Hands For Catching: Life of a Nurse-Midwife in Training

Metal or Plastic?...

noreply@blogger.com (Kim) — Sat, 08 Jan 2011 13:15:00 +0000

Speculums that is...

At my gyn clinical site in the fall, a wonderful local private practice, we only used metal speculums that were sterilized each night, and so I have never used a plastic speculum. I've practiced with a plastic speculum, maneuvered it, and manipulated it so that I have some idea of how to maneuver it during a pelvic exam. But, to be quite honest, I'm biased.

To be fair, it's true that metal speculums can be cold unless the office preheats them (my clinical site did not), but the list of disadvantages to the plastic speculum are so much longer. First, some of them have those plastic "tags" on them from the manufacturing process, and if you don't catch them, they can be uncomfortable for the patient. Second, they can break (oh yes, even during the pelvic exam!). And finally, they have that awful "click, click, click" noise that the client hears when you are opening the speculum.

So yes, I'm biased. I'm not sure yet where I'm placed for my antepartum clinical and I can't help but wonder if I'll be using metal or plastic speculums. Seems like such a minor detail but it's been on my mind.

So...which one do you prefer- metal or plastic? What's been your experience?

Skin to Skin Contact in the NY Times...

noreply@blogger.com (Kim) — Wed, 22 Dec 2010 14:32:00 +0000

I almost missed this great article in the NY Times on the benefits of skin to skin contact (also known as Kangaroo care) for preemies. The Human Incubator talks about how Kangaroo Care works as a low cost, low technology intervention that helped to mitigate overcrowded incubators in a Colombian NICU:

"The babies stay warm, their own temperature regulated by the sympathetic biological responses that occur when mother and infant are in close physical contact. The mother’s breasts, in fact, heat up or cool down depending on what the baby needs. The upright position helps prevent reflux and apnea. Feeling the mother’s breathing and heartbeat helps the babies to stabilize their own heart and respiratory rates. They sleep more. They can breastfeed at will, and the constant contact encourages the mother to produce more milk. Babies breastfeed earlier and gain more weight."

Enjoy!

The Emotional Rollercoaster also known as Clinical...

noreply@blogger.com (Kim) — Mon, 20 Dec 2010 17:22:00 +0000

I love clinical! I'm learning so much but it has also been such a humbling experience. For eight hours, you are constantly coming face to face with exactly how much you don't know, how not ready you are to be entrusted in the health care of another human being, and how much you still have to learn.

On my first day of clinical, my preceptor said to me: "I'm not here to tell you what you don't know- I'm sure you're already pretty good at that yourself." She was right and thankfully, she has kept this promise.

Clinical is a self-esteem rollercoaster. Some days you leave feeling like you are developing into just the sensitive, aware, competent, critical thinking practitioner that you envision yourself being. However, there are those days, those other days where you feel deflated, incompetent, forgetful, and overall just plain dense. Those are the days when my preceptor's promise is particularly helpful. Her words remind me that it's my job to be forgiving and gentle with myself, and to focus on the learning process.

My Schedule as a First Semester Midwifery Student...

noreply@blogger.com (Kim) — Tue, 30 Nov 2010 12:30:00 +0000

A reader recently asked me to provide more details on what my schedule looks like this semester. You might remember that I did something similar last year, here and here. This semester has been interesting because my schedule hasn't been static but rather, every month my schedule has changed dramatically. So, I figured I'd take screenshots of three distinct weeks from my actual Google Calendar and walk you through my semester so far.

First up is September. Notice that early on I had one glorious day where I was free to do nothing...but study. That study day is crucial because during the first month or so, you can see that we have several "Midwifery Intensive" sessions where we are learning all the topics that will make us minimally competent to participate in clinical: vaginitis, pap smears, immunizations, STDs, birth control, menstrual cycle, conducting a visit, and more. Along with juggling the overwhelming breadth of information we learn during the Midwifery Intensive, we also have to stay on top of our core MSN classes like Advanced Pathophysiology, Advanced Physical Assessment, and Research Methods.

Fast forward to October, we start clinical! For eight hours a week we provide gynecologic care under the supervision of our preceptors. It's amazing how varied our experiences have been and that is probably partly due to our site differences. Not only are we spread out over several states on the East Coast but we are at different types of site as well: including Planned Parenthoods, community health centers, private practices, and hospital-based clinics. These differences help to foster interesting discussions during our weekly breakout sessions, a space where we can discuss our experiences in clinical, teach each other about important clinical topics, and review case studies.

Lucky for me, my schedule in late November and early December now looks like this:

So much better! Most of that free time is already "spoken for" by the things on my to-do list: study dates, practicing for physical assessment skills check-offs, and going to meetings for extracurricular activities.

