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.

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.

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.

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?

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.

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.