labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Tuesday, December 15, 2009

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.

Sunday, November 22, 2009

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......

Sunday, November 8, 2009

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.

Thursday, October 29, 2009

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?

Wednesday, October 14, 2009

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.

Sunday, October 11, 2009

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.

Sunday, October 4, 2009

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.

Tuesday, September 8, 2009

We Can Never Predict Timing

...in many areas in relation to childbirth....

Or, in my case, totally overlook the fact that I was on call over the Labor Day weekend and couldn't put together the Rebirth Carnival.

I will be putting it up later this week....

Monday, August 31, 2009

Amen, Brother!

Rixa has posted her interview with Dr. Fischbein on her blog- it's an interesting read. I cried out, Amen, Brother! when coming across this quote:

Again, they use the idea of the 24-hour anesthesia as a reason not to allow
VBACs. Most emergency c-sections, the ones that occur suddenly, have nothing to
do with a uterine rupture. They are for placental abruption, prolapsed cord, or
prolonged fetal heart rate decelerations. And somehow the hospital can manage to take care of those situations. If hospitals can take care of those things, why
can they not take care of VBACs? If they can’t do VBACs, should they be doing
obstetrics at all?

Saturday, August 29, 2009

Statistical Prowess

For the research minded folk out there, I have to pick your brain. When I was in school, I loved performing research queries and reading the articles my school's search engine would provide(which was extremely user friendly, unlike my current hospital library...). I would frequently end up with thousands of pages of research articles, meta-analysis, and the like. I would even hope that I would be a main researcher during my career. Now, however, I am just so overwhelmed trying to balance life as a new nurse midwife with regular day to day crap (read: housework, errands, gym, and maybe a little relaxation) that I can't seem to do anything beyond the bare minimum. But I digress...

What I really wanted to say was that frequently many of the articles and published research in obstetrics have small participant numbers. I guess this is where meta-analysis comes in, but many times the participant numbers in obstetrical research are less than 500. A patient I was meeting with recently is a statistician at a local university and laughs at the "statistical power" of obstetric research. Her argument is that the conclusions we frequently draw from the literature are invalid given how small the participant numbers are. She points out that many times research on obstetrical care is also limited by the small geographic regions it's performed- for instance a group of 350 women receiving care at just one university hospital- and yet we extrapolate this to all women. And frankly, many times this is true when looking at it from a statistician's paradigm.

I think there are a lot of potential problems with performing research in obstetrics. This topic could provide fodder for entire program courses in midwifery and obstetrics so I realize I am not even skimming the surface. First off, the "gold standard" of research is difficult to perform ethically in pregnant women. Randomized controlled trials (RCTs) are the top tier of research, yet we are limited in performing it in this population. Ideally, wouldn't it be great if we could randomize women to home birth vs hospital birth? What a fantasy, I know, I know.... but it would be hard to argue the statistical power of a large nation wide RCT on the subject and quiet the subject once and for all. So we settle for smaller, less statistically powerful data or argue over the biases or errors (real or imagined) in what is out there.

Now I am just rambling, but what this leads me to is that if a trained midwife (me) is overwhelmed with this both professionally and personally, how can we expect the general public to draw sound conclusions from what's out there? I know there are plenty of midwives and women's health care advocates out there who have a really awesome grasp on the role of obstetrical research (see: Amy Romano, Henci Goer) in the care of women, and I highly admire that. And I'm jealous.

Sunday, August 23, 2009

Rebirth Carnival, Edition 1.1

Wow, what an awesome response for the second edition of the Rebirth Carnival. I've asked for what not to say to a pregnant woman, and did I get boatloads....

Christina is an independent childbirth educator (you all know how I love those!!!) who reminds us of how long the wrong choice of words can stay with you and making assumptions about other women's choices is just not cool.

Molly's personal experience shocks me, because I thought I heard it all til someone jokingly commented on her post-pregnancy body. Her post ends with a a quote that I believe shoots right at the heart of what I am trying to point out...

Gloria Lemay, a childbirth advocate, speaker, and writer shares two posts about how, although not always a bad choice of words, but bad timing can have the same effect and off hand assumptions can knock a confident woman down a few notches.

Leanne adds "Can I?" as something that should be said... and Enjoy Birth adds her thoughts on a similar thread. Also, don't eat a cheeseburger on the way to the hospital.

Heather (who calls me a "reformed labor and delivery nurse"...hmmm) mentions some things that she's heard- personal and to others- like "you will never go into labor". Eck, talk about boosting confidence!

Amy Romano thinks it's ridiculous that professionals would advise pregnant women to bribe your labor nurse. I agree.

And some have written some great lists of things not to say, some with extra commentary:




  • Kathy lists almost all the ones I've heard and her take on them all... with exception to "natural childbirth is like natural dentistry"... really? Come on, people!
  • Reality Rounds' list has sparked a lot of talk.
  • Ciarin offers up some things no one should say, including things health care providers should never say. Like "oops!"
  • SuSuseriffic provides some guidelines on what not to say including remembering that a pregnant woman is more than her pregnancy. Thank you for the reminder; I think it's something many forget!

Thank you, everyone, for such a great collection! The next carnival will be on September 6. Theme will be "first births"... so share the first birth you've encountered whether it be your own, one you assisted with, attended, or even just your thoughts on what you want for the first birth experience. Email your submissions to knitting-fool AT hotmail DOT com.

Thursday, August 20, 2009

Being Pushed

Recently I was having a discussion with a woman who was 2 week postpartum. She had an elective repeat c-section for her sixth child. The fifth was her unplanned primary c-section for fetal distress. The first four were vaginal deliveries that went smoothly (this is how she describes them, and her chart would support this as she had uncomplicated pregnancies and births with normal postpartum courses). During the visit we discussed how she had been recovering and how her planned c-section went. As it turns out, the morning of her planned c-section she went into labor. She arrived to the hospital several hours earlier because she was concerned that she might actually deliver before her scheduled time for surgery.

It was found that she was 6 centimeters on arrival. Her water broke 30 minutes later. Her baby was tolerating the labor just fine, and she said she was ok with her contractions. The nurses caring for her were simultaneously prepping her for surgery quickly while telling her that she can change her mind and have a VBAC. Clearly her body was doing well and there were no signs of uterine rupture (the big looming risk associated with VBAC which in her case is considered to be <1%). The doctor comes in and briefly says the same thing, but also states that anesthesia is on their way so they can just go to the OR right then.

Now, the patient tells me that she felt that she would have been able to give birth via VBAC without problems. She contemplated choosing the VBAC last minute, but since anesthesia was coming she didn't want to inconvenience anyone. And besides, the doctor had had several cesareans herself and did just fine with that.

I was really disappointed to hear this. I felt this woman was an excellent candidate for a VBAC. Spontaneous labor, her previous c-section was 3 years ago, she'd had 4 prior uncomplicated vaginal births. And she felt she could do the VBAC, but felt committed to the surgery because she didn't want to inconvenience anyone, not to mention that she felt that a repeat c-section was a good choice because her doctor had them, too.

I wonder how often women feel compelled to make a decision based on such factors? When counseling women on VBAC versus elective repeat c-sections, I am (I hope) as unbiased as possible. I quote them the literature on the risks and benefits of each, if they meet the criteria that is considered most safe for a VBAC, and then let them know that it is solely their choice. When asked what my opinion is for what they should chose, I do tell them that I can't answer this, but rather point out that they need to assess is what risks they are comfortable with and go from there. If pushed, I do tell them I would chose VBAC for myself because I feel comfortable taking the risk of uterine rupture of <1% in the ideal case; but point out that might be too much risk for other women to feel comfortable about. But again, I will almost never discuss what I personally would do because I am afraid their decision will be made based on my personal decisions. This is why I was bothered that this particular woman felt she should chose the elective repeat c-section because her doctor did.

