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

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.