Cooked

I'm done.

My blogging days are coming to an end here, at least for now. I won't say that I am done for good, but I can't see myself returning to it for a long while.

For those who have read this blog for a while, perhaps even the original blog I began over 3 years ago that eventually morphed into Rebirth, have probably noticed that my writing has been fewer and less, well...interesting.

I am no less passionate about women's health care and midwifery care. But in just my short career, I am burnt out. Crispy.

So it's time. Hope to catch you all around the interwebs. And who knows, I might show back up in the future if I find I can't keep my mouth shut.

Multip End Point

This morning I get an email from an old friend who is pregnant with her fourth child. This pregnancy was more challenging than her others, with more aches and pains, preterm contractions, questionable blood pressure issues, and then a few episodes of premature rupture of membranes. Everything has always turned out fine whenever she went in for an evaluation, whether at her doctor's office or the labor and delivery triage unit. Her most recent labor and delivery triage visit prompted a nurse to say to upon arrival, "Oh, I would have thought you would have delivered by now!" This made my friend feel a bit like a multip reject...like she should have been able to know exactly the right times to actually present for triage evaluation or have had something requiring her to stay instead of being discharged still pregnant.

Her previous three babies were all delivered between 36 and 37 weeks after spontaneous rupture of membranes and a fairly quick spontaneous onset of labor shortly after. So at 36 weeks we were all waiting for her water to break. And she reached 37 weeks. During the 37th week, she went in for several evaluations of varying concerns, all panning out just fine. She was feeling quite anxious at this point, given that she had never gone past 37 weeks.

And then 38 weeks...

Now, at just 39 weeks, and still chugging along, she tells me that she is going in for induction tomorrow. Just because. The reason her doctor gave her was basically a "What the hell...you're a multip and your cervix is 2 centimeters dilated and I know you want this over with."

And you know how I read this? "ACOG says it's ok to induce at 39 weeks, you've had 3 normal vaginal deliveries without problems, your Bishop score is favorable, and we are sick of you calling us everyday and I am on call tomorrow."

Why do I think this? Because my friend reports that her doctor had said it was fine for labors to be induced once a woman reaches 39 weeks in all women; that her doctor's office staff have said to her that she "got the award for the most phone calls from a multip ever", and he said routinely started checking her cervix at 37 weeks to see if she was "ripe" should she ever need an induction. Oh, and when she requested to postpone the offered induction by one day for childcare reasons, the doctor said it couldn't be done because he wasn't on call that day and it would just be better for all involved if she came in when he was there.

Now, I am not sure if my friend sees it this way, as she was delighted to be able to have an end point to her pregnancy that has been an anxiety provoking experience for months.

And it gets better...the reason my friend contacted me to discuss her induction was because the doctor ended her visit with saying, "Well, this all should go fine, but I think your baby is big so you might end up with a c-section."

Sigh......

Days Off

I have been finding my days off, be it a true day off or post call day, go by so quickly that they aren't enough. I feel the need to sleep in late, yet if I do I feel like I've cut off so much of my time off. I dread the sun going down and the need to start dinner because it means the day is coming to a close.

I fantasize about having chosen a different path in life. Like, had I stuck to writing like I wanted to when I was a kid and through most of high school, perhaps I could have been writing for money and not need to be awake at 24 hour intervals once or twice a week. I could have structured my day around going to the gym, running errands, and just flat out getting shit done so nothing ever feels like it is hanging over my head for days or weeks at a time. Like the tub would get cleaned even before the algae or mold or whatever that stuff is that seems to find it's way onto the tub walls.

Or perhaps I should have been fine with mediocrity and stayed a bedside labor nurse. I could do a few shifts a week, and go home with nothing following me like following up on labs, making sure someone shows up for their very important lab work because you think you might be dealing with an early ectopic pregnancy, or second guess that the meds you just started on someone was the right choice. I'd not be expected at every single freaking departmental meeting despite the fact I'd not gotten more than 15 minutes of sleep on my call shift and all I want to do is go home and curl up in my bed. Instead, if I worked through the night I could have just given report by morning and gone home.

