Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Nature Knows Best: The Problem with Unnecessary and Early Induction/Cesarean February 27, 2009

I recently stumbled upon an article on TIME.com published back in January 2009 (I know, I know, a bit late J) entitled The Risks of Early C-Sections by Alice Park.  If you haven’t seen it, it’s a short article and a quick read.  In the article, Park reports on a study conducted by researchers at University of Alabama at Birmingham (UAB) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) that was published in the New England Journal of Medicine which found out of a sample of 13,258 pregnant women who had had a prior cesarean section, 36% elected to schedule their next c-section delivery (with the support of their physicians) before 39 weeks of gestation, which is the safety cutoff recommended by the American College of Obstetrics and Gynecology (ACOG).  Park writes, “ACOG’s guideline is based on studies showing that prior to 39 weeks, babies’ lungs are often too undeveloped to function properly outside the womb, and babies at this age tend to have difficulty regulating their blood sugar.

 

Park quotes Dr. Alan Tita from the research team in saying, “The fact that one-third of elective cesareans were done before 39 weeks was surprising.”  After all, the research shows that babies delivered at 37 weeks by elective C-section were twice as likely as those born at 39 weeks to have complications, “ranging from respiratory problems, heart issues, sepsis and seizures — conditions that typically require resuscitation or ventilator support in a neonatal intensive care unit”.  Contrary to Dr. Tita’s reaction however, when I read about the findings of the study, my reaction was completely opposite; I wasn’t surprised at all.

  

What the article did not touch on is the scary fact that there is a growing trend among the obstetrical community of both scheduling cesareans AND elective labor inductions (that is, inductions with no maternal or fetal health indication) BEFORE the recommended guideline of 39 weeks.  So to the OBGYNS of this country I have a question for you: Let me get this straight… you mean to tell me that you are willing to aggressively defend and follow guidelines adopted by ACOG that are UNSUPPORTED by research (for example, that planned homebirths for low risk uncomplicated pregnancies, attended by a qualified and licensed midwife are more dangerous than hospital births) BUT when your organization actually adopts an appropriate guideline that is supported by research, you just ignore it? 

 

Does anyone else find this hypocrisy as OUTRAGEOUS as I do?  The scary truth is that this mind-set is (regrettably) just another common thread among the over-medicalized obstetrical model of care that sadly controls the maternity care system of our country.  Too many OBGYNs just do whatever they want, with complete disregard for maternal and fetal safety (even though they claim that it is their main concern) as well as complete disregard for evidenced-based research. 

  

I will digress for a moment to share with you a situation I found myself in as a labor and delivery nurse this past Christmas.  (As always, the names and any identifying information have been changed to protect confidentiality).  I arrived to work in the late morning as usual and was informed by the charge nurse that I would be admitting an induction into room 12.  Since it was Christmas I asked why she was being induced; After all, we do not schedule any inductions on holidays unless there is an urgent medical indication for delivery.  “I don’t know, because Dr. N is sick of listening to her I guess,” she frustratingly stated as she rolled her eyes.  Turns out the patient was triaged at our hospital the day before and was sent home for “false” labor since she remained only 2 centimeters dilated with an irregular contraction pattern after two hours of walking the halls.  Apparently after yet another sleepless night she had called Dr. N and stated “I am coming into the hospital today and if you don’t agree to induce me, I will refuse to leave!  I am too uncomfortable and am DONE with this pregnancy.”  When I questioned Dr. N about the situation, pointing out the fact that there was no medial indication for this induction and in fact, the patient was still only 2 centimeters and contracting irregularly every 8-15 minutes he said, “I have to give her what she wants.”  Excuse me…WHAT?  And furthermore when I pointed out the fact that the patient’s gestational age was only 38 weeks and 1 day he snidely remarked, “Don’t you worry, I’ll take the rap for it when it gets flagged and brought up in the peer review board.”  And do you know why he said this so nonchalantly?  Because that committee is made up of a bunch of other OBGYNs who don’t like anyone breathing down their backs and therefore, will only give him, at most, a slap on the wrist.  And that is EXACTLY what happened.  Talk about driving up healthcare costs; Not only were they were paying me double time and a half to be there on Christmas day but that baby boy ended up going to NICU for a “pitstop” for grunting and retracting (a sign of respiratory distress) within an hour of delivery!

 

 I would like to take a moment to share the fact that I have never been pregnant and therefore have never personally experienced the discomforts of pregnancy first hand.  Despite this I personally hold all pregnant mothers in high regard and have the utmost respect for the physical and emotional sacrifices that a pregnant mother has to make in the weeks that she is with child.  I feel that as a professional who works with pregnant mothers it is my responsibility to support and aid a mother through her journey in any way possible and if any woman complains or comments about her discomforts and pains, I make a conscious effort to provide compassionate and empathetic care and comfort to that mother.  In my opinion they certainly have good reason to grumble at times! 

