Sublimaze(d) Epidural Episode

My desire (long ago now) to contribute to the (re)production of midwifery knowledges by ‘interrupting’ it through research was conceived in the year when I was a midwifery student. As an ex-nurse, I undertook one of the final post-graduate courses for a diploma in midwifery, half way through completing my university degree majoring in Feminist Studies and Education. Here is a small vignette from my time as a midwife in training.

Pain, sublimation, and a naïve search for ‘(t)ruth’

When I was a midwifery student in 1995, I watched an anaesthetist insert an epidural catheter into a woman’s spinal column after the duty registrar made a diagnosis of ‘patient distressed’ and a treatment plan for ‘epidural analgesia’. I had thought the woman was labouring without many problems; it was her first baby, her husband was providing physical and emotional support, and she was also using the gas to provide some relief. I knew there were no obstetric complications and she was an otherwise well woman. Things had seemed fine till now. The midwife was keeping the registrar informed of progress. When the registrar popped her head in the door ‘just to see how things were going’ and subsequently make her diagnosis, the woman was standing leaning over the end of the bed, moving her hips around in circular
motions and moaning rhythmically and loudly, while her husband stood by holding the gas tubing to pass to her when she requested it with one hand, and rubbing the small of her back with the other.

I was doing little things to help me cope with the feeling that I was being intrusive, like passing on cold flannels and sips of water to the husband every so often to give to the woman, whilst silently hoping I would see a normal birth that shift; perhaps even catch the baby. The registrar asked the woman how she was finding the gas, and she replied that it was ok, but made her feel slightly nauseous. After a few brief and quiet words with the midwife that I was not a party to, the registrar left, and the midwife said “Well, I think we’ll pop in an epidural just to make things a bit easier for you if you like…I’ll just get the anaesthetist down to do it, ok?” The woman seemed ambivalent, but felt that the staff would know best and agreed.

Feeling disturbed but not really sure why, I carried on performing my small and helpful tasks, including smiling, as the anaesthetist arrived with a trolley. Helping the husband help her up on the bed, holding her knees up, so she could ‘curl up tight
in a small ball on the edge of the bed with your spine curled towards me’, while the midwife helped the anaesthetist by opening packets of gloves and other sterile equipment onto a trolley
by his side. Holding her nightie up to be taped to her shoulders while the anaesthetist painted betadine solution on her back, to create a sterile field where the needle would be inserted
between certain lumbar vertebrae into the epidural space, in front of the spinal cord. Smiling at the husband, trying to convey a sense of reassurance, of the everyday. Hoping he couldn’t see the disappointment in my eyes. Struggling with my feelings of confusion. Not wanting to meet the midwife’s eyes (what might I see/convey/not see?) Silently furious with the registrar – had she given birth? How old was she anyway, and why do they always seem so young and inexperienced? Wasn’t she familiar with normal birth? How could a female doctor make these
decisions? Why does this seem to happen all the time? What had been going wrong? Then the needle catheter was in, secured and taped over, op-site smoothed down firmly, drip stands organised, the woman settled back on the bed, nightie smoothed down nicely,
immobile except for her arms and head, blood pressure cuff blowing up on her arm, all set now, husband beginning to look relieved, ice cubes brought in to measure the level of loss of
feeling on her skin, good that’s a job I can do now, the block mustn’t go as high as the lungs or we’re in trouble, midwife just pops in the urinary catheter and drainage bag, that’s just there
because now she can’t feel when she needs to pee as well as to push… CTG machine on and galloping away, baby’s heart beat sounds fine (‘won’t be long now, have we got a name for him or her?’) Everything’s ok at last, big sigh of relief, husband in chair beside bed, no need to massage her now, she’s nice and quiet, midwife’s doing the paper work and checking the equipment.

Then I notice the anaesthetist putting an orange sticky label on the fluid bag, and I ask him quietly out of the couple’s earshot what he is adding. He says “It’s just a small amount of a
narcotic we pop into the bag as well, Ruth”. I say “Oh. I thought it was just a regional anaesthetic, why do they have that as well?” He said, “Well, we just find things work better in
combination like this, different anaesthetists use different combinations of drugs, it’s just asmall dose”. I say, again, “Oh”, and pick up the phial to read the label – Fentanyl, otherwise known as Sublimaze, the label tells me. “Sublimaze?” I say to the anaesthetist – “Sublimaze?” I repeat again, unsure myself what I want from him now. “Do they know they are getting it?” I ask, finally, and he says, “Well not specifically, Ruth, they know we use a regional anaesthetic and an analgesic and that they work very well together” – but it is clear his patience may run out soon so I stop my questioning of him. I feel flat, a bit nauseous and dazed, and am simultaneously kicking myself for having these feelings. After all, the woman seems happy, and her husband is certainly relieved. But as I go home soon after that, well before the woman birthed, I can’t get rid of the thoughts that the name ‘Sublimaze’ sounds like a combination of
the words ‘sublimate’ and ‘haze’ or ‘daze’. I look up the word in the dictionary when I get home and find that it says:

