It’s 6:30 am. The sun is beginning to rise and there’s a calm feeling in the air. My alarm pierces the silence. I jolt awake and instantly reach for my phone. I’ve been trained. I scan the list and see what is currently going on at the hospital. Maybe there are no labor patients, and I get to sleep in for another 30 minutes. Best feeling ever! Or maybe there is a multip (woman who has given birth more than once) who is 8 cm with a bulging bag of water. Yep, it’s the multip! Let’s call her Sara. I take a deep breath and mentally prepare for the day ahead. I jump into the shower, throw on some scrubs, and kiss my husband goodbye, if he’s awake. I have a 30-minute drive to one hospital, 20 minutes to the other. Guess which one Sara is at? Of course, the furthest one, and with the morning traffic, it can take up to 40 minutes. By 7:15, I’m rushing to relieve the midwife there by 8:00 am. I get there about 5 minutes prior, and Sara only has a rim of cervix, but thank God for that bulging bag of water. That’s the only thing holding the baby. I quickly don a sterile gown and gloves and prepare to push with Sara. With the first push, the bag breaks. I know this is going to go swiftly. Sara’s mom is crying because she can see the baby’s head. Sara is determined and her partner is looking at her with adoration. I’m calm. Few more pushes, and the baby slides right out. No cord around the neck and no vaginal tears. After delayed cord clamping, her placenta follows easily and there is minimal bleeding. It is literally the perfect birth! Unfortunately, they aren’t all so easy, as I’ll quickly remember as the day progresses.
As I head out to the desk to put in orders and chart the delivery, I take a more in-depth look at the list. I have another labor patient who is 6 cm on Pitocin (medicine to stimulate contractions) and has an epidural. It’s also her first baby. Then I have an induction that is still on Cervidil (a ripening agent). She was 1 cm last night. Fortunately for me, they are all in the same hospital. At the other hospital 15 minutes away, I have two patients who have already delivered and need to be rounded on. Where I’m at now, I have six patients to round on. At this point, nothing is emergent and I can run downstairs and grab breakfast. It’s about 9 am. Yup, only 1 hour into my 24 hour shift. After breakfast, I prioritize care and visit the woman who was 6 cm. Let’s call her Brittany. Before entering the room, I review her chart and labs. I want to know if anything is abnormal that I should be aware of. I complete an exam and determine Brittany is still 6 cm, but has a thin cervix and a bulging bag. I counsel her on breaking the water, and with her consent, use a plastic hook to rupture her membranes. This will usually speed things up because without the water, the baby’s head can apply more pressure on the cervix. The downside is that the contractions become more intense. Brittany doesn’t notice, however, because she decided to have an epidural for pain management. I tell her to rest and conserve her energy for pushing.
I then visit the patient who was 1 cm. I pull the medicine out of the vagina and complete an exam. She is 2 cm but still thick and baby is out of the pelvis. I order another cervical ripening agent for her called Cytotec. This medicine is placed in the vagina for 4 hours, so I plan to re-examine her then. It’s now 10 am. I make my way to the postpartum unit and review the charts and labs for the 6 postpartum patients. Some have blood pressure issues. I consult with my collaborating physician and receive orders to increase the dose of medicine for one with uncontrolled pressures. Then the nurse alerts me that one of my patients has a very low hemoglobin level (under 7). I plan to offer this patient a transfusion and make a mental note to counsel the patient. The rest are progressing normally, with two going home. While I’m in the chart, I order simple things, like iron for patients who are anemic and repeat labs for any concerning values. Once I have all my background information, I speak with and examine the 6 patients. For those going home, I discuss discharge instructions. The patient who requires the transfusion accepts, and I order blood. I counsel the hypertensive patient on her dosage change and discuss signs of elevated blood pressure.
