Saturday, January 17, 2015

Nitrous. Yes, No or Don't Know?

****I do not want this to become a discussion on the safety of nitrous. The evidence is strong and overwhelming on the safety; it has been used for decades with no documented concerns for women or babies. I am wanting to have a discussion about the philosophy of using something like nitrous.****

Several months ago my birth center started offering Nitrous Oxide (N2O) for the use of pain management in labor. This is something that I had been wanting to do for several years. I have been reading about it and researching it for quite some time. The first time I proposed this to the other midwives, it was not popular and was basically 'voted' down. A year or so passed, we had some changes in midwives and I presented the idea again. This time the response was very positive and we decided to go for it. I then did all the necessary things; staff training and education, ordering the equipment, letting our families know complete with educational handouts and consent forms, and all the other technical requirements. And in September of 2014 we rolled it out.

Prior to this, I had never seen N2O used. I was simply passionate about it as a safe option for women. As a midwife, I am committed to ensuring that women have options and are presented those options with true informed consent. I spoke with several people; other midwives, experts in the field and women and felt that it should be an option. At the time there was no other facility in our entire state offering N2O. Since then, one of our local hospitals has started offering it as well. I am very happy about that as it only increases access and choice to the women of my community.

Now that we have been using it, I have several observations from experience. There are things that I really like about it and others that I don't. Overall though I really like this option and am very glad that we have it available. I know for a fact that it has helped to prevent several transfers from our center to the hospital and that is a huge success to me. We have also used it to prevent a transfer postpartum for a laceration repair in a woman with severe anxiety about the process. Here is a little break down of my thoughts so far;

Things That I Like
  • The woman is in complete control.
  • It can be used in the birth pool, sitting on the birth ball, in the bathroom on the toilet, standing at the bedside...you get the point.
  • It can become a sort of focal point that helps her to focus on her breathing.
  • It really seems to decrease anxiety
  • It can be used at anytime during labor
  • It can be used for other indications; laceration repair, third stage, IUD insertions
  • If she does not like it for any reason, she simply stops using it and the effects wear off within minutes
Things That I Don't Like
  • The machine is cumbersome and takes up a good amount of space
  • The scavenging vacuum is loud, it becomes a 'white' noise but is still there
  • The mask can seem claustrophobic
  • It can be distracting for some women to figure out the timing, making it harder to focus on her breathing
Clearly, N2O is not for everyone and sometimes it just does not offer any benefit for an individual woman. It does not take the pain away and so the expectations have to be appropriate. What I have noticed in the social media forums is that there is a definite bias in some of the "natural childbirth" communities against N2O. Bias that using N2O is not "natural birth". That it is a type of cop out or that only women who don't have good enough midwives, support persons or who are not properly prepared would need it. To me, this smacks of judgment, which is something I think that we all as humans need to be very careful of. Judgment runs rampant in our current birth culture and this is just another example of that. So, what do you think? Have you used N2O yourself or have you had clients use it? I would love a positive, open discussion about all thoughts.

Thursday, January 1, 2015

Elemental My Dear

This work, the work of being With Woman, is elemental.

Conception is a spark, bright and warm, in the watery depths of the Mother. A spark fed by the eternal breath of the Creator.

The baby grows and develops in the dark, rich soil of the womb fed by the running waters of the Mother's blood.

Labor is a force of nature! It requires the passion of fire, the gentleness of water, the calm of air and the strength of earth. And let's not forget the Spirit, ever present and supporting.

As a midwife, the element that I most often channel is that of water. I am never exactly the same midwife for every woman. I am always myself (guided by Spirit) and bring with me my fundamental knowledge (supported by the Earth), have passion and compassion for my families and the work (fueled by Fire) and my critical thinking skills (through the lens of Air). However, it is as water that I enter each birth space. Each woman has her own song, her own path and will need me to adjust to her. Water takes the shape of the space it fills and that is how I enter; filling the space as needed. Water is soft, gently supporting and caressing, warm or cool depending on the need. Water is strong, clearing away obstacles and creating new paths. Water is quiet, whispering in your ear. Water is
booming, commanding attention when necessary. Water is my midwife elemental energy.

Midwives and Doulas out there...what is your birth element and why?....

Sunday, December 28, 2014

Stats....300 Babies!