sublimate (sub-lim-ayt) v. to divert the energy of (an emotion or impulse arising from a primitive instinct) into a culturally higher activity. Sublimation. n.

For some reason I feel quite stunned, and wonder for days afterwards if I really will practice as a midwife when I graduate; I almost think I don’t want to, I only want to do homebirths anyway, but how will I manage round-the-clock midwifery practice and juggle childcare as a single parent…I feel so exhausted all the time, just by being a student. I’m exhausted by having to ask questions constantly, and a desperate and lonely feeling that I can never find the right answers, no one seems to care about, or know, or tell, the ‘truth’….

Still looking for (t)ruth years later, after becoming a (non-practising) midwife, then a doctor, then returning to psych nursing. It’s gonna be ok.

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Night duty

And so then about 2330 after handover and everything, Nikita takes over from Kirsty. She comes over smiling and whispers that she’s sorry that she’s going to have to do my recordings Q4H through the night because it’s the first night post-op, and she really hopes she won’t disturb me too much. She knows I’m a nurse and we talk about night duties, I say how much I’ve always hated them and that I will never do them again in my life. But Nikita too like Kirsty is still in her NetP year, and younger than my own daughter. She has to do them as rostered, she is just at the very start of her journey.

I do like being in the hospital overnight as a patient though, and I’ve always liked the idea of the hospital at night, its dark secrets and bizarre institutional underbelly; the morgue and the funny orderlies and the sick humour we use(d) to manage everything. I realise I probably won’t sleep tonight and that feels ok, I lie there listening to and feeling everything. I think about what I am learning from these young ones, how much more I have to learn.

Then I hear the recordings trolley and Nikita comes quietly in; I listen to her gentle reassurance as she tends to my room mate, and then she comes to me. She does my recordings (BP only 98/50, crikey, that’s a surprise to me, after drinking so much water) then squats down to empty my catheter bag and I am embarrassed and tell her I wish I could have done that myself, if I could walk I would have gone to the loo and emptied and measured it myself. She laughs gently at me and we talk quietly about the intimacy of nursing bodies, how privileged we feel to care for the bodies, minds and souls of others. She tells me there’s 4 on tonight, which is good, last night they were one down and it was hard.

When she’s gone I feel the sinking in of the real night, my room mate breathing, the rain outside, the darkness. For the four hours until Nikita comes back I try hard to remember myself at 22, a new grad working in ward 29, Haematology. Doing heparin locks, taking bloods and I can still remember some regimes, is it MOPP or CHoPP, Vincristine, whatever. 35 years is a long time ago. The night shifts since then, palliative care in people’s own homes, then psychiatry, and the births and the deaths. The feeling sick about 4am, the comaraderie, and the driving home, against the traffic, and against my body clock.

Remembering, I stay awake the whole night, not trying to, but I can’t sleep and I’m wondering if I’ll ever feel the way I did then again, the ways these younger ones feel now. I think about the ED next door and below to here, I wonder which of the Crisis Resolution nurses I know will be there, right now in the middle of the night, hoping they are safe, with those that have tried to take their own lives, or wanting/not wanting to harm themselves, wanting to go to Hillmorton, agreeing to go to (my) Respite. I think about them.

Then it’s 0500 and she comes quietly in again, squatting down to the catheter and our night breaths mingling together as she realises I’m awake and we talk again. She tells me this is her hard time, she has to keep moving physically or fatigue will try to set in. But things are done, and we can talk. I tell her about my roster, 4 on/2 off for years, and now a fixed 3 week cycle, a mixture of pms and ams. I hate the alarm on winter mornings.
She starts earlier than me, 0645. I ask about parking, is it hard to get up even earlier, how grateful I am to have a park and meals at my work. I tell her the hardest bit of my roster, the one day off twice in the 3 weeks which finish on a pm then start on an am. The long two days off plus one study day in the roster make up for it, I say.

