Let's Talk Pitocin

Several comments on a post by the Unnecesarean seem to indicate that more than a few mothers suspect Pitocin had been"snuck" in to their IV's during or after labor when they were unaware of it. I commented at length about it in response to these posts on the Facebook fan site for the blog, but decided to reiterate, and expand my thoughts here.

First, Pitocin is not always a bad thing. True, it is grossly overused today (I love it when a mother comes on to my unit and gives birth with nary a whiff of the stuff...and I love teasing the residents..."Look...she had a baby without Pit! Who'd a thunk it!"). But there are times when a little Pitocin can be helpful; when you've received an early epidural and things have slowed down...the longer an epidural is in place, the more likely you are to develop a fever during labor, leading to a septic work up and antibiotics for both you and baby. Of course, the way to help avoid this is either not to get an epidural at all, or to wait until labor is well established before getting one...but not all mothers want to do this...especially if they've had a long prodromal labor and desperately want some sleep. If labor has stalled, Pitocin can in all likelihood get it going again...potentially avoiding a c/section for "failure to progress". If your water has broken, and labor hasn't started after 24 hours...and you are at term, that clock, unfortunately, is ticking...loudly...and again, Pitocin can help avoid a c/section, and possibly infection from prolonged rupture of membranes. Although they are few and far between...but some mothers just don't go into labor on their own. There is rising suspicion that obesity plays a role in this, but I'm not aware of any definitive research on it yet...I imagine this could be difficult to research without placing part of the research population at some theoretical risk. For these mothers, why not try to induce before going directly to surgery? And of course, there are those mothers whose delivery, due to complications such as preeclampsia, must be expedited. Better, if there is time, to attempt to induce labor with Pitocin than to go straight to surgery.

Pitocin is the brand name for a synthetic form of the hormone oxytocin that your own body makes. That doesn't make it harmless...it's not "the same thing your body makes"...it's synthetic! Labor is a delicate balance between your hormones and the baby's, and we really don't know what truly triggers it. It may be different for each mother-baby pair, depending on the chemical balance of hormones in each. The use of Pitocin doesn't mimic the action of natural oxytocin, and I don't care how adamantly anyone insists it does. Contractions induced by Pitocin, are, by the very fact that we can control how much of it you are getting, and our goal is to get you to contract every two minutes (or at least often enough to consistently change your cervix, which will be often be "checked" as much as every two hours), usually "longer, stronger, and closer together" than what often will happen if you are laboring under the oxytocin that your body makes. Your uterus has "oxytocin receptors" on it. It is these receptors that act as the "lock" the oxytocin "key" turns to stimulate labor. Without these microscopic receptors, all the Pitocin in the world will not make your uterus contract. The number of these receptors increases during pregnancy, and during labor, when they multiply dramatically as labor progresses; thus, you become more sensitive to the action of oxytocin as your pregnancy, and then your labor, progresses; but there is a finite number of these receptors...and when they have all been used, they are saturated...and until your body makes more receptors, no amount of exogenous (outside the body) or endogenous (made inside the body) oxytocin is going to effect your uterus. There are even times when we "rest" a woman who is getting Pitocin...i.e., she has been laboring under the influence of the drug for a long time, we've steadily increased the dose, and labor has either not progressed, or is slowing down. We'll stop the Pitocin for a half hour or more, and start it up later, and at a smaller dose...and quite often, labor kicks in and takes off! Her body has had time to absorb the exogenous oxytocin, and synthesize new receptors.

Do medical personnel ever "sneak" Pitocin into a woman's IV drip? I suppose it could happen, but it would be gross malpractice. Even with Obstetrics being as egocentric as it can be, this still is something that most obstetricians would be loathe to do. In addition, on most L&D units, the drug comes pre mixed from a centralized pharmacy in a bag that is separate from any other IV fluids; that bag is clearly marked, usually with a bright red, orange, or yellow label. Kind of hard to miss, even for a preoccupied laboring woman. If you have an IV, and are in first stage labor (prior to the birth of the baby), count the number of bags that are hanging on the IV pole. If there is only one, you are not getting Pitocin. During first stage, Pitocin is always...always hung separately from a bag of "maintenance" IV fluids; and it is always run along with those fluids...it is never given alone during first stage labor; so even if the Pitocin is mixed on the unit, and not appropriately labeled (which would be a grieivous error on the part of the nurse), if there is only one bag hanging, it had better not be Pitocin!

Here's how Pitocin is commonly administered:

For first stage labor, Pitocin is always diluted in a liter (about a quart) of normal saline. The most common concentration of it is 20 milliunits to a liter of solution. The drug itself, before it is diluted, is sold in vials that contain 10 milliunits of the drug. These 10 milliunits equal a total fluid volume of 1 milliliter. To give you an idea of how tiny a volume that is, an ounce of fluid is equal to 30 milliliters so the standard concentration of Pitocin is two 1ml (milliliter) vials of 10mu (milliunits) each into a liter (1,000 milliliters) of fluid. This should also give you an idea of just how powerful a drug Pitocin is...by fluid volume, there are only 2ml active agent to 1,000 ml normal saline in the bag of fluid that will be labeled "Pitocin"...a very, very dilute concentration, but oh, so powerful.

Pitocin for labor is always run along side another bag of "maintenance" IV fluid. An IV will be started with maintenance fluid...usually Lactated Ringers or Normal Saline. The "drip rate" of that fluid will be adjusted to approximately 125 ml an hour...so, without any boluses (administration of a large amount of fluid in a short amount of time), the 1000 ml bag of maintenance fluid should take about 8 hours to fully infuse. Considering that, "normal" (not optimal, in my not-so-humble opinion) obstetric management restricts oral fluids in laboring women, this isn't an over abundance of fluid...a liter of fluid a day is the minimum amount of fluid most nutritionists recommend to promote normal healthy hydration. The caveat here is that, if you choose an epidural, you will get at least a liter of fluid in addition to this "maintenance" fluid...to help prevent or minimize the drop in blood pressure that is the most common side effect of an epidural. If the baby shows any kind of distress you will get additional boluses of fluid, to promote blood flow to, and enhance oxygenation of the placenta. Since the use of Pitocin or other induction agents can overstimulate (hyperstimulate) the uterus and contribute to, if not outright cause fetal distress, this should give you pause. Of course, if your baby is in distress, the Pitocin should immediately be shut off! Finally, a lot of hospitals hang maintenance IV fluids for healthy laboring women to "gravity", meaning that the amount of fluid being infused is not being metered through an IV pump. The thinking is that a young, healthy woman can handle a lot of fluid, so there is no need for the pump. This is not the case if any type of heart, lung, kidney or circulatory disease (including preeclampsia) is evident...in such cases, fluid will be very carefully monitored, and metered out through an IV pump; but for the average laboring woman, the rate of this "gravity" IV can change depending on her movements, and that liter of fluid can be infused much faster than intended.

Once the maintenance IV is in place, the bag of Pitocin will be placed next to the bag of maintenance fluid, and its tubing will be attached to a port on your maintenace IV tubing. This bag of fluid will be very carefully "titrated" via the use of an IV pump. A common Pitocin regimen is to run the fluid at rate of "2 milliunits per hour, increasing by 2 milliunits every 20 to 30 minutes until 'adequate labor' is achieved". Two milliunits of Pitocin per hour is equal to 6 ml...less than 1/3 of an ounce of that entire liter bag of fluid of which less than 2 hundredths of a percent is actually the drug. Now, if that amount of the infusion jump starts your labor, that's great. Most women will need more, however; and even more care providers will continue increasing that drip rate until they see contractions happening consistently every two minutes. At 20 milliunits of Pitocin you are getting the solution dripped into your vein at 60 mls, or about 2 ounces an hour, along with your maintenance fluid. This is now considered a "high dose" Pitocin regimen, and to proceed above this amount is to proceed with caution; plenty of women receive higher doses than this. At this point a wise nurse will switch her patient to a more concentrated form of Pitocin that can be run at a lower rate, to help avoid the risks of fluid overload. Personally, if there are no other contraindications, I don't mind having an intrauterine pressure catheter (IUPC) placed at this point, especially if the mother is a little "fluffy", and her contractions are challenging to palpate or see on the fetal monitor. This gives a much more clear picture of exactly how strong, long, and close together the contractions are. I know that internal monitors are invasive, and as such, they are controversial; but I can't tell you how many times I've been in a situation when a mother laboring with any dose of Pitocin, low or high, doesn't seem to be contracting much, and we place an IUPC and find that indeed she is contracting strongly, every two or three minutes. Had we continued to increase the Pit, we might have caused uterine hyperstimulation, with disasterous results; but Pitocin, in my opinion, is invasive, and a judiciously used IUPC can help to limit the adverse effects of that invasiveness. If a mother were not using Pitocin, I wouldn't suggest using an IUPC...but with high dose Pitocin in use, I think it can have some value.

