What I've been learning

Here is just a sample of what I've learned in my clinicals:

• If the baby is not descending, and it feels like the position is direct posterior, be sure to check all around the cervix/head.  To be sure it's really direct posterior, because it could also be a brow presentation.
• Never trust a grand multip with immediate (4th stage) bleeding.  They will BLEED.  Especially if their uterus is "tired" from a long labor or prolonged induction.
• Be very active in management of 3rd and 4th stage in grand multips.
• Never turn your back on a crowning upon the perineum.
• Trust your gut -- if it says something doesn't feel right, it probably isn't.
• Keep lots of little snacks handy
• Oh, and coffee, lots of coffee
• Sleep is overrated
• Move quickly and efficiently in urgent situations
• Hospital beds are not comfortable to sleep on when on call (or ever)
• Sometimes you can teach a very seasoned provider something new
• I am always learning something new each day
• Thrombosed hemorrhoids are VERY painful
• A hearty breakfast in the morning after 24+ hours of call is priceless and complete bliss
• Just because you prescribe and educate on a medication, does not mean the client will take it.  Or her partner, when applicable.  Just keep educating.  And document.
• Babies are very resilient little human beings!

Cruising right along

I'm coming up on the halfway point of my clinical hours.  I really am just moving right along on my hours, type of patient encounters, and some continuity clients.  It's not easy getting true continuity when you do clinicals in a big practice.  There are a total of ten providers in the group (MD, CNM, NPs) and the prenatal visits are basically rotated through everyone.  I've had quite a few births where I have never even met the woman before she enters labor :-(    <---- face="face" p="p" sad="sad">
My preceptor is wicked cool though.  When we get morning report in the hospital on the postpartum clients, she let's me choose who I want to round on and see.  That way I get at least *some* continuity with clients I have seen prenatally.  For the great majority of my time on call, I also take first call, which means that when a woman comes in, I assess her first, then give a full breakdown of the clinical scenario to my preceptor, along with what I think the differential diagnosis is, what testing we might want to do, and how to proceed/treat (if needed).

I'm certainly getting the hang of how a midwife's life really feels.  I run on very little (or lack thereof) sleep most times I am doing a 24 hr call shift.  I definitely feel my stamina slipping by the end of the call shift if I haven't gotten even a little nap/rest.  When we're busy, my adrenalin keeps me running.  When we're not busy, my 8 bajillion cups of coffee are what keeps me going.

I'm almost at the halfway point for my minimum required number of births --- yeah!!  But, I'm not on call at the hospital for another week or so.  Boo.  Doing some office hours this coming week though.  Yeah!

My best advice for those who are considering the midwife pursuit as a career --- it's more like a lifestyle.  As for clinicals and working an RN job --- now I am truly seeing why it's best to try to not work as much as possible while doing your clinical practicum.  I am TIRED.  I currently work three shifts per week for my paycheck (we truly need it, or I would not be working), and then I have to try to schedule my clinical hours around that.  Not easy to do when my schedule is due to be finalized at work before I have a copy of my preceptor's schedule!!  I do clinical hours anywhere from 8 hours in one week (one office day), up to 50 hours in one week.  And anywhere in between.  I think my average is about 24 hours of clinical time per week (office and/or hospital call).  I think my preceptor's full time schedule is about 48-60+ hours per week, depending upon her call schedule that week.  It would be so awesome if I could just totally follow her schedule, and not have to work at my RN job at all.

So, to sum it up --- if you are seriously considering going to midwifery school, see if you can get away with not working a paying job (or very minimally working) so you can follow your preceptor's schedule as much as possible.  I think that I would get more out of my clinical time if I could follow her schedule more than what I do right now.

Role transition

The more that I am in my clinical site, the more I am enjoying my role transition to midwife.  I'm finding that I am liking my role as the nurse while at work, less and less.  This only proves to me that I am -- without a doubt! -- in the right environment for midwifery at my clinical site!  It also proves that yes, all of this struggle and huge student debts are worth it on my path towards midwifery.  From the basic classes (theory, research, pathophysiology, etc) to the middle level courses (ante, intra, post/NB) to the advanced level courses.........and finally in my clinical site, where I am putting it all together!

I am incredibly grateful to be at my clinical site.  These are fabulous co-workers and I can totally envision myself finding a permanent role at this site.  God/goddess willing, of course!

My clinical site ~ women are treated as true partners in their care.  Women are given choices, ALL of the choices, and are encouraged to ask questions, discuss their options with family/support persons, and then make their own choice as to what they would like their plan of care to be.  Food and drink are highly encouraged in labor (yes, even with VBAC women!), ambulation and intermittent monitoring is the norm, and nursing care is superb.  The hospital itself is a laid back, relaxed environment, where women and their families are treated well and with respect.  No rigid rules and regulations for family, visitors, and times for visitation.

It's quite a shell shock to go from such a warm, loving, woman & family centered environment........to the rigid and often times noisy environment where I work.

My "to do" list

Between working as an L&D nurse (one hospital), and doing clinicals (another hospital, plus the office locations), I am so busy!  But, I am loving every minute of it!  I learn something new each time I am in clinical.  Haven't been able to add any more babies to my running tally (to the right), but I hope to change that in the next few days!