  

That being said…I personally feel that the physical and emotional discomforts of pregnancy (although intense and very real) are all part of the deal and it is just one of the many sacrifices parents will have to make in their lifetime for their children.  Just ask any new mom…If you think it is hard to get a full nights sleep while pregnant, just wait until you have a newborn!  Basically what I am getting at is this: although I have the utmost respect and empathy for how uncomfortable pregnancy can be (heartburn, Braxton-Hicks, morning sickness, hemorrhoids, stretch marks, fatigue, backaches, leg cramps, varicose veins, swelling, shortness of breath, dizziness, the list goes on and on), these discomforts are NOT a good enough reason to end a pregnancy early when the risks for the baby are so high.  Likewise, for a physician to agree to an early induction or elective cesarean or even worse, to promote it (trust me, it happens!) is sooooooo wrong.  Although I agree with the article when Park writes, “Although most obstetricians are disinclined to schedule c-sections prior to 39 weeks, they still feel pressured by their patients to do so,” there are also many women who feel pressured by their physicians to undergo unnecessary labor inductions and elective cesareans, often under the guise of a bogus medical indication.  (My personal favorite is when physicians set up an induction for a woman for “preeclampsia” when every laboratory test we do on the patient shows that at most she might have “pregnancy induced hypertension” (which can be watched and controlled with simple medications and is NOT an indication for urgent delivery) and at least she might have had just one out-of-wack blood pressure in the office!  The list of these flagrant offenses goes on and on…) 

 

I have heard it with my own two ears; Doctors saying things similar to “Well you’ve got to give these women what they want or they will sue!”, or “The patients are calling the shots not me, it’s out of my hands!”  I mean COME ON!  Are they serious??!!!  That is so far from the truth it is LAUGHABLE.  First of all these types of excuses are LAME and UNACCEPTBABLE.  Doctors take the Hippocratic oath to “First Do No Harm” and agreeing to order, manage, and perform unnecessary early elective cesareans and labor inductions is negligent, irresponsible, and dangerous.  Tell me, if the fear of litigation is so strong in this country as to so powerfully influence a “defensive” and “litigation driven” approach to obstetrical care, why o why would any OBGYN agree to any unnecessary procedure that is shown, through research, to place the baby at high risk for complications?

 

Furthermore, if a physician refuses to perform an unnecessary early induction or cesarean for a mother who is demanding one, what can she really do?  It is very unlikely that she could change doctors since there are very few practices that will accept what is referred to as a “late transfer of care.”  Some doctors say they fear litigation.  Could you imagine that?  How absolutely unfounded and preposterous!  On what grounds could the mother actually win the suit?  I can see the opening statement now: “My client is suing this doctor for not performing an unsafe early labor induction/elective cesarean.  You see, your honor, her back hurt ‘really bad’ and she was ‘just sick of being pregnant.’  Clearly this doctor should be locked up for correctly following the evidenced based research that supports his decision!” Absurd!

  

In conclusion, I would like to say one thing to all the women and obstetricians out there desiring and performing unnecessary early elective cesareans and labor inductions: Nature Knows BEST!

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More Trouble With Repeat Cesareans February 23, 2009

On Thursday February 19, 2009, TIME.com published a remarkable article entitled The Trouble With Repeat Cesareans which takes a hard look at the rising cesarean rate in the United States, making C-sections the most common women’s surgery in the country.  If you haven’t yet read the article I highly suggest you do!

 

There are many things about this article that I like.  First off, to find an article tackling the lesser-known side of a debate, like the “VBAC-lash” as author Pamela Paul so aptly describes it, is uncommon in popular, highly circulated news magazines (“VBAC” for those that are not familiar with the term, stands for “Vaginal Birth After Cesarean”).  Typically media outlets like these go for what I like to call the “rare & scare” stories like such nonsense as, “The 100 ways your baby could die at birth!” and “Midwives Going Postal!”  The major and life-threatening consequences related to our country’s rising cesarean rate and the rapidly declining opportunities that women have to plan for a VBAC are serious public health and women’s health issues that need and deserve national attention!

 

The second thing I really like about this article is the title; “The Trouble With Repeat Cesareans” couldn’t be more appropriate.  Kudos to the editors of TIME magazine for nailing it with this one, considering that currently 9 out of 10 births following a cesarean are also a cesarean.  Clearly there are too many obstetricians and even many women not taking the risks of multiple major abdominal surgeries seriously! 

 

Thirdly, I think author Pamela Paul does a great job emphasizing the risks related to repeat cesarean sections when she writes,

“With each repeat cesarean, a mother’s risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman’s chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta–in which the placenta attaches abnormally to the uterine wall–has increased thirty fold in the past 30 years.”

Much too often articles related to this subject only report on the risks of VBAC and not the risks and complications of repeat C-sections which is both misleading and dangerous!  I would like to take this opportunity to elaborate on Paul’s list by citing some other serious risks related to repeat cesareans, as outlined in the book The Thinking Woman’s Guide to a Better Birth by Henci Goer (pg 168):

1.      Increased risk of injury to other organs, including bladder & bowels,

2.      Anesthesia complications including spinal headache, low blood pressure, backache, infection, nerve damage (including paralysis, loss of bladder and bowel function, loss of sexual function), allergic reactions, seizures, cardiac arrest and death (see: Redding Anesthesia),

3.      Scar tissue formation (called adhesions) resulting from every abdominal surgery leading to a more complicated surgery with each additional cesarean which increases a mother’s chance of chronic pain and bowel problems,

4.      Increased risks for baby including poor condition at birth, breathing difficulties, bruising, and jaundice,

5.      Increased risk of placental abnormalities including placenta accreta (described above) and placenta previa (where the placenta grows over the cervix) putting mother at risk for a life threatening hemorrhage during the pregnancy & delivery, which could result in hysterectomy in serious cases, and

6.      Increased risk of ectopic pregnancy (a surgical emergency where a fertilized egg implants somewhere besides the uterus (e.g. in a fallopian tube)).