As a clinician, I think it's hard to be unbiased all the time. But I can see how your counseling would be swayed by your own personal experiences. I mean, if you were ok with your chosen path, why wouldn't everyone else?

Friday, August 14, 2009

Call For Submissions

A little reminder that I am looking for blog carnival submissions for the second edition of the Rebirth Carnival for August 23. Topic theme for the upcoming edition is what not to say to a pregnant or laboring woman.

Please email links to your post (it can be an older post) to knitting-fool AT hotmail DOT com.

Pass the word!

Sunday, August 9, 2009

Rebirth Carnival, Edition 1.0

Well, here we are! The first edition of the Rebirth Carnival. I asked what drew you to midwifery, either as a career or as a client. So without further ado....

Reality Rounds tells us why she landed with midwives after her first pregnancy for "run of the mill" gynecological care and ended up with a wonderful VBAC.

Tiffany, of Bethany Women's Healthcare in Arizona (oh, I so want to visit Arizona!), tell us how she fell into midwifery after observing a laboring women in nursing school. She mentions how she had to reprogram herself into the midwifery philosophy of birth as a natural physicological process as opposed to the medical approach of pathology and danger at every point. I think this is something most L&D nurses who go into midwifery have to do to some degree.

Pamela Harnden (from New Zealand- how nice to have an international post here!) also began in nursing, but in a surgical ward. I love her reply in midwifery school if she can take a blood pressure... ya, my type of midwife!

Kathy uttered my favorite phrase said by any women before actually becoming pregnant (and many say it as soon as they are pregnant) Check that out here in the opening of her post on why she turned to midwifery care.

I am afraid that people have submitted to this carnival but because of my error of not writing my correct email, the person who had the knittingfool AT hotmail got your posts instead of me at knitting-fool AT hotmail.... so please repost your contribution in the comments for all to see!

Next carnival will be August 23. I want to hear about the worst things you've ever heard a health care provider say to a pregnant woman. This will be a good one.... I already have a few posts on the topic...

Wednesday, August 5, 2009

Pregnancy Care Follow Up

There have been several themes among the comments of my most recent post on a pregnancy care center's tactics that I have been thinking about. I have been pleasantly surprised that overall the comments have been very civil and respectful, so thank you.

But I want to follow up on some questions. First of all, I did end up investigating this particular center. They even have a website that I read through thoroughly. Frankly, after reading it, I can't imagine how anyone could say the place doesn't run on a political and religious agenda. For one, the main page has "In God We Trust" with bible verse quotes peppered in different sections. They have an entire section dedicated to their grassroots efforts of stopping "mandated abortion coverage" in the current proposed federal health care legislation. There are sections for visitors to leave prayers and donations.

Again, I think it's hard to argue that this place (and it's many national affiliates) doesn't have an agenda.

Another thing that had been brought up was what services beyond "counseling" are provided. I did find out that in fact they do provide diapers, car seats, and early infant items in limited numbers. When asked, items needed beyond an infant's needs are not provided. There were support groups, most of which were religious in nature (like bible readings). It was clear to me that they felt that providing religious counseling and some diapers removed the "barriers that make abortion the only option".

On the other hand, I can't fault the the organization entirely. I think, from my perspective, that they are very clear where they stand on abortion. But to an unsuspecting woman who hasn't done the research on exactly what the pregnancy care center is offering beyond "pregnancy care" or "counseling" or even pregnancy testing, it can be very misleading.

Wednesday, July 29, 2009

Pregnancy Care

Ok, I know these places are nothing new, but it was my first experience as a health care provider being faced with the major moral and ethical issues I have with it when it is intersected with caring for a woman. You know the places- anti-choice centers masquerading as "pregnancy care" centers.

So here is the scenario. 18 year old girl comes in for her first prenatal appointment. It's an unplanned pregnancy. She has been with her boyfriend for a year. She lives at home with her parents, works as a clerk in a mall store part time. Boyfriend is a year older, works as a day laborer and lives with his parents.

I am going over her history, and one thing that is revealed is that she has no idea when her last period was. She thinks it was in late May. I begin saying that we need to get an ultrasound in the next week or so to date her pregnancy accurately.

"Oh, but I already had an ultrasound," she says.

"Was this at another practice?" I ask.

"Um, ya, it was at that care center downtown," she says. She pulls out a card from her purse. The front of the card looks like a religious scene- ethereal clouds, a bird, faint beams of light. Folded neatly inside was two small ultrasound pictures. They reveal a tiny sac with the fetal pole floating inside. It looks like possibly she was around 5 weeks, if that, based on the pictures but there is no clinical information printed on the pictures. No measurements revealing the size and gestation. Instead, written across the image is "Hi Mom & Dad! I love you!"

I handed them back to her and said, "There is nothing on these pictures that tells us how far along you are. Did they give you a due date?"

"No," she replies, "they just talked to me how I would be a good mom and not to worry about not having enough money or anything."

I moved on in our conversation but I really was disturbed by it. The pictures given to her were a clear ploy to not terminate her pregnancy, something she was considering given her social situation, age, and ability to financially support this baby. A political agenda was pushed on this girl by telling her she would make a good mother (which I am not doubting) and not to worry about finances. Because, I am sure, they will help supply her with money to provide what her baby needs- diapers, clothing, food, housing... ya...I'm sure they provide that service, right?

Now, I am sure it's not a surprise to anyone who reads my blog that I am pro-choice. I strongly believe this is a right all women should have, whether they exercise the right or not. I also respect the belief that abortion is wrong, because everyone should have the right to chose to exercise those beliefs for themselves. I have no respect for those who push their beliefs on others, particularly on the vulnerable and unsuspecting. I wonder if these pregnancy care center people care about the long term well being of the women seeking their services? Do they follow up with them and help them out when they are struggling with supporting a child?

I think we all know the answer to that.

Any troll like behavior in the comments or generally mean discussion that does not contribute to a respectful conversation will not be posted. Consider yourself warned.

Saturday, July 25, 2009

Help me!

When I first started blogging, I really enjoyed reading blog carnivals covering different nursing topics. But with school, and now a "real" job, I've gotten away from really reading or contributing to them.

So, I was thinking that I would start up one!

My unofficial blog carnivals will be posted here, twice monthly. The carnival will be called The Rebirth Carnival (how original, I know, I know...). I will announce the carnival topic about two weeks in advance. Submissions can include old posts, or something written specifically for the carnival.

The first carnival will be up on August 9. I'm looking for posts about why you chose midwifery, either for your care or for your career.

Please pass the word!

Submit your post link to my email: knittingfool AT hotmail DOT com.

Friday, July 24, 2009

Natural Childbirth

I had a very stimulating conversation with a patient today that really got me thinking. I've thought about this before, but it was so refreshing to have the discussion with a pregnant woman who is looking forward to a midwifery attended birth. She's in her third trimester and taking childbirth education classes and just completed the section that reviews comfort measures, medications, and epidurals for pain control. She plans a "natural childbirth". I put this in quotes because "natural" means a variety of things to a variety of women.

Natural to me means without medication or an epidural. I could even stretch that to even a labor unhindered by medical interventions such as labor augmentation and artificial rupture of membranes. But typically if I say "natural childbirth" I speak of a pain medication and/or epidural free births.

Natural to others has meant a vaginal birth. The baby comes out of the vagina "the natural way". It totally disregards all the medical interventions involved.

However, going beyond this, natural childbirth to many people in the general public means the woman is either:

  • Crazy
  • Needlessly suffering
  • A hippie
  • One of those crunchy nut jobs
  • Clearly not of sound mind
  • A martyr

I disagree with all of the above, of course, but how often do we hear this? My best friend talks about getting hooked up to an epidural as quickly as possible when she was pregnant; medical assistants in the office joke about wanting an epidural before labor begins; men and women everywhere, it seems, are saying "hook me up!" (whether they are the pregnant one or not).

