Friday, August 20, 2010

I'm that friend...

My best friend is pregnant- yeah! She is due on my birthday- double yeah! But, I totally suck. Like seriously I'm not even sure that I should talk to her until she delivers. On the phone she asked an innocent question about how I handle working at Big County Hospital and I start to bitch and moan. I'm supposed to be the rah rah birth cheerleader and I start talking about vacuum deliveries and c/sections! What the heck is wrong with me!? She isn't even a nurse- so no terrible stories of her own! I realized what I did, but it was too late. She beat a hasty retreat and I sent her a long apologetic text promising only positive birth stories from now on... I suck. Seriously. Maybe I can blame Big County Hospital for making me jaded? I think I need some beautiful births to get my rah rah spirit back.

Thursday, August 19, 2010

The beauty of laboring down using the California Roll....

This post is specific for a mother with an epidural. Laboring down is nearly impossible for an unmedicated mom. It requires denying the urge to push and that is like trying to stop a speeding train with a feather.

Look at this animation showing the different stages of presentation....

Note all of the movement of the baby. A baby descending through the pelvis is like a key having to fit in a lock. The baby is as much of a participant in the birth as the mother, s/he is not just conked out in the uterus. The baby needs to turn her head one way, her shoulders another, and then rotate back. This doesn't necessarily happen because the mom is pushing, it happens because it is how we are made. It happens because it must.

One mistake that I think a lot of nurses may make is that they start to push a patient as soon as she is completely dilated. I feel that as long as the mom is not uncomfortable/ feeling tons of pressure than waiting for the baby to start to descend in the birth canal is very helpful. It keeps the mom off of that "pushing clock" for a little longer and it shortens the total amount of time and effort needed for her to push the baby out.

I also have theory. When a mother is nearing complete dilation and the baby descends, there is a usually a slowing down and spacing out of the contractions (in natural labor). I believe that this happens because the fundus of the uterus is empty (as the baby's bottom is now lower). I think that waiting and giving time to labor down allows the muscles in that uterus to contract back down around the baby's bottom to allow the uterus to be more of a helper during pushing. A Boggy Uterus doesn't want to contract, but a nice tight uterus contracts much more efficiently. If you wait you will see contractions that have spaced out start coming closer together. This break is God's way of giving an unmedicated mom a rest before she has to push. 

What should you do while waiting? Well, I believe that the epidural does not prevent a mother from being an active participant in the birth. Just because you have an epidural does not mean that you get to sleep throughout labor. I use a technique known as the "California Roll"- Google it and you just come up with sushi. It is sometimes called "Chicken Wing" (but that leaves an important step out). I am sure that other hospitals have different names for this, I am hoping that other nurses are already doing this. This is a great doula technique for you doulas who are attending a hospital birth.

I DO NOT like using high fowlers to labor a patient down. You do that and the baby's head is just slamming against that coccyx the whole time. You end up with a patient with terribly swollen labia, an increased risk for tearing, and a potentially swollen cervix.

1) I put the mom in a far left lateral position first- she is nearly laying on her stomach. The right leg is held up by the left stirrup, but the knee needs to be really flexed up as far as it can towards her stomach. I flip over the bottom left pad on my labor bed to support her left leg, but you can use a pillow here. This position allows her coccyx to be mobile. In a standard semi-fowlers, high-fowlers, or lithotomy position the coccyx is completely immobilized by her sitting on it! If you put a mom in this position, I want you to see how open her pelvis is, how much more room this gives the baby to descend. I leave her in this position for about 20-30 minutes.

2) I then sit her upright in a throne position in the bed. Essentially high-fowlers, but with a big twist. The bed essentially looks like a chair and I sit the father of the baby or another family member on the bottom of the bed in between mom's feet. She is leaning forward leaning on their shoulders with her belly falling between her knees. I then tell the Dad/family member to rock left to right and front to back. I leave them there for 20-30 minutes. This also works with her leaning over a birth ball, but with an epidural I prefer to have a person there to help stabilize mom.