High dose regimens of Pitocin increase the risk of uterine hyperstimulation, as well as the risks associated with fluid overload, including a disturbance in the electrolyte balance in your body, and "wet lungs" in both mother and baby, although, again, in healthy young women, these are rare. More often, since one of the side effects of Pitocin is vasoconstriction, a temporary "tightening" of the blood vessels (more accurately the smooth muscle lining the blood vessels), fluid leaks (is forced) out into the mother's body tissues and causes edema, or swelling. Over a few days, this swelling will leave the body, through urination and sweat, but in the mean time, it can cause some discomfort for the woman, and difficulty getting her baby to latch on to swollen breasts.

So. I've talked about Pitocin during first stage labor. A lot of women are surprised to find that even if they didn't get pitocin during first stage labor, that it is commonly run after the baby is born. Most practitioners will order the Pitocin solution to be run "wide open" (as fast as a liter or more per hour) as soon as the placenta is delivered, to help reduce the amount of bleeding after delivery. Others will order this as soon as the baby is delivered, to both expedite the delivery of the placenta and reduce the amount of bleeding. If you don't have a running IV, they will order an injection of 10mu pit into a muscle. This practice stems from the "Active Management of Labor" protocols that were developed in the United Kingdom in the 1980s. Of course, in the United States, we've adapted that protocol to our own agenda, but what else is news? Once the Pit is wide open, again, a wise nurse will turn off the maintenance fluid.

If you didn't want a lot of interventions in the first place, this is where things get tricky after the fact. Much of the time that bag or little shot of pitocin is up or in before the mother even knows what has happened..."We're going to give you a little shot to help with the bleeding", or "We're going to give you some Pitocin in your IV to keep the bleeding down"...and boom...there it is; but if you know ahead of time, and you decide you don't want it, keep your wits about you. First, if you had much in the way of intervention at all...any type of inducing agents, amniotomy (breaking the "bag of water"), frequent vaginal exams, internal monitors, a long pushing stage, "purple pushing" on your back, you might want to consider just letting them run the Pit...the more interventions you've had, the more likely you are to bleed heavily. If you had a long, exhausting labor, your uterus is tired too...and you should consider letting them run the pit...a tired uterus can't contract down effectively over the blood vessels that were opened when the placenta separated from the wall of the uterus. Second, if you are certain that you are no more at risk for postpartum hemorrhage than a mother who has given birth at home with no interventions, and you really, truly do not want the prophylactic (preventative) Pitocin after delivery, then keep your eyes open. We hang it so routinely, even with mothers who have a birth plan, and even with mothers who expressly request in their birth plan not to have it, that it's easy to forget and just hang/inject the stuff. I know it's a lot to ask if you are in the middle of recovering from labor, possibly experiencing a repair to a tear in your perineum, and bonding with your baby, but I've said it before, as it was said so wisely before me by Navelgazing Midwife, and it bears repeating "If you buy the hospital ticket, you take the hospital ride"...and part of the hospital ride is that, if you want to reduce routine medical interventions, you have to negotiate, negotiate, negotiate.

If you are adamant that you don't want Pit given to you after the fact, be aware that, for most caregivers, you are going to be asking them to step way outside of their comfort zone. If you've ever seen a postpartum hemorrhage, you'd understand...they can happen fast, with very little warning, they can get out of control even faster, and they can be devastating. Yes, I know, without many of the interventions a hemorrhage is much less likely, but consider that one of the most common reasons home births transfer to the hospital is postpartum hemorrhage. Sometimes I think we need to pick our battles. We know that induction in the absence of an absolute medical indication creates a certain amount of risk to both mother an baby. We certainly know cesarean section does; but what do we know about second stage/postpartum Pitocin? If its running full open through an IV, fluid overload is a concern; but in the absence of any other pathology, it is a small concern; it, for the most part is a temporary, reversible concern; and as soon as say, a quarter to half of the bag has run through, if your bleeding is at an acceptable level, you can request that your nurse turn the rate down to a slow drip, helping to avoid the possibility of edema. If your provider has, up to this point been truly trying to comply with your wishes (No IV, no internals, intermittent monitoring, self-selected pushing positions and techniques, immediate skin to skin with your baby), might it not be worth it, in the name of good will, to allow him or her this? There may be a few out there who are comfortable with not giving that Pit after delivery...but by few, I mean truly a few. Most are just really uncomfortable without that perceived "safety net" for their patient. In this case, it usually isn't a "control", "You patient, me Doctor" issue...and since the labor is over, it's not a "speed" issue. It truly is, even if misguided some might believe, a "standard of care" issue. If everything else has gone according to your wishes, you may want to consider...in the grand scope of things...how important is this to me?

I haven't listed the contraindications to the use of Pitocin, and I haven't listed all the potential side effects of it...just the ones most likely to be experienced. If anyone would like me to write more on the topic, I will...but there is a lot of good information out there that can give you this information...Henci Goer's "The Thinking Woman's Guide to a Better Childbirth" comes to mind. It's a good idea to keep an open mind to the use of Pitocin...but also to know your options; and you are the one who ultimately gets to decide if, and when it is going to be used. True, you may need to repeat yourself over and over, and to carefully watch the behavior of the medical staff...it's not always easy...and it's also not always advisable...because as I've said, there can be good reasons for the judicious use of Pitocin; but even if your care provider tries to convince you otherwise, the choice is yours.

For S....

You and your husband were sleeping when I left this morning...you in the bed you gave birth in a few hours ago, sweat- dampened hair askew on the pillow, your arm thrown over your face in a posture of total exhaustion...your sweet husband curled up on the hard vinyl couch of the birthing room, tightly bound in a thin white hospital blanket...as if attempting to comfort and protect himself from the pain the both of you hand just endured...and have yet to endure.

Your beautiful little boy lies wrapped in the too large gown (the closest one we had to his size), and a hand-knit cap and blanket, and placed as respectfully as we can place him in such an inadequate situation, in the clinical refrigerator on the unit, to preserve his tiny body until you ask to hold him again, perhaps for the last time, in your aching, tear-streaked arms.

I wanted so much to say goodbye to you, but I dared not wake you from your hard won sleep. I wanted so much to hug you, to tell you how strong you are, to reassure you, once again, that you will come through this...not without scars, and certainly not without seemingly unbearable sorrow for a time; but that you will survive this; that your son's life, all 26 precious minutes of it, had tremendous value; that that value will increase over time in ways that you cannot even imagine now; that this perfect, tiny, precious, all too short life will have an impact on you and those around you that will forever make you a better person, and this world a better place to be.

The night before he was born, while you still clung desperately to the "one percent" chance that a well meaning physician held out for his survival, while at the same time you grieved in anticipation of his all but inevitable death, I told you this...that your son, no matter how long or short his life, has a reason to be here; that God did not make this happen, but if it had to happen, then He would see to it that this child, this Beloved of His, would achieve his purpose on this earth, regardless of the time in which he had to accomplish it; that I believed this with all my heart. This so loved, so wanted child did live his purpose in those 26 minutes, and as time relentlessly pulls you forward, turning this painful memory into one hopefully more sweet than bitter, as your body and spirit slowly heal, you will begin to realize what that purpose was.