The Bottom Line: All of these complications increase a mother’s risk of prolonged hospitalization, hysterectomy, and maternal death. 

 

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Although I feel the article made some great points, I feel that some very important facts were either missed or not stressed enough in the article and at this time I would like to share some additional information that I feel will provide you with a more comprehensive picture of the VBAC/Repeat Cesarean debate.  Here we go!

 

(1)   FACT: The high-profile cases of uterine rupture during a VBAC in the 1990s were directly related to the use of the drug Cytotec (generic name misoprostol) for labor induction on women with a history of a prior C-section. 

 

Marsden Wagner writes in his book Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First that between the years of 1994 and 1999 approximately 25,000 women in the United States who had previously undergone a prior C-section were given Cytotec for labor induction and out of those women, 1,000 of them suffered ruptured uteruses, a rate that is a twenty-eight fold increase in the rate of rupture over having a VBAC without Cytotec induction.  He also writes that despite years of mounting evidence and research studies reporting the risks of using Cytotec for labor induction on women with uterine scars, OBGYNs continued to use the drug (which was neither approved by the FDA for labor induction nor clinically trialed in a research study for a safe and effective dose) for this very purpose proving once again the pervasive anti-precautionary obstetrical culture of “assumed safe until proven otherwise.”

 

 

(2)   FACT: Women can safely have a VBAC in a hospital, an out-of-hospital birth center, and even at home!  (And they have too!)  VBAC becomes more and more risky when you start to obstetrically intervene, like in the case of labor induction and augmentation.

 

Wagner writes,

    The phenomenon [with the increase in uterine ruptures during VBAC in the 1990s] was almost certainly related to the fact that the percentage of births in which powerful drugs, such as Cytotec, were used to induce labor had doubled, given that studies show there is an increased risk of uterine rupture with pharmacological induction.  But instead of acknowledging and addressing this connection by recommending that obstetricians not use Cytotec for induction, the organization recommended that a women not be permitted to attempt a [VBAC] unless she was in a hospital where an  anesthesiologist was [immediately available].  In other words, instead of preventing uterine rupture, ACOG said that we should surround the woman with experts to deal with the rupture when it happens.  This is like trying to solve the problem of children drowning at summer camp by not teaching the children to swim, but rather by putting a couple of life preservers in the lake.”

 

(3)   FACT: A cesarean section performed after an attempted VBAC is NOT necessarily an emergency cesarean section! 

 

In the TIME article, author Pamela Paul writes:

“Yet as of 2006, only about 8% of births were VBACs, and the numbers continue to fall–even though 73% of women who go this route successfully deliver without needing an emergency cesarean.”

 

In other words, the 27% of women that Paul describes needing a C-section after an attempted VBAC did not necessarily have an emergency cesarean, contrary to what Paul writes.  The high-risk urban hospital where I am currently employed as a labor & delivery nurse (which happens to have anesthesia and an attending physician in house 24/7) classifies the urgency of cesarean sections into 4 categories:

            ● Category I (STAT): Immediate threat to life of woman or fetus (e.g. prolapsed umbilical cord, uterine rupture, anaphylactoid syndrome, prolonged fetal heart rate deceleration with no return to baseline).  Luckily, these are the most rare type of all cesarean sections; however, the risk of needing a STAT cesarean increases with more obstetrical interventions.

            ● Category II (URGENT): Maternal or fetal compromise, not immediately life threatening (e.g. non reassuring fetal heart rate pattern, like prolonged and repetitive variable decelerations or repetitive late decelerations caused by cord compression or utero-placental insufficiency).  Indications for these types of cesareans allow for the physician and anesthesia to get to the hospital (quickly of course) and for nursing to prepare the patient.  Don’t get me wrong, these cesareans are considered an emergency, but they allow for decision making and (rapid) preparation, unlike category I cesareans, which always require immediate transfer to the operating room and general anesthesia.

            ● Category III (ASAP): Needing early delivery but no maternal or fetal compromise (e.g. “failure to progress,” “dysfunctional labor,” and “cephalopelvic disproportion.”)  This category of cesareans is what the majority of women who have attempted a VBAC but ended up needing surgery will encounter.  They require a timely delivery but these women often “sit” for hours if needed, like if the operating room is currently working on a more urgent case.  These are NOT emergency cesareans.

            ● Category IV (INTRAPARTUM SCHEDULED): At a time to suit the mother and maternity team (e.g. scheduled primary or repeat cesarean sections for indications such as breech baby, stable placenta previa, and elective repeat cesarean). 

As you can see, if you are one of the 27% of women who ends up with a C-section after an attempted VBAC it will not necessarily be an emergency, but unfortunately, that is what the public has been mislead into believing.  Regrettably, fear clouds good judgment.

 

 

(4)   FACT: The current medicalized culture of childbirth in the United States, as well as the territorial nature of obstetricians have resulted in the development and use of the so-called “informed consent” form for VBAC, but no such form is routinely given to patients who agree to scheduled repeat cesareans. 

 

In The Thinking Woman’s Guide to a Better Birth, author Henci Goer writes:

            “[The informed consent for VBAC form] details all the horrible things that could potentially happen should the scar give way during a VBAC.  But this form is not really about informed consent because it says nothing about all the equally horrible things that could potentially result from an elective cesarean.  In fact, the obstetrician editor of OBG Management, who devised its prototype and promotes use of such forms, openly admits that the motivation behind them is forestalling lawsuits and that using them will ‘send your C/S rates soaring.’”

