Equal Time...

...for nurses, residents, and physicians who work in obstetrics. In my last post I used a lengthy and extreme (but for all intents and purposes...had to change some facts to remain HIPPA compliant...true) example to whine about families who come to the hospital with expectations that they did not educate themselves about beforehand.

Well, now for the other (at least an other side) of the issue. It frustrates me how few nurses and physicians are vehemently anti-homebirth, (or any other kind of "alternative" birth) based on non-existent (e.i., their opinion), or poor research.

For a long time, all homebirth advocates had to rely 0n in terms of published research to back up their point of view was the "Tew" study, ( British Journal Obstet Gynaecol 1986 Jul;93(7):659-74) which is now over 20 years old. In a world where research over five years old is considered outdated, regardless of how well designed and carried out it may be, this is no longer going to cut it; nor are subsequent studies performed in the ninties. Now we have the Johnson/Daviss study ( BMJ 2005;330:1416 (18 June), doi:10.1136/bmj.330.7505.14), obviously much more recent, which, even in it's criticism of it's own limitations, makes a very good case for the safety of homebirth.

So why do so many of the people I work with not know about this study, or any of the others? Why do they think that the "homebirthers" out there are uneducated women who place more value on their experience than on the safety of their baby? Why do they make fun of women who choose to give birth in any number of ways that does not jive with the "norm" of being limited in movement by I.V.s and fetal monitoring equipment, no eating or drinking in labor (not even clear liquids, heck, not even popsicles! Does someone want to tell me what the difference between one contraband popsicle and half a dozen cups of "allowed" ice chips is?), pushing in lithotomy position while holding breath, who question the need for Pitocin if they are otherwise healthy and not post-term, etc? (Yeah, I know, it's a run-on sentence, but make some allowances for passion, OK?).

In a discussion I once overheard between several of our residents and one of our attendings regarding the "trend" of waterbirth, I heard the attending exclaim "and what if you get a shoulder dystocia while you are in the water, then you are screwed!"...(uhmm, excuse me, ever heard of theGaskinManeuver???...aside from the fact that "shoulders" are more likely to occur in lithotomy position).

Recently, a doula friend of mine told me about one of her clients who asked her physician (a woman who is an excellent diagnostician, and extremely skilled surgeon, and a favorite of many of the nurses where I work - including me - who chose her to deliver their own children) if she could push in a squatting position if she felt so inclined at the time. The physician said that she wouldn't be able to have clear access for catching the baby if mom chose to do so (hmmm...how so, when the mother would be several inches above the line of view if she pushed while squatting on the bed? I bet a lot of midwives would be surprised to hear that). This particular physician is part of a huge and popular practice, so I doubt that the loss of this one patient made much of a difference to her professionally, but I wonder if it made a difference to her personally? The mother subsequently gave birth to her baby at an outlying level-one hospital, in water, attended by a physician who is gaining in popularity because he seems willing to listen to his patients, and if nothing else, empathize with them. He managed to be able to have clear enough access to deliver this child, from the floor (I assume), and through water that, in all likelihood, became at least a little murky with the fluids of birth emerging with the baby. In the first situation, a woman denied a choice to another woman, seemingly for her own personal comfort. In the second, a physician who did not have the back up of countless residents and multiple ORs felt confident enough, and was willing to respect this mother's wishes. Professionally, this gentleman is very respected where I work. He doesn't transfer cases to us just because he would rather not deal with them, he doesn't take unnecessary risks with the cases he does transfer, and the attendings that I work with just seem to like him in general...he's a "buddy" to many of them; but there were more than a few raised eyebrows when I bragged that "hey, he's willing to do it, why aren't we?" I don't think it changed their opinion of him at all...but he's certainly not holding to the status quo, and I wonder how that is going over (unsuccessfully trying not to gloat here)?

As for waterbirth? Most of the nurses I work with think it's "gross"...I mean, you can get poop in the water (as if they don't see enough poop when the mother is up in stirrups); or, all that blood and goo in the water (what, they've never had to deal with blood and goo in this job?)! Can we get consistent here folks?

I once had a patient that didn't want pitocin routinely run in after she delivered her placenta. This was written on her (albeit, a little too long for my tastes) birthplan. When one of the nurses I work with, one who does a lot of training no less, asked "Why didn't she want Pit after she delivered?", the following conversation took place between the two of us:

"Because she didn't need it".

"She didn't need it?" (I knew I was being baited here, but I couldn't resist...)

"No. No one was yanking on her placenta, so she didn't need it".

"What do you mean?" (more baiting, my irritation and irrational need to win every
"argument" taking over),

"C'mon, C, you know better...left alone, a healthy one will come out on its own, you don't need traction, and there won't be any excess bleeding to worry about".

"I don't believe that"

"Of course you don't".

"Before we started using Pit after delivery, what was the main thing women died of
in childbirth?"

"If they were otherwise healthy? Infection"

"No it wasn't...it was hemorrhage!"

"You need to go back and reread your nursing school OB textbook".

Rolled eyes, sighs, shaking head, clucking tongue...tough having a "substandard" nurse like me on the unit.

And while I'm on a roll (am I ever not?)...about infection; we've recently been required to go to "handwashing" seminars, seeing as how insurance companies are planning to deny coverage should any of their insured's end up with hospital aquired infections (another lengthy post to come on this, I guaruntee). During the presentation, the well-known (I thought) story of Dr. Ignaz Semmelweis, the physician who originated the "germ theory of disease", based on his observations of the rate of puerpural infection when physicians treating pregnant women washed their hands between corpses and other patients and the laboring and postpartum patients. I assume we all know the outcome of this story? I assume we all know the story???? Evidently not...I was amazed at the number of nurses who had no familiarity with the story! Didn't this anecdote open most of our Med/Surge, Microbiology, Obsetrical, and Community Health texts, way back in nursing school? Sigh.