So this is my schedule in a nutshell. I have two and a half weeks left in this semester and then I'm on break for about three and a half weeks. It's hard to believe but in six weeks, everything starts all over again. New schedule, new classes, new experiences...

This Year is So Much Harder Than Last Year...

noreply@blogger.com (Kim) — Tue, 02 Nov 2010 21:12:00 +0000

You might remember my early September post entitled This Year Is So Much Better Than Last Year...

In reality, that post is still 100% true. But the year has been harder too! The midwives are juggling roughly the same amount of classes as we were in our Pre-Specialty year but not only is there more material to cover, but it's denser and more complicated. Additionally, the stakes are higher this year. This is the year when I actually learn how to be a clinician and thus the significance of that realization also adds another layer of pressure that goes beyond pure academic performance.

In some ways, I feel ungrateful when I say the semester has been overwhelming because my colleagues in other specialties are taking as much as six, seven, or even eight classes. Granted, some of them are not juggling clinical on top of those classes, but I still wonder how it is that I sometimes feel like I'm treading water when I'm only taking four classes. Even after testing out of one class, instead of gaining free time, I watch in amazement, at how my workload easily expands to fill whatever time I have available.

Anyway, this has all been a long-winded way to acknowledge how infrequently I've been blogging. :) Later this week I promise I'll share a few more details about my first semester of midwifery school...

P.S. If you're farther along than I am in this process or if you've already graduated, feel free to post "been there, done that and I survived" comments in the comments section. They would be greatly appreciated!

Good Reads on the Internet 9/8/2010...

noreply@blogger.com (Kim) — Wed, 08 Sep 2010 11:32:00 +0000

There's been a lot of exciting reads out on the internet this week:

NYTIMES Editorial: Who Should Provide Anesthesia Care? : A discussion about whether or not nurse anesthetists give a similar quality of care as anesthesiologists. This isn't about midwives but it's still relevant to the broader discussion of the role of APRNs (advanced practice nurses).

Laughing Gas for Labor Pain? Why not? : Holly Powell Kennedy, ACNM President, and others discuss Nitrous Oxide as a viable option for pain management during labor.

A Woman's Guide to VBAC: Navigating the NIH Consensus Recommendations: Kristen Oganowski, Amy Romano and a team of contributors pulled together "a collection of resources that address the most common and pressing questions women may have about their birth choices."

Enjoy!

This Year Is So Much Better Than Last Year...

noreply@blogger.com (Kim) — Tue, 07 Sep 2010 00:57:00 +0000

I know I'm only three days in but what a difference!

So far we've had an orientation day and two days of lectures. We're learning and re-learning info about the menstrual cycle, contraception, how to conduct an office visit, etc. They are preparing us for clinical and it's kind of a sink or swim situation right now. We are all knee-deep in Contraceptive Technology (this book will tell you more than you ever thought there was to know about OCPs, IUDs, Diaphragms, Condoms, and more). It is a great resource for a women's health clinician and is the primary text for my Gynecology and Well Woman Care class this semester.

In the midst of all the excitement, I'm realizing that there is just so much to read. Frankly, I'm nervous about fitting it all in my head. I'm usually someone that is good at memorizing through reading and repetition but the sheer volume of information has made me think twice about that method. Are there any more advanced CNM/NP (students) out there who have innovative study tips? Tell me- what worked well for you?

Kim

A Year Ago Today...

noreply@blogger.com (Kim) — Mon, 23 Aug 2010 11:50:00 +0000

I was sitting, for the first time, in a large windowless classroom with 80+ other pre-specialty students. It was the first day of orientation and I had no idea what the year ahead would bring. What would the classes be like? Would I be able to do well enough in my classes to keep my scholarships? I recognized a few faces from my interview day but I didn't actually know anyone. Would I make any friends? There were so many unknowns.

Of course, all of the unknowns worked themselves out- grades came easily, friendships were formed, and I didn't have to sign away my life to nursing school. It's a year later and now I'm looking ahead to the start of the first official year of midwifery school. This year, a whole new set of unknowns awaits. Where will I be placed for my clinical rotations? Will I be able to get some more international experience? What is the process for finding an integration site?

We orient on Tuesday and then begin three weeks of Midwifery Intensive on Wednesday so the answers to these questions and more are not too far away. For now though, I'm going to enjoy the last seven days of my vacation. Until next week!

Kim

It's Been A Long Year...

noreply@blogger.com (Kim) — Sun, 11 Jul 2010 21:16:00 +0000

And it's not even over yet!

We're on our last stretch but the first year is a long one. We've finished all of our academic classes but we're scattered around the U.S. in California, Connecticut, Nebraska, etc. completing our clinical rotations.

The clinical sites are incredibly varied. In September I expect to hear amazing stories from my peers who spent the month of July in mobile clinics, VNAs, community health centers, home visiting programs, jails and hospices.