300 Babies! Once again, I am honored and humbled to be in this position serving women and their families. I am eternally grateful for my own family who make it possible for me to do what I love; particularly my amazing husband who is my rock and my own Mother who is my biggest cheerleader and the best Grandma ever! I am also thankful for the birth center, it is a labor love and passion to work at and keep a birth center open, and I am thankful for each and every person who has worked with us in the past and present.

I have kept a detailed birth log since starting as a student midwife. I am committed to maintaining this personal tradition for a few reasons. I love periodically reading back through the birth stories, especially during trying times to remind me why I struggle and fight. I am a writer of sorts and it has now become a part of my process after each birth. And the reason I started keeping the logs in the first place, to have a record of my own outcome statistics. I cannot speak highly enough of this point, as midwives it is our duty to keep these records. Through these records we can objectively look at our outcomes to ensure that our practice is indeed providing the best care. Transparency is critical. I openly share my outcomes, some of which are difficult to share, in the hopes to inspire others and to keep myself honest. I will gladly discuss my outcomes, if the discussion is respectful and from a place of true constructive criticism.

Also, I work in a group practice, please know that these statistics are my own personal outcomes for the births that I have attended and are NOT from my birth center as a while. As a practice, we also diligently maintain and review our outcomes and participate in the national birth center data collection database, Perinatal Data Set or PDR.

Without further delay, here we go;
148 girls and 152 boys; 6 of these sweet ones were born en caul

Postpartum Hemorrhage: my overall rate is 16%, this is high and I have spent a lot of energy into looking at these numbers. (Please see the discussion from "Stats...200 Babies" and the follow up "The Great Chux Weighing Experiment") For births 201-300 I have been weighing each and every Chux pad and recording the actual EBL down to the ml. What I discovered is that for the first 200 births, I was over estimating EBL. Also, I have been more thoughtful about what actually constitutes a PPH. One woman may lose 700ml but not require any anti-hemorrhagic medications and not develop any symptoms of high blood loss. On paper, she technically has a PPH, but did she really? I would love to discuss this question....

Shoulder Dystocia: overall rate of 6%. This is another outcome that seems very high! However, in looking back, the vast majority were mild and under 60 seconds from birth of head to birth of the body. Some practitioners may not even consider those as dystocias. In looking at each birth, if I only
included times greater that 60 seconds and births that required more than one maneuver to relieve,
then my overall rate would be 2.3% which is much more appropriate. I think that I have been too quick to "label" these births. Again, would love a discussion on this topic.....

I preformed AROM in 13% of labors and it was always done as augmentation and with informed consent after discussion with the woman and her family.

I have had 6 retained placentas. In my birth center, per state regulations we have a time limit of 30 minutes for the birth of the placenta.

I have done a manual removal of the placenta twice, both times were for active heavy bleeding related to partial separation. I have had 4 cord avulsions, only one was severe and required newborn
transport. I have found one true knot in an umbilical cord. I have had one labial hematoma, which
resolved on its own and did not require transport.


My episiotomy rate is 3%. All of the episiotomies were done due to significant fetal heart decelerations with crowning. Approximately, one third of them extended to third or fourth degree lacerations.

Lacerations; intact = 102, first degree = 87, second degree = 95, third degree = 12, fourth degree = 4. For the vast majority of the third and fourth degree lacerations, they were either as a result of episiotomy or the birth happened on the birth stool. I have recently been actively working against birth stool birth for this reason, and that I have noticed higher blood loss. I still use the birth stool in second stage, but as birth approaches I encourage the woman to change positions.

My water birth rate is 37%.
Birth positions (I have rounded these rates up or down to the nearest whole number); hands and knees = 30%, semi-reclining = 17%, birth stool = 17%, McRoberts =14%, squatting = 11%, side lying = 9%, standing = 1.5% and supine = 0.3%.

I have transported 12 newborns; 7 for Transient Tachypnea, 2 for anomalies, 1 for congenital pneumonia and 1 for pneumothorax.

I have transported 27 women after the birth; 16 for laceration repairs, 5 related to PPH and 6 for retained placenta.

So there it all is. In the next couple days, I will post an update with my outcomes for transfers in labor, those births are not included in these numbers. I am ready and open for discussion...

