The Great Chux Weighing Experiment

For the complete background on this issue, please refer back to two recent posts: "Stats....200 Babies" and " Putting Yourself Out There".  Briefly, back in November, I was lucky to catch my 200th little babe.  Afterward, I put together some statistics from those births.  Some were expected and some were not.   One thing that surprised me was the rate of PPH.  (Again, for the full story please read the posts mentioned above.)  Since that time, I have been weighing every chux after every birth, and I just baby #210.  So, I thought that I would post an update:

Birth #201: EBL 200cc (my guess was 150)

Birth #202: EBL 100cc (my guess was 100)

Birth #203: EBL 500cc (my guess was 400), this Mama had no negative symptoms so I did not call it a PPH because it was not more than 500...

Birth #204: EBL 200cc (my guess was 250)

Birth #205: EBL 150cc (my guess was 150)

Birth #206: EBL 150cc (my guess was 200)

Birth #207: EBL 900cc (my guess was 850), this was a second time Mama who had a precipitous birth, she did have some symptoms and received two different anti-hemorrhagic medications.  She stabilized and finished her recovery at the birth center before going home.

Birth #208: EBL 2500cc (this is not a typo!), this primip Mama lost 1900cc at the birth center and was transfered to the hospital where she lost an additional 600cc.  She had a long-ish labor of over 15 hours, and a long-ish second stage of 3 hours and 15 minutes, third stage was 20 min.  She had SROM'd 18 hours prior to the birth, had been afebrile and the fluid was clear.  Baby was term and weighed 7# 15.5oz.  Initially, with the placenta she lost 700cc, received a dose of IM pitocin and stabilized.  Then at 1 hour and 45 minutes PP, over the course of 15 minutes she lost another 1200cc.  During that time, she received an IM dose of methergine, cytotc rectally, an IV was started and a foley catheter was placed.  She was very symptomatic and an ambulance was called for transport.  Upon arrival to the L&D unit, she had stabilized.  She was taken to the OR and a 600cc clot was removed from her uterus.  Then she completely turned the corner and had a good recovery...after receiving 2 units of blood.  An obvious cause for her PPH was not identified, there was no hidden laceration, the placenta and membranes were intact.  She is a healthy 25 year old who had had a completely benign prenatal course.

Birth #209: EBL 100cc (my guess was 150)

Birth #210: EBL 950cc (my guess was 900), this primip Mama had a precipitous labor with a hard second stage.  Her little one had double compound hands and she really had to work him out.  Baby was term and weighed 8# 10oz.  She had PROM'd about an hour before her labor started, she had been afebrile and the fluid was clear.  She received an IM dose of pitocin, then had some more bleeding and an IV was started with pitocin in the bag and she was straight cathed (she was unable to urinate in a bed pan or to walk to the BR).  She then stabilized and finished her recovery at the birth center before going home.  She is a healthy 25 year old who had had a completely benign prenatal course.

So, yuck...three big PPH's out of those 10 births!  Now, hopefully I won't have another one for a long, long time.  I have noticed that these things usually happen in clusters, so I am hoping for that.  In general, our Mama's have good diets, we recommend 65-75gms of protein per day and have the ladies do dietary recalls for us.  We recommend nutritive pregnancy herbs and regular exercise.

What I did learn from this experiment is that my EBL "guessing skills" are just ok, with a range of 50-100cc's off.  I found it to be much easier to estimate the loss when it was lower.  Thoughts?.....

Levitation

Ask and you shall receive....

Kim is preparing to welcome her second child.  The room is full of love. Represented by friends and family members, the seams are bursting with it. Smiles are everywhere to be found.  Kim and her family had been at the birth center earlier in the day.  She was in early labor and had gone home to rest.  Now they were all back and eagerly awaiting the baby's debut.  Kim was in the pool, gracefully laboring.  Her husband was at the side of the pool, a strong reassuring force and source of support and comfort for Kim.  He was a true Papa Bear.  Kim began to push and soon she was crowning, then the head was born, pink and healthy.  But then, babe was held up, he seemed "caught", but not by his shoulders.  I calmly and firmly told Kim that she needed to get out of the pool.  The very next thing I knew, Kim literally rose up out of the water and over the side to the floor.  It happened so quickly that I was left behind, still crouching over the edge.  Hurriedly, I went to her and discovered the problem.  Babe had two tight loops of cord around his neck.  He was still pink, but wanted to be born.  The loops were so tight that they could not be uncoiled and I really did not want to clamp and cut them.  So, I asked for quiet in the room, which I instantly got and told Kim to focus.  We took a breathe together and I told her to push out her babe. With her push I guided the baby's head in toward her thigh and his body came out.  He was still wrapped up, so before she got off her hands and knees, I unwound him.  Soon the room was filled with the squeals of new life and joyous welcome.

How had Kim levitated out of the pool?  Her husband had literally, in one scoop, given me exactly what I asked for...Kim out of the pool!