I've had the benefit of doing home visits with first time mothers which is nice transition point for starting midwifery studies in the fall. As for right now though, I'm counting down the days until my vacation.

Think You Might Faint?...

noreply@blogger.com (Kim) — Wed, 05 May 2010 18:33:00 +0000

A few tips on how to stay on your feet:

Flex your Quads.
Use the Mint on the Floor to Wake up your Senses.
Wiggle your Toes.
Keep Moving. If you have to stand in one place (say in a cramped OR room) try periodically alternating which leg you place your weight on.
Don't Lock your Knees.

If you think you're going down:

Find a wall.

If you're waking up from a faint:

When the nurses say you have to go to the ED because you hit your head on the way down- go! Don't argue with them...

I haven't had any fainting episodes (not yet at least!) but I've heard some pretty funny L&D fainting stories. Anyone have any good ones?

Our Witty T-Shirts...

noreply@blogger.com (Kim) — Wed, 24 Mar 2010 12:34:00 +0000

Remember when I talked about our witty t-shirts?

First Day of Maternal-Newborn Nursing!!!

noreply@blogger.com (Kim) — Tue, 23 Mar 2010 19:47:00 +0000

Finally.

I'm somewhat embarrassed to admit that much of this year represents a countdown to midwifery. But I can't help but think: "If I just get through the fundamentals this year, September 2010 will arrive and I will be learning all about gynecology and well woman care."

I know I should be focusing more on the incredible learning experience that Med-Surg (and Psych Nursing to a much lesser degree) represented in my journey to midwifery. But honestly, I've had such a one-track mind that now that we're learning something more directly related to midwifery, it's a relief. It will be a nice change to be firmly in the here and now rather than looking towards the future.

For half of the Pre-Specialty class, today was the first day of Maternal-Newborn Nursing. Most of the midwives are in Maternal-Newborn nursing but some are taking Pediatric Nursing. In six weeks we will switch places.

Today was a long day consisting of a five-hour lecture (with a couple breaks) on basic concepts surrounding pregnancy and fetal development. Glancing at the syllabus, I'm most looking forward to the lectures on topics that I don't have any direct experience in such as Intimate Partner Violence, Infant Loss, and Postpartum Depression. If today is any sort of template for the remaining weeks, the class will incorporate issues in global health and popular culture while using didactic instruction and small/large group discussions.

What's up Next?

Tomorrow is our first clinic day during which we will be learning about the language of birth, non-pharmacological pain support/labor positions (amazing huh?!), infant abduction and about what to expect for our clinical rotation.
Everyone's schedule is a little different but most people will begin their clinical this week or next.

This Post Is a Placeholder...

noreply@blogger.com (Kim) — Tue, 23 Mar 2010 19:24:00 +0000

This post is a placeholder for the experience I wish I had had during Psych Seminar and Clinical.

Nuff said.

I've Been Busy...

noreply@blogger.com (Kim) — Wed, 24 Feb 2010 16:09:00 +0000

Don't believe me? See what my schedule has been like for the past five weeks:

The good thing is that about half way through the first quarter of Spring semester, the Psychiatric Nursing Lab was replaced by a free day in which we had zero obligations to the nursing school!

The biggest difference between the Fall semester and Spring semester is that we're all able to do more! More students are taking jobs as babysitters or library staff. Additionally, more students are volunteering and taking leadership positions in volunteer organizations. Whereas last semester our lives were totally consumed with Medical-Surgical nursing, the Spring schedule has allowed us some time to branch out and experience graduate student life in New Haven.

So... What's Up Next?

Spring Break: Everyone will scatter for two weeks. Some people are going to enjoy themselves in New Haven. However, there is also a sizable number of us that will leave New haven to go on personal vacations, volunteer public health missions, or research initiatives abroad. Spring Break is just two exams and ten days away. It will be a much-deserved break since we have had one exam each week since the last week in January.
Second Quarter: The biggest change is that we start a completely new set of classes. Half of our class will be taking a Maternal-Newborn Nursing Seminar and the accompanying clinical (including me!). The other half will be taking a Pediatric Nursing Seminar and the accompanying clinical. Everyone will be taking Issues in Nursing and Introduction to Physical Assessment.

So that's what I have been up to for the past five weeks. There's still a lot to catch up on so I'll be back this weekend with more updates!

How to Prepare for Your Interview (And Other Useful Info)...

noreply@blogger.com (Kim) — Sun, 03 Jan 2010 00:39:00 +0000

Sections of this post were originally published on this blog on February 16, 2009, right before I found out that I had been accepted to the program. I have made a few additions to this version. Enjoy!

So, you've been invited for an interview? Congratulations!!

You might be really stressed out or perhaps you are as cool as a clam. Either way, I bet you are curious about what to expect on interview day.