3) I lay her back down in a far right lateral position. The exact opposite of step one. She is there for another 20-30 minutes.

Over and over I have had tremendous results with this. I have turned OP babies, I have fixed swollen cervixes, I have gotten a cervix to dilate that hasn't dilated in 5+ hours, I have caused a very tight pelvis to open and allow baby to descend from "sky high", I have fixed asynclitic babies, and I have saved moms many an hour pushing. I even had a brow presentation once with a G1 using this technique to help baby to descend. It gives both time and and the room for a baby to move down.

The goal here is to try and mimic what an unmedicated mom would do if possible. An unmedicated mom would NEVER choose to lay in bed in a semi-fowlers position if she wasn't hooked up to a monitor. She would be up rocking her pelvis and letting her belly fall forward.

An epidural labor will never be a "normal" birth, but a good nurse/doula can try to minimize a mother's chance of ending up with a surgical (vaginal or otherwise) delivery.

Wednesday, August 18, 2010

A woman had her baby taken away for three years for refusing a c/section...

I was incredulous to read this article on a woman at a New Jersey hospital who refused to sign a pre-consent for a c/section. Here is another article on the same situation. She wanted the chance to have informed consent at the time of the surgery instead of signing her rights away before it was medically indicated. I understand completely where she is coming from. There is always time for a signature- even in the most pressing of moments there can be someone getting a signature. As long as she was informed of the risks ahead of time, she could of waited to sign until she was rolling into the OR if needed.

This hospital has a 50% c/section rate. If I was delivering there, I would probably not want to sign the c/section consent as well! It seems that your odds are just as good for an operative delivery as they are for a vaginal one! Ridonkulous!

What really pisses me off about this is that she is made out to be a "bad mother" because she didn't want her baby to be delivered via c/section. C/S really suck for moms, but they are hard on babies too. Gunky lungs, difficulty breastfeeding, spinal anesthesia, and the list goes on and on.

What this really comes down to is whether or not it is possible for someone to have "informed consent" when they sign the c/s consent in early labor. The decision for an operative delivery is taken away from the parents and given to the doctors. The doctors decide if a c/s is necessary based on their own views. Their views are based on a lot of medical training, but also on a fear of litigation. If something goes bad and the doc did a c/s it nearly will always clear him because "s/he did everything possible". How can a parent make an informed consent for a situation that hasn't even happened yet? Does it really take so long to go over the risks of surgery in early labor (but not get a patient signature) and get the signature when the need arises? Is it really that big of a deal to tell a patient the reason that we want to section them? At least then they will feel like somewhat of a participant in their birth. During a stat there are nearly always lots of hands to get the work done, is it really that hard to make getting a signature part of the work? We can get a baby out in 6 minutes at my hospital. I don't see that number being affected by the need for a signature as long as the patient was informed of the risks of a c/s in early labor.

Does refusing to sign a consent make a woman a bad mother- bad enough that her baby is taken away for 3 years? I don't think so. Heck, does having a home birth without even an OR around make a woman a bad mother? Hell no. This thinking is just part of the medicalized childbirth model that really needs to be changed.

Saturday, August 14, 2010

The down and dirty. Yeah, I'm going to say it. Poop.

I'm going to be direct, I'm going to be blunt, and I am going to sound like a nurse for a bit.

Poop. It happens. It happens everyday for all humans (hopefully!) and for all other creatures that walk or swim on this Earth. There's even a kids book about it Everyone Poops- I highly recommend this book btw for your kiddos. It helps with potty training and associated pooping on the potty anxiety.

So, why is pooping during birth such a big deal? It is really part of the natural physiology of birth. It is normal.

First, watch this animation of a vaginal birth. Recognize that something very important lies between the coccyx and that baby's head- the rectum.

As the baby's head descends, it literally squeezes out the poop from the rectum like you would squeeze toothpaste out of a tube. If there is poop there, it is coming out- it is just a mechanical thing!