And not to mention the countless messages women get from media, magazines, books, celebrities, tv shows, and websites that send the message that its impossible to give birth unless numb from the neck down.

What does this do to women's confidence? Not only to the people they love and trust say to them that "you need an epidural to get through it", but the general message anywhere they go supports the notion.

Grrrr.....

I think this is to the detriment to women's self confidence. Because...guess what....women can and do give birth without medication! It's possible! But when those women are far and few between, and you are getting the message it's impossible, why bother even trying for a natural childbirth when "everyone ends up with an epidural anyhow"?

So, it was a great conversation discussing this with a woman, facing her own birth hoping to go the "natural route". I told her that if I was on call at the time of her labor, I would do everything I could to ensure her natural birth choice. That I would be there as her reminder of her strength. Mind you, I'd do this for any woman....but it feels good to be able to express this in in the context of our conversation.

I could turn this into a dissertation, but one more thought on the subject for now: part of this mindset, in my opinion, is from a belief that the pain experienced in the labor process is abnormal or signifies something bad. I can understand this, as any other time in our lives in which we experience intense pain typically means something has gone awry in our bodies. But the pain experienced in labor is almost always a normal phenomenon and a way of letting us know about the normal progression of the process. If we could embrace that concept, perhaps more people would be open to not medicating it.

Monday, July 13, 2009

Revisiting My Barren Uterus

I've said this before, in other posts, how I get asked very frequently if I have children. People I care for are trying to feel out if I qualify in knowing what to do with a pregnant or laboring woman by having experienced it first hand. I am sure that most of the times they are just trying to connect with me on a more personal level while still having confidence in my care. But what some are hinting at, if not being outright overt, is "a real midwife has birthed".

Being the new midwife in my practice has prompted this question over and over by many of the women and their partners when they meet me for the first time. I've asked the other midwives if they get asked this question, and they do. So I asked the doctors (the female ones, at least) if their patients ask them if they have given birth. Not one of the doctors said they've been asked by a patient if they have children. I think this illustrates my point very clearly.

Perhaps because midwives are so accessible (in a figurative way, as we know there are not enough midwives in all areas of this country) people feel comfortable enough to ask personal questions of us. But my feeling is that there is more to it than that. What many are really asking is if they can trust us because they think we don't really know how to be "with women" if we haven't actually used our womenly parts in their full capacity. It's flat out hypocrisy in my opinion, if a woman would judge me on whether I've given birth or not yet not hold one of the doctors in the practice to the same standard.

I've put this question out there before, but am interesting in seeing what other things you all have to say. Do you think a midwife is more effective as a care provider if she's given birth?

Wednesday, July 8, 2009

My Take On Pit To Distress

Wow. This one has me shaking my head....pit to distress is a saying I've heard kicked around, but not in the sense that is being discussed in the blogosphere. Let me explain:

-Pit to distress is being discussed as a method of pushing the IV pitocin to a point of fetal distress, thus giving a reason for a c-section.

-Pit to distress has never been anything I have ever seen as a nurse or midwife as described above. But- and this is a big but- I've heard of it being used in the past a bit differently, before more research went into effective & safe protocols for labor induction and augmentation. But (again)- never in a way to purposely gain a reason for performing a c-section. It was done more because the thinking was "more equals better and gets the job done quicker" and then all of a sudden trouble began. Or, I've heard it being used to describe how a physician was on a nurses case for not "pushing the pit" fast enough (like every 15 or 20 minutes on the nose) and the nurse muttering something like: "what- do they want me to pit to distress here?"

I can not imagine that such pit to distress protocols for the sheer purpose of requiring or leading to a c-section for fetal distress exist. It is such blatant malpractice, I can't imagine that it happening on several accounts. First, the nurse is the one physically "pushing the pit". Labor nurses put their licenses on the line if they were to administer a medication that caused injury. If a physician or midwife was to order an unsafe dose at an unsafe rate, a prudent nurse will question the order. If she gets resistance, she goes to her charge nurse or manager. Ideally. And even if she doesn't go through her channels of management, she can "push the pit"slower than ordered based on fetal heart rate and uterine activity, or because she doesn't feel safe going at doses and rates ordered. Technically this is a med error because she is not administering a medication as ordered, but if there are protocols in place that dictates safe usage she usually just has to maintain proper documentation to say why she is "holding" the pitocin at whatever rate she is at.

There are standard protocols that most hospitals use when it comes to pitocin, so a provider who goes off the protocol is calling attention to what they are ordering. Here is another opportunity to question such use of pitocin.

There are "high dose" and "low dose" regimes published in the literature and obstetric textbooks. The high dose regimes are not necessarily more effective than low dose, in my personal experience, but they still have never been used that I've seen to purposely create a distress situation that requires emergent c-section delivery.

Not sure exactly how this all got started, but thought I'd throw in my two cents on the matter. I'd be interested in hearing from other nurses or midwives who have experience with this, either seeing it first hand or not at all. I've worked in several hospitals and have never seen the pit to distress thing as described by others.

Monday, July 6, 2009

New Students!

I love students.

If being a student could be a profession, I'd have more PhDs, DNPs, and other degrees that people would think humanly possible.

So I thought I'd share two blogs by student nurse midwives.

Reflections of an Aspiring Nurse Midwife is brand new....I'm waiting to hear her stories and thoughts on midwifery school.

Hands Are For Catching: Life of a Nurse-Midwife in Training has some very thoughtful posts and is a Helene Fuld Trust scholar. Impressive.

Tuesday, June 23, 2009

Life As I Know It

I have an overwhelming feeling that I have a way to go before I feel remotely comfortable in my new role. Working as a nurse midwife has been awesome and scary all at once. And tiring.

I hope to find the energy soon to elaborate.

Thursday, June 18, 2009

O, Canada

Oh!! I am very excited about this- which I will just simply give you the link to Rixa's post on vaginal breech birth in Canada.

I guess this begs the question: when will the US "authorities" stop being so stubborn and start looking at the research?

Thursday, June 11, 2009

The Midwife Sorceress

Ok, this is a personal issue, but one that I think many of you would find themselves as irritated about it as I am.

My husband has been on this tear of calling me the "Midwife Sorceress". I think that this comes from my recent career start (finally, I must say!) and that he's been on a wizards kick.

It annoys me.

Actually, it annoying the living fuck out of me.

Now, I know my husband is just being foolish. He usually can't let 5 minutes pass without doing something childish. However, he also knows that I am passionate about midwifery and try so very hard to dispel any myths about midwives. He's even done his fair share of teaching people around him about what I do when people ask him, "So what does your wife do?" to which frequently gets a response of "A mid-what?" or "Oh, so she delivers babies in the woman's home who is anti-doctor?"

So, clearly, he knows that midwives do not perform any magic or wave chicken feathers. But if anyone heard him call me a "Midwife Sorceress" they would easily conjure up images of what the "Midwife Problem" propaganda of 100 years ago provided- because this was such an effective campaign on part of obstetricians of the day much of the mainstream still believes much of what is said about midwives today.

I have solved this problem by providing a nipple tweak that he is sure to not forget next time he has an urge to call me a "Midwife Sorceress". So there!

Wednesday, June 3, 2009

In A Maternity Care Utopia:

....women would birth unencumbered by machines, IVs, and interventions that were not necessary....

....home birth would not be viewed as unsafe for low risk women....

....labor curves would be a vague guideline, not a rule....

....informed consent would really be informed....

....birth would be respected as a normal event....

....women would trust in their own strength and be empowered to have positive birth experiences....

....medical intervention would be available only when needed and used prudently....

....every woman would have one on one labor support....