You will probably be relieved to know that your interview will be a small portion of the events of your interview day. The interview day is just as much about the university picking you as it is about you picking them. Keep that in mind as you are shuffled from one information session to another. Information sessions will be on topics like Financial Aid and Student Life. This is the time to ask questions about everything that concerns you from your yearly budget to where to live and to how you are going to get around.

Sometime between 10AM and 4PM you will have an interview with one of the midwifery faculty members. Last year, some interviews were scheduled during one of the information sessions that they have planned. I don't know if that will be the case this year too, but it's something to keep in the back of your mind.

My interview was fairly low key but I made sure to come prepared (well, mostly).

Here are some of the questions you probably want to prepare for:

Why do you want to be a nurse? - In hindsight, this is an obvious question. However, I totally forgot to prepare for this question and it took me completely by surprised. I was so focused on midwifery that I forgot to stop and think about nursing.
What's the difference between the roles of a nurse, a nurse-midwife, and an obstetrician? Why do you want to be a nurse-midwife as opposed to a nurse or an obstetrician?
What research experience do you have? - If you don't have any research, be honest about that. You may want to consider thinking about research that you would like to conduct or topics that you are interested in exploring.
What makes you unique as an applicant? - This is the time to set yourself apart! Especially among the midwifery applicants, it's not uncommon for everyone to have had some doula experience, so make sure that you reflect within yourself to figure out what makes you special.

Other suggestions:

I suggest that you know your personal statement really well, because you will be able to answer many of the interview questions using material you have already written. I even wrote out my answers as a way to make sure that I knew them. However, be prepared for questions that you haven't thought of and be able to think quickly and on your feet.
When they invite you for your interview, they may give you the name of your interviewer. Take advantage of this information and research your interviewer on the internet. It's helpful to know their background and, if you're so inclined, familiarize yourself with some of their research.

And, finally, make sure to go in confident, happy, and yourself -- you'll do great!

First Semester of Pre-Specialty Year: By The Numbers...

noreply@blogger.com (Kim) — Thu, 17 Dec 2009 15:00:00 +0000

When I reflect on my experience as a first-semester pre-specialty student, all I can really think about is the quantity of STUFF I had to attend, complete, perform, and conduct. Way back in September I posted about my daily schedule and you can see that most of my days were filled with some required or recommended activity. So, let me break the entire semester down for you using numbers:

11 Exams in 15 Weeks
5 Insulin Injections
0 All-Nighters (I think the latest I stayed up to study was 2AM)
Lots of PO (by mouth) medications
4 Skills Check-Offs
17 Pharmacology Lectures
1 Craniotomy!! (I am not at all interested in surgery but I have a lot of respect for brain surgeons. Absolutely amazing.)
3 Heparin Injections
8 Bed Baths
24 Med-Surg Lectures
3 GI Special Procedures (Endoscopies, Colonoscopies, etc.)
5 IVs
3 Cardiac Catheterizations
1 Discontinued Urinary Catheter
6 Hours Providing Health Care/Education to Veterans at Stand Down Connecticut
Too Many Incontinent Episodes
24 Bio-Med Lectures
120 Medical Surgical Clinical Hours
7 Midwifery Potlucks

Now imagine that I'll have to do this all over again next semester!

Finished...

noreply@blogger.com (Kim) — Wed, 16 Dec 2009 02:56:00 +0000

That's right! I survived my first semester of Nursing School! I am one semester closer to starting midwifery classes and one semester closer to actually working as a midwife!

I am now safely at home and I am thoroughly enjoying the fact that I have nothing to do.

Not. One. Thing.

Finishing the first semester of Pre-Specialty year was kind of like running a marathon (or so I hear). I tried my best to pace myself so that I wouldn't get overwhelmed. I can't say that I always succeeded but I crossed the finish line. And it feels so good. :)

Lessons Learned from my First Clinical Rotation...

noreply@blogger.com (Kim) — Tue, 24 Nov 2009 00:06:00 +0000

I finished my first clinical rotation several weeks ago and if I had to describe the experience in one word, it would be..."unspectacular."

Let me explain how the clinical experiences work during the first semester. For the first semester we complete twelve weeks of medical-surgical clinical. The twelve weeks are divided into two different six-week clinical assignments. For my first six weeks, I was assigned to a hospital almost 30 minutes away. On Mondays I traveled to the hospital to research the patient that I would be taking care of the next day. On Tuesdays and Wednesdays I spent six hours each day caring for my assigned patient.

I have since moved on to my second rotation but I wanted to share with you a few lessons that I learned from my first clinical experience.