**Update on 12/31/14**
I have just finished compiling my outcomes for the Ladies that I have transferred. At my birth center, when transfers are necessary, we work with some amazing OB's and are very lucky to have them. One of them actually does vaginal breech births! Also, once a client has transferred, we are no longer involved in the clinical management of their care.
Here goes: 39 women have been transferred by me to the hospital in labor. The primary reason was failure to progress or arrest of dilation. We do not have time limits on progress and our ladies are not on any type of clock. The decision to transfer for this reason is one based on how she and baby are handling the labor and is one made in conjunction with the entire family. They are not typically quick decisions and have a lot of thought behind them. The other major reason for these transfers was the presence of meconium in the waters. Per our state regulations, we are required to transfer for this reason unless "birth is imminent". Of those women who transferred, 18 had cesarean sections and one gave birth via Forceps assisted delivery. This gives me a c/section rate of 5.3%.

Monday, November 17, 2014

Aquarium Nets and Naked Men


Or, Laughing Through Transition. Every birth, every woman, every family and every baby are different. Some birth songs are fierce, some are soft, some songs are shy and some are boisterous. Each one is unique. The wonderful Ina May Gaskin has noted that the cervix and the mouth/jaw/throat are intimately connected during labor. If we can relax the throat and mouth it can often have a positive impact on the cervix. Nothing relaxes the throat better than a good laugh. As a midwife, I have seen this principle in action many times. I recently had the pleasure to attend a birth where laughter was the best medicine.

The couple was beautiful; connected, strong and confident in each other. The picture they painted was blissful. They worked through the labor together, walking around the center, bouncing on the birth ball and finally while she was in the birth pool.

I have to give some background now. At our birth center, we have a class called the 34 Week Midwife Chat. It is required for all of our families and covers things like when to call the midwife, what to expect when you get to the birth center, labor, birth and postpartum processes and transfer protocols. Talking about transfers is always a heavy conversation. So after we cover those, we like to end on a positive note and talk about the “Rules” at the birth center. The Rules are a little silly and are intended to make the class attendees giggle. Examples include; No naked people other than women in labor and newborn babies, No pot smoking at the center and No pets (dogs, cats, ferrets or iguanas) allowed. All the rules were created in response to actual situations….

So, this woman is in the birth pool, transition is imminent and her husband asks me to share the reasons why we have the “no naked people” rule.  There are two stories, both are true and may or may not have happened at our center. They both involve the male partners of a woman in labor. (There are other stories that involve other people but I will save those)

Story One (for our protection): A woman is in the birth pool, the midwife is kneeling in front of her, face to face with her. Behind the midwife the soon to be Dad is very excited and asks, “Is it time for me to get in the pool too?” The midwife replies that sure he can get in now. Remember that her back is to him as he prepares to get in the water. The next thing the midwife knows, the very naked man is literally stepping over her to join his wife in the pool….she literally got an “eyeful” so to speak.

Story Two (for your protection): A woman and her husband are in the birth pool. They are both naked. Often, in the second stage of labor women will pass stool, this is completely normal and actually a wonderful sign that everything is progressing normally. When this happens, we use a little aquarium fish net to discreetly scoop “things” out of the water. Well, a nurse thought she saw something in need of scooping at the bottom of the pool and used the fish net to try and retrieve it. Let’s just say that it was not what she thought it was. It was actually something firmly attached to the soon to be Dad and not something in need of retrieval.

These stories had the woman laughing and laughing, right on through transition. I think her husband knew that laughter would help her through this part of labor and wisely asked me to tell these stories. And shortly thereafter we all welcomed a sweet water baby earthside.
 
P.S. We buy our aquarium nets from a local pet supply store. One of my nurses was getting some and the cashier (a young man) asked her why she was buying so many. She politely told him that he really didn't want to know. He persisted and she finally told him, in full detail, what the nets were for. He very seriously replied, "You're right, I didn't want to know that."

Friday, November 14, 2014

Our Government in Action?....

I recently attended the national American Association of Birth Centers (AABC) conference in Washington DC. Part of the conference was a Lobby Day, where attendees visited their state representatives in person to educate them on birth centers and issues that we face.  It was a great experience, myself and the owner of our birth center were able to meet with one congressional representative and both of our Senators. We had prepared packets of information about us specifically as well as the materials that the AABC had put together on birth centers in general. We did have an experience, however, that I believe is a lovely metaphor for the dysfunction in our current government.....

