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

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.

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.

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

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?

______ 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.

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


Saturday, October 3, 2009


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!