....midwives would be embraced as the standard provider for maternity care, with all obstetricians specializing in high risk pregnancy and birth....

Saturday, May 30, 2009

Progress

Oh, boy! I received my credentialing packet (read: 6 inch stack of papers) for the hospital my practice is affiliated with and have been working on that. I have to say it is the most daunting part of this process. Actually, it's horrible. The amount of information that is needed is ridiculous, some of it I wonder if I can even provide. I am kicking myself for not keeping better records on the very specific details of each and every woman I cared for during her labor. Urg. But can't change that, so I have to do my best.

What is great, however, is that I can start in the office seeing women while the process is being completed, so that will be good.

I've recently been conflicted on how to proceed with this blog. Not sure if I should, not sure if I want to keep this up. I am overwhelmed with the thought of being a new nurse midwife in full time practice. Yet, I can't imagine not having this avenue to vent and discuss issues and situations in this field. So I don't know...

Wednesday, May 27, 2009

My Last Shift

My last shift as a labor nurse was today, and my last birth in this role was with a woman who was also a labor nurse. When I got report in the morning, and was told what she did, I thought it was an ironic way of ending my labor nurse career.

This woman worked more years than I as a labor nurse but worked at a different hospital. The hospital she works at is known for some major old school obstetrics. This place still does routine episiotomies, tethers women in bed, elective inductions as early as 37 weeks, and even have a few doctors that will do maternal requested c-sections. I get report from the off-going nurse and learn that she has recently received an epidural and plans to sleep until it's time to push. I hurried into the room so that I can catch her before she falls fast asleep (I hate waking sleeping women once comfortable with an epidural!).

So we chat some, and I offer her something to drink. She balked. "I'm supposed to be NPO!" (Nothing by mouth).

"We allow clear liquids here, even with epidurals," I said. I hate that the word "allow" is in there, but that is what it is.

She is clearly surprised but very happy to accept some apple juice. I get her settled, turn down the lights, give her the call light, tell her I won't disturb her for a little while unless she needs me or its time for some assessment.

Next time I see go in to see her, she is waking up. She's still very comfortable but curious how much further she's dilated. It hadn't been a long time since her last check, and I said since she was ruptured exams are kept to a minimum. Unless she was feeling an urge to push, the doctors will not be anxious to do an exam.

"Really? It's been two hours... our patients get checked every two hours on the dot without exception!" she said.

"We try not to unless necessary," I responded. Of course we have our exceptions depending on who's on call. But overall, if someone has been progressing in their labor, we just let it happen.

We continue to talk and then she asked, "If I am checked sometime soon, and I'm fully dilated, can I labor down?"

Laboring down is awesome. I can tell you I am all for it. It's a great way of helping a woman who would probably push for hours with a dense epidural with no urge to push and needing to be told each and every time when she should push. It cuts down on pushing time, and may help protect the perineal tissues from excessive trauma.

I tell her we use laboring down fairly often under certain circumstances. Again, she is surprised. Laboring down is not allowed at her hospital If you are fully, pushing must be started no matter what and the clock has begun to possible c-section for "failure to descend".

And so by lunch time she was fully, and not feeling any strong urge to push. Laboring down was the plan. She labored down for about two hours and then she started pushing. Her pushing was not all that superb so I tried all sorts of positions with her. She even said she wished she could sit to push, and I said, "You can!" She didn't believe me, because she thought this was not possible in the bed.

Now this is when I couldn't believe a more experience labor nurse had no clue how to manipulate a labor bed to help the woman in a sitting or squatting position. I even got the squat bar and showed her how to use it.

"I had no idea! Our patients with epidurals lay on their backs only," she explained.

Wow.

She went on to have a nice birth, a beautiful baby boy weighing 8 pounds even, and put him to breast immediately. She offered him up to go to the nursery but I said there was no need to- it would be better for him to stay with her. Of course she was very happy to keep him with her.

As much as I was saddened and a bit appalled that this very experienced labor nurse had no idea some of the very basic labor support methods nurses can use, I was so glad that she got to experience them first hand. Hopefully when she returns to work she will remember what she learned and teach her fellow nurses.

Thursday, May 21, 2009

Please Recommend

I am asking for your recommendations on pregnancy and birth books. I am currently have two books in waiting that I want to review in hopes of coming up with a few recommendations for my soon to be patients/women.

Also, anyone know how I can get my hands on a complementary copy of Our Bodies Ourselves: Pregnancy & Birth book?

Yes, I am shameless...

Tuesday, May 19, 2009

On "Medwives"

I've seen and heard this term quite a bit. I am sure most of the readers here have heard of it at some point, but for those wondering "what is a 'medwife'"- it is typically a derogatory term referred to nurse midwives who practice with a medical model. I've worked with a some at various points in my nursing career who were labelled as such, and have even heard some call any midwife who chooses the CNM route or any midwife who does birth in a hospital as a "medwife".

I will admit that I would personally find it insulting if someone called me a "medwife" because I went into midwifery to protect the right of women's normal life experiences with childbirth and such. My personal philosophies do not align with the medical model of childbirth for normal, low risk women (which is the majority of those giving birth). But, I have used medical technology in caring for laboring women both as a nurse and a student midwife (and soon to be practicing CNM!). I don't view this as a bad thing, but for some it would put me in the "medwife" criteria just for the sheer fact I have used medical technology. For instance, if a women truly wants medication, an epidural, or whatnot- I'm okay with that- although you all know my pet peeve is women not taking the risks for such things into consideration. I've cared for women as a student midwife who had prenatal complications that medical intervention was called for in some way. But does this mean I can no longer be truly considered a "midwife" in the spiritual and literal sense? I say- hell no!

But as I've said, I've seen what most refer to as "medwives" in practice. Not often, but it does exist. However, I think many times CNMs get labelled incorrectly as "medwives" because they work in hospitals that have high levels of medical childbirth care. I've come to see this as something that is inevitable in this push/pull type struggle between the obstetrics and midwifery cultures. Turf battles, if you will. Many times if a CNM wants a job, and wants to serve women and their families, they have to enter into such environments. I think for these CNMs, its a necessary part of trying to be a change agent in those medical models. Like, a group of CNMs who finally manage to get a practice going at a hospital that for years and years was only attended by old school obstetrics start by changing little things in the care- like no routine IVs in low risk women, and then no continuous monitoring on low risk women, etc. And over time, all these little changes add up and have changed the culture of childbirth care for that hospital. Sometimes going into an environment like a bull in a china shop does not work as effectively, as much as you want to turn things upside down to make it immediately midwifery friendly. So.... I don't know. Sometimes seeming to be a "medwife" might be necessary given the situation and environment until things really start changing.

I think the "medwife" thing is a double edged sword when it comes to nursing, too. Nursing staff have a strong influence on the care environment. There are plenty of nurses who provide care to laboring women as if it were a disease. Many do not feel comfortable unless monitors and IVs are strongly involved in the process. So imagine a midwife trying to do things that go against what the nursing staff is comfortable with. That's tough- but at the same time if the midwife is doing things that lean towards a medical model of care- then she is called a "medwife" by the same staff. I've seen this plenty, too.

So what are your thoughts on this? What do you view as a "medwife"?

Sunday, May 17, 2009

Sunday Afternoon Enthusiasm

Today I am feeling very enthusiastic about my upcoming career in midwifery. I begin my new career in early June, which will start with office midwifery and well women gynecology. Once my hospital credentialing is completed (which, for those unfamiliar with this torturous process- is a lengthy paper trail that is completed and collected by said applicant, which is then scrutinized, verified, and processed by a designated hospital credentialing coordinator. Once this is done- which in itself can take months- is presented to the hospital board of directors for every one's a-okay seal of approval to set foot on the care units of their blessed hospital.), I can start doing births!