But I can already tell you something that together, you, your son, and your son's father accomplished...and perhaps that can be part of your son's legacy, as it is certainly yours. You helped me to believe in myself again. You reminded me that I have a purpose too...that I am where I am supposed to be; that I am strong and resilient; and that no cold administrative rule, no heartless management agenda can ever, will ever change that. In a time when my department seems to be being systematically redefined by management that gives lip-service to "customer service", but whose actions seem to placing the very lives of those we "serve" in potential jeopardy born of cost-cutting attempts and the tyrannical pressure of overzealous, under researched regulation, you all reminded me that it's worth it to stick it out; to bloom where I'm planted; to let the roots that have grown deep within this rocky soil hold me firm in the winds that are trying so hard to uproot me and my coworkers in the name of...what??? Making an example out of us? Reminding all of us nurses...the ones who really keep this place going, the ones who really protect you, advocate for you, keep you as safe as possible...that we are expendable, not important, replaceable? WRONG!

Because of you, S., and other women like you, I have a purpose in this life; part of that purpose is my work, my employment, my vocation that is also my avocation; that purpose fulfills me and brings me joy (even the painful bittersweet joy of caring for you and your sisters in such sorrow), even when the world around my workplace is in such turmoil; even when that turmoil threatens to destroy my soul, the souls of my sister (and yes, brother) nurses.

We won't succumb to the threat. We'll above this useless struggle. Those who pride themselves on being in a position to decide will soon learn that their decisions that nearly brought disaster to this place, brought about instead, their own downfall; and while I do not wish them that downfall, if it protects those I am called to serve, I will not object to it.

S., I am blessed to have served you and your sisters. I am humbled by the opportunity to be so blessed. I am without adequate words to thank you for your gift.

My prayer for you is that you will, over time, experience the same gift of perspective that I had all but lost, but that you returned to me. I will be forever grateful; and I will forever hold you and your family in my heart.

Recession Babies???

The busy time for most L&D units is summer time..."prime time"...those crisp cool autumn, and long, cold winter nights come to fruition, and we are slammed for the months of June through August...and this year it's been worse than most.

This year though, we kept getting slammed right on through September into October. Things seem to have settled down a bit, but we are still doing more deliveries than we did a year ago...which prompted a discussion between the nurses and residents last night...

Are these Recession Babies?

The timing seems about right...if indeed the recession that we are now told is resolving, peaked in late 2008 to early 2009.

Think about it. You've been laid off...or your partner has been laid off. No money to go out, you can't pound the pavement every minute of every weekday, so what's a person to do...

Have Sex!!!!! Why not? You're not exhausted from a busy work week, but you are stressed out from not being employed; or maybe you are stressed from the fear of losing your job.

I don't know about y'all, but I think sex is a pretty good stress reliever. Of course, I, in my advancing years, am not as likely to conceive as others...Thank God!

So, I put this question out to all of my other L&D nurse blogger friends out there...

Have you seen an increase in births that don't seem attributable to the usual summertime surge in deliveries?

Inquiring minds want to know...

Have We Been Conned??? (or, Midwives and Doulas and Prosecuters Oh My! Redux))

So the big TLC event arrived...Anna Duggar gave birth to her first baby, a little girl, at home, and it was filmed by the crew and publicised for all to witness.

Good thing, right? After all, the Duggars have a big following...more ammunition in the "birth is not a medical event, homebirth is safe" arsenal.

Wrong.

When Josh and Anna "decide at the last minute" (I don't believe that for a minute...I suspect that this entire thing was planned) that they want to have their baby at home because their doctor is not in town, they call their Bradley teacher to ask her if she would still be their "doula" for their birth. Of course, she would.

Of course.

Except that the "doula", as it seems to appear on the show, was the only birth professional in the home at the time of birth. Interestingly enough, this "doula", seems to carry an awful lot of equipment that, during my training as a doula by DONA (Doulas of North America), I was specifically taught it was out of my scope of practice to provide to a family.

If indeed what we saw on this program is what actually happened, I think we've been conned by the Duggars, and their "doula".

Don't get me wrong. I think the Duggars are a pretty remarkable family. I don't agree with their "baby a year" lifestyle, but they seem to be self supporting, hard working people who unapologetically live according to their beliefs; but they've had the opportunity, thanks to TLC's penchant for pandering to the public's (and of course I've allowed myself to sink to this level) voyeuristic tendencies, to subtly or not so subtly use their show as a platform for those beliefs.

Now, we're all entitled to our beliefs...after all, it's a free country...but let's at least be honest about them, especially if we have the opportunity to display them in a platform that allows for millions of viewers to be exposed to them. If you believe in a concept, then say so; be willing to stand behind your beliefs...don't just sneak them in under the guise of something else, and, as a result, put that "something else" at risk to serve your own purposes...which is exactly what I think this family did.

The concept of a doula is difficult enough to promote in this culture of medicalised birth. When they appear to be attending home births as the primary birth attendant, a role for which they are specifically, if they are trained properly, taught is not in their scope of practice, their function is further undermined; as such, their role, along with the wonderful, needed, often vital service that they provide to both their clients, and yes, beleaguered nurses who support non-interventive birth practices, is subject to even more misunderstanding. This puts the entire profession (and it is a skilled profession), at risk...as well as the health of the clients they serve. It also puts the profession of midwifery at risk...allowing the public to think that anyone with training as a doula or a childbirth educator can hang out a shingle and call themselves a midwife.

Was it truly a "doula" that served as the attending professional at Josh and Anna's birth? Or was it a midwife flying under the radar, as it seems the one tending to the family in my most recent post was? To her credit, the woman who assisted Anna allowed herself to be filmed, and, if I recall correctly, her full name to be used when her Bradley Childbirth class was filmed; so if she indeed was a midwife posing as a doula, why not just say so? I don't know what the laws are in Arkansas regarding what professionals may serve as the primary attendant at a home birth; but with the recent press regarding homebirth being so negative, and with ACOG using every opportunity to bully the public into avoiding the practice, this episode of the show can only jeopardize the cause of those who are working so hard to establish a woman's right to give birth at home with a properly trained and skilled attendant.

With a properly trained and skilled attendant.

That is the key concept here.

There will always be those who choose to give birth unassisted. I don't agree with them.

Since the dawn of time, women have, by nature, sought out experienced women to assist them during their time of giving birth. Birth, while it is, given the right circumstances, i.e. a healthy mother, carrying a healthy baby, laboring in a clean, comfortable well-equipped environment, is safe, it is still unpredictable. The unexpected can happen, and things can go downhill fast. One of the biggest hindrances to homebirth in the United States (after the ignorance of the public, the sensationalism of the media, and the machinations of ACOG, the AMA, and now the ACNM, that is), is that we don't have the infrastructure that other countries that have such good homebirth statistics (and as a result, good overall birth statistics) have. We don't have a system where a family can prepare, with the full support of the medical community, for a homebirth. We don't have a system where the local emergency management system is made aware that a woman is laboring at home in the community, and resources are made available (i.e., an ambulance) should they be needed; and we're never going to get those things if the public, and the government remains ignorant of the safety of homebirth...with a properly trained and skilled attendant.

Families who chose to birth unassisted have the right, I suppose, to put their laboring mother and unborn children at the risk of the unexpected. If your "rugged individualism" means that you are willing to accept that risk (to say nothing of your unborn child, who doesn't get a say in your "choice"), then so be it; but don't attempt to con the rest of the world into thinking that you are doing it with an skilled birth attendant when you are not. Conversely, if you have a skilled birth attendant, then say so. Either way, be consistent. Don't allow your own selfish need to get what you want to confuse the issue for an already confused public, by default allowing the powers that be to use your "example" as a tool in their arsenal to damage what little progress homebirth and midwifery advocates have made.

There is homebirth, attended by a properly trained, skilled midwife; and then there is unassisted birth. The first is unquestionably safer than the second; and while it may be your right (ethically at least...because legal rights are being continually reinterpreted concerning reproduction), to give birth unassisted, it is not your right to do so at the expense of those who are working within the system, for their own right to give birth at home, with a midwife.

