Sunday, December 27, 2009

Share With Women: Am I in Labor?

AM I IN LABOR?

What is labor?
Labor is the work that your body does to birth your baby. Your uterus (the womb) contracts. Your cervix (the mouth of the uterus) opens. You will push your baby out into the world.

What do contractions (labor pains) feel like?
When they first start, contractions usually feel like cramps during your period. Sometimes you feel pain in your back. Most often, contractions feel like muscles pulling painfully in your lower belly. At first, the contractions will probably be 15to 20 minutes apart. They will not feel too painful. As labor goes on, the contractions get stronger, closer together, and more painful.

How do I time the contractions?
Time your contractions by counting the number of minutes from the start of one contraction to the start of the next contraction.

What should I do when the contractions start?
If it is night and you can sleep, sleep. If it happens during the day, here are some things you can do to take care of yourself at home:
● Walk. If the pains you are having are real labor, walking will make the contractions come faster and harder. If the contractions are not going to continue and be real labor, walking will make the contractions slow down.
● Take a shower or bath. This will help you relax.
● Eat. Labor is a big event. It takes a lot of energy.
● Drink water. Not drinking enough water can cause false labor (contractions that hurt but do not open your cervix). If this is true labor, drinking water will help you have strength to get through your labor.
● Take a nap. Get all the rest you can.
● Get a massage. If your labor is in your back, a strong massage on your lower back may feel very good. Getting a foot massage is always good.
● Don’t panic. You can do this. Your body was made for this. You are strong!

When should I go to the hospital or call my health care provider?
● Your contractions have been 5 minutes apart or less for at least 1 hour.
● If several contractions are so painful you cannot walk or talk during one.
● Your bag of waters breaks. (You may have a big gush of water or just water that runs down your legs when you walk.)

Are there other reasons to call my health care provider?
Yes, you should call your health care provider or go to the hospital if you start to bleed like you are having a period—blood that soaks your underwear or runs down your legs, if you have sudden severe pain, if your baby has not moved for several hours, or if you are leaking green fluid. The rule is as follows: If you are very concerned about something, call.

LABOR? WHAT DO I DO NOW?
First . . . If your baby is due more than 3 weeks from today and you are having back pain or stomach cramps, or there is fluid leaking from your vagina, or your baby has not moved for several hours, or you have other troubling symptoms, call your health care provider now!
Or . . . If you are overdue, be sure to see your health care provider at least once a week and talk with her about a plan for your care.

Flu.Gov

The Flu.gov website has easy-to-read information regarding the flu, vaccination, etc. It also gives H1N1 updates and has a vaccination location finder. Patients of Bethany Womens Healthcare who are pregnant or within 6 months postpartum can come to our office should they desire the vaccine.

YouTube Changing Birth Culture?

This is an interesting blog post by Amy Romano CNM. She discusses how YouTube could be a potential change agent for birth culture. Cool! A use for technology that is positive and helpful :)

I'll admit....in my desire to share what normal birth looks like, I have 'made' my daughters watch several YouTube birth videos. My 6-year-old, Liberty, finds them absolutely fascinating. She begs to come to work with me and see someone have a baby. I told her maybe someday. My 9-year-old, Daja, is not so interested. But she's also very much a tomboy and shies away from 'female things'. She has been to work with me and watched a birth. She did ok but I don't think she found it as awesome as I always do! She was a little green when the placenta came out. I had hoped to let her touch it (with gloves on, of course) but ended up sending her out of the room. :)

Annual Premature Birth Report Card

This is a subject near and dear to my heart as my son, Christian, was born prematurely at 34 weeks. He suffered complications that resulted in long term disability.

Report Card

Unfortunately Arizona scores a D.

Thursday, December 10, 2009

T's Birth

I had been seeing T all throughout this pregnancy as well as her first pregnancy. A student midwife and I had caught the baby last time. I was looking forward to catching this baby myself! T was kind enough to go into labor during my weekend on call :)

T is an herbalist and does not believe in taking any man-made medicines with the exception of life-saving. Her first labor and birth was done naturally and this one would be the same.

I had just left the hospital to go meet my mother to try and do some christmas shopping when T called me. She told me she had been contracting through the night and the contractions were pretty intense. They were also about every 6 minutes apart now. Her water had broke earlier that morning. I told her it sounded like she needed to come on in.

When she arrived, I was a little nervous because she looked very comfortable, even when having a contraction. She would breathe through the contraction but there were no other signs that she was having one....meaning her body and face were very relaxed. I was thinking that she might be very early in the labor. But I also know that everyone handles pain differently.

We got her settled in her room, got a quick strip of the baby, who looked great. Then we got her in the tub. Her cervix was dilated 5cms at this point! Woohoo! T and I sat in the bathroom for the remainder of her labor. Well, she was in the tub while I sat on a stool beside the tub :) T was amazingly relaxed and seemed to enjoy the tub. We talked about all kinds of things....from family to spirituality! I was worried that I was distracting her from her labor but she assured me that everything was fine. Her contractions eventually began to move closer together, until they were about 2-3 minutes apart. I was really enjoying watching her labor. I was able to tell when she moved into transition...not because she made more noise or anything, just because she stopped talking but still maintained a very relaxed appearance. I could tell that she was becoming more focused and drawing inward. She looked beautiful!

Eventually she told me that she could feel the baby moving down. I rechecked her while she was in the tub...she was 8-9cms now. However, I had a feeling that would be changing quickly. We waited a few more contractions until she felt like she needed to push. I rechecked her to find the baby at +2 station (+3 is crowning) and told her she was definitely ready! We moved her to the bed, where she made herself comfortable. She pushed when she needed to, focusing on her husband, who stood at the bedside. She was absolutely silent. She looked exactly how I would imagine a labor goddess to look :) She pushed with great control for about 6 minutes. She delivered another beautiful baby girl over an intact perineum approximately 2 hours and twenty minutes after arriving!

Congratulations T and I can't wait until the next one!!!!!!!

Monday, November 23, 2009

Midwife-led versus other models of care for childbearing women

Midwife-led versus other models of care for childbearing women
Hatem M, Sandall J, Devane D, Soltani H, Gates S
Cochrane.org

Midwife-led care confers benefits for pregnant women and their babies and is recommended.

In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality, continuity of care and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called 'team' midwifery. Another model is 'caseload midwifery', where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. All models of midwife-led care are provided in a multi-disciplinary network of consultation and referral with other care providers. By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects.

The main benefits were a reduction in the use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman's chance of being cared for in labour by a midwife she had got to know, and the chance of feeling in control during labour, having a spontaneous vaginal birth and initiating breastfeeding. However, there was no difference in caesarean birth rates.

Women who were randomised to receive midwife-led care were less likely to lose their baby before 24 weeks' gestation, although there were no differences in the risk of losing the baby after 24 weeks, or overall. In addition, babies of women who were randomised to receive midwife-led care were more likely to have a shorter length of hospital stay.

The review concluded that most women should be offered midwife-led models of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

Thursday, November 19, 2009

Vaginal Birth animation

Station of the baby video

CDC Commentary: H1N1 Vaccination

This two minute clip discusses the H1N1 Vaccination.

We currently have a supply of the individual pre-filled syringes, which are preservative free (meaning no mercury). We do recommend this vaccination for all pregnant and postpartum women. If you are interested in receiving the vaccine and are currently a patient, please feel free to stop by or ask for it at your next visit.

If you are feeling sick or are exposed to someone with a known case of the flu, please call our office for further instructions and advice.