Let alone when a mother is completely dilated! What is the simplest way to teach a first time mom to push out a baby? Let alone a mom with an epidural? Tell her to push just like she is pooping! Pushing out a baby and pushing out poop uses the exact same muscles. Of course, if you are using the same muscles that you use to poop with to push your baby out, there is the possibility that you may push some poop out as well. It is mechanical and normal. Heck, if I see a first timer moving poop, than I get excited! I know that she is pushing in the right spot! (Okay, I know that may sound weird to non-birth professional folks, but it is true). I am going to share one of my tricks here that other birth professionals may know. If a woman is pushing (usually a G1 here) and when I do a vaginal exam I can feel through the vaginal wall some hard stool, I will push that poop out by pushing down on the posterior wall of the vagina. This is for women with epidurals only. That hard stool can sometimes impede that baby's head as she is pushing if she is not able to push it out on her own. Soft stool just comes on it's own.

Let's talk about diarrhea during labor now. IF you go into labor on your own (this does not apply to induction) you may have loose stools for a day or two before labor begins as well as during labor itself. This is due to the release of the hormone prostaglandins which cause smooth muscle to contract. The uterus is made up of smooth muscle as are the bowel. Prostaglandins also serve the wonderful purpose of causing the cervix to soften so that it will open! If you are in active natural labor, than you may continue to have diarrhea throughout your labor. It is normal. It is your body doing what it is supposed to do to help your labor to happen. A lot of books say that "this is the body's way of cleaning out the bowels for the impending birth". They are just trying to make you think that the body is giving you a natural enema- which it kind of is, but having loose stools in early labor does not mean that you won't poop during pushing. There is a lot of feet of intestines there and there may be a lot of stool hiding.

What brought all of this up? Well, yesterday I had a patient that I was helping another nurse with. She was a G1P0 who came into triage booming in active labor. In triage she was 3cm/100/-1 and I got her into a room and got her an epidural (her choice). After she was comfortable the doc came in and checked her and AROM'ed her (this is a hospital people)- she was 6/100/0 at this point. Several hours later she was complaining of feeling a lot of pressure. I with a new LAD nurse checked her (the new nurse is checking behind me to learn the wonderful art of sterile vaginal exams). She had an AL (anterior lip)/100/+1. This was all done on her own- no pitocin. I noticed a large amount of watery stool upon this exam that the patient wasn't even aware of. I cleaned her up, and the new nurse wanted to see if the patient could push past the little lip of cervix since she was feeling a lot of pressure. I left the room to let the new nurse push her and as she pushed more stool came out, but apparently the father of the baby kept asking the mother if she had to go to the bathroom and looking really grossed out because of the poop. Now, we nurses cleaned her up. We removed the soiled chux and soiled linens from the room. He spoke Spanish and I came in and explained to him that it was his baby's head moving down that was causing the poop to push out and that his wife was doing wonderfully well. That this all was normal. I then told him that he needed to help her and tell her how beautiful she was as she birthed his baby. He looked properly chagrined and the patient seemed to like me chastising him, but she still looked embarrassed. I tried to reinforce how normal this was and praise her for doing so well, but I could tell that this would probably be something that she would remember in a negative light from this birth. I hate that.

If the idea of pooping during labor is something that you just can't handle than there are just two things that you can do. First, do NOT take Castor oil to help induce your labor. Castor oil induces labor by loosening the poop and causing the smooth muscle bowel walls to contract, the contracting of the bowels may or may not cause the uterus to contract as well. You will be having diarrhea all throughout labor if you take this. Also, taking castor oil really increases the chance that your baby will poop in utero (passing the first poop called meconium) and that is a complication that you really don't want. Second, if the poop grosses you out that much your only option is to give yourself a soap suds enema (available at any drugstore) during your early labor. It may actually speed up your labor and may keep the dreaded poop from appearing during pushing. Of course, enemas are uncomfortable and difficult to give to yourself.

What I would really hope is that you will embrace the poop as a normal part of birth. Realize that you are joining the billions of women throughout history that have pooped as they pushed their babies out. Get excited (just like us birth professional types) when the poop happens knowing that you are just that much closer to holding your baby in your arms. Educate family on the poop so that they know to expect it and how to treat you when it happens.