Where was the midwife at the Duggars birth? Who was the midwife? Was there a midwife?

ACOG is gonna love this.

Thanks, Duggars.

Midwives or Doulas and Prosecuters, Oh My!

There's a family in the midwest that is in a terrible predicament...one that is grossly unfair, and my heart goes out to them. The information on their website is that, after giving birth to a healthy child at home, with the assistance of a midwife "they made the decision"...(a few hours later)..." to call 911 just to be safe" because they were "a bit concerned about the mom". In the jurisdiction in which they placed the call, since a child was involved, the police were required to respond as well. The EMS personnel insisted that the baby "needed immediate medical attention", so mother and baby were transferred to the local hospital, both were found to be well and healthy, and after a few hours were released. The police took statements from both the midwife, and the woman's husband.

Two months later however, the family was served with a summons to appear in court having had the charges of child endangerment levied against them. At their most recent hearing, they were offered a plea bargain for the charge of "disorderly conduct", which the family chose not to accept because they feel that they "are not guilty of anything", that "a guilty plea would validate the charges against" them, and that a "guilty plea would give the impression that homebirth is wrong, and possibly open the door for other families to be prosecuted". All noble arguments, but not exactly in their best interests. In fact, despite this family's earnest sincerity (and I do believe they are sincere), I'm not particularly certain that their arguments are even in the best interests of the homebirth community at large.

I agree that this family did nothing wrong. I support their right to give birth in the place of their choosing, with an appropriately trained, skilled, experienced attendant of their choosing; but despite my compassion for this family, and my desire to help them, and my fervent prayer that the charges will be dropped, I have concerns. There must be more important issues for the authorities to be addressing than a homebirth where the outcome was healthy and safe.

Or is there?

Whenever I see "calls for support" go out over the web for midwives or families that are being pursued by the legal system for whatever charges that can be trumped up regarding a homebirth (practicing medicine or nursing without a license, child endangerment, etc.), it is in my nature to question both the reasoning of the local authorities, and the actual story of those who are being charged. More than once I've heeded the call to a "persecuted" midwife only to find out that there may actually have been some questionable management of the situation. It's a sad reality in our culture that, due to the tenuous legal standing of midwives in general, and homebirth and Direct Entry midwives in particular, that the care the family received must be beyond reproach. That is difficult enough to prove, even in the best circumstances, when we've got the machinations of the AMA, ACOG, and sensationalist reporting such as the "Perils of Midwifery" piece recently aired by the Today show swirling around us. It becomes even more difficult to prove when those who are being prosecuted are not being forthright with every minute detail of the situation.

So, quick to my trusty Iphone I went, dialed my beloved friend C., childbirth educator and doula extraordinaire, who also happens to be in regular communication with our local CPMs. It seems that indeed, a small piece of information has been overlooked in the most recent reports of the incident. In initial media reports, the midwife, when giving her statement to the police, identified herself as the family's "doula".

Whaaaat? Now, when a midwife transfers her clients to a hospital, she certainly does cease to become the primary care giver, and steps instead into the role of doula. However, during the incident about which she was giving her statement, she was acting as the primary care provider. That role, as such, places her in a position of responsibility regarding the outcome of the situation. By identifying herself as a doula, this midwife exposed her client to suspicion that they were attempting to give birth unassisted, and I said as much when I questioned the family and their supporters on the informational website.

What I did not point out at the time was that I was not questioning the family's right to give birth any way they chose (I wasn't...although I won't mislead anyone here and say that I am in favor of giving birth without a skilled care provider in attendance, be that physician or midwife...but that is for another post). I was simply pointing out two things that could have a very important impact on the outcome of their case. 1). Those who were telling the story, be they supporters or the family themselves were not being forthcoming with all the pertinent information, and 2). A midwife who identifies herself as a doula, is going to be perceived as someone with something to hide...and so will her clients.

Well, immediately I was accosted by both supporters of (of whom I still consider myself to be among...I just want more information), and members of the family, including the much beleaguered mother. Was I actually insinuating that this family did not have the "right" to an unassisted birth if they chose?; that the charges were valid if there wasn't a midwife present? From there the arguments became not about how best to support and provide for the best possible legal outcome for the family, but a heated discussion, mostly directed at me, about the family's "right" to choose to birth in whatever manner they saw fit. Try as I might, until one post late in the day, I could not convince those who saw red the moment they read my words, that this was not about the family's "rights"...it was about getting all the information in their defense out on the table where it could be considered...and perhaps improve their legal standing. Ironically, that post was from a mother who chose to have several of her children unassisted. She simply pointed out the dominant cultural biases against homebirth, and how being seen as potentially giving birth unassisted were not going to work in the family's legal favor, despite their philosophical "right" to do so.

The mother says that she stands beside her midwife 100 percent.

But is her midwife standing beside her 100 percent, when she identifies herself, not as a midwife, but as a doula, whose role by definition, is anything but midwifery?

The mother goes on to say that "It shouldn't matter that the authorities see homebirthers as irresponsible. They are supposed to enforce laws, not their opinions".

She's right, it shouldn't matter.

But, unfortunately, it does matter. It matters very much in our as yet unenlightened medico/legal culture. Is this family willing to martyr themselves to a cause that their trusted midwife does not appear to be willing to herself? After all, if indeed she is a midwife, she placed herself in the role of "authority"; and now when another type of authority is attempting to insinuate itself (apparently, tragically, and unfairly) into the situation, she recoils from that role? That is abandonment of her client...and that is irresponsible. What would we do if a doctor in similar circumstances said something to the effect of "Hey, don't look at me...I'm just the gardener!". I know I oversimplify...but truly...are we holding midwives to the same standards that we hold other care providers? Or are we, because we are so passionate to advance the cause, allowing them to assume less responsibility for outcomes we would not choose?

If the local authorities believe that a family is behaving irresponsibly, they are going to try to find a law to, if for nothing else, make an example of the family, if for no other reason than to further discourage other families from making a similar decision. In the process, the family in question is placed under great stress, both emotional and financial, at what should be one of the happiest times of their lives.

As often happens, the support discussions concerning this family have evolved, for those who rally around them, more in support of the philosophy of birthing rights than the support of the family (although there is much to commend supporters on regarding the level of financial and other support being planned and given). Of course we have the "right" to give birth in any way we see fit; but legal "rights" are, unfortunately, variable, based on how a judge and/or jury interpret the law. How we present our argument to them is going to have a definite impact on their decision making process, and the outcome of the case.

The mother writes that a part of the charges say that she "gave birth in an unsanitary place and did not seek immediate medical treatment for the baby". Since they (the charges) did not address the presence (or absence of) an attendant, she does not feel that the midwife identifying herself would have changed anything.

But of course it would!

If, indeed, the woman who identified herself as a doula was actually a skilled, experienced midwife, and had identified herself as such, then the defense could point to the safety of midwife attended births in study after study, and it's acceptable practice in nearly half of the United States (let alone many other industrialized countries with much better maternal/infant, and dare I say it, economic outcomes than our own), thereby at least placing a chink in the prosecutions argument; but this would place the midwife in a precarious legal predicament, since the state in which the incident occurred is not one of the more "enlightened" states that provide a legal basis for the practice of midwifery for families giving birth at home.

So now the question becomes...on whose shoulders does the responsibility for the safe health care outcome of this situation rest?

On the Midwife's!...or at least as much as the family's!

Of course a birthing family is responsible for choosing the best possible care for their pregnant mother and unborn child. If they choose themselves as such, then they are responsible for the outcome...and liable should the outcome be not as expected. If they choose a midwife for that care, then the midwife, by the act of attending them, assuming the role of primary care provider prior to transport (if a transport is called for), and in accepting compensation for that role in whatever form deemed appropriate (money, barter, etc.), should accept responsibility for the outcome. Here it seems, only the family is being subject to prosecution, and I want to know,

Where is the Midwife?

Is the family protecting the midwife? Is the midwife going to publicly step up in the family's defense? Of course, if she does so, she assumes the risk that she will be prosecuted as well...but didn't she assume this risk when she chose to be a home birth attendant?