So, in my enthusiasm today I have done some minor blog appearance updating. I've updated some links, as well. Also wanted to throw out a question to you- I've been approached quite a bit by others who want to "guest post". For the most part, I've ignored this- but if something was appropriate I thought it might be interesting. What do you think?

Thursday, May 14, 2009

Why I Became A Midwife

I have to say, I never set out to be a midwife. Actually, I never really set out to be a nurse either. Growing up, all I ever really wanted to do was be a writer. I wrote a lot when I was a kid, and even as an adult began writing fiction seriously (although no one ever seems to take you seriously when you say you write fiction). But it was very clear during high school my writing was not going to be cultivated as a practical career goal. And I was into biology and whatnot, and a teacher suggested nursing. Specifically, a teacher suggested I go to a local hospital's "Shadow A Nurse" program for high school students, and I was all for a legit day off from school. Funny thing was, as much as I ended up liking the Shadow A Nurse thing, I knew I didn't want to take care of sick people. And I was totally fascinated with the labor and delivery ward. And it was still a ward, likely the same type of ward I was born in.

Anyhow, back to why I went into midwifery. Like The Beatles say, it was a long and winding road. My first obstetrics job was in a large city hospital that had high c-section rates and low tolerance for normal. Of course, I didn't see it as that at the time. I saw childbirth as this very dicey event that was wrought in terrible danger. A lot of women needed c-sections. A lotof babies needed rescuing from the process. There were no midwives. And frankly, why would people see a midwife in a hospital when they were for homebirth, right? And while we are at it, only crazy people who want to take their and their baby's life in jeopardy....ya....so you get the culture I was in at the time. Of course I didn't see it this way back then. I just saw a lot of anti-normal practice and took it for the norm.

Same with the next job at another city hospital. I even remember this one shift where a homebirth midwife had come in with a woman who was ruptured with meconium for 3 days or so with no progress in the woman's labor and all of the nursing staff, residents, and attendings carrying on about it. This was my first experience ever with a homebirth transfer, and by this point I wasn't opposed to homebirth, but certainly wondered what the story was there. I was not their nurse or involved in any of their care, but the bias within the staff was so thick and the lack of respect for this woman and the midwife were so obvious the blind could see it. But again, this place was of a similar culture as the first place: normal birth didn't exist and a birth could only occur with any amount of safety with large amounts of intervention and technical monitoring.

However, this was the same place I began to see normal birth. There was a large midwifery group there and many of those midwives really did normal births. Intermittent monitoring, low intervention, spontaneous pushing....and the babies and mothers did so well that it was hard to ignore the difference.

From there I ended up working in another large city hospital (#3, if you are counting) that clearly was just turning out a product. At this point I was so fed up with the system that I began talking with the midwives of this large group about my feelings and thoughts about normal childbirth. I found that they also saw things how I saw things, and I started to read more about midwifery. But I never thought of becoming a midwife.

Fast forward to my last RN job- the one that inspired my blogging- and I wanted to protect normal birth. I was reading more and more about our backwards maternity care system as well as our horrible stats when compared to other countries that have high numbers of midwife attended births with better stats. I was seeing things I felt hindered normal birth, and even some practice that was a detriment to it. And by this point, I realized the only way I felt I could really help protect and preserve normal births was to actively participate in them as a midwife.

An opportunity opened up in my life to go back to school, so here I am. Now I am a CNM, and so ready to protect normal birth. I had a preceptor when I was in school who had always fought an uphill battle in her midwifery career, and gave me a great piece of advice: make small changes quietly until it adds up into something no one can ignore. I'm not so sure I have it in me to go hog wild and do big crazy things (at least, anytime soon) so I think her approach is the way to go. Isn't that something like the saying "walk softly and carry a big stick" or something? Or am I getting that saying wrong?

Sunday, May 10, 2009

Keeping Religion Out Of It

I've never been one to feel religion should cross the lines into health care. Before I go on, let me just say that I am not talking about the birth where the woman prayed throughout or a blessing was done for the baby shortly after birth. Because in those cases, the people are doing what they believe and their faith has helped them through the experience without involving others into it who may not share the same beliefs. Those things do not force others into care decisions or take away options. It is those things I have a problem with.

For instance, I recently stumbled upon a website of a birth center that is faith based in their care. Ok, totally fine. Absolutely wonderful for those women who want faith based care. I wondered, however, if this birth center was the only birth center in that area (I'm guilty- I didn't search to find that out) and I was a woman who really really wanted a birth center birth but wasn't Christian. Perhaps I was a Wiccan woman, and didn't want Christian prayer to be a part of my birth. Would that be possible? Could the birth center meet my needs outside of just having a birth center birth? I don't know...I guess it would be a dilemma for me if I were that woman. The practical thing to do is make and appointment and see how it goes and express my concern; but what happens when it's clear the midwives at the Christian birth center can't keep God out of it or the numerous religious relics make me uncomfortable?

Catholic hospitals come to mind as well. Clearly Catholic hospitals deliver faith based care. I realize that this doesn't mean that each person who comes to care for you performs mass or whatever, but it does guide what services are offered. I have personally never chosen to get my care at a Catholic hospital because I have a problem with places that deny certain aspects women's health care. I've even chosen not to work at Catholic hospitals for the same reason. I had been naive about their denial of birth control, emergency contraception, and abortion services until I was in nursing school and did an internship in a teen clinic. After being there a short time, it seemed like a major oxymoron of care. It's mission was to provide pregnancy care to inner city teens, but they couldn't discuss birth control with them!!! What the fuck? Does that seem wrong? It sure does to me! It seems to me the best way to serve these girls is to get them on birth control and discuss STI prevention. And what about the rape victim who asks for EC but is denied it? I would hope that she was at least told where to find it, but there are some providers who, based on their faith, would not.

I know many would say, "Just go elsewhere", which is fine when there is another local hospital to chose from or you can easily get yourself to it. But I do know of some areas, even near me, that the only accessible hospital for some is a faith based institution because its on the bus route. Getting to the non-faith based hospital would require more difficulty.

I've even worked with nurses who've commented on a patient who was being treated for a second trimester miscarriage or even a fetal demise at 30 weeks say they are being punished by God because of their previous history of abortions! Good grief! You know, fine, whatever, if you want to believe that, but keep your freaking mouth shut about it at work. Religious beliefs should not factor in your care for that woman. It makes me nervous, frankly, that somehow that would permeate how that nurse might treat that woman.


Ok... now I feel better getting that off my chest.

Friday, May 1, 2009

Hear Ye! Hear Ye!

Labor Nurse has a job!!!! Woo hoo... a jobby job for a new midwife has finally materialized!

So, I guess the question is: do I keep writing here on this blog, or start anew? Because "Labor Nurse" doesn't exactly reveal what I will now be doing.

Either way....

Woo hoo!!!

Sunday, April 26, 2009

What Ultrasounds Are Really For

I have to say that one of my biggest pet peeves are ultrasounds. Not ultrasounds by themselves, but how many women demand them for non-medical reasons, or totally ignore the fact that the 20 week ultrasound is done for a medical indication (ie, fetal survey for abnormalities) and not just so you can plan your baby shower in the right colors. I've cared for women who demand another fetal survey, or shall I say "the ultrasound to find out the sex", because everything that is required of a complete fetal survey is viewed, measured, and found to be normal and therefore completed, yet the baby has managed to tuck its genitals out of view for the entire procedure. And my answer, much to their dismay, has been- sorry, we can't do that. Even when the woman says, "But I will pay for it out of pocket", I've had to turn her down because the facility doing the ultrasound will only do medically indicated ultrasounds.