Don't expect to learn many acute nursing skills on a night rotation. In fact, there's very little to do because everyone is asleep. Why are they asleep? Hmm...maybe it's because it's nighttime and that's when people sleep. While my classmates were placing catheters, suctioning tracheostomy tubes, and caring for gunshot victims, I was still learning nursing 101.
You will get lots of opportunities to wake patients up so that you can do a physical and psychosocial assessment. This was the part of the clinical experience that made me feel like a horrible person. Imagine having to wake up a burn or stroke victim and telling them that you have to subject them to an endless list of psychosocial assessment questions and that you will have to percuss, auscultate, and palpate their belly and other parts of their body as well! I was lucky that my patients exhibited such gracious patience because some of my clinical group members weren't as lucky.
Nursing is not just about technical skills. My preceptor taught me the most valuable lesson. She's a nurse with over 30 years of experience and she said one thing to us that I'll never forget: "I know you guys didn't get to do a lot of technical things on this floor. But, that's not what's most important. Anyone can put in a catheter. What's important is to use this time to develop your nursing judgement. " I'm not sure if my other group members saw the wisdom in that statement, but, I couldn't help but apply what she said to my future career as a midwife. I realize that there will be many instances where, in order to protect the birth process, I will have to rely on my judgement rather than on a specific maneuver, position, or machine.

Before I started my second clinical rotation, I worried that our group was underprepared. Yet, after talking with other students, I soon realized that not everyone was having those spectacular medical-surgical nursing experiences that a few students had been so vocal about. It was clear that there was a large degree of variation among clinical experiences.

At the start of our current clinical, my preceptor was surprised that we hadn't yet learned how to hang an IV, give a clinical case presentation, or dress a wound. If she was disappointed by our lack of experience, she didn't show it. Instead, she assigns our patients strategically and proactively finds unique learning experiences for us. In just a few short weeks, I no longer felt like I was playing catch-up.

Anyone else felt like their clinical experiences have been...."unspectacular?" How were you able to make the best of it?

This Is Your Brain on Pre-Specialty Year...

noreply@blogger.com (Kim) — Sun, 15 Nov 2009 23:24:00 +0000

You might be wondering why my first post in three weeks (sorry!) begins with a picture of feet and a random stack of papers. Look closely at the picture. There's something that is not quite right.

As one of our professors often says: "Looking is Not Seeing."

If you still don't get it, here is what you're actually seeing:

1. I'm at the gym with my fellow smiddies! (Yes, we have time for the gym in our Pre-Specialty year).

2. I have lecture notes in my hand :( . (When you have three exams in ten days you have to study while you're exercising).

3. I'm wearing two different shoes. Yup...two completely different shoes! My fellow smiddies pointed out my error and we had a good laugh about it...

But, the really funny/pitiful thing is that this is not the first time I've made this mistake. Around this time last year, I was juggling a full-time job and taking my last pre-requisite class and I made the same mistake. I had had a crazy day and I remember having to run to class in order to get there on time. Well, right before we began our experiment my lab partner suddenly looked down and asked me loudly, "Are you wearing two different shoes?" LOL.

I figure this post would be an easy way to let you in on the craziness that has unfolded in the past few weeks. I wanted to write about so many things! The good news is that I have three weeks without any exams and Thanksgiving break is just around the corner. Since things have calmed down I will be back later this week to share. Until next time...

Movement In Labor...Not as Straightforward as it Sounds?

noreply@blogger.com (Kim) — Sat, 24 Oct 2009 21:52:00 +0000

When I taught childbirth classes as a Lamaze Certified Childbirth Educator, Healthy Birth Practice # Two: Walk, Move Around, and Change Positions Throughout Labor always held a prominent role in each class. I brought birth balls that moms (and oftentimes, dads) could sway on during class, I used various games that required moms and dads to get off the comfy pillows and onto their feet, and I staged "labor rehearsals" during which they would practice different positions and pain coping techniques.

However, being able to move freely during labor is not always as easy as "walk the halls of the hospital with your IV pole." There are times when women have to contend with many more tubes and wires. To illustrate that point, I frequently showed an image of a laboring mother who was "hooked up" to various wires and tubes in the hospital. The image (shown below) was published in Mothering magazine as part of their article "Cesarean Birth in a Culture of Fear" by Wendy Ponte in the September 2007/October 2007 issue of Mothering Magazine.

The image was illustrated by Kim Martens.

This illustration is, of course, an extreme, and I made sure to point that out. However, I really wanted to get across the idea that being able to move in labor depended on whether or not you could actually get out of the hospital bed! I couldn't help but feel like I would be doing a disservice to my clients if I didn't prepare them for the obstacles they might face if they did in fact want to be able to move around freely.

The issue of whether or not you could get out of bed was controlled by various external and internal factors, including:

Using routine interventions
Having care providers that do not encourage or support movement in labor
Choosing a birth setting that does not encourage or support movement in labor
Giving birth with pain medication

Some of the above factors are modifiable and can be planned for. But, birth planning can only go so far- it's impossible to totally predict the choices you will make and the needs you will have once labor and birth has started.