I'll be brutally honest here. I would have loved to trained as a midwife and provided care to mothers giving birth at home; but at the time, I was a single mother with two young children to support. I needed a steady paycheck, and I couldn't afford to risk being arrested and convicted of practicing nursing or medicine without a license, lest I lose custody of my sons. Does this make me unwilling to "put my money where my mouth is"? I guess it does. I decided get a bachelor's degree in nursing instead, and attend mothers giving birth in hospital. That does not mean I think that the hospital is the best place for a healthy, low-risk mother carrying a healthy baby to give birth. I don't; and every shift I work, I struggle with the dichotomy of my belief system while trying to give the best, most compassionate, physiologically appropriate care to my patients that I can. It helps (sometimes), that I work on a unit that accepts many complicated transfers of care, and that the majority of my patients are those who a qualified midwife would risk out anyway; but when a healthy mother in normal labor comes under my care, I struggle. That is my lot in life. I chose it, I live with the spiritual and emotional consequences. I don't have to live with the potential legal consequences that a Direct Entry Midwife has to, but that was my choice. Does that make me a less-valid supporter of a woman's "right" to choose her birthing situation? I still place myself in the position of risking my license if I would harm a patient with a medication or practice error, or by not advocating for her properly should I feel that her medical care provider not be practicing appropriately; and ironically, for all my work to avoid loss of income by choosing a more culturally accepted way to provide care, I've found myself in situations occasionally when providing that advocacy did, in fact, jeopardize my employment. It's not easy being a pro-birth choice nurse in a culture that sees technology and the practice of medicine as the preferable way to give birth; and it's not easy being a homebirth and midwifery supporter who works in the dominant health care system!

This family's freedom, as well as, should she choose to come forward, their midwife's is of paramount importance in this situation; but we need to be careful about how we couch our arguments in the current culture. The reality is that if we're to advance a woman's right to give birth in an environment of her own choosing, we are, again, going to have to hold ourselves to the highest of standards, both of care, and of how we present the appearance of that care to the "authorities". I don't see that happening here.

Again, I have only compassion for this family. I deeply want to see the charges dropped. I'm furious at the waste of taxpayer money being used to harass and traumatize them, for no good legal reason; but I think there is a missing piece of information that someone, somewhere, is unwilling to, for whatever reason, address that could help them.

And I think that information has to come from the midwife.

Trying...My Best...

To get back to posting. Navelgazing Midwife made a comment on Facebook recently that it seemed so much easier to post there than on her blog. I know the feeling...with Facebook we get nearly immediate response to our posts...it's more interactive than the solitary blog...and much more seductive when you have limited time.

I spend entirely too much time on Facebook. I could (and probably will at some point) write an entire entry on the media and how it affects communication between me and many of my peers. It can be a boon...lots of access to information that I might miss but that other nurses and midwives have come across...and even more access to public opinion (or lack of awareness of) that information.

But my original intent in starting this blog was to write about my experiences in, and transitions into various areas of women's health and maternity care; to hone my writing skills; and to increase my critical thinking/writing skills with the feedback of those who may still be checking in on my posts. The time I spend on Facebook has given me yet another way to avoid writing. Time to address that.

On a positive note...I truly am back...or at least rebounding nicely from...my recent health scare. Pulmonary Rehab has done wonders. I'll soon complete the program and return to work full time (I'm already back part-time). I'm exercising regularly, my sats are back to near-normal, and I've lost 24 lbs (to date)! In that department I have a long way to go...but it's been a great start...one that I plan to continue...

...just like this blog.....

In Praise of Level One Hospitals

Recently I received a comment from Ruralnrs, extolling the benefits of her workplace, a small, rural hospital. In her comments, she spoke of the low rates of intervention that occur to mothers giving birth at her facility, as well as the level of personalized care that would be difficult to match in a large metropolitan hospital. She spoke of the benefits of fewer "personalities" that (and here I paraphrase liberally), contribute to the multiple interpretations of policies that can "get in the way" of a mother's attempt to achieve a non-interventive birth in hospital. She also pointed out that the success of her unit in achieving a high level of non-intervention, as well as patient satisfaction, lies in the fact that, since the unit is not equipped to (routinely) handle high risk labors and births, they do not want to risk making a labor high risk by engaging in the administration of interventions thay may actually produce the risk! Oh, the exquisiteness of common sense!

Ruralnurs's comments were timely ones. Recently in a community not far from the large metropolitan area where I work, a tragedy occurred to two women, within 24 hours of each other, at the same small L&D unit of a small Level One hospital. Both women received epidural analgesia. Both delivered healthy babies; and both women, the day after giving birth, began experiencing complications that were first attributed to the epidural but which became progressively worse. Each woman was soon transferred... first to that hospital's ICU, and shortly thereafter to another large hospital in the city in which I practice. One of these women subsequently died. Of course an investigation is underway, the public has been "assured" that the cause of the illness, bacterial meningitis, is not communicable, and that everything possible is being done to both determine the cause of the tragedy, and to prevent it from occurring in the future.

Thanks to the "gag" order that has almost certainly been issued by attorneys to the grieving families, pending the inevitable malpractice investigation, we may never know the final outcome of the research into the incidents; of course, in the birthing community, suspicion immediately turned to the administration process during which each woman received her epidural.

Regardless of the cause, a woman has died, a family has been denied a loved one's continued presence in their lives, a child is motherless, and another family's anticipation of one the happiest times of their lives has changed from joy to horror as they gather to support the surviving mother in her journey back to health; and while I can't...could not possibly trump the tragedy being experienced by these two families, incidents like this place all of us in peril in a way, because they feed the usually incorrect perception that care at a smaller, usually rural, Level One hospital is "not as good" as care given in large metropolitan hospitals. Indeed, the continuing survival of this hospital, and many others like it, could be considered at risk due to this type of thinking, and unfortunately, when tragedies like this happen, that risk increases.

Don't quote me here...because I haven't taken the time to gather the research to bolster my words... but I've heard statistics that upwards of 50 percent...in some states, 80 percent...of babies are born in Level One hospitals. A Level One hospital is likely to be located in a rural area or a small town. If it does provide care to birthing women, often the services provided take place in small L & D units...two to four labor rooms as opposed to the dozen-plus common in metropolitan hospitals. There may be only one surgical suite, no Neonatal Intensive Care Unit (NICU), and only a handful of practitioners...Obstetricians and Midwives, usually Nurse Midwives. Access to anesthesia is often readily available only during daytime hours, and on an "on call" basis at night. In some Level One hospitals, access to surgical services...even emergency surgeries...depends on an "on call" staff that has to come in from home should a patient require unscheduled surgery during the night...hence ACOG's prohibitive stance on VBAC (Vaginal Birth After Cesarean) birth in Level One hospitals; they don't believe it is "safe" for a woman to labor on a scarred uterus in an institution of this size and limitation.

I beg to differ, both with the perceived public view in general, and with ACOG's stance in particular. These hospitals serve a huge portion of the population of the United States, and as such, are a critically important part of our country's health care system. To deny low risk pregnant women served by these hospitals access to the full spectrum of birth-related services endangers not only those women, but the overall health of our country, as well as our national economy.

Although I currently work in a large university medical center, I live about 30 minutes from my previous employer, a Level One hospital. It too has a small L&D unit, and it too has seen it's share of tragedies; but poor outcomes happen everywhere...the size of an institution is not indicative of the skill of its' practitioners. Indeed, the physicians at a Level One hospital need to be particularly skilled, in that in time of crisis, they are the point of access to care for the individual(s) involved, unlike in a larger hospital where there may be several (or many). These folks need to "know their stuff"... have exceptional critical thinking skills, and the confidence to put put those skills into action quickly; not that these attributes aren't necessary in a larger institution where there are more practitioners...of course they are...but in a smaller hospital, fewer hands can mean more responsibility on those hands. I can only speak for this one particular hospital...but if a woman I loved were to need care, I would have total confidence if she were admitted there. The skill and care given to women at this particular institution rivals that given where I work any day. No, they don't have a special care unit for infants; but the nurses were well trained to support even tiny preemies until transport from the nearest NICU could arrive. During my employment at that particular hospital I saw hemorrhages, fetal demises, preterm labors and births, even one uterine rupture...all handled expertly by the well-trained and skilled nursing and medical staff, and all with the healthy survival of both mother and infant. Until ACOG's edict limiting VBACs to basically only large tertiary care centers, that unit also saw it's share of successful VBACs.

