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?

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.

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.

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?

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!

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...

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.