Monday, November 9, 2009

Share With Women - Epidurals

SHARE WITH WOMEN - American College of Nurse-Midwives

EPIDURAL ANALGESIA

There are many options for managing pain during labor. You might decide before you begin labor that you want pain medication, or you may not want any medications. This handout discusses epidural analgesia.

What is Epidural Analgesia?
Epidural analgesia is a local anesthetic placed in a part of your back where it numbs the nerves that go from your pelvis and legs to your brain. The anesthetic is like the kind you get when you go to the dentist. With an epidural, you get an injection into the space around the nerves in your spine that makes your body numb below the site of the injection.


How Does an Epidural Work?
All of the nerves of the body send their messages to the brain through the spine. Anesthetics are
medicines that block the messages from traveling up nerves to the brain. When the pain messages are blocked before getting to your brain, you do not “feel” the pain.


How is an Epidural Done?
There is a very small space around the nerves in your spine. This is called the epidural space. A specially trained doctor or nurse places a thin tube, called a catheter, into this space. You will have to sit on the side of the bed or curl up on your side on the bed. The nurse or doctor will give you a shot of Novocain in your back. Then the nurse or doctor will put a long needle through the area that is numbed into the epidural space. When he or she has found the space, the thin tube will be threaded through the needle, and the needle is removed. A pump is then set up to deliver the anesthesia through the tube into the epidural space during your labor. After birth, the tube will be taken out. The numbness will begin to go away. You will be able to move your legs and walk in a few hours.


How Well Does an Epidural Work?
For some women, an epidural works very well. Within 15 to 20 minutes of starting the anesthesia, they lose feeling below the waist. Many women are so comfortable they can talk, watch television, or even sleep. Occasionally, the epidural does not work as well, and you may continue to feel pain or pressure even though your legs are numb. There is no way to guess who will get a “pain free” epidural and who will have an epidural that does not work completely.


Are There Risks Associated With Having an Epidural During Labor?
Your labor progress depends on lots of things: the size of your pelvis, the size of your baby, the
position of your baby, and the strength of your contractions. Most of this is out of your control.
Sometimes an epidural can help and sometimes it makes labor longer and more complicated.

Risks of Insertion and Placement of Anesthesia in the Epidural Space
● The epidural is inserted sterilely, but there is a small chance of infection at the site where the needle is inserted. A serious infection could cause paralysis or, very rarely, death.
● The needle could hit a nerve and cause nerve damage or paralysis. In most people, the spinal cord is above the area where the needle is placed, which is why this problem is rare.
● If the epidural is incorrectly placed too high in your back or into spinal fluid, you may lose the
sensation of your breathing and need help to breathe regularly.


Risks During Labor
● If your bladder is full, you will not be able to feel it, so you will need a catheter to drain the urine.
● Women who have an epidural have a higher chance of getting a fever during labor, and then the baby may need additional blood work and observation to rule out infection.
● Women who have an epidural are more likely to need medication to make contractions stronger.
● Your legs will be numb. If your baby gets stuck in a “crooked” position, you will not be able to move around to “jiggle” the baby into a good position. This may increase your chance of needing a cesarean section.
● It may be hard to feel your contractions when you need to push. Pushing takes longer.
● Women who have an epidural have a higher chance of needing a vacuum or forceps to help give birth.


Risks Afterward
● The most common risk of an epidural after the baby is born is a “spinal headache.” This only happens one or two times for every 100 epidurals that are used. This is a terrible headache that comes 1 to 2 days after the epidural is removed. If you get a spinal headache, you will need to return to the hospital to have a special procedure called a “blood patch.” The patch usually helps right away.
● Your baby may have a harder time getting started breastfeeding.
● Many women report ongoing back pain after an epidural, but we do not know if this is because of the epidural or because of other things that may have happened during their labor.
● There is a very, very small risk of permanent paralysis—loss of the ability to move your legs.


What Are the Benefits of an Epidural?
● If the epidural works well, you will not feel the intense pain.
● Sometimes—especially with a first baby—early labor may be long. An epidural can give you a
chance to rest so that you can gather your strength for active labor and birth.
● If you are very anxious, an epidural may help you relax. In some women it appears that the epidural may actually make your labor go more quickly.
● If you need a cesarean section, your epidural can be used to make you numb for the surgery.
● Women with twins or babies in a breech position who plan a vaginal birth may use an epidural so they are prepared for a cesarean section if their baby (or babies) have problems during labor or birth.


FOR MORE INFORMATION
Childbirth Connection:
Options: Labor Pain (Epidural and Spinal)

Friday, October 30, 2009

Birth Symposium Pictures

The Birth Symposium was a fabulous success attended by many smart and hip women! I was able to attend the first couple hours before having to see patients in the office. I hear that the remainder of the time was no less than stellar though! I took a few pics while I was hanging out...

This is Fatima Muhammad - a doula and driving force behind the symposium...






One of the birth center rooms set up with multiple displays...




Some attendants :)












A patient of ours experiences some of the doula techniques used in coping with labor...


Sharon Olsen IBCLC was available for those with breastfeeding questions or issues...




Lisa Sherwood CNM provided a lecture on the Midwifery Model of Care...






Vendors that attended...










Pam Degraff is a licensed massage therapist as well as a doula. She was on hand to demonstrate the benefits of prenatal massage!


Lynnette Casey CNM and Lisa Sherwood mugging for the camera!


Lynnette Casey CNM, speaking with an attendant. She also provided a lecture on VBACs as well...






Monday, October 26, 2009

Cord Blood in Regenerative Medicine

More and more families are questioning the possibility of banking umbilical cord blood for assisting with potential medical treatments later in the life of their baby. How could it REALLY be used? The most recent edition of "The OB/GYN and Infertility Nurse" has an article describing the growing use of newborn cord blood in regenerative medicine. The future of utilizing cord blood is exciting. Here's a story about one little girl and how she has benefitted from her parents saving the cord blood at her birth.

"The Case of Chloe Levine...
Jenny Levine of Denver, Colorado, first learned about cord blood's potential medical uses at her OB/GYN visit. She and her husband Ryan, decided to privately bank their second daughter, Chloe's cord blood before her birth. Gradually, her parents realized she was not developing properly. 'At 9 months, Chloes was still unable to hold a bottle and was unable to crawl properly. She had limited use of the right side of her body', said her mother. Chloe was diagnosed with right-sided hemiplegic cerebral palsy, most likely due to an in-utero stroke. 'My husband and I were completely devastated,' said Jenny. The Levines were told that Chloe faced 17 to 18 years of therapy, with no guarantees of success. But the family soon discovered a Duke University study where children with cerebral palsy were being reinfused with their own cord blood stem cells, with encouraging results. Chloe was accepted at Duke and intravenously reinfused with her cells on May 27, 2008. Shortly after, Chloe began to show changes. 'Enough of the stiffness in her right foot had disappeared, and for the first time she could push the peddle down on her battery-powered tractor,' said Jenny. 'She began to expand her vocabulary, saying things like her nickname, Coco. Therapists had worked for weeks before to get her to produce words like these without success.' Today, a year and a half after infusion, Chloe no longer receives physical or speech therapy, and her occupational therapy has been cut in half. She began preschool this fall; she no longer qualifies for special needs services at school."

Yeah, Chloe!!

Friday, October 23, 2009

Midwifery Model in New Zealand




Beautiful country...beautiful babies!


Baby Ewan



In 2007-2008 I had the gift of being able to practice midwifery on the South Island of New Zealand in a rural town on the edge of Fiordland National Park, Tuatapere. The town has a "medical centre" which houses "Tuatapere Maternity", a small rural "birthing unit" (similar to our freestanding birth centers in the US). I just returned from 3 weeks "holiday" there and caught up with many of the families I was privileged to serve during my time there. Great fun to see how these sweet babies have grown.

