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Posts tagged ‘Cesarean’

Amazing Woman has an Amazing Home Water Birth

Go GINA GO!

I lit my Blessingway candle in the wee hours of the morning when I saw that her labor at home was underway.

I faced the candle in a window towards her home 1500 miles away.

I like how the reflection makes it appear as though the light keeps spreading west towards her…….

sending love and support…..

Not only did she have a VBAC today–

She had a HOME VBAC !!

AND during Cesarean Awareness Month!

Gina of The Feminist Breeder is one of the most courageous women I have ever met!

Yep- I met her! She invited me … little ole me… to her Blessingway in March when I happened to be in town. I was so incredibly excited to meet her and all her fabulous birth team! Yep- I’m in that Blessingway post she did.

Photo of the TFB Blessingway Group

Here’s one of the beads I gave her for her necklace.

ICAN Cesarean Awareness Bead

Congratulations Gina and John!

Welcome Jolene!

But it’s her story to tell……. Head over to her blog and check the coolest EVER live blog birth event. The whole thing can be read and viewed from last night thru til this morning. The audio and video clips are for QuickTime player and each clip may take a few moments to load before you can push play.

I had it on today … at work… in the NICU and took the opportunity to try to educate..

Thanks for sharing Gina!

I am so so happy for you!

Push for Real Changes in our in-hospital Maternity Services

The average consumer may not know what could possibly be helpful in exacting REAL change in our hospital maternity care. I am certainly no expert in this field and would welcome additions or corrections to what I say here….. but I want to offer a little perspective from the inside. Maybe this will help somewhere.

I am a Birth and Breastfeeding Junkie and I am proud. I don’t care if someone recently didn’t like that nomenclature….. That’s what I call myself and how I relate to other like minded individuals. I have a need to know what’s going on in that world.  We junkies read and discuss all the current evidence, all the latest recommendations from the WHO, NIH, CIMS, ICAN, ACOG, AAP, AWHONN, ILCA….. and so many more. We love all birth stories and learn from each other. We educate ourselves. We STAY current. We want informed decisions. We want options. We want this type of evidence-based care available where we live. We advocate for those individuals who may not even know there may be another choice. We want to see the women of America have access to respectful quality services everywhere!

Ok –> that said…. When I see new evidence, research or new recommendations; what I have done over the years to offer up any proposal for process improvement or care delivery change including whatever may be needed to implement these changes… is to collect resources, develop a policy or plan and present to docs, manager and staff. The response is usually positive. Sometimes I get a lot of “smile and nod” and “please hurry up I have other things to do I’m not really listening”…. but mostly positive. Sometimes it’s only positive in that “My you’ve done a lot of research..and Good Job!”  instead of–Yes let’s do this! The changes are not always adopted and there isn’t a total “Buy-In” from everyone to make it a successful total change in practice. Eventually and unfortunately, because these things aren’t monitored, many practitioners go back to their own comfort zone of past [outdated] practices. Arrghh

Project poster inservice example

There must be a better way.

I was sitting in a Professional Practice Committee meeting a few weeks ago listening to a mandatory (did I say Mandatory?) action plan presentation by the Director of Patient Relations/ Patient Satisfaction when it hit me how there may be more avenues for REAL change driven by the consumer than those of us in the trenches. All of the directors (suits) were there and were required to come up with unit-specific mandatory action plans to improve patient satisfaction and positive perceptions of their hospital experience.

She was presenting an action plan based on the latest HCAHPS report.

What is HCAHPS?? Maybe you know- maybe you don’t. Skip over this if you already know.

“The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey is the first national, standardized, publicly reported survey of patients’ perspectives of hospital care. HCAHPS (pronounced “H-caps”), also known as the CAHPS Hospital Survey, is a survey instrument and data collection methodology for measuring patients’ perceptions of their hospital experience. While many hospitals have collected information on patient satisfaction for their own internal use, until HCAHPS there was no national standard for collecting and publicly reporting information about patient experience of care that allowed valid comparisons to be made across hospitals locally, regionally and nationally.

Three broad goals have shaped HCAHPS.