Ultimately, like all of the other Healthy Birth Practices, being able to "Walk, Move Around, and Change Positions Throughout Labor" does not exist in a vacuum and is dependent on the larger birth culture. It's especially difficult to talk about factors such as birth setting and care provider in a childbirth class because the expecting mothers are seven/eight months pregnant and at that point expecting mothers *usually* find it difficult to consider those factors modifiable.

Thus, what starts off as a discussion about movement during labor can morph into a valuable discussion about making choices before and during labor. It's also a great opportunity to review the concept of informed consent and to discuss how to foster an atmosphere of respect and equality when communicating and negotiating with a caregiver. Because ultimately, these are the tools that couples will need to be able to call upon when they are confronted with obstacles that might prevent them from moving freely in labor.

Interview with Amy Romano from Science and Sensibility (Part 2 of 2)

noreply@blogger.com (Kim) — Thu, 22 Oct 2009 10:54:00 +0000

Today is the second and final blog post in a two-part interview series with Amy Romano from Science and Sensibility. Click here if you missed the first post. Amy Romano is a Certified Nurse-Midwife, a YSN graduate, and the primary blogger at Science and Sensibility.

Nurse-midwifery is often looked at skeptically because of it's ties to hospitals and physicians. Unfortunately, nurse-midwives are often assigned the pejorative role of "medwives" (midwives who are more closely aligned to the obstetric model of care). I wrote about this dilemma when I discussed the compatibility of Holistic Midwifery and the CNM. Do you think nurse-midwifery is compatible with holistic midwifery? Do you consider yourself to be a holistic midwife? If so, how do you incorporate holistic midwifery into your practice?

"I do think that nurse-midwifery is compatible with holistic midwifery, but I think that our system gives all midwives two choices: assimilate or opt out. So every midwife faces a choice of whether she wants to improve care from within the system or accept being marginalized in order to provide a more family-centered style of care. Of course there are exceptions to this rule in both directions, but in general I do think it's assimilation or marginalization. There are some pockets in the U.S. where hospital-based CNMs are providing truly exemplary care with physicians who understand collaborative care and the midwives' independent scope of practice. We need to continue to be vocal about these practices and show how this midwife-led model, regardless of birth setting, contributes to the best outcomes and satisfied consumers. I realized recently that very few midwives are aware that there was a 2009 Cochrane Review that showed quite conclusively that *independent* midwifery, aka midwife-led care, is safer and more effective than physician-led care (where midwives work for doctors) or even shared-care (where midwives work with doctors). And the findings held for women whether or not they were "low risk".

With all of that said, I think that the current way that nurse-midwives are educated does contribute to medicalization of the profession. I think that the reasons I was able to practice "holistic" midwifery were despite my education, rather than because of it. For one, I worked in a birth center in Guatemala during the summer before I started the GEPN program and for the two subsequent summers. The U.S.-trained midwife who ran the birth center was a really important mentor for me and taught me a lot about normal birth. In addition to that, the hospitals we would transfer to in the case of complications provided really inadequate care, and basically everyone who transferred would have a c-section. So we "managed" a lot of things at the birth center that would certainly have led to transfers in the United States. It gave me an understanding of how to handle complications in a humane and mother-friendly way and bring in only the aspects of technology that were needed to correct the problem rather than throwing the baby out with the bathwater (i.e., converting completely to a paternalistic interventive style when complications cropped up and reserving "midwifery model" care only for those lucky enough to have no complications).

In addition, when I was in midwifery school I briefly decided I was going to do a dual degree program and get my Masters in Public Health. Well, I got about 2 weeks into the public health stuff before I realized that I had taken on way more than I could chew. So I withdrew from EPH and ended up having a year off in the middle of my two midwifery years. I was expected to keep up with my clinicals, though. So I did a regular GYN rotation and also designed two independent study rotations. One was following an entire CenteringPregnancy group from their first visit through their postpartum care. The other was a home birth rotation with Birth & Beyond. I learned more in those two rotations than I did in any of my previous clinical experiences. Centering allowed me to learn a facilitative style, really dig in and talk about nutrition or domestic violence or you name it, and include women in their own care. I got the same lessons from the home birth rotation but was also able to attend the births and learn comfort measures, how to correct problems with labor progress, how to give good breastfeeding support, and when and why to transfer or refer women. I would be a very different midwife were it not for these experiences, but it was truly a random thing that I got to experience them.

I think midwifery programs in the United States need to think about placing more students in these types of settings, and students should be demanding these types of experiences. When I was practicing with Birth & Beyond we constantly had students asking if they could come shadow us or set up a clinical assignment, but no one ever followed through. In the meantime, though, we had a high school student, an undergraduate nursing student, and a medical student intern with us. And they all had wonderful, eye-opening experiences!"