Midwifery is alive and well in this island nation! It is a country and culture where midwives are the primary obstetric care providers. (If you want to see a physician, you must get a "referral" from your midwife!!) They practice in various settings and promote the "naturalness" of pregnancy and birth. All facilities where birth takes place have been mandated by the government to be certified as "Baby Friendly". Quite a statement about breastfeeding!! Women in New Zealand can have their babies in whatever setting they choose: home, birthing unit or hospital and it is totally supported (and paid for) by the government. Midwives are also responsible for care of the newborn for the first 6 weeks. The government mandates weekly postpartum HOME visits by the midwife. There is only one category of "midwife", unlike the US where we have multiple initials that connote a variety of paths to midwifery (see our BWHC website for a description of major categories). They are governed by a Midwifery Council that describes the practice of midwifery:

"The midwife works in partnership with women, on her own professional responsibility, to give women the necessary support, care and advice during pregnancy, labour and the postpartum period up to six weeks, to facilitate births and to provide care for the newborn.

The midwife understands, promotes and facilitates the physiological processes of pregnancy and childbirth, identifies complications that may arise in mother and baby, accesses appropriate medical assistance, and implements emergency measures as necessary. When women require referral midwives provide midwifery care in collaboration with other health professionals.

Midwives have an important role in health and wellness promotion and education for the woman, her family and the community. Midwifery practice involves informing and preparing the woman and her family for pregnancy, birth, breastfeeding and parenthood and includes certain aspects of women’s health, family planning and infant well-being.

The midwife may practise in any setting, including the home, the community, hospitals, or in any other maternity service. In all settings, the midwife remains responsible and accountable for the care she provides."

If only our government would see the value of midwifery care and breastfeeding...we could be a critical piece in health care reform. (Midwives have been "reforming" healthcare for a very long time!) We could benefit so much from implementing strategies countries the world over have embraced to decrease the maternal -infant morbidity/mortality rates, improve breastfeeding success rates and increase women's satisfaction with their pregnancy and birth experiences.






Monday, October 19, 2009

Seasonal flu and H1N1

We have a lot of questions from patients in our practice about the flu and H1N1. Should they get the vaccines, are they safe. Here is some information to help you decide.

Pregnancy and the Flu
Complications of both the seasonal flu and H1N1, like bacterial pneumonia and dehydration, can be serious and even fatal. Pregnancy can increase the risk of these complications. Pregnant women are more likely to be hospitalized from complications of the flu than non-pregnant women who are the same age. Some of the physiological changes in pregnancy, like those to the immune system, heart and lungs, can increase the risk for complications from the flu.
The American College of Nurse-Midwives, the Centers for Disease Control, the American College of Obstetricians and Gynecologists and the March of Dimes have come together to develop a clear statement about the seriousness of H1N1 flu and the importance of receiving the vaccination.

Can the 2009 H1N1 flu vaccine be given at any time during pregnancy?
Seasonal flu vaccine is recommended for all pregnant women at any time during pregnancy, and has not been shown to cause harm to a pregnant woman or her baby. The Advisory Committee on Immunization Practices also recommends that 2009 H1N1 flu vaccine be given to all pregnant women at any time during pregnancy.

If I deliver my baby before I receive my seasonal flu shot or 2009 H1N1 flu shot, should I still receive them?
Yes. In addition to protecting you from infection, the vaccine may also help protect your young infant. Flu vaccines are recommended only for infants 6 months or older. It is recommended that everyone who lives with or provides care for an infant less than 6 months old receive both the seasonal flu vaccine and the 2009 H1N1 flu vaccine.

I am breastfeeding, can I receive the vaccine?
Yes. Both seasonal flu and 2009 H1N1 influenza vaccines should be given to breastfeeding mothers. Breastfeeding is fully compatible with flu vaccination, and preventing maternal infection provides secondary protection to the infant. Maternal vaccination is especially important for infants less than 6 months old, who are ineligible for vaccination. In addition, transfer of vaccination-related antibodies by breastfeeding further reduces the infant’s chances of getting sick with the flu.

Is the 2009 H1N1 flu vaccine safe for pregnant women?
Flu vaccines have not been shown to cause harm to a pregnant woman or her baby. The seasonal flu shot has been recommended for pregnant women for many years. The 2009 H1N1 flu vaccine will be made using the same processes as the seasonal flu vaccine. Studies that test the 2009 H1N1 flu vaccine in pregnant women began in September. More information is available at http://www3.niaid.nih.gov/news/QA/vteuH1N1qa.htm.

Does the 2009 H1N1 flu vaccine have preservative in it?
Multi-dose vials of flu vaccine contain the preservative thimerosal to prevent bacterial growth. There is no evidence that thimerosal is harmful to a pregnant woman or a fetus. However, because some women are concerned about exposure to preservatives during pregnancy, manufacturers are producing preservative-free seasonal flu vaccine and 2009 H1N1 flu vaccine in single dose syringes. CDC recommends that pregnant women receive flu vaccine with or without thimerosal.

Can I get the seasonal flu vaccine and the 2009 H1N1 flu vaccine at the same time?
Seasonal flu and 2009 H1N1 vaccines may be administered on the same day but given at different sites (e.g. one shot in the left arm and the other shot in the right arm). However, the seasonal vaccine is available now in numerous areas and the 2009 H1N1 influenza vaccine won’t be available until mid-October. So, pregnant women are encouraged to get their seasonal flu vaccine as soon as it is available in their community. The usual seasonal influenza viruses are still expected to cause illness this fall and winter.

Can pregnant women receive the nasal spray vaccine?
The nasal spray vaccine is not licensed for use in pregnant women. Pregnant women should not receive nasal spray vaccine for either seasonal flu or 2009 H1N1 flu. After delivery, women can receive the nasal spray vaccine, even if they are breastfeeding.

What are the possible side effects of the 2009 H1N1 flu vaccine?
Pregnant women are not known to have an increased risk of side effects from the flu vaccine. The side effects from 2009 H1N1 flu vaccine are expected to be similar to those from seasonal flu vaccines. The most common side effects following vaccination are expected to be mild, such as soreness, redness, tenderness or swelling where the shot was given. Some people might experience headache, muscle aches, fever, fatigue, and nausea. If these problems occur, they usually begin soon after the shot is given and may last as long as 1-2 days. Fainting may occur shortly after receiving any injection and has uncommonly been reported after the flu shot. Like any medicines, vaccines can cause serious problems like severe allergic reactions. However life-threatening allergic reactions to vaccines are very rare.
Anyone who has a severe (life-threatening) allergy to eggs or to any other substance in the vaccine should not get the vaccine, regardless of whether they are pregnant.

What can I do to prevent getting the swine flu?
There are things you can do to prevent getting the the flu. Little things can make a big difference:
* Wash your hands well and often.
* If water or soap are not available, use hand sanitizer.
* When you cough or sneeze, cover your nose and mouth by coughing into your arm. This should be done so that the spray from your cough does not get into the air.
* Properly dispose of your tissue after you use it.
* Wash your hands after coughing or sneezing.
And remember the ‘‘Don’ts’’:
* Don’t touch your nose, mouth, or eyes if you are sick, because that’s where germs like to live.
* Don’t spend time around people who are sick or crowds.
* Don’t go to work or school if you are sick.

Most importantly, call your midwife or doctor if you think you are sick. Medicines are available to help you.

Man in Labor

I thought everyone could appreciate this :) It's a man in labor - and he doesn't make it very far!


