a family, into a community. We were all waiting for him. His experience has taught him this already, and we will teach him more, with our stories.

And there are the women. What does it mean, to a mother, to have that experience of giving birth at home? To be given the space to do the work she was born to do, knowing that, nearby, a reservoir of help and encouragement is waiting; all of us eating cornbread and trading tales around the table. What does it mean to the women? Birth is transformative, even in the kitchen. The women present know each other’s stories now, have shared a vigil, and will always remember this night, spent together in watching. The veil will lower and the memories will fade, but this experience, shared, binds us together. Here is a place during homebirth, one of many, where the esoteric intersects the practical: we become a community through nothing more magical than time spent together. Birth in the home gives us that time, stops the clocks and holds us all, in the kitchen, with a common purpose. In parenting, hard days are inevitable. Life brings grief and hardship, celebration and surprise. But the women who birth at home, and those who wait outside the door, have help inside of them. Out of the past, and, I hope, the present, too, the circle calls them to pick up the phone or knock on a door.  To ask for the help and companionship they know is right downstairs.

This is a preprint of an article accepted for publication in Midwifery Today Copyright © 2011 Midwifery Today, Inc.

The International Confederation of Midwives (ICM) 29th Trienneal Congress will begin in South Africa next month; as flights are booked and reservations made we are confronted, daily, with the joys and challenges of navigating another culture. Meanwhile, at home in the US, the Midwives Alliance of North America will emphasize cultural competency during its Fall program, “North American Midwifery: Beyond Boundaries.”  The MANA conference, this year a joint venture with the Canadian Association of Midwives, along with the ACNM, underscores the midwifery community’s renewed interest in the relationship between culture and care.  How do we define culture?  English Anthropologist Edward B. Tylor called it the “complex whole which includes knowledge, belief, art, law, morals, custom, and any other capabilities and habits acquired by man as a member of society.”  This Spring’s NNEPQIN meeting took advantage of an opportunity we all have to improve relationships between cultures in our own communities. Through participation, focused effort and case review, we began to bridge the gap between the long-estranged homebirth community and the hospital system of care.

About NNEPQIN

The Northern New England Perinatal Quality Improvement Network (NNEPQIN) is a multi-hospital, regionally-focused quality improvement organization. NNEPQIN’s goal is to improve perinatal outcomes in Northern New England by:

• Collecting and analyzing data regarding patient safety
• Providing independent and confidential case review for unanticipated outcomes
• Developing best practice guidelines
• Providing a forum for interaction and collaboration among hospitals in our area
• Facilitating continuing education for physicians, nurses, and midwives.

Speakers at the Spring Meeting included:

• Dr. Jeffery P Phelan MD, JD, of Citrus Valley Medical Center and the Childbirth Injury Prevention Foundation (CA) who spoke about the legal concepts of notice and duty to warn and their implications for clinical practice. He also discussed strategies to more accurately diagnose PROM (see below).
• Dr. Joseph Wax MD of Maine Medical Center who reviewed recent changes in PPROM management and the evidence regarding the efficacy of magnesium vs. alternative tocolytics.
• Dr. David Laflamme PhD, MPH, of NH’s Department of Health and Human Services who discussed strategies for using NH birth certificate data for research and quality improvement, as well as anticipated changes to the state’s birth certificate database. He also touched on the NH Early Postpartum Breastfeeding Quality Study, which included participation by some NH Certified Midwives.
• The meeting attendees also previewed possible changes to the NNEPQIN VBAC Protocol, after recent statements by the NIH and ACOG.
• NNEPQIN’s Protocol For Care of the Obese Patient was presented and accepted by the assembly.

Implications for Midwives:

While much of Dr. Phelan’s presentation focused on legal issues pertaining to negligence and malpractice, his information on effective diagnosis of rupture-of-membranes might prove to be extremely helpful to midwives practicing outside the hospital setting.  In particular, Dr. Phelan compared the efficacy of nitrazine, ferning, ultrasound and sterile speculum exam with the placental alpha micorglobulin-1 (PAMG-1) immunoassay test. The PAMG-1 was put forth as the most accurate and cost-effective test for diagnosis of ROM. I’ve contacted the regional provider rep for AmniSure to discuss cost, storage and use by community-based nurses and midwives. Look for a future post with more information.

The Homebirth Taskforce met during the lunch hour and finalized their draft of a transport tool. The tool will be used by out-of-hospital (OOH) midwives and receiving physicians or CNMs during a transport from home.  It provides a script for telephone communication, and could also be used as a hard copy for fax communication or charting.  Additionally, the taskforce continued work on its document “Guidelines for Consultation and Transport” for planned OOH birth.  This document will serve as a reference for hospital-based midwives and physicians and outlines the conditions under which NH and VT midwives must transfer care or seek consultation.  NH and VT midwife-representatives to the taskforce are completing brief biographies of licensed/certified midwives in their states for publication on the NNEPQIN website.  Also discussed was the role that NNEPQIN might play in encouraging hospitals to communicate with local midwives outside of immediate, patient-care situations.  The taskforce remains focused on building communication and trust between the OOH and hospital-based systems, as well as educating each system about the practices of the other.