Health care dollars being limited, resources are going to have to be distributed where they are likely to be used the most; hence Level One hospitals, particularly those few that remain independent of larger healthcare "systems" such as Humana, will rarely be the ones to have the newest and latest of the technology; JCAHO standards should provide that a reasonable standard of care in terms of technological resources will be available at any hospital. Should a patient require more, resources for adequate support should be available until a transfer can be arranged; but for initial access to care, particularly for low risk situations such as normal labor, a community based hospital is the most cost-effective and appropriate level of entry to care (actually, I really believe that home is the most appropriate level of entry to care for laboring women, but my topic being levels of medical care for laboring women, and our culture being what it is, that statement will have to suffice...for this post at least).

I think level of entry and access are the core issues here. A healthy woman experiencing a normal labor does not need all the "bells and whistles" of a unit like the one I work on; she needs care that is accessible...in her community. One of most ridiculous misuse of resources I've ever seen occurred, ironically, in the same community as the hospital that I just praised so highly. The health department in this community contracted its prenatal care to the residency staff of a larger city hospital over 35 miles away! When the women cared for at the public clinic went into labor, they were expected to travel into the city. Not all of them had the resources to get there however. Those that did not have transportation to get from their homes in the town ended up...of course...at the local Level One hospital, where the only access we had to their prenatal information was via fax...and that was if we could track the information down, and if we had time to get the information faxed to us before the mother gave birth. It made absolutely no sense, when right there in the woman's home town a perfectly good medicaid eligible clinic was available to her, within the very hospital that she would ultimately give birth in...attended by physicians she was familiar with.

It can be difficult enough to get access to health care in our country. Even in the city where I work, there are more than a few mothers who get little or no prenatal care because they cannot manage the bus fare to get to clinic; or they do not live near public transportation. How much more of a burden do we place on women in sub-suburban communities we close down the L&D unit in the local community hospital, forcing them to travel, if they have the means, to the next town or city over? Often the woman cannot meet that burden, and she goes without prenatal care, possibly setting off a sequela of events that turn a healthy, low-risk pregnancy into a high-risk situation...and a high cost situation ensues, should that mother and or her infant end up requiring a level of care that may have been avoidable had she had access to good prenatal care. How much of a burden do we place on a woman when we prevent her access to VBAC based on the perceived level of care at a hospital that may have a proven record of successful VBAC births, forcing her instead to travel out of her community, adding yet another expense on top of the considerable (and avoidable) expense ( as well as the increased risks and discomfort) of a scheduled cesarean? Neither situation can be considered a good outcome for either mother and infant...and it can't bode well for a health care system that is already crumbling under the weight of not enough financial resources to provide access to all of its citizens. Prenatal care is, more often than not, preventative care...head the high risk situations (those that we can) off, and prevent the huge expense (and increased potential for morbidity and mortality) of an unnecessary surgical delivery...or of a mother or infant in intensive care.

Our culture has collectively "forgotten" that there is an entire world of medical care independent of the big, dramatic city hospital we see on primetime television with it's depiction of exotic diseases and traumatic occurences that seem to happen every day and require the highest and most expensive level of technology to treat. We forget that when we use resources appropriately to maintain our health, that this level of drama and expense is the exception, not the norm. Of course the tragedy that occurred in the Level One L&D that I depicted in the beginning of this post was just that...a tragedy (and likely a very avoidable tragedy); but with appropriate investigation into the cause, and corrective intervention taken (albeit after the fact), the hospital involved can reduce dramatically the likelihood of a reoccurrence. It would be an even larger tragedy to close the unit, and reduce access to the pregnant women of the community served by the hospital.

I love what I do...I love where I work...but my family continues to utilize the same health care providers that we did when I worked for my previous employer. I've found, both as a patient and as an employee that the care is both cost, and health effective. Level One care can be, and often is the very best care.

STAY TUNED.....

I've had the misfortune of experiencing the evolution of a simple upper respiratory infection into a major exacerbation of long asyptomatic asthma. As such, I've had little time or energy for much more than multiple physician's visits interspersed with frustrated, boring days at home with the occasional tentative (and frequently abortive, due to shortness of breath and a general inability to tolerate much in the way of activity) foray to the grocery store or the bookstore.

And so, the blog has suffered my absence.

My husband though, I think has suffered the most, bless his heart. He, in addition to running his own small consulting firm, has been keeping up with (well, as much as any non-homemaker can) the housework, laundry and cooking, dealing with the misadventures of raising two impetuous, impertinent, impulsive, sometimes rebellious, usually know-it-all, but always endearing and beloved teenage boys, and a wife who is one minute crabby and whiny, and the next remorseful and grateful. God bless that man!

I miss work. I haven't been there for nearly two months! After multiple trips to my family physician and pulmonologist, one trip to the ER (I tried to go back to work...wasn't gonna happen, my body immediately let me know), and even one trip to an urgent care center two days before Memorial day (sure...let's just add double otitis media to the mix...I can handle it...not), I found myself in the care of an amazing Nurse Practitioner who works in my pulmonologist's office. What a stroke of luck! My appointment with this wonderful woman came only after multiple phone calls trying to get another appointment with the pulmonologist ("No, July 25th will not work, I'm consistently satting 90 percent at rest, I've got to be able to get well enough to get back to work, and I can't wait two months to find a way to get this fixed!".) Finally I called my case manager in a weight loss-program I am now involved in and told her my plight...I was afraid to exercise unsupervised until I got this respiratory thing under control, but I couldn't get an appointment to get the advice of my physician. She, bless her, brought up the idea of pulmonary rehab. Really? Did I really need something that drastic?

Turns out I did. I made one call to the coordinator of the pulmonary rehab department, who promptly got me an appointment with the NP. That wonderful woman (the NP, although the director of the rehab department is wonderful as well) did more for me in one 30 minute appointment than the ER, and three physicians had done in six weeks! In the past week I've undergone a slew of pulmonary tests, I've been x-rayed and CT scanned, scheduled for allergy testing and a sleep study, been exercise tested (managed to gasp my way through), and admitted to the pulmonary rehab program.

All indications are that I should be able to return to work with in a month's time, probably part-time first, gradually increasing back to full time.

I knew being an L&D nurse was a big part of my identity, but this experience has really pushed home just how true that is. Maybe that's not a good thing. Maybe I need to get moving on some of those "transitions" I talked about when I began this blog. I've certainly had time to think about them enough.

It's also hard to "watch" via Facebook, my friends working their backsides off, knowing that my absence is contributing to a lack of staff during the busiest time of year on our unit. When coming off of a shift, they will comment to each other how busy things, are, how tired they are, and here I sit...in front of the computer, inhaler at my side, just wanting to be there to lighten their load a little. I love my family. They are my first priority; but I get a lot out of my job (in addition to the frustrations), and I respect the work that my coworkers do.

C'est La Vie. What is, is. For now, I'm slowly improving, looking forward to getting stronger and learning more about how to control this disease through rehab, and I've even managed to start losing some of this extra weight ( "...the journey of a thousand miles begins with a single step..."). With my husband's help, and my "expert" directions, I'm starting to get caught up on all the long-neglected organizational tasks that I've put off in favor of sleep when I wasn't working, and I'm hoping that will clear a path to beginning some of those "transitions" (I'm the kind of person that needs to be organized in order to have a mind clear enough to concentrate effectively...at least at home...at work, I've learned to with the flow...the crazy, ridiculous flow...it's called survival!). Truth be known, I think this has been coming for some time. I wasn't taking care of myself well enough. The last few weeks at work I could barely make it to the car, so exhausted would I be at the end of a shift. My body finally revolted and forced me to take a good long look at how I've been not caring for it, and here I am; but I think (hope, pray) that I've dodged a few serious bullets in the past few weeks, and am now on the road to a full recovery, with a wiser appreciation of just how important it is to not let myself get run down.