She tells me she works up to 7 days in a row, that its ok. I ask about short changes and she says there is a few, now and then. She says she lives nearly an hour away, that makes it a bit hard, there’s parking too. I say ‘but don’t you have to have a 9 hour break, or is that only in psych? Couldn’t you start at 8, if you finish at 2300, but really 2330, then get home about 0030?’ But I couldn’t find a park by then, I may as well start at 0645 – it can take up to half an hour to get a park, remember, she says. I count backwards, and say ‘but if you start at 0645, and have to figure in maybe half an hour for parking, what time do you have to get up, about 0515, then?’ I say. She shrugs and says, oh it’s about 0500, or 0515. We look at each other in the dawn. We check each others maths like good RNs, laughing at and with each other.
‘So those short changes, you basically have four hours sleep, if you can even sleep then, what with the drives and the parking’ I say. I guess so, 4 hours, she says. We laugh again, laugh-whispering, semi-delerious we are in the dawn, and we don’t want to wake my still-sleeping room mate, and she says it’s nearly time for handover now, anyway, and she better go, and I say thank you Nikita, you don’t know how much you’ve taught me.

Hospital in March

Compelled to write something for the #hearourvoices Nurse Florence movement as I lie here first night (of one – maybe 2!) post-op in CWH – the reason for op largely related to rarely lifting properly when training 35 years ago…no hoists in those days – and if alone at the time feeling desparate to get the huge person who’d fallen off the bed or loo up – and rarely able to listen to body for loo stops etc r/t no time, too busy, shift work etc…I remember hearing so often ‘you girls better look after your backs and pelvic floors!!’ now 35yrs later here I am! Not c/o that, just glad to get it done after only 4 months on waiting list.

My reason for posting is because I’ve related to 99% of posts, all in so many different ways, and agree so strongly with each and every concern shared re ‘safe’ staffing, and ridiculous pay, and staff assaults, etc etc, paperwork, bullying, burn-out, compassion fatigue, car-parking, audit culture etc and on and on we go. Mainly been in MH, where I am now, in an NGO. Done a bit of tutoring in my time too.
I’ve felt pretty dispirited and sad and angry (at the ‘System’!) while following on here since it’s inception (thank you SO much, both Florences; and your poor families!!).

Not gonna lie, I was nervous (especially after very foolishly watching the start of a Utube ‘how to do’ video of my op – just, don’t, ever!) So it’s been fantastic right from arrival this morning….I’ve felt so safe and supported every minute with every single staff member, in any/every role they may be in, and I’m feeling so heartened and inspired, and grateful to come across the passion and hope again.

Tremendously impressed with all theatre and recovery staff and procedures and safety checks and bed-side manners. Now been up on the ward since about tea-time. Been having hilarious time with my lovely room mate! We are pretending to be ‘difficult patients’ for fun, watching ‘Bravo’ channel, discussing BMs and stitches etc, and together share the most incredible RN (think she’s got a caseload of about 4-5 post-op pts plus a 2nd yr Ara student).

I cannot sing her praises enough. If she is over-run, over-worked, exhausted on her 9th shift, or has even been on a double shift r/t short-staffing, stressed about her student loan, or suffering any other number of personal or professional problems I would never be able to tell it. She’s coached and mentored her student perfectly. She’s joined in our fun and teasing most appropriately. She’s not been nervous knowing I’m a nurse, nor (thank goodness) tried to impress or give me special Tx. All boundaries great, cultural safety spot-on, practical tasks wonderful. Wasn’t expecting (or even wanting) time for a bed-change and a bowl for face-wash and teeth clean. To my great surprise she’s just near the end of her first year or so! And whizzing through assignments etc. I know she’s handed over late and then has to walk home.

And then guess what. As we chatted just before she left and I thanked her so much for everything, including restoring many of my ideals, hopes and beliefs; and told her what a wonderful tutor or CNM/CNS she will be in 5 or so years (after i nosily asked her age), she humbly told me it was actually her birthday. Today.

Kirsty – you are amazing. All that, freely given to me, and others on your own 22nd birthday. Thank you. And f**k the PDRP! You’ll fly through, anyway.

Florences – I can still just see the lamp glimmering. It may flicker and fade at times – but Kirsty held it out for me tonight. May I now do so for others.

#happy22birthdaykirsty
#hearourvoices
#gratitudelist
#mightjustloveitagainsoon

On death; Heather/Alison, revisited in May 2017.