 

Why are we teaching our women to fear birth but blindly accept risky obstetrical interventions and major abdominal surgery as no bid deal?  We’ve got it backwards!  When the operative consent for a repeat cesarean is reviewed with patients at my hospital, the residency staff is taught the following spiel, and I quote, “This is a consent for your doctor to perform a cesarean section for you today.  The risks of the procedure include injury to your bowels or bladder, infection, and bleeding, all of which are very rare and can also occur in a vaginal delivery.  Sign on the X please.”  Talk about spinning the facts and lying by omission! 

 

The obstetrical community spends a lot of energy arguing that it should be a woman’s right to choose whether they undergo the “risks” of VBAC or choose the more “controlled” and “predictable” option of the repeat cesarean section.  While I agree with basic idea behind this (i.e. that a woman deserves the right to make choices about her own body), OBGYN providers in this country are NOT providing patients with true informed consent.  In addition, these obstetricians are especially not letting women on to a very important and real phenomenon that is a direct result of the cesarean epidemic: The first cesarean is very easy but the second, third, forth, and fifth cesareans are exponentially more complicated and dangerous. 

 

Which leads me to my next point…

 

(5)   FACT: Women are notoriously bad at predicting how many children they will have at the time of their first delivery.

 

A 2008 research study published by physicians in the Division of Maternal-Fetal Medicine at the University of Michigan, Ann Arbor in the journal Obstetrics and Gynecology found that at the time of a woman’s first pregnancy, “many women underestimate their final parity,” meaning at the time of their first baby, almost 40% of women thought that they were eventually going to have fewer children than they actually ended up having.  This research finding is very important to the VBAC debate because many women figure that if they are only planning to have one more baby, then it is “no big deal” to have a repeat cesarean.  

 

…Until of course they separate from their partner or go through a divorce, meet someone new and want to have baby with their new partner.  Or what about those women who never expected that “oops” pregnancy after what was supposed to be their last baby. Or the couples who decided that they really do want to try for that baby boy/girl they don’t have after all!  Not only do these scenarios happen but they are common in today’s society.  So what are we left with?  A bunch of women who thought they were going to have just one more cesarean, that now are going for their third or forth, resulting in even less providers who will attend their VBAC and even more risk for complications if they even try.

 

Bottom line, we need to change our whole mindset when it comes to VBAC.  When a woman undergoes her first C-section, everyone should just assume that if she gets pregnant again she will plan for a VBAC, NOT the other way around!  North American obstetricians should not have to be dragged into doing VBACs.  If there is a good reason why a woman can’t VBAC, like prior classical uterine scar/extensive uterine surgery or placenta previa, its then and only then that our providers recommend a repeat cesarean.  OBGYNs tend to forget that the only way one can know that a VBAC will or will not be successful is to allow the woman to labor!  In her book The Thinking Woman’s Guide to a Better Birth, Goer reports that several studies published in leading obstetric journals have found that when physicians “genuinely encouraged women to have VBACs, most of them did, and when they said nothing or acted neutral, most women didn’t.”   

    

(6)    FACT: Physician convenience should not enter into the VBAC debate at all!  With the safety of our mothers and babies at stake, the “make it home in time for dinner” phenomenon among obstetricians is unsafe, selfish, and irrelevant.

 

In the TIME article, Paul writes,

“Among obstetricians, many solo practitioners are unable to stay for what could end up being a 24-hour delivery; others calculate the loss of unseen patients during that time and instead opt to do hour-long cesareans, which are now the most commonly performed surgeries on women in the U.S.”

I feel Paul has correctly captured the attitude of too many obstetricians in this country (and how outrageous it is!).  First of all, putting “time limits” on how long a woman should be “allowed” to labor is preposterous and irresponsible and often leads to the unnecessary “cascade of interventions” too often seen during labor in a hospital setting.  Newsflash! Labor takes time.  This fact of life should not be an indication for cesarean section.  This is why physicians and midwives form group practices, so one can be “on-call” while the others can be in the office seeing patients or have the day off.  Perhaps “solo practitioners” need to rethink their business strategy instead of “opting” to perform unnecessary major abdominal surgery on the unsuspecting women of our country. 

 

And lastly…

 

(7)   FACT: BIRTH IS SAFE, INTERVENTIONS ARE RISKY!

 

I wish I could scream this from the rooftop of every labor and delivery ward in this country.   In Paul’s article she reports, “Some doctors, however, argue that any facility ill equipped for VBACs shouldn’t do labor and delivery at all.”  I hate to break it to these physicians but 24/7 in house anethesia is not necessary for a woman to have a VBAC.  It seems like it is just impossible for many obstetricians to open their eyes and realize that the research and statistics of 26 other countries with better maternal and fetal mortality rates than our own have shown, time and time again, that birth can safely happen OUTSIDE of the hospital.  You heard me right!  For women with normal, low-risk, uncomplicated pregnancies, labor and delivery can safely and does safely occur in homes and out-of-hospital birth centers around this country (and the WORLD) every single day. 

 

Look, if it was true that prominent national figures in power were never wrong, then John McCain wouldn’t have told the American people that “the fundamentals of our economy are sound” two days before our country began its slide down into the biggest economic crisis since the Great Depression!

 

So what does it all mean?  In conclusion, whether you are a pregnant mom, partner, labor companion, concerned citizen, healthcare professional, or birth advocate, I just hope that when it comes to the “VBAC debate”, you will make a truly informed decision based on sound research and evidenced-based recommendations rather than become subject to the dangers of defensive medicine and poor or untrue information that currently plagues our existing maternity system in the United States.