Thursday, October 15, 2009

J's Birth

J was sent over from the office to the hospital for a NST (non-stress test) and to check the fluid around the baby as she was 41.2 weeks pregnant. The plan was for her to come in the next morning to have her water broke as a means of getting labor started. Her cervix was 4cms in the office that day with the baby's head quite low in the pelvis. Diane had called me to let me know she was coming. Diane would be on call the next day.

J had previously had epidurals with her other children. From what she told me, it sounded like she would get to transition then was offered an epidural, where her response was yes. Then she would deliver 30 minutes later. Her previous children were all caught by doctors. She very much wanted to do this natural.

When J arrived and was put on the monitor in triage, I was a little concerned. I didn't like how the baby's heart rate looked so opted to just keep her for the night. Well, I may have jumped the gun because once she came back to L&D, and was on the monitor, the baby looked fantastic. She was also contracting about every five minutes but feeling just a bit crampy with them. I asked her what she wanted to do...stay and break water tonight, stay and do nothing tonight, or go back home. Her and her husband had already made arrangements for their other children (a set of twins and a singleton) and they lived a fair ways away. She decided to stay.

We discussed breaking her water versus not, and she decided to have me check her first. Her husband wasn't there yet but would be in about an hour. She asked if breaking her water would cause her to deliver before he returned. I told "oh no, you won't go that fast!".

Famous last words.

She was 4-5/100/0 when I checked her so she opted to have her membranes ruptured. We even waited until after the nurses' shift change (maybe 20 minutes) before we did it. Once her water was broke, I asked her to walk a bit. She was also looking forward to getting in the tub and trying the birth ball. I went to do some paperwork and saw her walking a bit in the hallway. In hindsight, she looked a bit out of sorts, but at the time I didn't think too much of it.

A few minutes later she went back in the room and the nurse came and asked me if she could have something to eat as she was feeling light-headed. I went in to check on her and she was sitting on the edge of the bed. She told me this was what she didn't like about labor last time either...I suggested some protein as well as carbs. I told her I would be right back to check on her. I went to another patient's room to check in on her. While I was in there the nurse came and stuck her head in the door to tell me that J was asking for an epidural.

I was like "what???" She was doing fine when I had just been in there. So I tell the nurse not to do anything, I'm coming to check on her first. When I get to the room, she's still sitting on the edge of the bed. She tells me I can't do this. Then she grunts and bears down.

I'm thinking "what the heck?" I told J, let me check you before we make any decisions, you haven't tried the tub yet, and it sound slike you are getting close. She was spontaneously bearing down with each contraction. I checked her and she was 9 and a half cms! I said no epidural. She wanted to get in the tub so she squatted in the tub. I sat at her side holding her hand. I started worrying that her husband wasn't going to make it. I don't think she was in the tub more than 10 minutes when she started pushing again. She told me that the baby was coming. I checked and she was certainly correct - she was completely dilated and the baby was at a +2 station. I asked her if she could get out and maybe squat by the bed for delivery (we aren't supposed to do waterbirth although if she hadn't been able to get out, oh well). She was able to move over by a chair in the room. My thought was that she could lean on the chair and I would catch the baby from behind. Not quite how it worked out.

She squatted while I sat on the floor. She had one arm around my shoulders with her other hand on my leg for support. The nurse stood near by, not really sure what to do. She wanted to listen to the baby's heartbeat but I said not to worry about it, we could listen when the baby came out. I could not see what was going on as my head was crushed against J's chest. It was kinda funny :) I kept talking her through her contractions. She would talk completely normally in between contractions, asking what to do. I had one hand at her vagina, where I could feel the head crowning. She slowly and gently pushed the head out. It was such a thrill to not be able to see what I was doing but feel the head being born into my hand. We had a little trouble with the shoulders but nothing that wasn't remedied by me getting both hands involved. She gracefully pushed out the rest of her baby. I brought the baby up to her arms and the nurse threw a blanket over them. The baby was doing absolutely fine as was momma. We helped her move to the bed where she could rest while latching the baby on to the breast. Her husband walked in literally five minutes after the birth.

She pushed out her placenta just as gracefully. She had just a small perineal tear requiring no stitches.

Congrats J on a beautiful birth!

Sunday, October 4, 2009

Funny Birth Plan

This was a birth plan handed to me by a patient. She was funny but serious :)

I am a midwife patient.

We are very excited about our upcoming birth at Phoenix Baptist Hospital and have really enjoyed our experiences with the Bethany Womens Healthcare midwives and all of the staff. In order to help make our birthing experience as enjoyable and positive as possible, we have written this birthing plan. While we hope there are no complications during the birth of our child, we understand that circumstances may require us to re-evaluate our desires. If the need does arise for medication or medical procedures we hope to avoiud, we would like to have everything explained to us as fully as time will permit so that we may give (or my husband's, if I'm unconscious for some odd reason) informed consent.

VAGINAL EXAMS
As mush as I enjoy vaginal exams, I prefer to limit them during the course of this birthing to the following situations:
1. An exam upon admission to the hospital seems appropriate so we all know where we are in this epic adventure together, and to ensure that I am, in fact, in the throes of actual birthing.
2. If progress appears to have seriously stalled, and to be sure that I'm not trying to force a grapefruit through a straw.

MOVEMENT OF MOTHER
I prefer to move around freely during my birthing time, stand on my hand, or assume any other positions I find comfortable.

PERINEAL MASSAGE
I'd love the midwife to massage my perineum with oil during crowning and birth. Peeled grapes and a handsome greek god fanning me with a palm leaf would be ok too. Of course I want to avoid an episotomy, who wouldn't?

THE BIRTH
______ wants to cut the cord, which hopefully won't be clamped or cut until the cord stops pulsating.
Please let ______ announce the gender of the baby. Of course, we are breastfeeding. No one with a birth plan like this would feed his or her kid formula.

PLACENTA
Do feel free to toss it after it is all out. I waive the right to fry it up and eat it. Thanks.

THANK YOU SO MUCH FOR HELPING US TO HAVE A SAFE, JOYFUL BIRTHING EXPERIENCE.

Saturday, October 3, 2009

Inductions

From time to time, women will ask about induction of labor for many different reasons. Unfortunately, the response is often a no on our part. While we are often empathetic when it comes to the miseries of pregnancy, the reality is that inductions are not a benign procedure. Inductions often involve greater risks than spontaneous labors and are far more time-consuming than most women realize.

It seems to be a common misperception that if a woman is scheduled for induction, she'll have her baby that day. It ain't necessairly so! Women who have a 'favorable' cervix are likely to have a baby in one day but not always. A favorable cervix is one that is thin (effacement), preferably already dilated a little, and midposition or anterior (where the cervix is - if I ask you to put your balled up fists under your hips - that's not a good sign!). An unfavorable cervix would be what we call 'closed, thick, and high. Oftentimes, when the cervix is unfavorable, an induction can take 2, even 3 days. Sometimes women might be sent home to return in a few days to try again. Spending 2-3 days in the hospital just trying to have the baby gets old quick! The beds aren't comfortable, you have people going in and out of your room at all hours of the day and night, no food on demand, etc.

Another common misperception is that inductions are not harmful. There are risks involved in any 'procedure'. Women who are induced, particularly with unfavorable cervices, are more likely to end up with a cesearean section, especially if it's their first baby. The risks of induction can vary depending on what type of induction is being done but the big ones are fetal distress (where the baby does not tolerate the labor) and emergency c/s.