I'd like to thank Amy again for taking the time to answer these questions. It's always great to hear from more experienced midwives!

If you are interested in exploring more about using research to improve maternity care, visit Amy's blog Science and Sensibility: A Research Blog about Healthy Pregnancy, Birth & Beyond.

My Email Should Be Working Now...

noreply@blogger.com (Kim) — Thu, 22 Oct 2009 02:22:00 +0000

As some of you know I have been having problems with my email address! I apologize if you tried to email me and received an error message. My email address should be working now.

If you need to contact me, please email me at: nursemidwifeintraining [@] gmail [dot] com. If you are still having problems emailing me, then leave a comment on this post.

Thanks!

Resources for Care Planning

noreply@blogger.com (Kim) — Sat, 17 Oct 2009 12:43:00 +0000

If you're a nursing student then you know that care planning is a necessary evil in nursing school. Besides taking up at least four hours of your time, it helps you to think about the most important nursing considerations when it comes to contributing to the care and health management of your patient.

I'm not an expert on care planning but I wanted to give current and future nursing students (especially accelerated students) some quality sources for nursing care plans.

General Tips:

Think of nursing care plans as a way to organize your time during clinical and a way to start developing clinical judgement
Find the mix of electronic and print sources that work for you
Use your school's electronic books system! Your nursing school most likely has several electronic nursing diagnoses books and resources of which you should take advantage

Electronic Drug Resources: All three of these resources include the basic information for drugs such as indications, adverse effects, contraindications, and drug interactions. I've mentioned three sources below that I like for different reasons.

Electronic version of 2009 Lippincott's Nursing Drug Guide: This resource includes nursing assessments, interventions, and client teaching points. It's great for in-depth care plans and for helping you create a cheat-sheet for your clinical.
Electronic version of Davis's Drug Guide for Nurses (2009): Love this guide for the same reasons as the Lippincott's Nursing Guide and because it also includes nursing diagnoses to accompany the nursing assessment section for each drug.
Micromedex: A great quick reference that is often available in hospital computers as a bookmarked link when you are on the floor and need to do some quick research on new drug orders. Be aware, however, that it is not nursing specific and so you won't find nursing considerations such as assessments, interventions, and client teaching points.

Preparing for Clinical: On one sheet of paper have the following things:

A chart of all of the drugs that your client is taking, including why THAT INDIVIDUAL is taking it. Include the other indications for that drug only if you think your preceptor is going to ask you about them. Besides the clinical justification also include: the dose, any notable interactions, and the relevant nursing considerations. For example, with a diuretic, one of your nursing considerations will be to make sure you check the electrolyte balance, specifically the potassium level, before you give the drug because if the potassium level is too low and you give the diuretic anyway, your patient could end up hypokalemic.
A schedule so that you can organize your time. For the 6 hours that you are in clinical, map out when you will give a bed bath, give meds, do your physical assessment, interview your patient, have your post-conference with your preceptor and fellow students, change wound dressings, and so on and so forth. It's important to be organized because time will get away from you!

Finally, if you need help identifying nursing diagnoses, try the Ackley and Ladwig Care Plan Website. I love this website because it allows you to identify nursing diagnoses based off of specific symptoms or disorders.

Hope this helps anyone struggling with care plans and preparing for clinical. Are there any quality resources that I've missed?

Interview with Amy Romano from Science and Sensibility (Part 1 of 2)

noreply@blogger.com (Kim) — Fri, 16 Oct 2009 04:14:00 +0000

Today I'd like to share Part One of an online interview with Amy Romano. Amy Romano is a Certified Nurse Midwife, a YSN graduate, and the primary blogger at Science and Sensibility. I "met" Amy online through this blog and have been corresponding with her for the past couple months. Her story is incredibly dynamic and she agreed to share it with all of you. Amy provided such comprehensive and thorough responses to my questions that I decided to divide up the interview into two blog posts.

I have to say that as a student it has been immensely helpful for me to connect with Amy because her journey as a young midwife proves that there is a great deal of clinical and professional potential within the midwifery profession. Be inspired!

In my experience, the path to midwifery is rarely straight and frankly, it is often roundabout. Yet, it's clear that every midwife at some point in her life receives a calling. What led you to midwifery and why did you choose the Yale School of Nursing?

"I didn't know there was any such thing as a contemporary midwife until I was a sophomore in college and was taking a Women's Health course at the University of Michigan. A midwife who worked at a freestanding birth center gave us a guest lecture, and her message just completely resonated. I left that class thinking to myself, "I want to be a midwife." By then, though, the thought of transferring to the nursing school seemed overwhelming to me and I didn't really know enough about direct entry midwifery to realize that it was a viable option, so I kept on in my liberal arts education. I graduated with a B.A. in Women's Health and Economics and thought I was going to end up going back to school for public health.