In the meantime, the writing bug is hitting me again (a person can only knit so many preemie outfits and blankets, watch so much TV, read so many books, or vegitate on the internet...did I mention I'm spending money I don't have on things I don't need on EBAY?...for so long), and just in the nick of time I got a (coincidence...I think not) response to my last post that gave me the idea for my next one.

Stay tuned!

On Childbirth Education

More than once in my work I've met a couple who brought with them the expectation that what they learned in childbirth class is what they would experience in the hospital. Simple, right?

Unfortunately, no.

I know a few childbirth educators. Most of them are excellent (My beloved friend C., well, she's just the absolute best of the best). Others, not so much. At least one of them is not particularly supportive of her clients who are planning to birth in a hospital (read that...she can barely contain her disgust), and therefore, not helpful at all...a total waste of her clients' time and money. Others are just plain not giving their students accurate information - for example their couples come in asking for oral vitamin k instead of injected vitamin k for their baby (we don't have it); they ask to be monitored via doppler or fetoscope (we don't have a fetoscope, and we don't have the staffing to use doppler monitoring...aside from which, no hospital is going to risk not having a paper tracing of a labor; they ask that the newborn nursery not bathe their baby, but simply massage the vernix into his or her skin (fat chance!); or, they ask to be allowed to eat during labor (good luck), or my personal favorite, not to be administered an enema or shave prep (we haven't done this in over twenty years, so I'm wondering why these particular educators are not checking to see if their information is realistic, accurate, or current). I'm not saying any of this is right, it's just what is, albeit at best unfortunate. Finally, several educators, whose classes I've not had a chance to observe, or who I don't have an opportunity to converse with often, are, well, I'm just not certain what kind of information they are giving (or not giving) to their students.

Case in point: I once cared for a sweet couple having their first baby, who were genuinely shocked that their very aggressive obstetrician was just that...extremely agressive. This couple came in, and Mom was 4 centimeters dilated, with bulging membranes. She was laboring beautifully, and I told her physician as much. As if he didn't hear a word I said, he ordered "(have a resident) Rupture her membranes, put in internals, and start 4 by 4 Pit (twice the amount of Pitocin that is normally used)". Truth be known, it was the day of "The Big Game" in our town, and Mr. MD wanted this delivery over before "all the traffic started up". Baloney...he didn't want to risk being called away from his toasty box seats, but what do I know...I've only watched this ass leave several dozen labor rooms looking like the aftermath of a suicide bombing, always in such a hurry to be done that he can't bother to leave a perineum intact, put instruments back on the table instead of dropping them on the floor, or even put his bloody gown in the biohazard can instead of tossing it aside for the nurse to pick up. This is one of those guys that make me wonder why in the hell I keep doing this.

Why indeed...because I want those who choose to give birth in a hospital to know that they have options...options that far too many physicians and nurses don't let them know they have. No, I can't monitor you with a doppler...and I can't find oral Vitamin K for your baby, but, damnit, if I don't think you need Pitocin (yet), I'll tell you...and If you want to wait until your membranes rupture on their own, and you and your baby are doing well, I'll remind you that you don't have to consent to that. If I can't "effectively facilitate communication" between physician and patient (some physicians are not interested in two-way communication), I'll advocate for my patient.

This couple stood their ground though. they gently, but firmly asked the resident who was itching to carry out their physicians orders why this was necessary. They asked for more time to make a decision. Finally, after being cajoled and hassled for hours, they gave in. They consented to having the water broken.

But we have a happy ending...for this couple at least...miracle of miracles, before the resident could finish a delivery in another room, I saw a look..."that look" come over the mother's face, and my heart nearly leapt for joy as "that look" turned into an unmistakable grimace, followed by a surprisingly loud grunt from such a petite woman, and a splash of fluid from beneath her gown spilled onto the floor, over the shoes of her startled husband, and flowed into the towel I quickly flung onto the floor to catch it. At my urging she climbed into bed just in time for her little boy to squirm his own way into the world, without Pitocin, without internal monitors, without artificial rupture of membranes, heck, without even a doctor in the room! Baby in the Bed! I loved it. Take THAT Dr. Ass (as if he cared...as if he even realized it was possible).

But for those situations that are not the recipients of such Grace, what are the Childbirth Educators in question telling their students? I wish I knew. This poor couple, when I told them what their OB wanted me to do, were absolutely stunned...who wouldn't be? They had learned in their childbirth class to stay home as long as possible, that they could avoid pitocin if the labor was progressing well, that internal monitors were an uncessary intervention if the baby was doing well and easy to trace (as was the case here), and that they should avoid having the membranes artificially ruptured if possible.

All good information; but were they encouraged the to speak with their care provider about this information? This wasn't the first couple that had come under my care with these same or similar expectations, only to be blindsided by the basic hospital "business as usuall" delivery system. All of these couples seemed genuinely confused that their physicians would order care that was so different from that they were taught to avoid.

Perhaps the educators did encourage these couples to speak with their care providers, and the couples did just that, only to be brushed off or outright lied to. Perhaps the couples, as expectant couples are sometimes apt to do, just assumed that their care provider would practice as their childbirth educator taught, so they sort of "zoned out" when the educator was advising them to speak with their provider...like so many couples do when the topic of cesarean section is brought up...they assume it won't happen to them, so they don't really listen. Or maybe, just maybe the ecucators themselves are simply teaching a philosophy...without reminding their students that theirs is not the only philosophy out there...and that, if they can, they need to learn the philosphy of both the hospital, and of the provider they are trusting to care for them during the most important moments of their lives...or at least be prepared for the possibility that they may have some significant "negotiating" ahead of them, and be given suggestions (doula anyone?) to help navigate those negotiations.

Moms, Dads, what do you think? What has been your experience? Educators, do you ever hear from your students after they give birth? What do they tell you?

Enlighten this frustrated Labor Nurse, please.

The Ultimate Transition

She was only fourteen. Fourteen. A tiny wisp of a girl, a pale, sweet, freckled face encircled by ringlets of short red hair. And she was going to become a mother. She had gone into labor the night before, things had stalled, and her labor was to be augmented with pitocin. When she went to her local hospital, her blood pressure had shot up, so she was transferred to our unit. She labored in the haze of a magnesium-induced fog, an attempt to prevent the seizures for which she was at risk because of her blood pressure.

The father of her baby was nowhere to be found. "He's too young for that" his parents had explained to her. I'm thinking...hmmm...well, he wasn't to young to make the baby...and she doesn't get to say "I'm too young for this". Instead, she prepared to raise, with the help of her family, the little boy that she carried.

She had wonderful support though. Her sisters were there...all four of them, all with the same fair skin and curly copper-colored hair. They ranged in age from mid-thirties to late teens. It seems our little mother had been a surprise baby herself, conceived during a rebound relationship of her mother's shortly after her sister's (half-sisters, but sisters, just the same) father's death. It was not lost on her that she was the offspring of yet another absentee father.

Her mother wasn't there. I didn't know why, but many telephone calls were going out to friends and family who seemed to be in close contact with the soon-to-be grandmother. Perhaps there wasn't transportation, or enough money for her to get the several hundred miles from her home to her daughter's bedside. That happens a lot on my unit...we transfer mothers in from hundreds of miles, covering three states. A lot of the families of the mothers we care for are desperately poor...too poor to follow the ambulance or Medivac helicopter to our hospital.

I felt sad for her. A woman needs her mother when she is about to give birth...especially such a young girl-woman; but this precious young woman was surprisingly, yet precariously stoic...the kind of stoic that made me caution myself to choose my words...even the inflection of my words carefully...lest I cause her to burst into tears.