Women may be offered induction when there is a medical reason to do so. These reasons might include gestational diabetes, blood pressure issues, and post dates (and in our practice this isn't considered typically until 41 weeks and some women choose to go until 42 weeks). Having a big baby is NOT a reason to induce - research has shown that women with big babies are more likely to be sectioned when induced then if they had awaited spontaneous labor.

Elective inductions (induction for social reasons) are occasionally done with a favorable cervix. However, not prior to 39 weeks since the latest research now shows that baby's brain development may continue up until this point. Elective inductions are typically done when a woman's cervix is very favorable...for example the exam is 3-4cms, 70-100% thinned out, and the head is down low (-1 or better) in the pelvis.

Women who are planning natural childbirth would benefit from avoiding induction. The methods of induction, while they may vary, can be more limiting on a woman who plans natural childbirth. For example, having to be on the fetal monitor continuously while using pitocin or cytotec. A spontaneous labor is much more tolerable than a forced one. While pitocin attempts to mimic a woman's own natural hormone (oxytocin), it's impossible to administer it in the same pulsatile fashion that a woman's brain will do. This often creates a more intense labor, thereby making it more difficult to labor naturally (without pain meds).

Here's what an induction can look like at it's worst...

Day one 6am - Admitted to the hospital. Pitocin started. That evening, no cervical change has occurred so pitocin stopped and woman to rest through the night.

Day two 5am - pitocin restarted. Late morning some change in cervical exam. Water broken. Continue pitocin. That evening, no change in exam. Pitocin stopped and cytotec started through the night.

Day three 7am - cervical exam much more favorable with good change, pitocin restarted. Delivery 5 hours later.

Now, not all inductions are this lengthy, but it's hard to predict in advance how an induction will go.

Being induced is not a decision to take lightly!

Monday, September 28, 2009

Breastfeeding Woes

Jill at The Unnecesarean.com blog is holding a Best of review. One of the posts that really struck me was Dou-La-La's story about breastfeeding her daughter. She faced many challenges but ultimately overcame them. It's an inspirational story, especially for me as I had breastfeeding struggles with my first and second child. It took me three kids to get it right!

Thursday, September 24, 2009

Birth Strategy Class


Our September class was full (and running over). We had a great evening with 13 couples participating in our newest effort to assist families in having the most optimtal birth possible. Register early to assure your spot in this VERY fun and informative class!

Sunday, September 20, 2009

D's Birth Story

D and her husband called me earlier in the night around 9pm. Her husband wanted to let me know what was going on. It sounded like D was in labor with her first baby!

I had met this couple initially in the office and seen them a couple times throughout the remainder of the pregnancy. D had initially expressed an interest in having an epidural for her labor. When I saw her again towards the end of the pregnancy, she told me that she wanted to wait awhile but then would get an epidural unless I would convince her to do otherwise. I didn't - I told her that she was the only one that could make that decision. I didn't see her again until she came in for labor.

When her husband called me, he said she was contracting regularly but could talk when she was having them and they were about every 5-6 minutes. It sounded like they could stay home for awhile still. She had been 2/80/-2 in the office that day when seeing Lylaine. I asked him about her plans for pain management and was she still planning an epidural. He told me not necessarily. Cool :)

I got the call from L&D about 1:30am that D and her family had arrived. She was 8-9/100/-1 and didn't want anything for pain. I got myself out of bed and headed in to the hospital as quickly as I could. When I arrived, she was coping beautifully with her contractions. Her husband was at her side for support as well as her parents. D tried the tub for a bit but then wanted to get out and lay down for awhile. She laid on her side, while I rubbed her back. Eventually her water broke - with a very loud pop and a tidal wave all over the bed! We got dry linens on the bed while D began to feel like she needed to push. I checked her to discover she was 10/100/+1 - and told D that she could push whenever she felt ready too. We were checking the baby's heartbeat intermittently and baby was doing wonderful.

D stayed in a side-lying position to push. After pushing for just over an hour she delivered a beautiful little girl over an intact perineum, weighing in at 6 pounds 14 ounces. Her control during crowning was amazing. Her and her husband did a fantastic job with natural childbirth!

Congrats guys!

(posted with D's permission)

Monday, September 14, 2009

Today show and poor reporting

Unfortunately, the blogosphere is ablaze about the piece, entitled Perils of Homebirth (originally titled Perils of Midwifery), by the Today show. This 'informative' piece tells viewers how homebirth is trendy and unsafe. The focus is on a couple who sadly experienced a stillbirth after a homebirth delivery. It's as if they are implying this would never happen otherwise, and certainly not in a hospital. No one speaks to the rising cesarean rate or the moratlity rates in this country. The Today show clearly does not believe that midwives are the answer to the current crisis in women's healthcare despite ample and sound evidence that says otherwise.


Here are links to other blogs talking about this issue, including ACNM's response.








Our Bodies Our Blogs

*Thanks to Kathy at Woman to Woman Childbirth Education for the code mec button!

Birth Symposium

Birth Symposium
“Building A Better Birth with Midwives and Doulas”

Are you planning a family, pregnant or have you just given birth and need support? Come to the Birth Symposium at Bethany Womens Healthcare to learn about the clinical and support options available to you in the commu-nity. Meet with local Midwives and Doulas (labor support paraprofessionals) to explore options on how you can build a better birth and postpartum ex-perience. This will be an interactive day filled with pampering, comfort measure techniques for labor, information, demonstrations and 30 minute talks about topics surrounding the childbearing year. This is a FREE event and open to the public. Dads & significant others are encouraged to attend.
October 29th, 2009
10 a.m. to 3 p.m.
Bethany Womens Healthcare
3660 W. Bethany Home Rd.
Phoenix, AZ 85019
More info: 602-973-3200 / 602-931-7045

Monday, September 7, 2009

World Breastfeeding Challenge Phoenix, AZ

World Breastfeeding Challenge Phoenix

Saturday, October 3rd 2009

9:00 am-12:00 pm

6932 W. Pershing Avenue
(near Thunderbird/67th Avenue)
Peoria, AZ 85345

Breastfeeding Counts!

Join Phoenix families to celebrate breastfeeding!

*9am-11am: Support local
mom-owned businesses.
Enjoy kids music
and activities.
*11:15am: Be Counted!
Gather on a blanket with your breastfeeding children.
*11:30am: Raffle to Benefit
La Leche League of Arizona

Cash Donations Only Please

Local Businesses who will be on site:
*A Great Little Balloon Company*
*Arizona Diaper Company*
*Cuddlebug Cloth Diapers*
*Free Car Seat Safety Checks*
*Formula Fed America Documentary Director*
*Groovy Kids Music Party*
*Heaven Sent Doula Services*
*Herbal Jules Herbal Clinic*
*Inspired By Finn Amber Jewelry*
*Piggy Paint Natural Nail Polish*
*Lil Boy Blu Kids Clothing*
*Little Treasures and More*
*Modest Middles Nursing Wear*
*Shaklee Healthy Home Products*
*Sunshine Baby Slings*

BIRTH, A Play by Karen Brody--BOLD (Birth On Labor Day)

Why I Became a Midwife - Lylaine

OK. I admit it. My name is Lylaine and I’m a birth junkie.