We first visited with a Congressman. After we checked in I realized that I had accidently left the extra copies of one of our documents at the hotel.  I asked the Intern at the desk if it would be possible to get two copies of this one sided, standard sized page. He was very polite and said that he could. This Intern looked to be in his early to mid twenties, was dressed very professionally and I assume that as a White House Congressional Intern is either in the process of, or has just finished a high level of college education. For the next 20 minutes, in my peripheral vision, while waiting for my appointment I watched him attempting to make me two copies. He went back and forth between a copy machine and fax machine and eventually had another Intern come help him. Between the two of them, the confusion seemed to increase. Eventually, he approached me very apologetically to say that he was only able to make me 1 copy. Now, in my opinion being able to only make one copy is kinda worse than not being able to make any.....I graciously took my one copy and thanked him for his effort.

Next, we went to the office of one of our Senators. This office also had Interns, this time they were female but also appeared to be in their early to mid twenties and I assume also are/were in process of upper level education. After checking in for our appointment, I asked if it would be possible to get one copy of my document. I was very politely informed that the Senators office does not make copies for the public.

So, there ya go. One group wanted to help me and tried and was only able in the end to partially help me. The other group just wouldn't help me. What do you think? Does that sum it up nicely?

Tuesday, August 26, 2014

#LifeOfAMidwife:Struggles

This life is not for the faint of heart that is for sure! Here are some examples of issues often not talked about....

My low beam headlights are out, they have been out. I have been driving at night with the high beams. When will I be able to make it to a garage to have them fixed? Good question!

My oil needs to be changed, see above....

My daughter had her first day of third grade last week, I was not able to drop her off or pick her up. Daddy and Grandma were there, but I was not.

I think I have friends...somewhere out there in the regular world. It has just been a while since we have seen each other.

At my birth center, we have to fight everyday to stay open. Insurance companies don't want to pay us, hospitals are threatened by us and can make life very difficult. The relevant government agencies don't support us and seem to actually hurt us.

My bank account is sad. I make significantly less money than my peers who work at hospitals and don't even get me started on student loan debt.

I wish that I could serve more women and that getting paid didn't matter, but it does. I have a family to support as well.

And yet, to me I have the best "job" possible. I don't want to whine too much, after all, I made a very conscious decision to follow this path and answer this calling. I believe that there are much more important things in life than wealth, however, that does not mean that the struggle doesn't get exhausting sometimes. Why should supporting women and their families be so hard?.....

Tuesday, June 17, 2014

#LifeOfAMidwife: Fluidity

The phone rang, I am hopeful that it is a woman in labor. It has been a couple weeks since I was able to catch a baby, and I feel the urge tickling in my fingers.

I can tell instantly from her voice that this is not the reason for her call. She is early in her pregnancy and experiencing spotting, she is nervous and concerned. We talk. I offer her reassurance and comfort; based on her symptoms this could be nothing or it could be everything. After our discussion, we hang up the phone with plans for her to call me with any needs or changes in her symptoms.

Mere moments later, the phone rings again. This time it is a Mama in labor. Her man is the caller and I can hear her in the background working with her labor. We talk. It is still a little early in the process, so I offer reassurance and comfort. We review labor patterns, I encourage good hydration, eating a light meal and movement. We hang up the phone with plans for them to touch bases with me soon.

Another call, the first Mama. Her bleeding has increased, she is crying, she has questions. We talk. I offer her comfort and a shoulder to cry on; I tell her that now her symptoms are likely a miscarriage happening. Based on those symptoms and the timing of her pregnancy, I recommend that she go the hospital for an evaluation, she agrees.

A short while later and the phone is ringing again. The laboring Mama is ready to come in. When they arrive, she is beautiful, alight in that sweaty glow of labor.  She and her man are working together in such a sweet way.  She progresses well and has a sublime waterbirth to welcome her babe Earthside. It is a birth that feeds the soul of the world. They are then snuggled up in bed, safe and warm.

A final call, the other sweet Mama is now home from the hospital. She has indeed lost her baby, she is heartbroken. We talk, mostly I listen. There are no magic words for these experiences, the only healing is through time. Having someone to listen and simply be present is the support we can give. We then schedule an appointment for her to come in, so we can give her more love and help her through this process.

This is the life of a midwife.....