Once I have seen everybody, I head back to the desk to chart, put in orders, and write prescriptions for those going home. It’s noon now, and I still need to head to the other hospital. I check Brittany before I leave and determine she is 8 cm, but again it’s her first baby. I tell the nurse I’m going to run to the other hospital and come right back. I see the two patients at the other hospital, sending one home. As soon as I start thinking about grabbing lunch, the first hospital calls to say Brittany is completely dilated and feeling lots of pressure. I rush back to the first hospital. On the way, I text my medical assistant and tell her I will not make it to the office. By the time I make it, the baby is down enough for us to start pushing. I coach her through pushing, but she is unsure of herself because it’s her first time. We try pushing on her side and using a towel for a tug of war motion, but our options are limited as she can’t move well with the epidural. Finally, after determination and patience, the baby starts to crown. I can tell Brittany is getting tired, but I tell her she’s so close. I offer her to touch the baby’s head or let us grab a mirror so she could see. She quickly declines lol, most actually do but it works for some people. An hour after pushing (which is actually good for a first time mom), the baby’s head slips out. I tell Brittany to stop pushing and check for a cord. There is one. I try to slip the cord over the baby’s head, but it’s too tight. I change my maneuver to somersault the baby. Unfortunately, Brittany ends up with a second-degree tear (through the skin and muscle) and her epidural isn’t that great. I give her local anesthetic to help with the repair. As I’m finishing up this delivery, another nurse rushes in to tell me my other patient’s baby isn’t looking well on the monitor. She also states her exam is still 2 cm. I tell them to call the physician as I finish taking care of Brittany.
As soon as I walk into the other patient’s room (let’s call her Ashley), the baby’s heart rate decreases significantly and is not coming back up despite our interventions. The physician is 5 minutes away. My heart is beating like crazy, but I remain calm. I order terbutaline (medicine to stop or delay contractions) and this recovers the baby until the physician arrives. The decision is made to proceed with a C-section as Ashley has made no change and the baby’s heart rate starts to decline again. We rush to the OR and because Ashley did not have an epidural, she has to be put under general anesthesia. We rush to get the baby out, paying no attention to neatness as once a patient is put to sleep, the baby must be delivered quickly. Baby comes out vigorous with strong cries and we all breathe a sigh of relief. Once I finish the C-section, my stomach is angry, and I’m feeling lightheaded. It’s now 4 pm, and I haven’t eaten since 9 am. I’m exhausted, but all the patients are delivered. I head home to eat and relax.
I’m thankful to have some time to spend with my husband. I answer a few calls here and there from the answering service, but for the most part I’m able to relax. Praying for a quiet night, I fall asleep. At 1 am, I’m jolted awake when my phone rings. It’s the hospital. A multip just walked in 8 cm and desires a water birth! Water births are my favorite, but they always seem to happen in the middle of the night after I’ve already had a taxing day. With no time to really think about being tired, I jump out of bed and stumble to get ready. I fly to the hospital, grateful it’s the closer one and make it just as the tub is ready. My patient, Tanya, is 9 cm with a strong urge to push. We carefully assist her to the tub and intermittently monitor the baby’s heart rate while she finds temporary relief amidst the warm water. Through each contraction, she cries out. The nurse, doula, and I encourage her to breathe. Tanya waits until her body starts to naturally push. We try different positions, such as hands and knees and squatting. She’s doing phenomenal and her baby will be here very soon. I am here to monitor; Tanya knows exactly how to birth this baby. As the baby glides out and the parents cry tears of joy, I am reminded why I endure the sleepless nights. These births are the most beautiful and remind me that women are extremely strong, including me. I make it back home around 3 am. Only 5 hours left in my shift, but I know a lot can happen in that time. I plead for some rest. I’m called again at 5 am for a patient who thinks she’s in labor, but is only 1 cm. I order an ultrasound and send her walking for two hours; amazed that I can still be coherent at this time. Though I’m agitated to be woken up, I’m grateful that I can stay in bed. At 6:30 am, I give report to the next midwife coming on at 8 am. Again, I pray all hell doesn’t break loose before then lol. My prayers are answered, and I’m grateful to have the next day off!
This is a compilation of incidents that I have encountered during my time as a Midwife. No real names have been used while writing this article. As you can see, I manage both low risk and high risk patients and facilitate births with zero interventions and multiple interventions, including being an assist for C-sections. No day is predictable and literally anything can happen. Welcome to my world!
xoxo, Global Midwife
Disclaimer: This is not medical advice, only education. Always check with your healthcare provider.