By the way...the aforementioned patient whose placenta so elegantly slid out without traction, and whose body (shockingly) required no Pitocin to keep its immedate postpartum blood loss under 300 mls, had been laboring most of the time on her hands and knees. True, it was a PITA to keep her baby on the monitor, but we managed. Just about when I thought my arm would fall off though, the same nurse I would soon have the previously mentioned conversation with came in to help with the delivery (so, we have our differences, but for the most part, we're always there for each other...just like any dysfunctional family). The doc was at the end of the bed, and baby began to crown. The mother was doing a fabulous job...her perineum was beautifully pink, stretching nicely with her short, slow, powerful non-valsalva grunts and pushes...no white, blanching, evidence of an impending tear. It would have been so easy just to guide baby out, and let the nurses help Mom while she lifted her leg over baby and turned over in bed...but no, the doc insisted, baby on the perineum, that the mother turn over in the bed immediately...and as she turned, baby's head ratcheted in the opposite direction, and you guessed it...a third degree tear ensued. Ask any other nurse on my unit and it occurred because the mother was on her hands and knees (grunting like a cavewoman I heard one nurse say...arghhhhh!)...and not because she was forced, at exactly the wrong time, to work against gravity and turn over! I could scream. I know the poor mother did...so unecessary!

In this same delivery, a young nurse, a nurse-midwifery graduate student, and an excellent new L&D nurse came in to help as well. She is a lovely young woman; confident; secure; patient; a breath of fresh air when things are getting intense and the primary nurse needs a hand or a new perspective. She soothed and comforted this mother with her lovely, calm voice and demeanor. In other deliveries I've seen her in, she just has a knack for gaining the absolute trust of the woman she is caring for. After the birth, I thanked her for her help, and complimented her on what a nice addition to the floor she has become. She, in an attempt to commiserate, I can only assume replied, "You're welcome...and thankyou; but it is all so much more pleasant and controlled when the mother has an epidural. I wish she had had an epidural...it would have been so much nicer!". I was so taken aback by her comment that I just let it slide by. I've always meant to gently revisit it with her, but have never been able to find the right time (or, I must admit, the nerve) to broach the topic with her again. This is a brand, new, "malleable" L&D nurse, a future midwife, an excellent clinician, with an excellent mastery of her craft, with so much potential to bring so much respect and compassion to her clients, and it turns out to be all an act???? How dissapointing. Why do we keep potentiating this?

And there are so many excuses why we don't change. I made no secret that I was reading Jennifer Block's book, Pushed during down time on the unit. I made certain to leave it conspicuously out on the table in the nurses station when I was with a patient. Did anyone ask me about it? No. Did anyone bother to turn it over, take a look at it? Not that I'm aware of. Instead, I overhead one nurse say "That's all well and good, I suppose, but it's different in the U.S. (excuse me, but the book was written by an American author, about American women, giving birth in the American medical system)...we've all intermarried with different cultures, and we have all different sizes of pelvises, and partners, and you just can't generalize about how easy it should be to give birth when you aren't a member of a more uniform culture". She never even looked beyond the cover of the book! She had no idea what the book was about; and, if her "theory" is so true, does she want then, to explain to me how so many of our not even five-feet tall Latina patients, giving birth to 8 and 9 pound-plus babies of big, tall, husky Caucasian and African-American fathers are able to do it so easily? I've seen plenty of tiny Asian women give birth to big babies as well, with very little, if any trauma or drama. Does this woman think that the pelvis of the American woman has evolved into something mostly inadequate for birthing, in the space of under 300 years? Please. It's not our pelvises that have become dysfunctional, it's our thought processes. To have read the book and had a rational discussion of it would have made it necessary to question the illusion of our own Golden Calf.

Finally, I get so frustrated hearing my coworkers referring to the midwives in town as "Lay" midwives!!!!! They don't know what a CPM is, they don't know what MANA is, they don't know what NARM is. Why????? The few times I've attempted to "educate" them about it, I got quizzical looks from them until I showed them printed materials from both groups, including the endorsements from physicians and state governments where they are recognized as collaborative members of the health care team...then I got little more than shrugged shoulders, and they still refer to these woman as "Lay" midwives...despite the fact that the founder of the most active group of midwives in this town is internationally known! She's a gem, she's a recognized expert in her field, she's drifting quickly into retirement, and we've never taken advantage of her opinion and expertise! What a loss.

For all my griping, I really do respect the nurses I work with. They can be nothing short of awesome in a situation that is going downhill fast. Most of them love what they do, and their patients love them. They know their stuff , particularly when it comes to high risk deliveries. I seriously believe that, in a city with too many L&D units, they are the best there are. They are the first person to be there if a nurse is in a situation that is getting hairy. If someone I loved or their baby were in trouble, these would be the nurses I would want to take care of them. Honestly, I would trust my very life with them. They are that good...I just wish that they had more respect for those who make different choices than they would. I wish they had more respect for the low risk side of things. I wish they would at least examine the other view before so staunchly defending their own.

I don't get it. I just don't. These are educated people. They know how to critically read research. The information is more readily available to them than it is to anyone else.

What Gives?????