SO….why did I become a midwife? Guided by the Universe, I guess…and numerous influential women. My entire career has centered on mothers and babies-starting with scrubbing delivery tables in the 1960’s while attending college. I can still picture Mrs. Dodge, the labor nurse in her starched nurses’ cap and white apron, who instructed me in proper cleaning of equipment after each birth (maybe why I feel compelled now to “tidy up” after births). And Mrs. Tidwell, the cherubic nursery nurse who let me rock babies when I wasn’t cleaning (maybe why I feel magnetically drawn to little babies). Next came along Mrs. Bonny, the maternity nursing instructor. She had a way of making each student feel important and confident. She instilled my life-long belief that birth is a miraculous event, a natural process, not an illness. Then while working as an RN in Labor and Delivery at Good Sam, Mrs. Thomas taught me to stay calm in the midst of crisis. There were many others who have contributed to my evolution as a midwife, especially Anne Marie Faxel and Nancy Bolles who were the first midwives I ever met. Joyce Roberts and Lorraine Guyette were marvelous mentors and always made time to “be with” student midwives. Kitty Ernst and Ruth Lubic are others that have inspired and motivated me to continue the advocacy and empowerment of women in pregnancy and birth. The sisterhood of midwives is a marvelous place to be, a network of like-minded souls sharing love and joy with families at such important times in their lives.

Working in Labor and Delivery as a nurse (for about 15 years) solidified my love affair (and fascination) with birth. What I saw in the first midwives I met (at Phoenix Memorial) was an opportunity to get to know women and their families and be “with women” at birth in a more related and deeper way.

Since becoming a midwife, I have learned most of what I know about birthing from women (and their babies). For each and every one of them, I am truly grateful. And to mothers yet to cross my path, I cherish the opportunity to be with each one as I continue to learn from my most profound teachers.

Friday, September 4, 2009

Birth Physiology by Michel Odent

One of our favorite birth advocates, Michel Odent, has some wonderful wisdom and knowledge to share...Read on!

Lylaine

BIRTH PHYSIOLOGY:
AN OVERVIEW
by Michel Odent

What are the basic needs of human mammals when they are giving birth? In spite of thousands of years of cultural interferences, it is possible today to rediscover such needs with the help of a small number of physiological concepts (Odent 2001).

BASIC MAMMALIAN NEEDS

Our current understanding of birth physiology is based on the adrenaline–oxytocin antagonism: when mammals release adrenaline they cannot release oxytocin. We use the word ‘adrenaline’ as a simplified way to refer to the ‘fight and flight system’. Such an antagonism has been understood for a long time and evaluated in relation to myometrial response (Zuspan 1962) and milk ejection response (Whittlestone 1954). The first data have been confirmed by clinical studies among humans (Lederman 1978). Today oxytocin is often presented as ‘the mirror image of adrenaline’. (Uvnas-Moberg 2003).

It is well known that mammals (including humans) release adrenaline in situations such as being scared, feeling observed, or being cold. We can therefore draw the preliminary conclusion that in order to give birth a woman needs to feel secure, without feeling observed, in a warm enough place.

Although the adrenaline-oxytocin antagonism is theoretically established, it is not well-digested knowledge. It disagrees with deep-rooted beliefs. It is still commonplace, in natural childbirth circles, to include recommendations based on the simplistic idea that walking and using the force of gravity will make labour easier. Finding these recommendations strange is not new. As early as 1833, William DeWees wrote that ‘the preposterous custom of obliging her (the labouring woman) to walk the floor with a view to increase the pains when tardy should be preremptorily forbidden’. Today scientific evidence tends to support De Wees’ point of view. Since the prerequisite for labour to establish itself properly is a low level of adrenaline, it is a good sign when a labouring woman does not feel the need to stand up and walk. During the first stage of an easy and fast birth, women are often passive, for example on all fours or lying down. To suggest any sort of muscular activity at that phase can be counter-productive, even cruel.

This belief that a woman in labour should walk can still influence medical circles as well. This is how we can explain the popularity of the term ‘walking epidural’ and also the publication of randomised controlled trials to evaluate the effect of walking on labour and delivery. Of course none of the studies could demonstrate any effect. It is significant that, in the most authoritative of these studies, 22% of the women who were assigned to walking stayed in bed.(Bloom 1998)
In natural childbirth circles, labouring women are also often compared with athletes who are advised to consume large amount of carbohydrates before starting extreme physical exertion, such as running a marathon. Authors of articles about nutrition during labour have suggested that we should learn from sports medicine. Many birth attendants are influenced by these comparisons and encourage women to eat food such as pasta at the onset of labour, and to drink something sweet when labour is established: ‘You need energy!’.

These ideas about nutrition are also in contradiction with our current understanding of the adrenaline-oxytocin antagonism. A low level of adrenaline and good progress in the first stage imply that the striated muscles are at rest. When a birth is as physiological as possible, the labouring woman has a tendency to be immobile during the first stage. When all the skeletal muscles are at rest, such as when the mother is lying on her side or is on all-fours, energy expended is insignificant, and the need for carbohydrates is minimal, insofar as glucose is the favourite fuel of skeletal muscles. The energy expenditure of the uterine muscle is insignificant. Smooth muscles are between 20 and 400 times more energy efficient than skeletal muscles. Furthermore they can easily use fatty acids (rather than glucose) as fuel. In practice there is no risk of fuel shortage for the smooth muscles. The observations by Paterson and colleagues are highly significant. They found that ketone levels were higher in women who had been starved for twelve hours before an elective caesarean under general anaesthesia than they were for women who had been in labour. This confirms that labouring women spend less energy than those who are only waiting for an operation without being in labour.

Comparing labouring women to marathon runners is misleading and potentially dangerous. The side effects of sugar during labour are well documented. There is evidence that when the mother has been given an infusion containing glucose, the risk of lactic acidosis in the fetus is increased and the intensity of jaundice in the neonate is greater (Kenepp et al 1982)..

These theoretical considerations are supported by what we can learn from observation. Mammals in general do not eat during the process of parturition. For several decades, either in a hospital or at home, I have learned from thousands of women who were neither encouraged nor discouraged to eat and drink in labour. Although there are always exceptions, it is possible to summarize several simple observations. The first point is that labour rarely starts when a pregnant woman is hungry. This makes sense since hunger tends to increase the level of catecholamines. Second, when labour is really well established, women do not feel the need to eat.

OVERCOMING THE SPECIFICALLY HUMAN HANDICAP

A specifically human handicap during the process of parturition is the huge development of the neocortex in our species. During the birth process (or during any sort of sexual experience) most inhibitions are related to neocortical activity. In general rational control of the procreative drives is a byproduct of human brain evolution.

The evolutionary process found a way of overcoming this vulnerability. Neocortical activity simply becomes reduced during the birth process. This had not been understood by the Pavlovian physiologists whose theories are, directly or indirectly, at the root of most current schools of ‘natural childbirth’. It is, on the other hand, easily interpreted by those who have the experience of undisturbed, unmanaged and “uncoached” births. When a woman is giving birth easily, without any interference, there is a time when she seems to cut herself off from our world. She becomes indifferent to what is happening around her. She tends to forget her plans and received ideas. She behaves in a way that would be considered unacceptable in the daily life of a civilized woman. When, for example, she dares to scream, or to swear, or to be impolite, it means that there is reduction in neocortical control. She can find herself in the most bizarre, unexpected, and often primitive, quadrupedal and typically mammalian postures. She seems to be “on another planet”. This reduction of neocortical activity is an essential aspect of birth physiology among humans. It implies that labouring women need to be protected against any sort of neocortical stimulation. We must remember the main stimulants of the human neocortex are, if we are to avoid such stimulations.