In the meanwhile, I have plenty of other things I'm working on:

-- Reflection for advanced women's health
-- Group project (two of us in the group this time) for advanced women's health
-- Getting started on the research portion of my antepartum case study, which is not due until next term, but I'm getting a jump start on it
-- Keeping my eye out for a good intrapartum case study project (also will be due next term)
-- Keeping my eye out for a good follow through patient for the postpartum/newborn journal assignment.  This assignment requires following a mother baby couplet for up to 8 weeks postpartum.  BIG assignment, lots of points, and must be done before I start the winter term in January.
-- Keeping track of each prenatal patient I see, so hopefully I will have (at some point!) five continuity patients to follow through from antepartum, to birth, to postpartum.
-- A side project in the early planning stages that I wish to present to my clinical site (the office).  It's a patient education piece on nausea and vomiting of pregnancy, with a comprehensive teaching tool for non-pharmaceutical methods of relief.  This is a major topic of discussion and education at the new prenatal appointments.  I really feel that a clear, well written patient education handout would be prudent for the practice.  Giving someone a verbal list of things to try, or writing it down on scrap paper, well, it just doesn't seem complete or professional enough in my mind.  I'm grateful that my preceptor is big on handouts in her practice.  Although, it seems that time used to run to the computer to print out ACNM Sharing with Women handouts, then running to the printer, then going back to the patient, seems very un-streamlined.  I feel that a pre-made patient education handout (for many topics, not just this one) would be beneficial to the practice.  Heck, while I'm at it, I may end up writing an entire "discomforts of pregnancy" booklet!

A self reflection

I have two days of hospital call as an SNM coming up this week.  Hoping for some more births!

So far, I feel good about doing postpartum rounds (seeing women, post op c/s or postpartum vaginal), doing their physical assessment, making sure their needs are met (breastfeeding, pain, incision/perineum, emotional), then writing the SOAP note on their exam.  (SOAP = subjective, objective, assessment, plan).

Writing SOAP notes -- very different then writing notes as a nurse.  It's hard to change from thinking like a nurse to thinking like a provider/midwife.  It's just.....different.  You know how you become an expert at something, and then you learn something new and have to start all over as a novice again?  That's what this student midwife role transition is like for me.  What I have known for over 10 years has now changed.  The basics and physiology of pregnancy, labor, birth and postpartum is not any different, but rather, it is the care provider role that is different.  I honestly don't now how better to say this!

Postpartum examples --

Nurse: physical assessment of the woman & baby, help with breastfeeding, provide extensive education re: breastfeeding, baby care, self care.  Ask provider for medication orders, treatment orders, discharge orders.  Documentation: checklist for physical assessment and patient education.  Annotate if outside the normal values on checklists.  Spend far too much time on paperwork. Spend several hours total with the woman and baby during your shift.  Frequent vital signs and physical assessments, depending upon how far postpartum she is.  Manage IV if she has one.

Midwife: physical assessment of the woman, evaluate emotional status, evaluate breastfeeding relationship, provide education, assess if pain management regime is adequate, prescribe medications as needed, order labwork as needed, order consults if needed, consult with MD as needed.  Documentation: free text SOAP note, decide what type of treatment/plan of care is needed, if consults are needed.  Spend 10-20 minutes with the woman.  Move on to the next woman.

Some similarities.....some differences.

So far, I feel like I am spending less time with women, getting to know them less as the student midwife, versus when I am working as the RN.  I was not expecting to feel this way at all!  I really enjoy bonding with women and their families as I help them through the labor process and in the early postpartum period.  As a student midwife, I am back to the mode of my technical job functions (get this task done on this person, move on and get this done on the next person, document, get the next task done on the next woman, etc).  This is the learning portion that I am not a fan of: learning new tasks/jobs, and having to learn how to organize it all in my brain as well as proper documentation.  As I become more comfortable with the new job role, and more comfortable with my documentation, then I know that I will be able to look beyond the tasks that need done, and be able to sit down and really spend quality bonding time with women, getting to know them and their families more.  <---- because THAT is my favorite part of my job/career!!!!

Sigh.  Yes my fellow Frontier CNEPers, you can call this a written reflection.  Those things we dread so much?  It's actually helpful to me, to be able to write it all down and work it out "on paper", or rather, on my computer screen.

First day in the office as an SNM

I know you are all waiting to hear about how the clinicals are going for me.  Off to a great start!  I've caught one baby so far, and have done one labor management.  For my first office day, I had several new OB clients, and almost a dozen return prenatal appointments.  Weaved in there were several things referred to as "common health problems", but for the sake of HIPPA, I will not go into detail here.  Needless to say, these were fairly common health concerns, but they also needed addressed for women at their visits.

I have several complete physical exams, complete with pelvic exams and breast exams under my belt.  Those seem to have come fairly easy!  Luckily, everyone was pretty straightforward and "easy" to examine, but very minimal variations.

Checking a cervix: piece of cake.  Then again, I have been doing that very same thing for well over ten years now.

I also had an NST to review (also, a piece of cake, I can do those in my sleep).

All in all, a very good start to my clinical hours and experiences as a student nurse midwife.  I have an AWESOME preceptor, who I just LOVE LOVE LOVE!!!  She is so kind, gentle, understanding, and oh so smart.

My hospital site is very mother-baby friendly.  A truly amazing place to be, and to learn how to be a true midwife.  The practice is a very laid back, flexible practice, and I am eternally grateful for my preceptor to agree to take me on for at least the next six months.