Her sisters were lovingly, literally at her beside. When they weren't hovering near the telephone, they hovered over their laboring sister, rubbing, massaging, loving, wiping away the occasional tear. When she balked at the idea of getting an epidural, they encouraged her...gently...to reconsider. "So much pain", they murmured, more to each other than to her..."why take more?"..."especially when there's a choice".

She chose the epidural. While we usually allow only one support person bedside during epidural administration, I broke policy and let them all stay, because I couldn't bear to tear them away from their little sister who seemed to depend on them so. She suffered no untoward side-effects from her epidural, so I placed her foley, tucked her in, and stepped out of the room.

I felt a tap on my shoulder. When I turned around, I faced the oldest sister, who was wiping a tear from her cheek.

"I wanted you to know...we're not purposely being rude to you"...rude??? They had been anything but rude. I thought they had been perfectly lovely, and I told her as much. "Well", she said, "Thanks...but there's so much going on...I just wanted to let you know; She doesn't know...and we're all having a difficult time keeping it from her. Our mother is dying. Literally. Probably tonight. She has breast cancer".

Now, how many times does a nurse hear something like that? Not often, I would imagine, even on a unit prone to as much melodrama as ours. But, indeed, this was the situation, and here we all were: A fourteen year old girl about to give birth to her first child; her four older sisters to whom would soon fall the responsibility for them both; a still fairly young woman, their mother, hundreds of miles away, slowly slipping into that pre-death coma from which she would never wake up; and me, not quite certain how to respond to the sad uniqueness of it all. Instinct took over and I wrapped my arms around the now sobbing sister, as I held back my own tears.

I showed the sister our family consult room...the little room near the back of our unit that is used for physicians to talk to family members when things aren't going as planned with the birthing women they are supporting. It holds an institutional wood and vinyl couch, and two chairs, along with a lamp and a selection of out of date magazines; not much in way of comfort, but at least it's private...and it has a telephone.

The sisters each took turns going into the consult room to check in with the family that was caring for their mother. She was "in and out" they said. She seemed to be aware of what was happening to her "baby" daughter. Through a haze of pain killers, she had been repeatedly asking to speak her, but the family wanted to spare the laboring girl the pain of knowing her mother's death was imminent.

Our little mother slept through most of her labor until she abruptly sat up in bed and called out for her mother. "He's coming now! When will she be here?" I checked her, and indeed, her baby was nearly crowning (pretty rare for a first-time mother). I called out for a "doctor for delivery", and instantly the dark womb of the room became once again a bright, too-noisy hospital room. The sisters took their place around the bed, I "broke the bed down", the resident took her place at its end and began exhorting the girl to push.

She refused. "I won't!" she wailed..."Not until she get's here!" We all stopped and looked around at each other. By now, anyone who was involved in her care new what was happening. Eventually this baby would be born no matter if his mother pushed or not...but as often happens, his heart was slowing with each contraction as her body moved him ever closer to his birth. Most babies do fine, even with this...but it can be unnerving if the birth isn't imminent...if the mother isn't helping things along by pushing...at least a little.

The youngest of the four sisters finally broke rank from the Circle of Women around the bed and picked up her cell phone...you know, that piece of equipment that you're not supposed to use in the hospital because it might interfere with the other machinery? Too bad...she was on a mission, and I wasn't about to stop her. She punched a speed dial number, spoke quickly into the phone and placed it next to her laboring sister's ear.

"I will. I promise. I know. I love you tooooo.....", and her little body twisted up off of the pillow with a powerful involuntary push, and as her sister lifted the cell phone high in the air, a tiny, five-and-a-half pound little girl wailed her way into the world amidst the sobs of joy, surprise, and heartbreak of her mother and aunts (so much for the accuracy of late-term ultrasound). Time of birth...4:01 A.M. Grandma was listening.

After promising into the cell phone that she would call back soon, the youngest sister snapped it shut and began to attend, along with her older sisters, to her little sister and niece. As a group they dried the baby off, and placed her against her mother's body. The older sisters, mothers themselves, gently encouraged the new mother to hold her daughter close, showing her how to feed her, pointing out every precious, miraculous, infinitesimal little finger, toe, and wisp of downy, copper-colored hair. The baby never cried, not once after her entrance announcement...but curled into her mother's warm body, turned little her head sideways, and watched her aunts smiling down at her.

I moved around the room as inconspicuously as I could, clearing away the delivery paraphernalia, charting, and tidying up between checking on the new mother and baby. Once satisfied that all was in order, I left to give the new family their privacy. A few minutes later, the oldest sister walked up to our reception desk and asked for me. When I approached her, she asked me..."What time was she born?" A tear rolled down her cheek with my answer.

"Our mother died at 4:05".

Now I was crying...and not just a dainty little sympathetic tear or two to streak down a cheek...no, I had to be sniffling with the red nose and blood shot eyes of someone who has had entirely too little sleep...it wasn't pretty...but it was heartfelt, and the sister knew it. She asked that no one say anything to her little sister until she had had a chance to get a few hours sleep, after which they would tell her, and of course we all agreed...but it wasn't easy to stifle those tears and act cheerful while I helped the new mother into a wheelchair and tucked her baby into her arms for their trip to her postpartum room.

As often happens, I never saw this patient or any of her family again. I wonder how she reacted when she learned of her mother's departure so soon after her daughter's arrival. Two souls had literally crossed in the night. Did they reach out to and greet each other along the way? Did that precious little baby feel the warmth of her Grandmother's kiss on her cheek? Will she carry a tiny, almost imperceptible memory of it with her? She will most certainly experience her love through the love of her very young but very special mother and her very special Aunts. She is part of a very special Circle of Women indeed...one that reaches down from heaven, flows through her family, and wraps itself around her.

A bittersweet story...but a very fortunate little girl.

Transitioning Back

Four and a half months????? How can that be? How could I get so sidetracked with the holidays, the boys, the relationship, the job, the house, my workouts, meal planning, (slowly) shrinking profile, and all the other things I use to distract myself from climbing the stairs to my little study and writing?

Of course my family are not distractions...they are priorities...but the other things? Well, I've got to find a way to motivate myself to get back here more often.

I'm so impressed with At Your Cervix...despite all of her obligations, and now graduate school, she manages to keep up her blog. Me, well, I'm wondering if I just don't particularly like always being so far away from my family when I'm writing. I love my little study. It has all my books, my favorite photographs and art projects, my professional journals and texts, along with piles of yarn, fabrics, and other needlework supplies stashed in the closet. Maybe I need a studio too, someday...when the 19 year old finally decides to move out of the bonus room over the garage that I had targeted for it. But back to my study...I've decorated it in my favorite colors. I love the huge old rolltop desk (my husband calls it my womb), overstuffed chair and ottoman, and bookshelves I've managed to squeeze into the tiny space. It's mine...it says me, and me alone to anyone who walks into it. There are times I just want to shut the door on the testosterone chaos (even the pets are male) in my house, pour a cup of tea, wrap up in one of my throws, and read, knit, write, journal, listen to music, and sometimes even drowse off in that wonderful chair...but not always; and with the amount of ideas for writing rolling around in my brain, all of the experiences I want to process, I could spend days...weeks up here getting it all out in text. I've tried sneaking in to my husband's office to write while I'm down in the thick of family life...but invariably he needs to get on the computer or I become an unwilling partner in his engineering business, taking calls, filling, or chasing receivables...shudder!

So what's a reticent writer/blogger to do?

I may try to work some extra shifts and get a laptop...something I could keep downstairs, in the middle of all the family mayhem, and use when the spirit strikes me. I could keep my recipes and meal plans on it; I could keep my food and exercise logs on it; I could fiddle with my fledgling photography hobby on it; plan my grocery trips while perusing all the coupon sites...fritter away time on Facebook...well, ok, I'll need to try to curb the temptation to do that...not easy when just about everyone I work with...nurses, techs, attendings and residents alike...use it to unload on each other after shift upon shift of craziness ( I guess if we can't debrief at work, we can do it online).

So; until that laptop shows up, I've got to find a way to spend more time, at least every few days, back at this computer.

Here's to good intentions!