Lions and Tigers and Tenaculums, oh my!

Happy new year! Your negligent, itinerant blogger here. My apologies for being too tired to blog much lately. However, I’m coming up for air (hopefully) as I am now *drumroll*…three weeks away…from being a year TWO midwifery student. Yes, you heard me right: Year One is nearly over, and I have survived!

I wanted to update all of you on what’s been going on in my clinical placement the last few weeks. I finished my postnatal rotation, and I’m now two weeks in to a three week rotation through the Early Pregnancy Unit, Sexual Health, Outpatient Gynaecology and Uro-gynaecology. It’s been fascinating so far! But it’s also reminded me about how much of my practice I’ve been losing since moving here. Here in the UK, midwives only work in maternity, for the most part, and only with pregnant women (for the most part). However, in the US, well-woman gynaecology is within the scope of practice for Certified Nurse Midwives/ Certified Midwives, and doing pap smears, treating UTIs, STIs, discussing the pros and cons of different methods of contraception (and prescribing said contraception), inserting intrauterine devices (IUDs) and managing complaints ranging from heavy periods to painful sex to bleeding between periods was all well within the range of midwifery care. Which isn’t to say that as a midwife you always knew what to do for every issue, but you generally had a good idea of how to at least start to manage the case, when to refer to a gynaecologist, and what tests would be useful/ needed prior to that visit with the gynaecologist. It was never my favourite part of the job (pregnancy and birth was always my favourite part), but I don’t think I ever realised how much I missed it until now.

The Early Pregnancy Unit (EPU) is a very somber place. The waiting room is small, the faces in the waiting room are tense, and a huge amount of discretion and sensitivity is required. This is where women come when they’re having spotting, bleeding or pain in early pregnancy and there are concerns about whether a miscarriage has occurred or not. In many of the cases, everything is fine, and the couple can be reassured. But 1 time out of 5 (statistically, at least), a miscarriage has occurred and the woman and her partner are now faced with heartbreaking choices about how to proceed–whether to wait for the miscarriage to pass spontaneously on its own, or whether to opt for medical or surgical management. There are also concerns about ectopic pregnancies in the EPU, which is when the embryo implants outside of the womb rather than in the womb (this occurs most commonly in the fallopian tubes–called a tubal pregnancy–but can also more rarely occur in other places like the ovary, in the abdomen or even in the cervix). Ectopic pregnancies can be very dangerous, particularly if the growing embryo ruptures, which can cause severe bleeding, shock and even (very rarely) death. It’s a medical emergency when this happens, and if a pregnancy is confirmed by urine pregnancy test but no embryo is visualised in the womb on ultrasound, then it’s assumed to be an ectopic until proven otherwise, since you really have zero chances to miss an ectopic. The level of care that the women received at this unit was incredible, despite the sadness. The amount of follow-up was also breathtaking, and the team was able to move very quickly to provide urgent sonograms for pregnant women presenting in A&E with bleeding and pain . Every woman was tracked, every lab result was tracked, every beta-HCG drawn was placed in a book to be checked on at a later date, and every ongoing case was discussed weekly at a multi-disciplinary team meeting. To be honest, I enjoyed my time in this unit, despite the sadness, and was able to listen, offer tissues, take bloods and explain warning signs to be watching out for etc.

After EPU came Sexual Health, and this is something I also enjoyed very much. The caseload was incredibly varied–anything from people coming in for a routine check-up to those presenting with specific complaints (burning, itching, discharge, smells, lumps or bumps etc.) to routine medical management for HIV positive patients to people seeking post-exposure prophylaxis (PEP) or pre-exposure prophylaxis (PREP), both designed to help prevent HIV transmission after (or before) unprotected sex. The staff was very welcoming, and the clinic I was in was huge and able to manage nearly all of their results on site, even staining their own slides to look for clue cells, monilia, gonorrhea, trichomoniasis etc. We would prepare our own “wet-mount” slides in the US sometimes, and would look at them under the microscope to diagnose trich versus bacterial vaginosis versus yeast etc., but staining slides to look for gram positive or gram negative microbes was something I had never done or seen before, and it was fascinating. I’ve got to admit, though, it was a bit surprising to be taking care of men in a clinical setting again–the last time I had male patients was way back in 2003, when I was training as a nurse!

After Sexual Health, though, I was thankfully plunged back into womens’ health care again as part of my outpatient gynaecology rotation, and to be honest, I think outpatient gynaecology has been my favourite rotation so far. When you think about it, pregnancy and childbearing is an incredibly important part of a woman’s life, but it’s just a small piece of her total healthcare experience. Gynaecology spans the woman’s entire life, and encompasses everything from contraception needs to menstrual issues to peri-menopause/ menopause, and everything in between. This includes hysteroscopies, hysterosalpingograms, polyps, fibroids, cysts, prolapses, dysfunctional uterine bleeding, abnormal pap smears, colposcopies, menopause, vulvar issues, painful sex (dyspareunia) and even sub-fertility/ trying to conceive. It was really heartening to see many of the practitioners taking time to listen to women, explain how their bodies work, discuss their symptoms and options, and in many cases reassure women about what was going on, and why it might be going on. I was also able to observe one of the doctors through her day surgery case load, and it was fascinating to be in the main ORs in the hospital with the OR staff, where I found the experience to be quite different from being in an OR during a cesarean. For one thing, the staff was so efficient at their jobs that they had the entire process laid out like a precision science, with the next woman being wheeled into the OR for anaesthesia prep only a few minutes after the previous woman had left. All of the women were put under general anaesthesia as well, which was also very different from cesareans, which are normally done under epidural or spinal anaesthesia. It was also amazing to watch how relaxed the anaesthesiologists were! There is a point between when the woman has been put to sleep but is not yet intubated during which time she’s not really breathing on her own, and I kept watching with baited breath, waiting for the intubation to occur and then the chest wall to begin to rise and fall again, but the anaesthesiologists always appeared so calm through this entire process. And once she was intubated again and they were using an ambu-bag to ventilate her, again there was never any sense of panic or urgency to it. It made me reflect on how different general anaesthesia (GA) is on Labour Ward. If a woman is under GA during a cesarean, it’s usually because something has gone very wrong and there was no time to put in an epidural. GA is used during cesarean births when seconds literally matter, and in those situations, there is often a palpable sense of urgency and stress through the entire thing. And the same applies to ventilation–I have only ever seen it in the context of resuscitation, which is never a calm or relaxed situation. It was really eye-opening to observe routine GA, with calm, workday efficiency surrounding it, rather than barely-controlled panic.

One more week of outpatient clinical placement ahead of me, and then….I am more or less done for Year One! And I promise I’ll find some time to write a few more blog posts soon!

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