  • First,the survey is designed to produce data about patients’ perspectives of care that allow objective and meaningful comparisons of hospitals on topics that are important to consumers.
  • Second, public reporting of the survey results creates new incentives for hospitals to improve quality of care.
  • Third, public reporting serves to enhance accountability in health care by increasing transparency of the quality of hospital care provided in return for the public investment.

With these goals in mind, the Centers for Medicare & Medicaid Services (CMS) and the HCAHPS Project Team have taken substantial steps to assure that the survey is credible, useful, and practical.” HCAHPS fact Sheet 2010

The reason hospitals are taking these results so seriously is that.. well… I’d like to say they ONLY care about the patient, but they are a business and it comes down to money in reality.

$$$$$$$$$$$$

If a hospital scores fall below a certain number in patient satisfaction… they can lose like 3% of Medicare Reimbursement. That adds up to a lot of money really. You may think that doesn’t apply to Maternity Services but it does, ultimately, because that survey goes out to all adult inpatients. If the scores for satisfaction are low for obstetrics, it can throw off everything, and affect the reimbursement to the facility. That, in turn, can affect how much money is available for overall improvements.

Medicare has also started to cut reimbursement to cover the costs of “preventable” conditions, mistakes and infections resulting from a hospital stay in 2009. That is older news so you may already know about that.

The thing is– what the big two Medicare and Medicaid… [The Centers for Medicare & Medicaid Services (CMS)] often set the bar and other insurance companies follow in the private sector. The 2009 National Health Insurer Report Card may give you more information about what is or is not paid. I don’t know much more about that.

HCAHPS is the first I’ve heard of actual patient satisfaction scores steering reimbursement which is transparent and publicly reported. I have heard many pt satisfaction reports but they were never given this much attention. At least in my hospital.. Perhaps I’ve been too much of a Birth Junkie to notice. 🙂


The other big catalyst for positive change is the new JCAHO Perinatal Core Measure Set. The MotherBaby Summit website has an excellent review of these 5 elements, explains them and provides further references.

There are two new employees who only work on JCAHO compliance and data collection. They are looking at the PC-05 Exclusive Breastmilk Feeding numbers and are not happy…. Well — neither am I !!  I have been trying to do something about that particular issue since 1988 !  Since these are now factors for regulatory compliance as well as patient satisfaction… Now we are going to do something. I am pleased to announce that we are forming a Breastfeeding Task Force!! YAY! We also have a new Pediatric Dept Chair who is a no bullshit we are going to do it kind of guy… so YAY!

Bottom line: The hospital is sitting up and seriously taking notice about the consumers opinion AND how regulatory agencies are now monitoring things have never been monitored before.

  • Action plans are being developed to comply
  • The consumer has more of a voice than ever before

Here’s what you can do

Before the hospital:

  • Have a prenatal interview with your provider… ASK : Do they have current evidence based practices/protocols in place ….. do their standard orders reflect the most current evidence based guidelines and standards of care…. do the dept members all follow these standards. Do the nurses actually follow these orders….
  • Do the same with your pediatric provider
  • If you are not happy with the provider and choose NOT to use them, make sure they know exactly WHY… what were the points which caused you not to choose them.
  • Have a birth plan and discuss it with all providers, nurses and even mail it to the manager where you will deliver. Ask your manager to please make sure your wishes are communicated with the staff.
  • Use words like RESPECT, SATISFACTION, Patient RESPONSE Time JCAHO Core measures.
  • Ask for numbers when you have your interviews.. for instance..what are your CS rates? VBAC rates? What are exclusive breastfeeding rates? If they don’t know, ASK for the name of a hospital person who can help you get that information. I am sure they have the numbers.

