Been away from posting so long I hadn't even noticed! Too cool, even if there are only a few.
Now I need to give them something to follow.
Hope springs eternal...really, truly...I have more than a dozen "drafts" in the works, just can't get myself focused enough to flesh them out.
Getting right on that...ASAP.
Stay tuned.
Thursday, January 28, 2010
Friday, November 27, 2009
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.
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.
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.
Wednesday, October 14, 2009
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...
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.
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.
Tuesday, September 29, 2009
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.
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.
Thursday, July 23, 2009
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.....
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.....
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