My first job was a communications internship at the National Cancer Institute, then I got a job at Population Services International, an international NGO working in reproductive health social marketing. (I got to travel to Uganda and Burma!) I started to reach my two year shelf life at that job and got itchy to make my next move. I had a friend from school who *had* gone on to be a nurse-midwife and by then she was practicing. I called her and asked what she thought about me going to midwifery school.

In retrospect, it was a pretty random decision. I could have seen myself making any of a dozen other arbitrary career moves at that time. I don't think it was well into my midwifery education that I realized how much I was meant to work in the field of midwifery. A series of really important mentors helped me clarify my philosophy and politics about birth, and entrusted me with way more responsibility than I probably deserved. I ended up at Yale because it was one of the few schools that didn't require a B.S.N. and (more importantly) because the word on the street was that it was one of the best nurse-midwifery programs."

You graduated from Yale in 2004. What have you been doing since you graduated?

"I gave birth to my first child right after graduating. I expected not to look for midwifery work for 6 months or longer, but I wanted to do *something* midwifery related. Mary Ellen Rousseau (one of my YSN professors) passed along a job announcement to the student list. The job was an editor for the Lamaze Institute for Normal Birth, the advocacy arm of Lamaze International. I applied and, to my sincere disbelief, got the job. As it turned out, I ended up seeing my dream job pop up on MidwifeJobs.com just a few weeks later. It was a midwife-owned birth center on the East Coast, three of the characteristics on my first-job wish list. I knew jobs like that were few and far between so I applied and got the job. So for the first two or so years after school, I worked at The Birth Center: Holistic Women's Health Care in Wilmington, which I just adored. It is one of the oldest birth centers in continuous operation in the United States and the community there really treasures it. I felt really connected with my clients because I had a new family of my own so our ample office visits (30-60 minutes) provided time to connect on the woman-to-woman level, not just the provider-patient level.
In 2006, I gave birth to my second child and decided to take some time off from practicing. We moved back to Connecticut to be closer to family. When my son was about nine months old I began working very part time for Birth & Beyond, the home and hospital birth practice in Madison, CT, and a few months later I became a full midwife in the practice. Unfortunately, that practice closed down this summer as a result of multiple factors - we lost our physician back-up which in turn meant we lost our hospital privileges and we had a very difficult time recruiting a third midwife after one of the midwives in the practice left. The practice was too busy to continue with only two midwives, so we are officially on hiatus until we can sort out a practice model that is sustainable and does not result in midwives who are completely burned out.

In addition to practicing, I've worked for Lamaze International since 2004 and also have worked with the Coalition for Improving Maternity Services as part of the Expert Work Group that evaluated the evidence basis for the Ten Steps of the Mother-Friendly Childbirth Initiative and in their work promoting The Birth Survey, a tool for women to find and provide feedback about providers and birth facilities. I also am co-authoring the next edition of Obstetric Myths versus Research Realities with Henci Goer, due out in late 2010. Basically, everything I do has to do with using research to improve maternity care."

I'll post part two of the interview with Amy Romano next week. If you are interested in exploring more about using research to improve maternity care, visit Amy's blog Science and Sensibility: A Research Blog about Healthy Pregnancy, Birth & Beyond.

Holly Kennedy Induction as First Helen Varney Chair In Midwifery at YSN

noreply@blogger.com (Kim) — Tue, 06 Oct 2009 00:41:00 +0000

In honor of National Midwifery Week (October 4 - October 10) I wanted to write a post about one new Yale Midwife in particular, Holly Kennedy. Before taking the appointment at Yale this summer, Holly Kennedy was an associate professor of midwifery at UCSF. However, roughly three weeks ago, YSN celebrated the induction of Holly Kennedy as the first Helen Varney Chair in Midwifery.

YSN held a reception with wine, hors d'oeuvres, and remarks by Helen Varney (author of Varney's Midwifery), Holly Kennedy and YSN Dean Margaret Grey. Earlier that day I wasn't even sure if I should attend because I had so many things to do, but I was glad that my smiddies talked me out of that silly thought :). Friends and fellow midwives of both Holly and Helen came from near and far to commemorate the occasion. The room was filled with dozens of midwives and midwives-to-be, young and old, and the energy was intoxicating.

One of the reasons why the appointment is so exciting is that Holly Kennedy is also the President-elect of ACNM. After one year as the President-Elect, Holly will succeed the current ACNM President, Melissa Avery, and she will serve three years as ACNM President. She is well known for her research, particularly as it concerns linking midwifery care and health outcomes.

Is it naïve to hope that the midwifery students will have her ear? That we will have the chance to have meaningful interactions with her? If you could discuss one thing to the (future) president of the ACNM what would that be?