And lastly, the Spring Meeting was my first as a participant on the Confidential Review and Improvement Board (CRIB), which was also the first time that a direct-entry midwife contributed to case review. Participation by direct-entry midwives will enable the CRIB to look at issues such as communication during home-to-hospital transport, the midwife’s scope of practice as defined by the states, and how to improve both outcomes for homebirthing families and the professional relationships between midwives and physicians. In addition, I see that participation in NNEPQIN and the CRIB will serve as a valuable resource to OOH midwives who are interested in quality improvement. There are many intelligent and creative providers on the Board, who share our interest in applying best practice to home-based care.  We midwives bring a unique set of skills to the review process as well: expertise in community-based practice, comfort using infrequent intervention, and a firm grounding in patient-centered care.

What’s Next:

The Homebirth Taskforce will continue to meet via web conference, and the Fall NNEPQIN meeting (in association with AWHONN) will be held October 21-22 in Manchester NH.  Feedback, especially on our homebirth work, is very welcome.

NH Early Postpartum Breastfeeding Data Quality Study

This study did include participation by some NHCMs, most of whom have practice-wide breastfeeding rates of nearly 100%.  Homebirth midwives may not have to puzzle over the ambiguous wording of the breastfeeding items on the NH birth certificate worksheet, but many other doctors, nurses and midwives do.

Are you aware of state protocols regarding the breastfeeding item on the birth certificate worksheet? Does your practice or facility have its own guideline for answering the breastfeeding questions?

One hundred and fifty multiple choice questions, finished. That’s a.) 600 choices b.) one hour of time c.) 9 months of our lives d.) all of the above. Not to mention three weeks of  eleventh-hour “review” and scrawling lab values on my arm with a sharpie. The sharpie & arm method of data storage comes in very handy if you have something to memorize during grocery shopping, or at, say, a fencing meet. Three years ago I decided to become a nurse. I have three years to go, but right now I’m focusing on the three months we have- starting now- out of school and in to summer.

My kids used to keep track, “Are you on call?” Are you going to school today?” Somewhere back in October they stopped asking. For the past year the tally of my weeks has been 5 hours in class and sixteen in clinical. Twenty hours at my practice and eighty-something on call, every weekend.  Ten hours of homework and 7 commuting to Manchester. One hundred sixty eight hours in a week, minus one hundred thirty eight of Mom-works-and-goes-to-school equals, well,  no-wonder-I’m-so-tired.

One of my preceptorship students is, herself, the daughter of a midwife.  She and my daughter have it nailed. You get dropped off with your dad, down the street, at the neighbor’s.  Somebody else shows up to get you from school. “You have to keep your knitting AND your notebooks in your bag,” my daughter told her, “because you might get marooned at the babysitter’s house. For. Ev. Er.” Add in Mom’s nursing school schedule and you get … young adulthood spent in therapy. Right?

Fortunately, It doesn’t add up.

Last summer, at my brother-in-law’s wedding, the grown-ups stood on a  balcony overlooking a narrow mill-town river. I watched the sunset backlight my beautiful kids playing (yes, in their dress-ups, though they had ditched their shoes somewhere between the lawn and the river’s edge) among the boulders and explained to a woman I’d just met that I owned a birth center and was about to start nursing school. Her response? What a wonderful gift to give to your children, to show them that women have important work to do in the world. That the world needs their mother as much as they do.

Because there is this other math. The c-section rate, just shy of 40%, in my city’s hospitals. The rising maternal mortality rates in the US (how high is left to rumor- nightmare, maybe – no one is really counting), the shameful gap between birth outcomes for American-born Black women and their Caucasian neighbors.  A world where over 500,000 mothers die every year for want of a midwife.  According to the World Health Organization, “unavailable, inaccessible, unaffordable, or poor quality care is fundamentally responsible. They are detrimental to social development and wellbeing, as some one million children are left motherless each year.” One million motherless children.

My own temporarily motherless children are here now, at the end of this year, tall and wide-eyed. A little frustrated with so much time away from home, wanting only to “stay here” this summer, vetoing camp and in favor of hanging around at my office. Maybe they learned, as my balcony friend suggested, that their mother’s work is important; more likely that kind of analysis will come later. For now they’ve learned that, yes, Dad can make dinner and tell star-dragon stories. I see that they know something about self-reliance; something beyond remembering schedules, lunches and library books. It’s confidence arising from daily proof that they live in a family and a community where they are loved and cherished by many, many good and kind people. That whether I was in class or a health corps volunteer 2000 miles away, a strong circle of adults was here, with them, to supervise homework, listen to stories and tuck in the quilts.

For the next three months, I’ll take them home. Mothers do matter, they are not replaceable, that is the premise of my work, and for a little while I’m blessed with time. It’s come full circle, all those times I was away from my children so that another mother could hold hers close. I missed my kids this year, a lot. I want them with me, and to live in a world where women are safe and families are together. It’s mid-May, the summer in New Hampshire and on the Cape is stretched ahead like a long and sandy trail, and we’re just at the start. Today, right now, we have seashores to walk, stories to tell, campfires to build, and a forest to wander.