 

 

 

 

The Lithotomy Position is NOT a Form of Squatting! February 18, 2009

The other day while at work, I heard an obstetrician utter a phrase that both confused and outraged me.  I had spent the last eight hours caring for a couple in their late thirties who were in labor and expecting their first baby (let’s call them Laura & Matt).  Laura had broken her water at 4 o’clock in the morning and after talking to her doctor on the phone, came into the hospital around 8:00 am.  Dr. Q, the couple’s obstetrician, followed in soon afterwards to check her…2 centimeters, 50% effaced, -3 station.  She was contracting about every 6-7 minutes and in true obstetrical fashion, was promptly started on the pitocin augmentation protocol for “dysfunctional labor” (a term I feel is often thrown around willy-nilly and almost always “diagnosed” improperly.) 

 

I should probably digress for a moment to explain the “like-dislike” relationship I have with Dr. Q and many of the other obstetricians I work with.  Dr. Q and the other two OBGYNs in his practice are fairly new to my hospital.  They used to practice at a community hospital that has their own in-hospital birth center and no in-house residency staff.  Due to their history, I have generally found this practice to be less aggressive than others when it comes to managing labor as well as personally more involved with their own patients (e.g. regularly checking on their own patients when they are on call, as opposed to requesting that the residents manage their patients until delivery).  So it is traits like these that I am supportive of (*like*).  However, it is becoming more and more frequent for this group, as they become assimilated to the “high risk hospital culture,” to do things like order pitocin augmentation on a primip* for “dysfunctional labor” after only “allowing” her 4 hours “show progress” (*dislike*)!  See what I mean?  Now back to my story…

 

When I took over Laura & Matt’s care from the day-shift nurse, Laura was 5 centimeters dilated, sitting up in the rocking chair, and breathing through every contraction like a pro!  Her husband was very supportive and they both worked well together as a team, which is super important since they had been planning and preparing for a natural birth.  I was excited to be a part of their experience and spent the next several hours offering my assistance as a labor companion with position changes, comfort measures, brainstorming, personal hygiene, etc., on top of performing my nursing responsibilities like monitoring the fetal heart rate, assisting with vaginal exams, charting and so on. 

 

At 10:00pm it was finally time to push!  Dr. Q was pleased to inform Laura that not only was she fully dilated, but all that intense rectal pressure she had been experiencing was for a good reason…the baby was at a +2 station!  And here is where the infamous comment was made.  Since Dr. Q prefers to catch babies while sitting on a stool, I was instructed to “break the bed**” and position the patient in a modified lithotomy position.  Since the patient was not under the influence of any pain medications or anesthesia, I tactfully broached the subject of trying any other position, but my suggestions were promptly dismissed by the doctor.  “The baby is small,” he said, “she won’t be pushing for very long.”  What kind of a reason is that!?  Anyways, so there she was, lying on her back with her head at about a 30 degree angle as her husband and I supported the bottom of her feet, awaiting the “okay” from Dr. Q to begin pushing.

 

And here is where the infamous comment was made…

 

As the patient began pushing, Dr. Q turns to me and says (and I quote), “Do you know who invented this position?”  Puzzled by why he would bring this up at this particular moment I responded hesitantly, “Who?”  “The Mayans,” he stated confidently and with a smile on his face, “all it is really is a squatting position!”  Shocked at his blatant disregard for historical fact I confidently, but quietly, stated back “No it isn’t!  This is nothing like squatting!” but of course, I did not think this was the appropriate time or place to have such a discussion and so I quickly turned my attention back to my patient (where it belonged!) and boiled a little bit inside until I could say more to him after the delivery outside of the room.  When I did finally get a chance to confront him, he smiled and said, “Well, you know what I mean…”

 

Actually Doctor…I DON’T know what you mean because you comment borders on delusional!  Is this how obstetricians think?!  Is this why so many women I talk to tell me that their OBGYN, as they put it, “acted totally different in the office than in the hospital during labor.”  Is this what they mean when they tell patients that they are willing to let you try “alternative” positions for delivery!?  YIKES!

 

For the record, lying on your back with your legs in the air is NOT squatting and ANYONE who has EVER done an actual squat will tell you that!  According to the Merriam-Webster dictionary, to “squat” is to “assume or maintain a position in which the body is supported on the feet and the knees are bent so that the buttocks rest on or near the heels; to cause oneself to crouch.”  When you assume the squatting position for delivery (or any other upright position for that matter) gravity is working with you not against you!  This is why every culture around the globe for thousands of years developed their own upright positions for birth.  And, for that matter, it is why toilets are designed the way they are!

 

The lithotomy position was actually first used in ancient times to remove kidney stones, gall stones and bladder stones via the perineum (a.k.a. the region between the “who who” and the “poo poo” J).  In fact, the word “lithotomy” is derived from the Greek words for stone (“lithos”) and cut (“tomos”).  The lithotomy position came to be used in childbirth when doctors began attending deliveries, as they found it easiest for performing obstetric interventions including: maintaining sterility, monitoring fetal heart rate, administering anesthetics, performing and repairing episiotomies, and using forceps.  Notice how NONE of those reasons includes “because it was best for mother and baby” (and in fact, the research shows it isn’t!)

 

So to all the providers out there who might feel the same way as Dr. Q, I have one thing to say to you.  If it looks like a duck, swims like a duck, and quacks like a duck, THEN IT’S A DUCK DAMMIT!

