Saturday, August 29, 2009
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.
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!
- 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
- 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
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
Uterine rupture is catastrophic if it occurs. It can result in fetal and maternal damage or death. However, the early stages of research included women who had one or more sections, women being induced with prostaglandins (cytotec, cervidil, etc) and/or pitocin. So trully the early research was not an accurate picture of the risk of VBAC. Again, true to obstetrical history, everyone jumped on the bandwagon and stopped offering VBACs.
In the past few years, research has been refined and continues to be improved upon in this area. Now, research tells us that women can safely and effectively VBAC when certain criteria is met. Recently, Obstetrics & Gynecology released a study that yet again found positive outcomes associated with VBACs and negative outcomes associated with elective cesarean. This journal is also known as the 'green journal', and is associated with the American College of Obstetricians and Gynecologists (ACOG).
So research shows us that women having elective repeat cesareans are more likely to have infants with respiratory distress, have less children than women having vaginal deliveries, increased risk of stillbirth, increased risk of placental abnormalities in future pregnancies...not to mention all the risks of having major abdominal surgery (infection, hemorrhage, damage to organs, death). And this is just a brief overview!
For more information regarding cesarean sections and VBACs, check out these links...
Childbirth Connection - Cesarean Sections
Childbirth Connection - VBAC versus Repeat C/S
Sunday, August 16, 2009
While raising four children and working, I left my job as an office manager and returned to school. I went to a community college where I received an Associate of Science degree in nursing. I worked as a Labor & Delivery nurse while earning a Bachelor’s degree from Northern Illinois University and finally a Master’s of Science in Nurse-Midwifery at University of Illinois at Chicago. As a life-long resident of Illinois who was dying to get away from the cold winters, I luckily found a position at Bethany Womens Healthcare in Phoenix. Along with my husband and four children, we packed up and moved across the country.
I feel very lucky to have found a position in a practice with other midwives who share my passion. I hope to educate women about their own health and about the natural event of childbirth, to be a guide and counselor through one of life’s most dynamic passages. I hope to make a difference in women’s lives, the way my midwives made a difference in mine.
Saturday, August 15, 2009
On Tuesday night D called, my new postpartum client. She was worried about her milk supply and is supplementing with formula on the recommendation of the hospital nurses. I sort of gently reminded her that breastfeeding is supply and demand and in order to increase her supply she needs to nurse, nurse, nurse! And also relax! Because so often I see women and they're so tense. They're fretful about the positioning or the baby not latching right away or the baby not nursing for very long and you can see the beads of sweat forming on their brows. But if you can relax and let go and let it flow....you probably will! Same with labor - if you're all tense and tight and holding your breath and clenching....that completely goes against what your body is trying to do - open up.
We talked about how, if she is going to continue supplementing, then for each supplement she needs to pump. Your boobs don't know the baby is getting formula so how will they ever know to make enough milk? I mean obviously I don't want her to be supplementing with formula to begin with - this is another "intervention", "risk", whatever you want to call it of birthing in a hospital with a typical OB and an uneducated nursing staff versus either birthing at home with a midwife or birthing in a hospital or birth center with a supportive team that you love and trust. Hospital staff are all too often completely ignorant about breastfeeding. So they of course encouraged her at the hospital to supplement with formula because she had a 9 pound baby and couldn't possibly make enough milk to satisfy such a big boy's appetite. First of all - way to set a mom up mentally! And second of all - what a great evolutionary design! Let's make women's bodies inadequate so that they don't produce enough milk for their babies. I understand, yes, sometimes there are issues with supply. But in most cases our bodies are perfectly designed to feed our babies a more than satisfactory amount. I just wish people would try more things instead of going straight to formula. But it's just like with birth - I wish people would try more things before going straight to a cesarean. But then you have the ultimate issue - going straight to formula is way easier (for the doctor, nurse, hospital staff, etc. not for the mother obviously) than sitting with a woman for an hour and helping her to relax, reassuring her, helping her find the right position, etc. And going straight to a cesarean is way easier (again for the doctor, hospital, etc.) than having her labor longer and staying with her and helping her walk or change positions or helping her to open up about anything emotionally that she may be holding on to.