It is totally normal and fine for healthy, low risk pregnancies to not have more than one ultrasound, that being the fetal survey around 20 weeks. First trimester ultrasounds are only done in cases of infertility, history of miscarriage, symptoms of miscarriage or ectopic pregnancy (bleeding, pain), or nuchal translucency tests to screen for Down Syndrome risk- the latter being completely elective. Third trimester ultrasounds are done for medical indications like gestational diabetes, lupus or other connective tissue disease, growth concerns from fundal measurements or medical conditions, postdates, or follow up on placenta location from the fetal survey. (I realize my list is not all inclusive- I am sure this will be pointed out- but I wanted to keep this to the most common indications).

So as you can see, none of the ultrasounds that are done in pregnancy- whether it is one or ten- are done just so mom can have pictures and find out the sex of her baby. Those are just complementary benefits that are done for good customer service. I suppose this is where those places that offer the 3-D ultrasounds for an out of pocket fee that give you fancy pictures or a video of the entire scan fill a need. I even have seen obstetric private practices offer this service for several hundred dollars, but make it clear that it is separate from the official fetal survey, and is not meant for any diagnosis.

Monday, April 20, 2009

Keeping My Mouth Shut

I've taken to keeping my mouth shut when family members and friends discuss their personal pregnancy goings-on. But its really difficult, particularly when I completely disagree with the management or decisions being made. I am very aware that many people may view anything I say in response to these things as being a radical moonbat. Even just telling some people that I am a midwife evokes images of a patchouli smelling, hairy legged, Birkenstock wearing freak who waves chicken feathers and tries to summons Goddesses to help in the birth of babies. (And on any given day, they might get this notion confirmed if they saw my legs....but they aren't hairy because of my profession).

For instance, my cousin is pregnant with her first baby. She is due in several weeks. Her pregnancy has been uneventful in terms of medical issues (because no pregnancy is ever uneventful for the mom!) but interventions were being discussed as early as 12 weeks. Even when she had her 18 week ultrasound- the fetal survey, or as parents like to think of it as "the ultrasound so I can find out the sex of my baby"- her doctor was talking c-section because the baby was breech. I really, really, had to walk away from that one because diagnosing a breech at 18 weeks for a c-section is just freaking ridiculous. (This I am sure will illicit responses of readers that had 18 week ultrasounds showing a breech position of the fetus who ultimately ended up with a c-section for a persistent breech position- I realize that this can happen- but why even set someone up to thinking that is ultimately going to happen when there is plenty of time for that baby to turn vertex?????)

Now, my cousin is 36 weeks and was found to be 3 centimeters dilated. Her doctor is going to induce her in two days because of this. She is very excited about this. Again, something I had to walk away from because I think it is a bad call. First off, why was she even checked at 36 weeks? Turns out, just because. Next, why is a physician going to induce at 36 weeks and some change just because she is 3 centimeters dilated? She is a primip, this baby is not going to fall out at any random moment. And women walk around in the late third trimester all the time with a some dilation...doesn't qualify for a medical indication in any of the books or research I have come across. Not to mention babies at 36 weeks are considered premature. Sure, most of them do very well transitioning to extrauterine life....but they are at increased risk of breastfeeding difficulties, blood sugar stabilization problems, jaundice, and respiratory issues to name a few!

So... I guess I get to just vent here instead.

Friday, April 17, 2009

Did You Hear?

I've been reading on a few blogs around the web that the British Journal of Obstetrics & Gynaecology has published a study from Holland that shows home birth is as safe as hospital birth in low risk women.

I don't have access to the full article so I can't really comment much on it. But, I'll be obvious and say that I am very happy to see such a large study sample and the conclusion that home birth is as safe when women are cared for by skilled midwives and have smooth access/transfer to hospitals when indicated.

It does make me curious how the home birth naysayers will criticize this the study. Like I said, I don't have access to the full article, so I can't critique it myself. But it sounds like it might be hard to ignore this evidence as good evidence!

Sunday, April 12, 2009

Why You Should Be Prepared

I don't remember who put out those commercials (I think maybe the March of Dimes) that shows this stork walking around an office and all the reactions of the various women that are there. The message is a good one: be prepared for pregnancy because you never know. Almost 50% of all pregnancies are unintended, and means that the women has unlikely been preparing her body for a healthy pregnancy. So, I am going to make a case for all women to be prepared.

I had mentioned in the previous post that most women do not make preconception visits with their women's health provider. For those of you who do want to become pregnant in the coming months or even year- please make an appointment with your midwife, nurse practitioner, or gynecologist. I, of course, am biased when it comes to nurse midwives and nurse practitioners for obvious reasons but I would put money on the fact that those specific providers would spend more time with you in answering questions and teaching important aspects of preconception readiness. (Not saying doc's aren't doing that well, but... nursing backgrounds seem to lend those providers with a better approach).

Here are some of the things that are discussed at a preconception visit: (this is not all inclusive- give or take some of this stuff)

  • Current method of birth control
  • Review of your menstrual history
  • Review of previous pregnancy history, if any
  • Review of your medical & mental health history and discussion of ways to improve your health to decrease pregnancy risks if applicable
  • Nutrition and exercise, and recommendations to improve on these things (because we know we all can!)
  • Smoking & recreational drug use and cessation
  • Immunization status
  • Folic acid intake (400mcg/day supplementation ideally up to 3 months before conception)
  • Genetic risks
  • Family history of birth defects, stillbirths, or miscarriages
  • Partner's health

Based on this information, the provider will make recommendations to improve whatever may pose a risk on a pregnancy. High risk issues, such as a family history of a genetic disease, may lead to an appointment with a genetic counselor. Specific discussion about the timing of conception is important, too, as well as learning about the menstrual cycle and how to "read" your own cycle is discussed. I've also found that distinguishing how infertility and fertility can help, too, because so many women worry that if they aren't pregnant within two months of trying they are infertile. This also ties in the importance of understanding the menstrual cycle and even mapping your own cycle to know what are you best days for conception.

The ultimate goal of of preconception counseling is for healthy moms and babies. There are things some women just don't want to hear (like weight loss, or adding exercise into your life) but are really important factors so when that stork shows up you are prepared whether you planned for it now or not.

Tuesday, April 7, 2009

How Many Children is Enough?

I have purposely avoided discussion of Octo*mom, but there have been some ethical dilemmas rolling around in my head that I thought I'd throw out there. The main one being: whose decision is it, ultimately, when it comes to how many children a woman has? What factors are taken into account? Who controls such things?

Ultimately, I know that one question leads to another and arguments can be made in so many different directions. All sorts of "well, if this wasn't allowed, then the following wouldn't be an issue" points can be made. I think the biggest one for me is: had the reproductive endocrinologist only placed 2 or 3 embryos perhaps this wouldn't have been an issue. I don't even know how many embryos were placed in the Octo*mom case, but I do know that even if 2 embryos are placed during the IVF procedure, you can certainly end up with more than 2 fetuses.

What bothers me, I guess, is how this woman was vilified in the press for this. The raging feminist in me saw her being judged not just because she was on Medicaid and lived in a modest home with her 6 other children and her parents- it was because she decided to have these children without a husband. I think the underlying theme was how could this one woman dare to have these children as a single person? How dare she take charge of her fertility in such a way in the absence of a man!

Now, I understand people's anger that this woman is on Medicaid and how taxpayers' money is paying for all this. I get that. But this is where I have more questions. Can we, as a society or government or any other collective entity, tell individuals what they can and can not have for children based on their socioeconomic class and/or race? Thoughts of the ol' "prophylactic appendectomy" in the 1930s (and beyond!) in the South come to mind here. Is it just or ethical to put limits on these things for individuals? I would imagine many people would disagree with laws such as the China one child thing. So how is limiting the number of children for those who don't make 6 figure salaries or have a husband any different?