But, that's not what I wanted. I keep reminding myself of this, even on my days off.

From The Other Side

What I've been finding interesting now that I have been working a few months on the labor floor is the differences in nursing care. Now, having been that bedside labor nurse for many years, I clearly understand the value in a good nurse. I'd like to think I was good at bedside labor nursing care, but now I often wonder what the providers I worked with prior to becoming a midwife thought of my nursing care.

But here is an example of what I mean. I was attending the labor of a young girl who I had seen for most of her prenatal visits. I had gotten to know her fairly well, and knowing that she didn't take any prenatal classes or even bother heading to the library to check out some books on labor, I knew she would definitely need a lot of support. She happened to arrive just as my call shift was beginning, which is the same time as the nurses' change of shift. So basically, she was getting the same provider and nurse for the duration of her labor and birth.

The nurse she was assigned to was Nurse Nikki- a personable younger nurse with decent experience but.... had no clue that the little nursing things are just as important to women in labor as having certifications in fetal monitoring interpretation and the ability to act quick in an emergency.

Nikki spent little time at the bedside, and hung out at the nurse's station most of the morning. When I could, I would leave this young laboring woman's room so I could finish postpartum rounds and frequently found Nikki sitting in the nursing lounge eating a snack or sipping coffee. Once my rounds were done, and I could focus on the woman in labor, I stayed by her side in the room. She had plenty of family there, so perhaps this is why Nikki felt her nursing care was not needed, but the woman frequently reached out to me for reassurance and help with each contraction. When she entered transition and started to be fearful of what was happening within her body, all she could do was say my name out loud while laying as still as a stone. Basically, the young girl needed professional, comforting support.

Then it became time to push, and Nikki was no where to be found. The first few pushes were very strong, but she became scared and fought the urge. I had pressed the nurse call button in the room to get Nikki in there, because I believe the nurse caring for the woman needs to be at the bedside for pushing. Perhaps it's just me, but the second stage of labor is an intense time that needs both the nurse's and provider's full attention.

Anyhow, about ten minutes later Nikki shows up. I tell her we started pushing about twenty minutes ago (basically so she can write that in her documentation). And then she wheels in an extra stool and plunks herself down by the monitor. She stays rooted there for the entire second stage. Even when the patient has pooped a significant amount (on the chux pad), moved around while pushing, and subsequently smeared it all over her butt cheeks.

So why didn't you just clean her up, Labor Nurse CNM, you ask?

I had been, but at this point I was gowned and gloved- and despite the fact vaginal birth is not a sterile procedure, I was not going to reglove with new sterile gloves a dozen times. It's wasteful, and at this point it only makes sense for the nurse to do this. I mean, is it wrong of me, a former labor nurse, to think the labor nurse's duties include cleaning up poop from pushing women?

And then there is Nurse Eileen. She was caring for another of my young primips in labor who was much like the first woman. Eileen stayed at the woman's side for just about her entire labor, with exception of an hour long nap the woman took after an epidural placement. She reassured the woman each step of the way. I could see that this girl really appreciated Eileen's care, and even shared the baby's name with her when they kept it a secret from everyone else. And the woman was kept clean and dry after her water broke and during pushing.

Now, I don't think Nikki thinks her nursing care is sub-par. I don't think she thinks that she ignores her patients. But I wonder what she thinks when she's sitting at the nursing station while all her coworkers are always stuck in the room?

Online Reviews

So have you seen the latest Angieslist.com commercial? I got a kick out of it, personally, but it got me thinking. Can we trust reviews of health care providers on websites? I know this question has come up plenty of times before on other sites and other forums, but...

The commercial shows a couple in the hospital, the woman very pregnant. A female voice over narrates the scenes. It goes something like this (I am ad-libbing this here, it's not verbatim):

My OB told me I needed to be induced by 41 weeks. So we went into the hospital and pitocin was started. I was told that I needed to get pushing by 1 o'clock because he had an important meeting at 2. But I wasn't dilating and ready to push before he had to leave. So he comes in to say goodbye wearing tennis gear! An hour later I was having a c-section with another doctor.