 

 

Notes:

 

* “Primp” is a term used to describe a primiparous woman, that is, a woman who has given birth only once or is about to give birth for the first time, regardless of how many times they have been pregnant.

 

** Many hospital beds that are designed for labor and delivery allow you to remove the foot of the bed to reveal stirrups and foot holders and the term for putting the bed in this position is called “breaking the bed.”

 

Couldn’t Have Said It Better Myself… February 16, 2009

The current issue of the AWHONN (Association of Women’s Health, Obstetric and Neonatal Nurses) publication Journal of Obstetric, Gynecologic and Neo-Natal Nursing includes an amazing editorial about ACOG (American College of Obstetricians and Gynecologists) and the AMA’s (American Medical Association) 2008 official resolution against home birth and out of hospital birth centers as options for women and against home birth care-providers.  The author Nancy Lowe, an editor for the journal, carefully looks at the research on home birth and responds to the resolution in a powerful and thought provoking way.  The editorial is so well written that it is worth reading for yourself:

 

The “Authorities” Resolve Against Home Birth   by Nancy K. Lowe, Editor

 

Thank you, Ms. Lowe, for your inspiring and empowering words that ring so true to my ears as both a birth advocate and labor and delivery nurse!  I too feel caught up in the system.  I know in both my head and my heart that the current arrangement of maternity care in the U.S. is not serving our mothers and babies well!  But the good news is, we are not alone!  It’s not “hippy,” “earthy-crunchy,” “granola,” “weird,” “dangerous,” “selfish,” or “gross” to support homebirth, natural birth, breastfeeding, and birth choice.  It’s about the EVIDENCE!  It’s about EVIDENCED-BASED RESEARCH, which unfortunately is something many obstetricians (even ones I work with on a regular basis) refuse to acknowledge, adopt, and respect!  I wish I could scream it from the rooftops sometimes!

 

One thing I would like to add that I feel Lowe did not address in her editorial (although she alludes to it by way of scare-quoting the word Authorities in the editorial’s title), is that ACOG and the AMA are by no means governing bodies and do not hold any authority to rule over anything!  ACOG and the AMA are NOT agencies of the United States Department of Health and Human Services and have NO authority or responsibility for regulating and supervising maternity care in the United States.  The thought that they are “governing bodies” is a myth that is often perpetuated by OBGYNs themselves.  In reality ACOG is professional association of medical doctors specializing in obstetrics and gynecology while the AMA is the largest association of physicians and medical students in the United States. 

 

 You do not have to belong to these organizations in order to practice as a physician.  The main mission for both of these organizations: To advance the interests of physicians and to lobby for legislation favorable to physicians.  When you really break it down they are just clubs!  PLAIN AND SIMPLE!  Don’t get me wrong, I understand that it is their American right to lobby for their own interests but it is important for the public to realize that what is in their best interest isn’t necessarily what is in the best interest for mothers and babies.  (And in fact, history has proven this time and time again.  I highly recommend the book Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First by Marsden Wagner.  It will truly blow your mind!) 

 

There is a quote I stumbled upon recently by François-Marie Arouet (better known by the pen name Voltaire), a French Enlightenment writer, which I would like to leave with you… 

 

“It is dangerous to be right on subject on which the established authorities are wrong.”  ~Voltaire

 

Eerily relevant for an 18th century philosopher, isn’t it?!

 

 

If Help Is What You Need, Then She Will Breastfeed!

By now it seems like everyone has either seen or heard about the Nightline segment that aired on ABC on Thursday February 12, 2009 showing actress Salma Hayek breastfeeding another woman’s starving baby during her trip to Sierra Leone to support a tetanus-vaccination project.  I have to admit that while checking the news Friday morning, this story did indeed catch my eye as well.  As one can imagine, comments posted for the video ranged from praise and adoration to outrage and disgust. 

 

Many news sources have tried to present the story in the context of the current debate surrounding breast milk banking, cross nursing, and wet nursing (for example see the recent Time magazine and ABC news articles on the story).  Some include La Leche League’s official position statement on human milk banking and cross & wet nursing as evidence of the wrongness of Hayek’s actions.  In contrast, I would like to take the discussion out of this context.  I believe that the media’s portrayal of this story and hence the public’s reaction to it is completely and utterly misguided in the fact that they fail to approach the story in the context of Hayek’s motivation and reasons for her actions in Sierra Leone. 

 

According to the segment and Hayek’s own explanations, the actress was not breastfeeding this baby to promote cross nursing, wet nursing, or even human milk banking.  In fact, it does not even matter what side of that debate she supports!  Of course one can argue against her actions (whether founded or unfounded) by citing emotional, physical, or cultural risks and concerns.  Let us remember that Hayek states she breastfed that baby because she saw a child in need…a child in need in a country where infant mortality and starvation rates are heartbreakingly high and stigmas surrounding breastfeeding negatively affect the amount of woman willing and able to breastfeed for a healthy and adequate amount of time.  In addition, it is motivating to see a celebrity advocate for breastfeeding as both normal and natural!  (We certainly do not see this enough in our society).  Instead of analyzing the situation, why don’t we just look at the story as inspirational for the intrinsic principle it promotes and message it sends rather than the practicality of the action itself, just as the story of Jiang Xiaojuan’s heroic breast-feeding of several babies orphaned by China’s devastating earthquake in May of 2008 is.  Anyone arguing against Xiajuan’s heroic actions on the basis of risk or infection or disloyalty to her own nursing baby is sorely missing the point! 