Nobody is vilifying the 18 & counting family....(sorry, don't know their names) and I presume because of the following: it's a married couple, all naturally conceived, and not on public assistance. Same with those other TLC shows that have large families, with the exception of the method of conception. I mean, these people are getting TV shows and lots of money for having large numbers of children- but I think the big difference is that they are married couples- and dare I say it??? Caucasian, too! Yes, I will pull out the race/ethnicity card on this one, because this is another thing I think is a factor here.

Perhaps what I am getting at is, who gets the rights to be the parent police? Where do they draw the line? I can come up with countless stories about women I have cared for during their pregnancy, birth, or otherwise that many would shake their heads at and ask, "Who let this one have a pregnancy/baby/be a parent?" And I guess my feeling is, no one should get that right except the woman who decides on having that baby (or babies, if you will). I'd be lying to say I've never thought, "Oh jeez! What was this woman thinking?" but as I've evolved as a provider in this crazy field of babies, women's health, and parenting, the more I realize it's just not my decision to make.

This brings me the hypothetical situation of counseling a woman who has come to me for preconceptual counseling (something women rarely do- a topic for another post another day) who is single, perhaps older, perhaps has a few medical issues that could potentially put her in the high risk category. What would I do? I'd be honest. I'd tell her what the risks are to a pregnancy with her given medical issues, what she can do preconceptually to minimize those risks, discuss how age would play a role in both ability to get pregnant and risks to fetus and pregnancy, and discuss her readiness for parenthood. I mean, what else can I do? Say, "Oh but you are 39, almost 40, have high blood pressure, and are single....I don't know if you should even be having children!" I do not feel its my place to tell a woman if she should have children or not. As a women's health care provider, I feel my role is to be upfront with how her specific factors can impact a pregnancy, how she can improve anything that poses a risk, and hope that she makes an educated decision on whether to proceed with a pregnancy.

I don't know...I guess my questions will remain as such. But I hope no one ever tells me that I am too old or shouldn't have children because they just didn't think it would be a good idea. I do know that it is unlikely I would be judged or hit up by the parent police, because I have all the "approved" factors that society deems necessary to have children the right way.

Wednesday, April 1, 2009

Poop....

....because shit happens. And it does happen in labor.

So many women worry about pooping during labor and when they push. And I can't alleviate anyone's fear by saying it doesn't happen, because it does. But not one except the women tends to care about it.

There are things that can be done to make it less anxiety provoking. One is the thought that if you were lucky enough to get the shits prior to labor (read my post about what happens before labor under The Childbirth Education Series on the right hand side) then you are likely fairly well emptied out. If not, start pushing on the toilet. Granted, this can only occur if you do not have an epidural and/or a provider who has locked you to the bed. You won't get to birth there (but maybe squatting near by!) on the toilet, but if you are going to poop, what a great place to be!

Your nurse (should) has tons of chux pads - disposable absorbent pads with a water proof backing - that she keeps under your butt while in bed. I know I frequently bring in several packages of the chux because they are so handy. I also have baby wipes in the room, too, in case it gets a little messy. The other thing the nurse will do is quickly and discreetly wisk away any poop that comes out. This is for mutual reasons for all parties involved: less embarrassment for the woman who is anxious about it and the less time it hangs around the less everyone smells it.

If this is a concern for you, let your nurse know. This way she can be super vigilant and super discreet for all involved. Not saying alarms would go off for those women who didn't say they were nervous about it, but it is just a nice heads up to the nurse because it is so second nature to us that we may not detect your fears.

Friday, March 27, 2009

Men In a Women's Field

You know, I've heard so many women say they wouldn't go to a male ob/gyn or midwife because they "don't get it" or for the sheer fact of being male. I don't necessarily agree with this, but I certainly don't think people should go with someone they aren't comfortable with regardless of the reason.

The reason I don't necessarily agree is because just being female does not make the provider a better ob/gyn physician or a midwife. Some of the most horrible things I've heard come out of providers mouths were from women. Some of the worst manipulation of a perineum has been done by women providers in my presence. So as you can see, I just can't agree that men providers in the obstetrics and gynecology fields is backwards.

I do, however, often wonder what drives men into women's health. I wish I had asked some of the great men providers I've worked with why they chose the field. Many of these male providers are the same age as my parents, so they entered at a time more men were entering the field in general. None of the residents I work with now are men, so I don't have the opportunity to ask any entering the field now.

But, I do want to share something I witnessed that expressed such caring and compassion that I was struck speechless (not something that happens often) that may have answered my questions about men entering women's health. After an arduous labor and second stage pushing that seemed to last my entire 12 hour shift that ultimately led to a cesarean for failure to progress, the doc followed us into the recovery room. This particular doc is a man of few words, and awkwardly tried to express his well wishes despite the situation. As he did so, he gently took a warm blanket and spread it over the bed. Before he left the women's bedside, he pulled the blankets up as if tucking her in. I am sure some will read this as a patronly act, but I know this was not the intention. This very simple act of trying to provide comfort and warmth for this mom and baby was very touching.

Friday, March 20, 2009

The Interview, Part 2 & 3

So last week's interview led to another one earlier this week, followed by a third at the hospital the following day. All interviews went very well, I felt very comfortable with all of the providers I met, and was impressed with their very low c-section rate. I was given some very nice compliments by those I met with, and told on several occasions by several different people that I would hear from them soon- right after they check my references.

I see a job in my near future! Woo hoo!!!

Monday, March 16, 2009

Getting Rid of the Fear

The editorial in the most recent Journal of Midwifery and Women's Health got me thinking: what can I do as your nurse midwife to make labor and birth as fearless event?

So many women fear childbirth. And with good reason. We are told it is the worst pain ever, that it will feel like you are being ripped in half, that you can't do it unless you get boat loads of drugs or a dense epidural, that it causes women to lose total control of themselves and scream bloody murder, or it is better to just schedule your c-section because you can avoid labor altogether. At least, this is what our culture makes it out to be.

And I am not saying that having fear is wrong. I think its only natural. I mean, this is what I do- this birthing business- and even I have my fears. Specifically, I fear two things: perineal lacerations and lack of options requiring me to give birth in an environment riddled with needless interventions and an attitude that birth is a pathological process that needs to be "cured".

Now, I understand there are women who have a history of sexual trauma can have major anxiety and fear about childbirth- I am not referring to this root cause of the fear in this post. That is a whole other can of worms that deserves special attention outside of this.

I am just talking about your everyday woman who fears birth.

One of the things I stress when I teach childbirth classes is how fear plays a big role in perception of labor and birth, and for many will actually heighten the pain experience. I truly believe this, and have cared for many women who are so frightful that active braxton-hicks contractions has them tearing up the walls and pleading for death.

I try to help alleviate fears when I get the sense that a woman I am caring for is anxious or fearful. I do this by being calm (you'd be surprised how much difference it makes when a nurse or other provider comes into a room very high strung, loud, or abrupt, among other ways, can make a woman in labor more fearful or anxious). I listen to what she is saying. I validate what she is saying. I try to reground her when she spirals into her fears. I give encouraging, positive words when needed.

Prenatally, outside of listening, educating, encouraging the woman to further educate herself, I don't know what else to do. So, as I asked earlier, what can I do to help alleviate these fears?

(And a congrats to Rixa for the publication of her article Staying Home To Give Birth in the same issue of JMWH)

Sunday, March 8, 2009

The Interview

I have another interview coming up this week; I am hoping it goes well but I'd be lying if I said that I had high hopes. I have gone into every interview with a positive attitude, did my best to portray the CNM I would be and what I would add to their practice. I've walked out of each one thinking I had it in the bag. And then.... nothing.