Language is a specifically human stimulant of the neocortex. When we communicate with language we process what we perceive with our neocortex. This implies, for example, that if there is a birth attendant, one of her main qualities is her capacity to keep a low profile and to remain silent, to avoid in particular asking precise questions. It will probably take a long time for people to realize that a birth attendant must remain as silent as possible. It is difficult to get rid of the after-effects of the Pavlovian theories. Velvovski and other Pavlovian theoreticians had understood the neocortical origins of inhibitions during human parturition. However, probably because they were not practitioners directly involved in childbirth, they ignored the reduction of neocortical control as an essential aspect of birth physiology in our species. They assumed that the practical objective should be to ‘recondition’ women in order to eliminate the inhibitions and to make childbirth painless. From their point of view labour pain is a conditioned reflex, and therefore cultural. Such theories lead to the concept of ‘verbal analgesia’. After visiting the Pavlovian theoreticians in Russia in 1951, Lamaze introduced their concepts in Western countries. This is how the birth attendants started to overuse language and became invasive guides, helpers and even ‘coaches’.

Light is another well-known stimulant of the human neocortex. Electroencephalographers know that the trace exploring neocortical activity is influenced by visual stimulation. We usually close the curtains and switch off the lights when we want to reduce the activity of our intellect in order to go to sleep. This implies that, from a physiological perspective, a dim light should in general facilitate the birth process. These are important considerations in the age of electricity, when we have the power to switch on a bright light simply by pressing a button. It is noticeable that as soon as a labouring woman is on ‘another planet’ she is spontaneously driven towards postures that tend to protect her against all sorts of visual stimulations. For example she may be on all fours, as if praying. Apart from reducing the back pain, this common posture (with many asymmetrical variants) has several positive effects, such as eliminating the main reason for fetal distress (no compression of the vena cava), influencing the process of rotation, and therefore minimizing the mechanical difficulties that characterize human parturition.
Feeling observed is a situation associated with neocortical stimulation. When we feel observed, we tend in return to observe ourselves and to correct our attitude. This is another way to interpret the importance of privacy (i.e. not to feel observed) as a basic need during labour. Understanding the need for privacy makes us anticipate, for example, that there is a difference between a midwife staying in front of a labouring woman and watching her, and another one sitting in a corner. It might also make us anticipate that devices that are perceived by the labouring woman as observing tools (such as a camera or an electronic fetal monitor) should be introduced with extreme caution in a birthing place. The surprise produced by the results of randomized controlled trials comparing the effects on statistics of electronic fetal monitoring versus intermittent auscultation is a symptom of a lack of understanding of birth physiology. It might have been anticipated that the only fact that a labouring woman knows that her body functions are continuously monitored tends to stimulate her neocortex. Stimulating the neocortex risks making the labour longer, more difficult, and therefore more dangerous so that more babies must be rescued via the abdominal route. Photos in books for the general public and videos shown in conferences constitute proof that the need for privacy is not understood by the natural childbirth movements: it is commonplace to see a woman in labour surrounded by several people watching her.

The perception of danger is another possible stimulant of the neocortex. Since in situations of danger it is an advantage to be alert and attentive, neocortical activity is an appropriate response. Analyzing such a situation is another way to consider the need to feel secure as basic during human parturition.

Understanding the solution the evolutionary process found in order to overcome the specifically human handicap in parturition appears today to be a necessary step towards rediscovering the basic needs of labouring women.

BASIC NEEDS DURING THE THIRD STAGE OF LABOUR

Provided there have been no major deviations from the physiological reference during the previous phases of labour, mother and baby share similar basic needs during the third stage. From a physiological perspective there is a key event between the birth of the baby and the delivery of the placenta. It is the high peak of oxytocin that human mothers have the capacity to release immediately after the birth, which is arguably the highest level of oxytocin a woman can reach during her whole life. (Nissen 1995) This peak of oxytocin is vital, since it is necessary for a safe and bloodless delivery of the placenta, and since oxytocin is the main component of the 'cocktail of love hormones' that is supposed to be released in the perinatal period.

Whatever the circumstances, a release of oxytocin is highly influenced by the environment. We must therefore look at the factors that can have a positive or negative effect at the beginning of the mother-newborn interaction. By mixing theoretical considerations and clinical observations we can identify two main groups of factors. At this phase of labour, the vulnerability of mothers to an inappropriate ambient temperature is well known. This is why shivering (a sign of adrenaline release) is a frequent physiological response to an insufficiently high room temperature. In fact, just after the birth of the baby, mothers never complain because the place is too hot, while nonverbally they often indicate that it is not warm enough. The concept of adrenaline-oxytocin antagonism, alongside clinical observation, must bring us to the conclusion that, as soon as the baby is born, the thermo-regulation of the mother must be at rest. In other words, maintaining an appropriate ambient temperature should be the first preoccupation.An undisturbed interaction between mother and newborn is another factor facilitating oxytocin release. During the third stage of labour an appropriate maternal hormonal balance is more easily obtained if, in an atmosphere of privacy, the mother can feel the skin-to-skin contact, can try to establish eye-to-eye contact, and can smell the odour of her baby…without any distractions. Eliminating any distractions is difficult: as soon as a baby is born, there is always an irrational need for activity around; there is always somebody who wants to do something or to say something. This need for activity has been ritualized in many societies. It is impossible to offer an exhaustive catalogue of all the possible ways to interfere with the mother-newborn intimacy. Let us imagine, for example, that a mother is still in such a state of consciousness that she has forgotten the rest of the world while discovering her baby; suddenly somebody appears with two clamps and a pair of scissors in order to cut the cord. This distraction is a dangerous interference with the physiological processes.

At the very time when we are starting to understand the importance of the third stage for the ‘development of the capacity to love’, we have to realize that this particular phase of labour has been dramatically disturbed by all cultural milieus via a great diversity of beliefs and rituals. Furthermore we have to realize that, in the age of the safe caesarean, this phase of labour can be purely and simply eliminated for the first time in the history of mankind.

References

**Bloom SL, McIntire DD et al (1998) Lack of effect of walking on labor and delivery. N Engl J Med; 339: 76-9
**Kenepp NB, Shelley WC et al (1982) Fetal and neonatal hazards of maternal hydration with 5% dextrose before caesarean section. Lancet ii:1150-52
**Lederman RP, Lederman E, Work B, McCann DS (1978) The relationship of maternal anxiety, plasma catecholamines, and plasma cortisol to progress in labor. Am J Obstet Gynecol 132(5):495-500
**Nissen E, Lilja G, Widstrom AM, Uvnas-Moberg K (1995) Elevation of oxytocin levels early post partum in women. Acta Obstet Gynecol Scand 74:530-3
**Odent M (2001) New reasons and new ways to study birth physiology. International Journal of Gynecology and Obstetrics 75:S39-S45
**Uvnas Moberg K (2003) The oxytocin factor. Da Capo Press. Cambridge MA

**Wittlestone WG (1954) The effect of adrenaline on the ejection response of the sow. J Endocrin 10:167-172
**Zuspan FP, Cibils LA. Pose SV(1962) Myometrial and cardiovascular responses to alterations in plasma epinephrine and norepinephrine. Am J Obstet Gynecol 84(7):841-851

Wednesday, September 2, 2009

Homebirth CNM

This CNM has started her own practice in Kansas City, MO. She spent part of her clinicals with us at Bethany last year so I can attest to her skills personally. She's sweet and a fantastic midwife - and that was as a student! You can contact her through her website...

Awakened Birthing

Tiffany

Another fabulous birth

This young woman was having her second baby and showed up to the hospital almost in transition! She had natural childbirth with her first and wanted to do the same with this one.