 

With the availability of modern technology that allows thorough testing and pasteurization of donated breast milk, I could see that from a public health standpoint, perhaps cross nursing is not something to support in a formal position statement.  But when it comes to people helping people in tough times or devastating crises, let us focus on the good in this inspirational and empowering story!

 

Attn Docs: Natural Labor is NOT a Medical Emergency! February 12, 2009

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I recently read an article that made me smile on the Mothering magazine’s website entitled “Juicy Labor” by Esty Schachter.  Schachter writes about her labor with her second son as involving lots of walking around her apartment for most of the day until eventually deciding to go to the hospital after breaking her bag of waters.  One thing I found endearing about her story is the description of her experience in the triage area of the labor & delivery ward: “I said I wanted to push, but no one except Jon [her husband] seemed to hear me. That’s when I should have realized a vital bit of information: quiet women in labor will not get attention. Labor is simply not the time for restraint or subtlety.”  Schachter describes the initial skepticism of her doctor and the triage nurse that she had actually broken her water and was in labor followed by shock when it was realized that she was fully dilated (or as the doctor described it, “good to go!”)

           

I have been in this very position myself many times in my short career: woman approaches desk in wheelchair, restless, doing the “one cheek sneak*,” but very in control, turns out to be 9 centimeters with a bulging bag of waters!  The funny thing is that there is an inside joke around my department that if a patient approaches the desk calm, somewhat apprehensive, and without any luggage…she is probably in labor.  On the contrary, if a patient approaches the desk hooting and hollering with six suitcases and two pillows, chances are, it’s not the real thing!  Despite this inside joke, by default hooting and hollering always ends up getting you more attention, as Schachter so eloquently described!

           

What really hit home for me when reading this story, however, was the interaction the author describes in the delivery room between the nurse and the obstetrician.  Maybe it’s the adrenaline rush of hurrying a stretcher down the hall, clumsily setting up the delivery cart and baby warmer, and barking orders at each other and the mother (“Don’t push!,”  “Start an IV!,” “Break the bed!,”  “Get me that…!”) that many doctors, and even some nurses, thrive on.  However if you think about, if a woman comes in ready to, or almost ready to deliver, it is more important than ever to try and keep things as cool, calm, and collected as you can, not only the mother’s emotional wellbeing, but for the progression of labor as well.  I have tried to explain this very concept to many of the new residents at work: A woman in transition or one ready to give birth is not a medical emergency!  True, we must all work as a team to provide appropriate care and support in a timely and efficient manner, but we don’t need to be busting through doors and screaming “PUSH!!”  I love how the nurse in Schachter’s story told the author to “do what nature told [her] to” despite the brash doctor’s demands.  It is a line I have used quite often in my own practice as an L&D nurse, right after I dim the lights and demand some level of quite from the bustling staff around me J.  At that moment, my attention is on mom and her needs, not the needs of anyone else. 

           

To all the attending obstetricians, residents, and old school L&D nurses out there (who are probably not reading this post J), let us try to remember that when push comes to shove (no pun intended!), the admission assessment, IV, history & physical, and other paperwork can wait.  Your job at that moment is to help support the mother and include her partner or other labor companion in doing whatever will assist her the most.  She is, after all, the one doing all the real work and you are, in truth, privileged that she is even allowing you to be there to catch!

 

 

 

*Note: The “one cheek sneak” is the affectionate name used to describe a move that is typical of a woman in true labor (although it’s meaning to L&D nurses is a bit different than it’s meaning per the late George Carlin!).  The rectal pressure from the baby and the back-to-back contractions make it difficult to sit without lifting one of your buttocks off the chair, all the while trying to maintain your composure and pant through the contractions!

 

Top Ten Things Women Say/Do During Labor (And trust me… they are totally normal!) February 8, 2009

You’ve read about it.  You’ve talked about it.  You’re totally prepared for it…right?  Until it actually happens, no couple can be totally ready for what they will feel, say, and do during childbirth…especially when she gets to transition.  Transition, the shortest of the three phases of the first stage of labor, is the most intense as well as the most physically and emotionally demanding phase.  For those that have been planning a natural childbirth, it is also a time when many women want to change their birth plan and ask for pain medication.  The good news is that since transition is the shortest phase, when she finally gets to it (at about 8-10 centimeters) she is almost there!! 

 

The following is a list of the top ten things I have discovered to be very common among women working through labor, especially if she is doing it naturally!  If you have experienced or assisted someone through labor, you might remember these moments with a chuckle.  If you are about to embark on a natural birth, either personally or as a coach for your wife, partner, sister, daughter, niece, or best friend, my hope in writing this list is to alert you to these very thoughts, feelings, and actions that you/she will probably experience. 

 

It is easy to get scared when your loved one is in so much pain she wants to change her birth plan.  Not to say, of course, that a woman shouldn’t have that right.  There is a great chapter in the book The Birth Partner by Penny Simkin that describes this very phenomenon and suggests reviewing the “Pain Medications Preference Scale” and discussing the use of a “code word” before going into labor.  I highly recommend this book as part of your childbirth preparation.  However, if more couples knew about these thoughts, feelings, and actions, they might realize what their labor & delivery nurse, midwife, or doula already know…that she is acting totally normal!

 

10) “I don’t know how much longer I can do this!”

