Wednesday, November 28, 2012

Taking Her Time

Sweet baby girl waited 42 weeks for her birthday, then couldn't wait to make in to the birth center for her birth!  Her Daddy called me after his wife had one hour of labor.  They live a bit away, so I told them to go ahead and come in.  He called me back an hour later, giddy with excitement, to tell me his daughter had just been born in the car.  I could feel his joy through the phone line and it was contagious.  Everyone was healthy and well.  The only bummer was for me....I had really wanted to be their midwife!

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!!

Monday, November 12, 2012

Stats...200 Babies!

I can hardly believe that I have been blessed to catch 200 babies.  As I sit here writing this, I am overcome with gratitude.  Gratitude for all the families that have shared their births with me, gratitude for all of my teachers along the way, gratitude for my own amazing family and gratitude for the birth center itself.  Back in April of 2011, I reached the milestone of 100 babies and decided to calculate some personal stats.  It was very informative and I decided to go through the same process every 100 births.  The stats that I list are not for the birth center as a whole, but only the stats for the births I personally attended.  I have combined the results from 1-100 with the new 101-200 to give a total.  Here goes;

100 boys and 100 girls (what are the chances of that?!?), 5 of these were born en caul (2 girls and 3 boys)

There were 33 cases of PPH (16.5%), the vast majority being less than 1,000cc

There were 10 Shoulder Dystocia's (5%), however 3 were very mild and easily relieved by 1 position change

I performed AROM in 34 labors (17%), primarily this was done for augmentation of labor.

I had 5 cases of retained placenta. (At our center, per state regulations, the cut off for retained placenta is 30min.)

I performed 1 manual removal of a placenta at the center secondary to hemorrhage, also for that birth I performed bi-manual compression while en route to hospital.  I had 1 cord evulsion, found 1 true knot in a cord and had 1 labial hematoma.  The hematoma was not severe and resolved on its own.

I have performed 7 episiotomies (3.5%). Two of which extended to fourth degree lacerations. All were done for significant fetal heart rate decelerations during crowning.

Intact perineums = 75, first degree lacs = 59 (about half requiring repair), second degree lacs = 56, third degree lacs = 7 and fourth degree lacs = 3

8 newborns were transferred to the hospital; 6 for TTN, 1 for congenital pneumonia and 1 with severe anomolies.

17 women were transferred PP; 5 for retained placenta's, 3 related to PPH's and 9 for repairs of extensive lacerations.

My water birth rate is 36.3% (for 21 of my catches, water birth was not an option per the site)
Birth positions: semi-reclining = 35, hands and knees = 58, birth stool = 36, McRobert's = 29, squatting = 21, side lying = 18, standing = 3

Additionally, something that I did not keep track of for the first 100 births, was my rate of intrapartum transfer.  I have since started keeping track of those numbers. Since April of 2011 through November 8 of this year, I have transferred 24 Mama's that were in labor, none of them were emergent.  (These 24 are not included in the above numbers.)  Of those ladies transferred, 11 required a cesarean section.

So, there it is in a little nutshell.  It really is an experience to go back and look through these numbers.  In reviewing my birth logs, I get to re-visit these births and families.  Overall, I feel good about my outcomes and am glad to share them. 

Sitting on My Hands

Right now, literally, I am precepting a wonderful new midwife.  She is guiding a lovely first time Mom through second stage.  I am down the hall, well within hearing distance (don't worry though, the Mom cannot hear my typing ;)), trying very hard not to be over her shoulder.  We have worked together for years, we both started here at the birth center as nurses.  She is more than capable, she is fantastic, she is doing a great job.  I am going crazy out here.  I have precepted many students by now, and find that role easier and easier.  With a student, I am still ultimately "in charge" and am always present in the birth room.  This is different and new for me.  She is a midwife, on her orientation and needs to be completely independent...she need to know that I am here, but that she can do this all on her own.    Wish me luck on my process of sitting on my hands.....