When I arrived, she was just getting out of the tub. She wasn't feeling too comfortable in there, with her back hurting. She stood in the bathroom for a while with her boyfriend to lean on. Eventually she came out and stood by the bedside, with her mother on one side and her boyfriend on the other. I asked her what she wanted to do and made some suggestions, as she wasn't really sure what or where she wanted to be! She didn't like the idea of hands and knees, and really just wanted to lay down. She requested to be checked as well. She was 9cms with a very stretchy, soft cervix. That's the kinda cervix that tends to slip away if momma starts to do some grunty pushes. I figured it wouldn't be long.

She didn't want to be touched and I think her boyfriend's feelings were a little hurt. I explained to him this was a normal part of birth and some women were a little irritable at the end - nothing he should take personally!

After about a half hour had gone by, she told me she felt like she needed to push. I said go ahead but she seemed really nervous about doing that without me checking her. I waited a bit and she spontaneously started bearing down...she couldn't help herself. She asked me to check her. Of course, she was 10cms and the baby was at a +2 station. The bag of waters was still intact. I told her she could have the baby whenever she was ready. She wanted me to put my gloves on. I told her I would when she showed me the baby :)

Which she did, in about 2 more contractions. I could see the bag, with clear fluid in it and the baby with lots of hair! I threw my gloves on and got ready to catch. I did rupture the membranes once the head was crowning - just made a tiny little hole. She pushed the baby out with great control over an intact perineum. The baby went up onto her chest, while we waited for the cord to stop pulsating.

Tiffany

Saturday, August 29, 2009

Pregnancy loss links

The loss of a child is a sorrowful event, whether it occurs in the first trimester or at the end of pregnancy. Each woman experiencing a pregnancy loss needs to go through the stages of grief. Unfortunately, there are not many resources available to women experiencing a loss. Particularly women with a early loss may find it difficult to locate resources. I wanted to share a couple links...

This blog, The Fifth Element, is by a patient of mine. She uses her blog to tell her story and to work through her grief over her loss.

This post at Our Bodies Ourselves contains links to different stories and resources.

This post offers some helpful advice to dealing with someone who has had a pregnancy loss.

Tiffany

Flu Vaccine (seasonal and H1N1) Q&A

Delayed Cord Clamping

A common request on birth plans, delayed cord clamping does offer benefits for baby.

Immediate cord clamping is part of routine obstetric procedure in the US. This is part of active management of the third stage (third stage being the time from delivery of the baby to the delivery of the placenta), which is considered optimal for reducing risk of postpartum hemorrhage. The cord is often clamped within 30 seconds of birth. However, there is no practice guideline that indicates when cord clamping should optimally occur. A guideline for what 'delayed' is does not exist either. The various research studies on delayed cord clamping use different time intervals, anywhere from 60 seconds to 3 minutes.

Anywhere from 25% to 60% of the baby's blood volume can be found in the placenta at term. Allowing this blood to return to the baby's circulation after birth can provide the baby with a 30% increase in blood volume and up to a 60% increase in red blood cells. This blood volume increase can contribute as much as 2% of the baby's weight!

The benefits

  • Waiting 1-3 minutes in term babies has been shown to result in an increase in Hemoglobin and hematocrit, meaning lower rates of anemia in newborns
  • The difference in Hemoglobin and hematocrit continued to be significant at 2 months and 6 months after birth
  • Ferritin (iron) stores were significantly higher at 2-3 months of age in infants where delayed cord clamping had occurred
  • Delayed cord clamping can increase the rate of hematopoietic stem cells to the newborn, which may play a role in reducing certain blood and immune disorders

The down side

  • There is potential for polycythemia (the infant's blood becomes overly thick due to the increase in volume). The studies done on this show mixed results. However, of significance is the finding that no polycythemic infants were symptomatic or required treatment
  • Several studies again show mixed results regarding hyperbilirubinemia (elevated bilirubin levels cause jaundice and sometimes require treatment with phototherapy).
  • Transient tachypnea (faster than normal respiratory rate in the newborn) may occur as a result of delayed lung fluid absorption casued by an increase in blood volume realted to delayed cord clamping. One study showed that no additional respiratory support was necessary in these infants while another study showed that similar numbers from each group (delayed versus immediate clamping) reuired additional support

FYI

  • Immediate cord clamping is not formally a component of active management for prevention of postpartum hemorrhage. Research provides no evidence that this practice increases the risk of hemorrhage
  • There is some question of where the newborn should be placed to allow optimal transfusion of placental blood. Not much research has been done on this particular topic.

The midwives of Bethany Womens Healthcare routinely delay cord clamping :)

Eichenbaum-Pikser, G. & Zasloff, J. (2009). Delayed Clamping of the Umbilical Cord: A review with implications for practice. Journal of Midwifery & Women's Health, 54(4), p321.

Sunday, August 23, 2009

Prevent Cesarean Section

Reducing Infant Mortality

Reducing Infant Mortality from Debby Takikawa on Vimeo.

A Day in the Life of a Midwife

Typically we do 24 hours of call at a time or a whole weekend, however there are occasional 12 hour call shifts also. I was on call for 12 hours recently...and it was very busy!

0700 Call starts - I'm in bed.

0745 The first page of the day from Labor & Delivery (L&D). Someone's water has broken - which is ok because she's supposed to be having a baby anyway.

0747 Get up and help the husband get the kids off to school. Avoid the whole raised-by-wolves-look by actually brushing the girls' hair.

0815 Think about getting dressed.

0816 Lay back down.

0820 Get up, get dressed in my fashionable hospital scrubs. Go play on computer (blogs, email, etc).

0840 Page from L&D, patient #1 is ready to deliver

0933 Patient #1 delivers

0950 Start making rounds on the two other laboring patients and charting on everyone

1100 Head to postpartum to see postpartum patients and chart on everyone

1145 Grab some lunch in the doctor's lounge and head over to the office

1200 Pull into parking lot of office when L&D pages, patient #3 that just came in at 8cms and feeling pushy.

1201 Bang head against steering wheel

1202 Head back to hospital with lunch in hand

1215 Arrive at patient #3's room to find her smiling and contracting every 6-7 minutes.

1216 Contemplate stepping outside of room to bang head against the wall but opt not to as I have a headache already

1216 Discuss labor support, etc with patient #3. She doesn't feel like getting out of bed at this point.

1220 Call office and tell them I will try to be there by 2pm

1240 Patient #2 is complete and starting to push, I proceed to spend most of the next hour and a half working with her, while running next door to check on patient #3, who is planning natural childbirth

1300 Call office to tell them I will try to be there by 3pm

1400 Call office to tell them I ain't coming.

1438 Patient #2 delivers.

1500 Patient #3 is hurting and just generally not having a good time. She's still the same exam

1515 I get her in the tub and I sit on the toilet. With a chux over it which turns it into a chair. I realize how bad that sounded.

1530 the tub works its magic.

1545 Patient #3 delivers

Meanwhile patient #4 is gradually getting into labor, which was the goal.

1605 Admit patient #5 for labor

1609 Sit down and try to catch up on charts, without mixing up deliveries and patients

1630 The doc wants to know if I will take over his patient as he is going off call and a doc from another practice will be covering (if the patient is ok with this). The patient (#6) has met me before and is fine with me taking over. She has also been stuck at 8cms.

1635 Bang head against the wall

1636 Utilize the magic peanut with patient #6

1645 Sit and catch up on charts

1700 Re-check patient #4 to determine the next course of action. She's definitely in labor now so onward and forward

1715 Sit down and do nothing for a few minutes.

1745 Re-check patient #6 - complete and ready to go!

1800 Call Lylaine to give report as she comes on call for the weekend

1815 Patient #6 delivers

1840 Check on patient #5, who is doing well and making progress.

1855 Leave the hospital

1900 Off call

Tiffany