Lately it feels like all our friends are dying. It’s just a few – three, maybe; but that’s enough when you’re only 55. Since I wrote this piece below on 27/09/01, my partner and I have also lost both our fathers, to good old age, and her nephew, at a tender 25 years, to the February 22nd 2011 Christchurch earthquake. So I’ve been thinking about death a bit. At the start of my academic journey as a sociologist 25 years ago, I was more interested in birth. I had just trained as a midwife, had a five year old daughter, and was convinced that childbirth was a field the potentially feminist profession of midwifery might reclaim some lost ground over. That was a while ago – indeed, a lifetime ago; and now it seems I’m faced with more death than life. Can there be a re-death? I’m very familiar with re-birth as a metaphor, but re-death? Never heard of it. I’ll keep thinking. In the meantime, this is what I wrote back then.

Heather and Alison

Alison invites me silently with a smile, a nod and raised eyebrows to enter the room. I follow her, trying to be silent and almost invisible, as she indicates a seat for me beside the bed that Heather lies in. I reach out and take one of Heather’s hands in mine, after feeling momentarily unsure about whether I should do so at this time; I don’t want to disturb what she is doing. She seems so incredibly inside herself, oblivious, almost, to the presence of Alison and me in the room with her. Her belly is huge. I wonder if she is in transition. Her breathing seems quite laboured now, but she seems to have found a certain rhythm to go with. There is some soft music playing; an Indian meditation piece with some very quiet and slow chanting. It provides a feeling of absolute peace and serenity in the room. Alison is completely in tune with Heather’s rhythms; she follows her lead in everything. She watches Heather’s face continually from the other side of the bed. If Heather licks her lips, Alison holds a glass of water out for her to sip from, before watching Heather sink back into the pillows. She seems to be comfortable; what pain there is seems to be manageable.

Alison whispers to me: ‘she’s just going with the flow so well, isn’t she…’ and I feel my tears well over at the enormity of being part of this. I am in awe of Alison, who seems to be in a perfect partnership with Heather; they are symbiotic. No one comes to disturb us. There are no noises from outside. It almost feels as if we are in a womb of sorts, ourselves. The lighting is soft and dim and I can see the contours of Heather’s face changing as she breathes, and at times hums, and sometimes moans.

Heather’s daughter, Celia, who had been born nine years earlier by caesarean, comes in to the room with Heather’s mother, ponders Heather’s face for a while, and then goes back out to play. She appears unconcerned at what her mother is experiencing, and slips in and out of the room from time to time thereafter. There are three generations of the women in this family present; their connection to and knowingness of each other is tangible. Heather’s mother asks Alison quietly if there is anything she can do, but Alison shakes her head, and so her mother sits back down and returns to her reading. It seems a perfect way to give birth; surrounded by women related by blood and by friendship, with no need for words, communicating silently and often with eye contact and facial expressions. There is a sense of incredible peace and acceptance, of going with the flow, accepting the process, and not hurrying the forces of nature. There are no clocks on the wall. I still wish that more women could, or would choose, to give birth like this, with no hurrying, no time limits, surrounded only by people who love them and will follow their lead in the process. Going through this experience now was the closest Heather had felt to her family in her life, she had told me a few days earlier.

Heather isn’t giving birth this time, though; she is dying, of lymphoma. The cancer has swollen her belly to bizarre proportions; the rest of her body is excruciatingly thin. Alison and I have had a whole month of getting used to this moment; for a long time we haven’t known whether Heather was ‘living’ or ‘dying’, and realized we would have to accept a limbo state, a grey zone of not-knowing, that no one could tell us one way or the other, after treatment stopped, what would happen. So we approached it now almost like a birth, as Heather herself did by that stage. She considered her impending death to be a spiritual transition, and at times talked to me about how this felt. She wasn’t afraid of the transition; she had finally let go of her earthly concerns and surrendered herself to the process as it was unfolding. Her sister, Alison, was being with, midwifing, Heather, through this transition.

Spiritual care for the dying has been described as “midwifery for souls …keeping the body comfortable, passage peaceful, soul triumphant, and family present” (in Paine, 2000:367). Perhaps the needs of those dying, and of those birthing, are more similar, and much simpler, than we realize. Perhaps there is not much difference between being-with in birth, or being-with in death, for nomad midwives….

*******

Now being a ‘Death Doula’ is a thing (in America, so far). I worked as a nurse in palliative care for a while, well before, and in fact leading to, my interest in home birth. I thought home-death was lovely, and home-birth would be even more compelling. I’ve come a long way, baby, but have much less direction, now. Maybe I’ll figure some things out in the course of these musings. Maybe not. But I am going to try a bit more writing, just for company, along the next leg of the journey.