I've reviewed everything about these interviews to see what could I have done that turned them off. And I honestly can't find anything. Seriously. And I can find fault with lots of things; this is not one of them. Actually, the one thing I could say is a negative is something out of my control: I'm a "new grad". I've got that stigma. I would require extra work on part of the providers in the practice because of the extra nurturing and mentoring I would require. And I've requested that I get adequate mentoring.

There has got to be something out there for me! My plan, however, is to pursue the NP route if this job doesn't come through. I am more than 6 months out from graduation and even if all the experience I can get right now is outpatient office care, then so be it.

But I really want to catch some babies!!!

Friday, February 27, 2009

You Can Lead A Horse To Water...

You may have noticed that whenever you have a health care encounter- an office visit, your gyn exam, an emergency room visit, when you birth in a hospital- you are asked if you are safe in your relationship. This is typically asked by your nurse, and (hopefully) asked in private. It has become a standard question on the admission process in hospitals, regardless of your age or gender or why you are there, and even at your primary care doctor's office.

This is a good thing- it can help those who may be in a bad situation. The unfortunate thing about asking about abuse and domestic relationship issues is that many do not disclose this information. It may be because the person doesn't want to, or doesn't believe they are a "victim" of domestic abuse, or because they are afraid to. I remember going to a conference on domestic abuse in the health care setting and hearing that it takes a women seven encounters by the same health care professional before she will disclose her domestic abuse situation. That may never happen for many women- except for the prenatal care setting. Where else does a woman consistently see her health care provider so frequently in such a short period of time?

I work with a nurse, Kerry, who is one of those women. But she is one of those who doesn't realize that she is in an abusive relationship. She comes to work, many times visibly upset or distracted, taking 20 phone calls before the shift is half over from her husband, who calls to check on her. She makes numerous calls to him, as well, where you can hear her making excuses for her "behavior" or apologizing for whatever angered him most recently. Kerry talks about how he controls her money, her friends, and her contact with family. Her husband even checks on her computer history everyday to see what websites she is on, and must keep her passwords to accounts open to him.

Kerry has for years talked about how much she hates all this. But yet she doesn't see it as abuse. And she so desperately wanted a child. She even said, to every one's surprise, that she thought a child would help her husband be a better person and would love her more.

Kerry's husband did not want to have a child, but she did become pregnant. She recently gave birth to her son, and chose a doctor that we work with. Kerry was now one of our patients, and the admission nurse asked the requisite question about domestic abuse. Of course, Kerry poo-pooed this question, saying something along the lines of, "Oh, no, never!"

And so what do you do? This situation is different than most, as most of the nursing staff knows Kerry well and has heard and seen all sorts of things that point to an abusive relationship. No one did anything more than ask the question; and I can't think of what else could be done. I have been witness to, as well as part of, conversations at various points in the past few years with Kerry where she has been confronted with the nursing staff's suspicion's and concerns. Kerry never admitted to being in an abusive marriage, but would often cry- something that made me believe that she knew something wasn't right. Another nurse set her up with a therapist, another gave her a book about women in abusive relationships. She accepted these things, but never followed through.

If Kerry was a minor or a senior, this abuse would have to be reported to the police for investigation. But with an adult women, all you can do is lead her to the available help. It's up to her if she is ready and willing to accept it. This is so frustrating, especially when it's one of your own.

Friday, February 20, 2009

VBACs- Where to get 'em

Want to know if you area hospital "bans" VBAC? Here is an awesome list from ICAN. Also poke around their site for more info on VBAC and the ridiculous things that hospital talking heads say why VBAC is "banned".

You can also submit info about VBACs at your hospital to ICAN, or if they missed one you can tell them.

Tuesday, February 17, 2009

Nakedness

So another nurse I work with started discussing how a woman she was caring for insisted on being naked throughout her labor, and even after when she first got up to go to the bathroom after she gave birth. The nurse was bothered about "where to put her hands", and that this woman seemed to have a complete lack of modesty.

I argued why not be naked? Who cares? And why exactly do your hands have to be on some part of her? I mean, if the woman was steady on her feet enough to get up and go to the bathroom, you only need to stand next to her as a just in case she decides to go down. Not to mention that many women feel encumbered by all the stuff we attach them to when the come to the hospital. I know that I would probably be annoyed by having belts strapped around my abdomen, being tethered to an IV pole, and given a johnny to wear that has scratchy, starched ties that continuously rub the back of my neck.

Also, it wasn't like this woman was walking the halls naked, alarming some of the other visitors and patients.

And on point of modesty, that gets left at the unit entrance when a woman comes into the hospital. If a woman is comfortable enough to be naked, then so be it. We expect that women just open their legs at our convenience when they are in labor (I'm not condoning this but I've seen so many providers with this expectation), so I don't get why all of a sudden the expectation is that women need to be covered up to not possible offend the staff.

Bottom line: who cares.

I mean, it's must preferred over seeing some random woman in the gym locker room who is just from the shower, bent over completely naked while she dries in between her toes. Because, to me, that is bothersome.

Thursday, February 12, 2009

Homesick

Ya know, as much as I bitch and complain, and how much I hate that where I work as a labor nurse is close minded to midwifery (well, the docs, for the most part), I will really miss working there. There is something about the place that feels right. It feels like home away from home. Disaster could strike, a major emergency, anything and everything bad to the nth degree...it feels ok no matter what. When I go to work I like being there with my fellow labor nurses. Even the night shifts.

As time passes, and I still don't have a job as a CNM, I wonder how well the transition will go. Will a new place feel like home? And when I say home, I don't mean like a place I'd want to live, but a place that I feel comfortable in. Will I like the nurses?

Sigh....

That and I am very petrified of suturing perineums after having such a break from the last time I did them....

Friday, February 6, 2009

Read This

Thought I would share this editoral, found in a recent issue of JOGGN- the obstetrical & women's health nursing journal. I don' t think it states anything that people who read my blog would be surprised to learn, but keeps the discussion going.

Monday, February 2, 2009

Have It Your Way

I think there is a common misconception about midwives and epidurals or IV medications during labor. I think many people believe that midwives want (and perhaps force upon) women to go completely unmedicated and stay away from epidurals. Or that women who go to midwives have to go unmedicated. Neither is true in most cases. Of all the midwives I've met or worked with, I can't think of anyone as an "unmedicated birth pusher". I even had one preceptor who said that after she had her own children she suddenly couldn't understand women who wouldn't be open to pain relief.

I personally feel that a great birth is what the woman wants. Some women want the traditional midwife birth- unmedicated, no epidural- and they are very happy with that. Others are open to how things go- and either get an epidural, or use IV medications- and are very glad they did that to help them. And others want an epidural right away- and are very happy with their birth when they get to have an epidural. Should I tell them that what they want is wrong because of what I believe? No.

But I do want one thing: please be educated about your options.

It does bother me that women don't take any childbirth classes or read any books because their sister, friend, mother, etc, said just get the epidural because birth is not possible without one. They come in thinking the epidural will be immediate and are unaware that there are risks involved with the procedure. They are completely ignorant to other methods of laboring, like use of a jacuzzi, or being out of bed, or even a birth ball.

On the other hand, it has happened that a woman comes in saying quite defiantly that she wants an unmedicated birth, has done a lot of prep during her pregnancy to be ready for an unmedicated birth who then ends up begging for medication or an epidural during her labor. Perhaps this is where some take it that midwives push unmedicated birth on women, because most will discuss her original wishes with her, suggest another measure like a new position, a massage, the jacuzzi, you name it, before you go on to medication. Because you know that this woman has worked so hard towards an unmedicated birth, you want to help protect that for her, and perhaps using something else can help her get over the sudden panic that she needs medication or an epidural. But if she is still asking after she tries something else, then so be it.

I think most midwives are totally fine with whatever women want for their births when it comes to pain control. I know I am. I just want women to be educated about what their options are and not just taking an epidural or medication because someone said they should or couldn't birth without it.