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!

Putting Yourself Out There

Putting yourself out there is very difficult.  I think it is important, but hard none the less.  As a birth worker...one 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!!

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.....

And what is this?.....placenta?!?....

So, as I work at an out of hospital setting, it is logical to assume that I believe in natural, physiologic birth.  I believe strongly, that most of the time, if well supported a woman and her baby will safely navigate the birth process together.  However, sometimes this is not the case.  If you are a reader of this blog, you will have already read some of my stories that discuss less than optimal situations.  Fortunately, by the grace of the divine, my learned skill, years of training, the amazing nurses,  our healthy low risk population and a sprinkling of luck I have not had a "bad outcome".  I also know that, if one works in this realm long enough, it is more and more likely to happen.  My reasons for sharing this story are complex and I have thought long and hard about whether or not to do so.  In the end, I have decided to share it.  Not to tout the "crazy" things that may happen in an out of hospital setting. But to highlight that even in an out of hospital setting, when a trained and skilled provider is present, many unexpected high risk scenarios can be handled safely and well.

 At our center, we do not require that Mama's get any ultrasounds.  We believe that ultrasound is a tool, to be utilized thoughtfully.  I will say that a majority of our clients do get one ultrasound, the traditional 20 week anatomy scan, but it is optional.  If something comes up during the course of a clients care, for example: bleeding, her fundal height measuring too big or too small, we will request that she get an ultrasound.  Other clients may get an early ultrasound to establish a due date if we don't have accurate menstrual or ovulation information.  And if a Mama goes into her 41st week we will use the ultrasound to get an AFI (amniotic fluid index) level. ***I do realize that there is controversy around the use of AFI to assess fetal and placental status, but in our community it is the standard of care so we include it our assessment.*** Recently, I attended a birth that caused me to seriously question my stance on ultrasound...

Sue and her husband are open, intelligent people with a beautiful family.  She is very involved in the local birth community as a doula and educator. They are preparing to welcome a new child to their family.  She has been rumbly for a day or so and we decide to have her come in and check things out.  She arrives with her husband, children and a friend/doula.  She is in labor, but it is still a little early.  My student checks her cervix and finds it to be about 3cm.  We all decide that Sue and her family will go home and return when her labor has picked up.  My student goes home to sleep and I go lay down in our midwife sleep room.  About two hours later my phone rings and it is Sue's husband, I can hear Sue in the background and tell him that they should just head in.

When they arrive, it is clear that Sue is ready to begin pushing.  The family gets settled and I listen to the baby's heartbeat, a strong and steady 140bpm.  Many times when a multiparous woman starts to push, I will not check her cervix, however, this time I felt that I should.  Sue layed down on the bed and I checked her cervix, which was completely dilated and effaced, the baby head was at 0 station.  However, there was also something else presenting, a soft, spongy, "tissuey" something from about 12 o'clock to 3 o'clock.  It takes me a moment to realize what this is that I am feeling.....placenta!!!!  Everything that happened next seemed to take forever, but in reality happened extremely quickly.  I looked at Sue and calmly (hopefully) told her the situation and that she would need to pull out her inner Mama Bear and birth her babe quickly.  I called for help and then set up one of our birth stools.  I had calculated in my head the time it would take to get Sue to the hospital v. how long it would take her as a multip to just push out her babe and decided it would be quicker to just do it. (Had she been a primip I never would have attempted this!)

Sue got on the birth stool with her husband behind her, I will never forget the look on her face.  She was preparing to fight for her baby and would not accept anything other than winning.  It was powerful and exactly what we needed.  With the next contraction, she pushed the babe to +2, the waters broke and the baby had a low heart rate.  We all breathed, gathered our focus and prepared for the next contraction.  Thankfully, it came quickly and with one more mighty push the babe was born!  She was beautiful and still, had a good heart rate but needed some resuscitation.  I worked on her, Mama and Daddy talked to her and she came around to join us in the world.  The placenta was birthed very soon after that, with a chunk sheared off but still attached to the membranes, and otherwise normal.  I helped Sue, her husband and the new babe get into bed and settled.  Then my help arrived! Basically, as soon as I saw my nurses I left the room and collapsed in the hallway, my legs just buckled out under me and I started to cry.  I remember repeating over and over again that they were both well and thanking the creator.

During the course of her prenatal care, Sue had declined any ultrasounds.  Her pregnancy had progressed normally and was a healthy one.  She never had any signs, like vaginal bleeding, that would suggest she had a partial placental previa.  In the initial days after this birth, I felt strongly that as a center, we needed to change our policy on ultrasound and begin requiring them.  Then, through talking with other midwives, processing the birth and visiting with Sue and her family, I began to slowly shift back to my original thinking.  Birth work will continually keep you on your toes, will cause you to question your beliefs and require that you are always learning and adapting.  Each birth will give you new insights into the process...information to gain and information to discard.