Saturday, November 24, 2012

Putting Yourself Out There

Putting yourself out there is very difficult.  I think it is important, but hard none the less.  As a birth who often struggles with the apparent lack of accountability in US maternity care, I feel that it is a duty to be open and transparent with my own stats.  In publicly posting my stats I knew full well that I was opening myself up to criticism.  My hope was the the criticism would be constructive, aid in my own introspection and help me to improve the care that I give.  For the most part this has been true.  I participate in a forum that is closed to the public and made up only of other birth workers, particularly but not solely, out of hospital workers.  I shared my stats blog post with the group.  I felt that I was prepared for some good discussion and mostly that is what I got.  Many of my numbers were questioned and "called out".  At first, it felt constructive and the discussion was valuable to me.  The very numbers that had troubled me, were the same ones that caused questions from the group.  Then, after a while it started to feel less and less productive and little more...hostile is not quite the right word but the closest that I can come up with.  This was most likely not the intent, and I am trying not to be overly sensitive about it all.  But it is not easy...I have a tendency toward being over sensitive and I know this about myself, so am constantly trying to balance my reactions.  I do not regret putting myself out there and am ultimately gratefull for the discussion.

One of the things that surprised me in the discussions was that most of the participants have never done their own stats.  I found this to be true with other people also, ones that I discussed my "project" with in person.  This surprises me.  How can we maintain standards and improve outcomes if we do not objectively look at our stats?  Before doing my numbers, I would have thought many outcomes were different.  Looking at them in black and white really puts things into perspective and has been invaluable to me.  As I said, this process is not necessarily comfortable and more than a little intimidating.

So, to further my process, I will delve into the "number" that caused the most concern in the forum group, postpartum hemorrhage (PPH);
Initially, I listed 33 PPH's, which worked out to be 16.5%.  That is a high rate!  I went back to really analyze the data.  After doing this, the number of PPH's that required intervention (medication) and/or caused symptoms (low BP, dizziness, etc) in the women was 12 which equals 6%.  Better, but still  high!  Where would this high rate come from?  The vast majority of our ladies are well nourished and healthy.  Our practice recommends nutritive herbs and 65-75grams of protien per day.  For the most part, births are physiologic with woman directed pushing, I practice immediate skin to skin care and baby led breastfeeding, third stage is physiologic and the cord is clamped after the birth of the placenta.  All of these factors should help to decrease the rate of PPH.  All throughout my training, I was taught that providers routinely underestimate the amount of blood loss.  Perhaps, I have over compensated for this and now over estimate.  Sometimes, especially when there appears to be a lot of blood loss, I will weigh the chux pads.  So for those cases I do know the actual amount.  I have two thoughts now; 1. if providers do routinely understimate blood loss, then it seems possible that the actual rate of PPH my be higher, and 2. is the current accepted definition of PPH (loss greater than or equal to 500cc) appropriate?  I have been very particular about noting any EBL over 500 as a PPH, the majority of my 33 were 600-800cc and caused no problems for the mother.  So, what is a midwife to do?  Well, it appears that this midwife will begin weighing ALL the chux after ALL the births and attempting to get a handle on the actual number of blood loss.  Stay tuned for results of my experiences in chux weighing..........

Finally, I would like to throw out a challenge; please keep records, please compile them on a regular basis, please use them to improve and strengthen your practice!!


  1. Thank you for being a role model for us all.

  2. A little update.....since I have started my great chux weighing project, I have caught 8 babies. Once I get to 10, I will discuss the results. So far, it has been a good experience and I am so glad that I am doing it.