            Many L&D nurses are used to hearing this phrase typically as a woman begins the transition phase.  When you hear it, know that reminding your loved one of how much progress she has made and how little she has left to go will probably help her cope.  Many women mistakenly feel that if their labor took hours and hours to get to this point that it will take a comparable amount of time to get to the second (or pushing) stage.  Except in the rare case of arrested dilatation, this is NOT the case!  She is way more than half way there, in fact, she is almost done!

           

9) “I’m done!”

            Wanting to “give up” and just have it be over with is also a common desire of a woman going through natural labor.  It may be helpful to remind her that the pain she is in right now does not feel as bad as holding her baby will feel good!

 

8.) Throw Up/Burp Frequently

            Vomiting is a common sign of the transition phase, whether or not a woman has been eating throughout early labor.  Some coaches find this hard to handle.  Think of it as a way of “making more room” for the baby J.  In fact if something was rhythmically squeezing your insides, you would probably throw up too!  And let’s be honest, with a new baby around, you are bound to see a lot more throw up!  Since vomiting, like holding your breath or making a bowel movement, is a vagal response, it inadvertently helps your cervix dilate and hence, is a great sign to a labor & delivery nurse!  The body does awesome things to help the process along!

 

7) “No really, I have to poop!”

            As the baby descends further into the pelvis with each contraction, the pressure on the rectum becomes incredibly intense.  So intense, in fact, that it feels exactly like the need to have a bowel movement.  I can’t tell you how many times I explain to a patient who is in early labor that if she feel rectal pressure “like she has to poop” that she has to call me first and NOT just get up to the bathroom.  But time and time again when my patients begin to feel this pressure what doe they do?  They almost always get up and try to poop!  Many a woman I have found on the toilet straining to pass a BM and when questioned, try their best to convince me, “No, you don’t understand, I swear I have to poop!”  Okay, okay, if you had just eaten a meal and it was during early labor, I would agree.  But you are 8 centimeters now so TRUST ME!  It is the baby! (SEE: Top 10 DOs & DON’Ts of Pooping During Labor & Birth)

 

6) Shake/Tremble

            The hormonal rush a woman experiences during labor, especially natural labor, is overwhelmingly intense.  These hormones will cause all women to being to shake as they approach full dilation.  This shaking, in fact, continues for at least an hour post partum, even after a cesarean section or medicated labor.  Many partners and family members try to pack a woman with blankets to help her out only to find that she insists on not only ripping off the blankets, but sometimes even her clothes!  In reality, it is unlikely that she is cold and if you continue to ask her if she is, she will just start to get irritated with you.  It’s normal to shake, I promise J

 

5) “Can’t you just take/cut the baby out of me!?”

            Even the most level-headed, experienced mom can sometimes feel so out of control that she begs for a c-section.  Trying to rationalize with her is not going to make it better.  As an L&D nurse, both you and I know, as well as she, that a cesarean might seem like less pain now, but it is a hell of a lot more pain later!  It might be helpful to gently remind her that she is almost done and that everything she is doing to regain control of her breathing is helping the baby.  But please don’t try to reason with her…you are just going to upset her!

 

4) Cry

            Whenever a patient of mine begins to cry, my heart always starts to break.  It is at this moment that most L&D nurses, partners, and other birth coaches wish they could trade places with her, if even for a moment, to just give her a small break!  (Alas!  If only it was possible!)  If my patient begins to cry, I try to gently persuade her to save her tears for happy times when the baby is born and that crying is only going to give her a headache and make her feel more terrible. 

 

3) “Don’t touch me there/like that!”

            Many birth coaches are hurt to discover that the techniques that were working wonders in early labor only make their loved one upset and annoyed during transition.  In my experience the major culprit is rubbing her belly!  I know, I know…all the Hollywood movies show the father of the baby rubbing mom’s belly as she moans through her contractions.  Looks loving and almost romantic right?  WRONG!  (At least during transition anyways!)  To all the well intentioned fathers and birth coaches out there, my humble advice to you is this: unless she asks, don’t rub her belly…seriously, don’t!

 

2) Ignore You

            The only time I start to feel bad for the partners and labor coaching working with my patients is when their loved one starts to ignore them.  In reality, it is a fantastic coping mechanism!  Fact: Women often do not know what they want during transition.  They feel out of control and utterly uncomfortable in every way.  So when you ask her if she wants a sip of water or a cool cloth on her forehead or to change position what does she do?  She ignores you!  It is hard for me to explain that this is normal while in the labor room so since I have the opportunity now, I would like to let all birth coaches know that your loved one is no longer with us.  She is in her own world so she can make it through!  Hence don’t ask her any questions, especially silly questions!  My humble advice is to just do what you think will help and she will tell you otherwise if it is not working.  Many women can only talk in one work responses at this point anyways: “No!,” “Stop!,” “Drink!,” “Stronger!,” “Softer!,” “Oww!”  So just hold the straw up to her face; if she wants to drink she will!  If not, she’ll tell you!  And while I am on the subject, please don’t take offense if she is short with you.  Just do what she asks with an understanding smile and for the love of God please don’t sass her back!  She is, after all, having a baby!

 

1) “This is the last/only time I am going to do this!  No more babies for me!”

            If every labor and delivery nurse had a dollar for each time we heard a woman say this during labor, we could bailout this country single-handedly!  This comment makes me chuckle every time I hear it.  Let it be known that once she has that baby in her arms, she is going to forget all about the pain.  What she will remember is how well loved and supported she felt during the whole process.  And if you have done your job right, she is going to want a lot more kids someday!