It's quite obvious, I think, to the general public that this narrative shows a poor customer service review (what Angieslist is providing) of this particular doctor. And, ya, this scenario was really shitty in terms of the important meeting being some tennis match. But what the underlying problem I have with this is that a 30 second commercial glosses over other aspects of potentially poor obstetrical care. And this is why online reviews make me a little nervous. Are we, as readers and potential customers of these providers, given the full picture behind the review?

Probably not.

There is so much missing from such a case as described above. Like, was there any evidenced based obstetrical care being provided? For instance, this woman was induced at 41 weeks. Was her cervix favorable? Multip or primip? And why the section? Of course a 30 second commercial can't wrap that up, but would an online review? I mean, how many times have I mentioned here that women, be it family, friends, or random strangers who learn what I do for a living, start telling me about their obstetrical care and birth experiences and don't seem to have a full grasp on the reasons behind the management of their care?

The other factor is that for people who have an ax to grind will write flaming reviews just because they are so angry, whether there is reason to be or not.

A problem I see with hate reviews is that sometimes a patient could be angry over something that would have been solved if there had been some open communication between patient and provider. And yes, patients can initiate that and demand that their provider make time for them to review and discuss their concerns. The flip side of that is a provider who brings in a patient to review their care plans, of which the patient is not following and therefore takes this as an attack when they are being called on the carpet for not following through.

The other thing to consider is that some providers just don't click with some patients; it doesn't make them a bad provider. I can tell you that in all my years in health care as a nurse and now a midwife, there are just some people I click with better than others. But all will get the same care out of me. Just because I don't bond as well with Jane as compared to Mary doesn't mean Mary gets better care. Mary's perception of me will obviously be better, and Jane would probably say I was just okay.

However, before you all go hating on me for sound all against online reviews of health care providers, I think they definitely have their place as well. If enough reviews about a provider are available, and a trend is obvious, then I think they can be useful in deciding if you would want that person or group caring for you. If specifics are being used to support the review, as opposed to "Dr or Midwife So and So are real asswipes and I wouldn't even send my neighbors dog to them", then they can be informative.

All About Choice

This has been one of the best posts I've read in a while. Thank you, Heather.

My postings has been sparse of recent as life has thrown me some major schedule curve balls...but I've been keeping up as best I can on all my fave blogs. I really enjoy all the thoughtful posts on birth and maternity care, but Heather really got me thinking.

We are such frickin hypocrites, aren't we? I mean, we (I speak in general terms here) say we want the best care for our newborns- and clearly breastfeeding is by far one way of ensuring a healthy start for our children. Yet, as Heather points out, are American women really given the choice to do so? So many women spend a fair amount of time considering their options on breast vs bottle with many messages supporting breast as best (well...it is...). However- as Heather points out- women are given messages and are shown through our (health care providers, employers, family, friends) actions that her breast milk is either not enough, inappropriate, or just plain ol' not supported. Even in my own personal experiences, I have seen this happen. My best friend was told quite frequently by her family that her babies seemed "hungry- just give them a bottle!"; another friend had to stop breastfeeding her thriving baby when she returned to work because it was frowned upon to need "so many breaks" so she could pump; many patients tell me their plans are only to breastfeed til they return to work for the same reasons; at times, the mom's I round on in the hospital tell me their baby spent the night in the nursery at the nurse's suggestion so she could get some sleep and baby could "get enough food". And this is just the tip of the iceberg of examples.

Please speak to me in the comments.

Highly Delayed Rebirth Carnival 1.3

Well, folks, life has been crazy- good and bad- and had seriously delayed the carnival and my blogging capabilities.... but alas! Finally, here is the third edition of Rebirth Carnival, which focuses on first births.

Many women find themselves drawn to midwifery and childbirth care because of their own personal experiences. Ciarin shares how her personal births led her to midwifery path.

Molly shares the birth of her first child, taken word for word from her personal journaling of the experience just days later.

This is the first birth I'd ever witnessed...

And Sheriden shares her first birth as a doula.