Everyone poops. Almost every woman poops during labor/pushing. It is NORMAL. Do not be afraid. The act of birthing a baby is a much more intimate and important event than someone just seeing you poop.

Tuesday, August 10, 2010

Breast, Bottle, or Both?

Breast, bottle, or both? Is what I am supposed to ask. A high percentage of my patients would choose "both". I don't ask that though. I ask Breast or Bottle? When the patient tells me that they want to bottle feed too, I have a long teaching moment about why it is so important to exclusively breastfeed in the hospital. There is a lot of educating my Latina moms as colostrum is not viewed as something good for the baby in most Latin cultures. There is a lot of encouraging them to "call for that pizza (aka breast milk)" every 2 hours by putting the baby to breast. There is a lot of explaining about how little a newborns stomach is (the size of a marble) and that they really don't need a huge bottle within the first 24 hours.

When I have a vaginal delivery, I always place the baby skin to skin. I always try to get that baby to latch on. I almost always call the nursery to see if I can keep the baby for longer than the hour that I am allotted to help mom to breastfeed.

Why is it that this is not the norm? I work with some awesome nurses. Really, I do. There are only a couple that wouldn't encourage a mother to breastfeed. There are a couple more that really don't care one way or the other. But, the majority really do give a shit.

I just wish our exclusive breastfeeding rates were better. Why do we even offer "both" as an option? I just don't get it.

Monday, August 9, 2010

Induced Labor May Double the Odds of a C-Section

The induction of first time moms really needs to be drastically reduced. According to this study, first time moms who had their labor induced doubled their chances of ending up in the OR. I see this cycle happen all of the time.
1) Induce a first time mom because she is at 41 weeks, or baby is estimated to be LGA, or for doctor's convenience (not so much at county though).

2) Round one of cervadil (12 hours). Potentially NPO during this phase if the nurse doesn't advocate to be able to feed the patient.

3) Round 2? of cervadil. Seriously, it happens.

4) A balloon (8 hours). Hopefully she is 4cm when we take the balloon out.

5) Pitocin.

6) More pitocin.

7) Pain and epidural. Break her water.

8) Now, she is chorio because we keep sticking our fingers and other things up her vagina. Antibiotics.

9) Internal monitors at some point.

10) Still NPO, for over 24 hours at this point. (and we wonder why the uterus doesn't want to work anymore)

11) Failure to progress (better), massive fetal decels (worse) and a trip to the OR. Another unnecessarian.

12) Honey, it wasn't your fault- it was ours.

This happens over and over. I hate it.

Wednesday, August 4, 2010

Gisele! Who woulda thunk it?

Color me shocked. Check this article out in the Huffington Post. Apparently, the supermodel Gisele gave birth to her son in a bathtub (where else would a baby be born? :D) and is now advocating breastfeeding! In an article in September's UK Harper's Bazaar, she states:

“Some people here [in the U.S.] think they don’t have to breastfeed, and I think ‘Are you going to give chemical food to your child when they are so little?’” the brainy beauty told the UK magazine. “I think there should be a worldwide law, in my opinion, that mothers should breastfeed their babies for six months.”

She backpedaled a bit in the Huffington Post article, but wow! I am impressed! Would it rock any boats to say that I AGREE with her?!?! Sure, not every mom can breastfeed, but MOST can. Sure, some babies are adopted, but there are great supplemental nursing systems out there. There is NO reason to not breastfeed your baby for at least 6 months.

Denying your baby breastmilk is just not right. The WHO agrees with Gisele and recommends breastfeeding until 2. The AAP even agrees with Gisele! Why is it so controversial that Gisele said this? Good for her for using her fame to support breastfeeding!

Long time, no post...

I know, I have been gone for a bit. A lot has been happening! I fractured my ankle (healing slowly), Bean had a birthday (5!), summer vacation, getting my house ready to sell, and OMG applying for grad school! W00t!