Now this is often the hardest part for me about being a doula - to be able to communicate effectively with my moms in a way that is educational and informative, but doesn't make them feel like they have done or are doing anything wrong. And I always try to take an attitude of 'you know, let's acknowledge what we maybe could have done differently and let's deal with any emotions regarding that (I'm not a big fan of denial), but let's move on and focus on what we can do now'. I think this is actually harder for me because I generally just blurt out whatever I am thinking at any given time. Trust me, my husband has spent the better part of our three year marriage trying to teach me "tact". And boy, can I rant and rave with the best of them. It's just another way that being a doula has made me a better person. These communication skills I've learned serve me in all aspects of my life. Anyway, I encouraged D on the phone and she seemed to feel better just talking it out. We set up a time for me to come over the next day."
To be continued...
Tuesday, August 11, 2009
I don't think that money is always the motivating factor. At least not in terms of making it. I think providers who jump to c/s are more concerned about the loss of money as well as practice, in the form of a lawsuit. I think for this policy to be successful, some changes to the malpractice environment also need to be changed. I am certain we weould see an impact on the section rate from that as well.
Please share your thoughts!
Monday, August 10, 2009
Please feel free to email blog posts or requests or questions and we will be happy to post as appropriate. Email here
Saturday, August 8, 2009
S came in the day before the induction was scheduled with increasing contractions that felt stronger. Her exam was basically the same so I offered to go ahead and break her water, which she promptly agreed to :) There was clear fluid and the baby was quite the happy camper so I sent S off to walk. I wanted her to wait until the contractions were becoming more uncomfortable before using the jacuzzi tub. She walked for a bit with her boyfriend and I attended to someone else who was also laboring naturally for a bit (it was a busy 6 hours of running back and forth between the two!).
After maybe an hour, S was starting to feel more intense contractions about every 3-4 minutes, so in the tub she went. She stayed in the tub, doing squats or just lying back resting. After some time had gone by, her contractions seemed to be spacing out a bit and less intense, so I suggested walking again. I suspected that the baby may have been OP or 'sunny-side up' due to the back pain she was experiencing and the fact that labor wasn't progressing quite as fast as I thought it would (shows how much we can predict these sorts of things!).
The walking seemed to do the trick, as her labor began to pick back up again. She was also feeling a little pressure so we decided to check her cervix prior to getting her back in the tub. She was 7/90/-1 which was great progress. Things began to really pick up speed at this point. She stayed in the tub for a bit. The night shift nurse came on around this time, and happened to be a very NCB friendly nurse by the name of Kim. Fortunately Kim was able to sit tubside when I would need to leave to check on my other lady. Unfortunately, I would come back to find S getting more agitated and restless. I would then sit with her and she seemed to become a little more at ease. My other lady got an epidural around this time so was able to focus more time on S.
S started to feel more pressure so we got her out of the tub and checked her - she was now 8-9/100/0. But she was definitely hitting that transition phase. She was starting to say 'I can't do this Tiffany' over and over. She was becoming very restless. I got her back in the tub. She was asking for pain medicine but I had told her that it was too late...that she was moving along quickly now....she could do this even if it felt like she couldn't. Maybe fifteen minutes later, she started pushing in the tub. I decided to attempt to check her while in the tub as I didn't want to make her move unless it was time for the birth (unfortunately, we are not doing waterbirths...yet). She was definitely ready - 10/100/+1-2. So she got out of the tub and wanted to sit in the bed to push. She pushed for maybe 10 minutes, the entire time telling me that she couldn't do this :) She pushed out her first daughter with wonderful control over an intact perineum!
The first thing she immediately afterwards?
"I did it!"
Wednesday, August 5, 2009
IMPLANON is one progesterone rod, about the size of a matchstick. It is inserted in the upper arm, and is effective up to three years. IMPLANON is reversible and can be used in women who have never given birth. It is also safe for use in women with a past history of pelvic infections.
IMPLANON works by suppressing ovulation, increasing the cervical mucus, and decreasing the thickness of the uterine lining. It is greater than 99 % effective.
The most common side effect is random vaginal bleeding or spotting. Some women will experience absence of menstruation. Each woman's experience will be different and the bleeding pattern cannot be predicted.
If this method sounds like it might be a good fit for your lifestyle, please call for a consultation. If you decide this is the method you want, our office will start the insurance authorization process and order the IMPLANON.
Jeanene Traynor BC-WHNP
Tuesday, August 4, 2009