Lots of big news going on. ACOG has finally recommended VBAC after c/sections x2! Can you believe it? My jaw seriously hit the floor when I read this one! Does anyone on my unit know, or care? Heck no. Will this change my hospital? I don't know yet. I mentioned ACOG's new stance on VBAC's to my nurse manager and she wrote it down on her little notepad to talk with the medical director. My hospital is a pretty progressive one (in the area anyways) as we encourage women to VBAC after one c/section. I am really hoping that we will implement a new policy based on these recommendations. *fingers crossed*

Bean turned 5! He is my homebirth baby and somehow 5 just seemed like more of a milestone than 3 or 4. He will be starting kindergarten this fall. He is turning into a kid, no longer such a toddler. I really miss having a baby around, although if he had his way I would still be nursing him (he was weaned at 3) and carrying him in the sling (which I do, but man is he heavy now) all of the time. He is a mama's boy to the 9th degree! I am wondering now if I will have another baby, and that makes me sad. I am young enough, but with the dissolution of my marriage there are a lot of ducks that would need to get in a row for that to happen! *sniff* my baby is growing up!

Grad school! Is it really time for that already? I have been getting my applications together for several online midwifery programs: Frontier, Stony brook, and Univ of Cincinnati. There is a local DNP program, but I want the flexibility of an online program. As a single mom, childcare is hard to come by! Plus, I am really hopeful that I will be able to move back to my home state out West in the future. With an online program, I could continue my studies uninterrupted. Of course, there is always the issue of finding a preceptor, but I am hoping that my homebirth/ birthcenter connections will help with that. The local DNP program is lacking  out-of-hospital birth experience which is the PRIMARY reason that I am going to grad school! Why would I choose a program that will never let me see an out-of-hospital birth from a midwife's perspective? Some of the local midwives at my hospital have kind of looked down on the online programs, but they are right up there on US News and World Reports rankings of graduate midwifery programs. Frontier is 12th, Stony Brook is 28th, and Univ of Cinn is 29th! Is my local DNP program listed? Nope! The only brick and mortar school that I am interested in attending is UCSF, but that would require a BIG move and for me to be completely fluent in Spanish- which I am not yet. Anywhoo, wish me luck! There are a lot hoops to jump through to get these applications in.... Jumping through hoops is not my favorite thing in the world.

Along the education lines, I have been researching what I need to accomplish in the next year to sit for the IBLCE exam to become a lactation consultant.  I would be on Pathway one and really just need to complete a lactation course to receive my 45CEUs in lactation management. I am trying to figure out if my hospital is willing to shell out the $700 that one of these courses costs. I really hope so, because we have had 3 positions posted for L.C. in my unit for a long time. Clearly, we need more L.C.s but are they willing to pay for it?

The ankle... Le sigh. It is slowly healing. Management has finally seemed to understand that "light duty" really means I can't take care of patients. Lots and lots of paperwork though. I hate it. Really really hate it. I am so ready to labor patients again, but as long as I have to wear this boot I am stuck.

Random conversation overheard between two Attendings in the OR hallway.
Attending one: "You do circumcisions, right?"
Attending two: "Sure, the money is good."
Attending one: "I used to be so fast at them! But, then I realized that one thing that you shouldn't be fast with is a circumcision."

I really want to know the story behind that one. Poor little boys and their missing foreskins.

July. Do NOT ever, ever get sick or have a baby and go to county in July! July is when we have a whole new batch of 1st year docs start, the 3rd years become 4th years, and everything is discombobulated. July is also the start of LAD's busiest time of year. In LAD, you always need to think about what was going on 9 months ago. Well, 9 months ago the holiday season was starting, it was starting to get cold, and people were making babies!  I am dreading September and October of this year because we were snowed in so much this last winter! Holey moley, the babies are raining down! It doesn't help that we are really short nurses (not just me, but many others too). Just craziness everywhere. We did over 650 births at my hospital in July! I was out much of July completely because of my ankle, and now being back light duty it is really hard to not jump in and help.

Too random? Too much? Hopefully I will actually manage to post more than once a month now!