In the Hospital:

  • Get the names of those individuals/ midwives/ doctors/ nurses/ etc who were good and those who were poor caregivers in your opinion. Write them down somewhere and why. Specifics help.
  • If you don’t feel your wishes are being honored or disrespected, ASK to speak to a patient representative. There is most likely somebody on hospital staff who has that role and can assist you. Use the words Satisfaction, Respect or what is relevant etc…
  • Ask for options if they are not discussed. Don’t rely on a Birth Plan you made weeks or months ago to be always remembered by everyone. Even if it’s right with your records. Different options may be available that weren’t before. For instance, We recently installed telemetry fetal monitoring allowing for increased mobility. If somebody asked a while ago, we did not have that option. You may have to repeat yourself… esp in a very busy Labor&Delivery or Mother/Baby unit. Sorry. That’s the way it is sometimes. It can get crazy but you are just as important as anyone!

After You Go Home:

  • You will be very busy with your baby and good or bad… your individual experience will be a memory that could fade over time. We still need to hear what you have to say IN WRITING whenever possible.
  • Please Fill out your survey –> it may be long but most are a multiple choice and allow for a write in comment section. Put in the names of the good and the bad!!  Please do it.. then actually mail it
  • Please make written comments. Include names. Specifics help.
  • Please Make Us Accountable. Write a letter to administration (Head of unit, Head of nursing or Head of hospital) include specifics. They HAVE to personally answer to this type of thing first! They get this info long before the surveys. Write for the good or the bad parts of your experience.  Including if you make suggestions. It may be monitored or tracked how many times they receive a comment about a certain issue. Definitely tracked for negatives– especially for specific individuals.
  • Please also write a letter to the Head of OB or Pediatrics Departments and let them know who else you sent the letter to. Include everything from above.
  • If you are certain what you experienced was NOT evidenced based medicine or care…. PLEASE mention exactly what you know.

 

Thanks for reading this, I hope somebody out there takes the time to give the needed feedback which will help mold and improve our care.

Skin to Skin Minutes After C/S in the OR… Speaking Up and Making it Happen

Beautiful Skin to Skin after birth (iStock Photos)

Submitted for the Healthy Birth Blog Carnival #6: MotherBaby Edition


Skin to Skin immediately after birth is an extremely important part of the continuum of the nurturing of pregnancy, the process of birth and the transition of nurturing from inside mom to outside mom. This is the natural habitat where baby should transition and begin his own regulations of breathing, heart rate, temperature etc… This is recognized by the AAP in their changes to the Neonatal Resuscitation Algorithm back in 2000. The recommendation was to keep baby with mom and provide all initial evaluations and steps with baby on moms chest for all healthy babies!  We all know that babies have an inborn innate ability to self attach and nurse right after birth. These recommendations are not just for vaginal births. Kathy Petersen has a beautiful description of the importance of STS after a Cesarean birth on her Woman to Woman Childbirth Education blog in her 5/30/10 post Skin-to-Skin in the O.R. after a C-section.

As soon as I heard about the last edition of Science and Sensibility’s Healthy Birth Blog Carnival with a theme about “keeping moms and babies together after birth”, I wanted to write about my tiny little efforts, struggles and some successes in providing moms and babies with an environment that supports and protects their need to stay together. My recent role in the protection of such an environment and subsequent privilege of watching a baby self attach in the OR 15 min after a C/S birth has re-energized my efforts to get more mother’s and nurses to speak up and make this a standard for healthy babies!

Then….. I saw a link on Laura Keegan’s Facebook fan page for her book Breastfeeding with Comfort and Joy to an awesome video and a beautiful photo posted by the author of Cesarean Parents Blog about her birth. I had heard of Laura’s search for images of STS after C/S and asking for mother’s experiences. Amy Romano from Science and Sensibility alerted Laura of the photo: Kathy blogged about STS after C/S and I was working on this post! Such uncanny timing! I am just in awe of this marvelous networking community! Head over to Laura’s facebook link and share your experience for her info gathering. Here is the fabulous video they are all talking about “Breast is Best” from Norway:

Why is it so hard for the doctors and nurses to get on board? Most of them understand the word “bonding”.  But what many don’t realize is that it took a long time for the actual concept to take hold, to allow “time” for bonding to occur.  It sounds silly but many times if the baby and mother are still together after 2 hours…the nurses call that “extended bonding”.  I have been doing this for over 35 years now and the changes from the 70’s to now are fascinating and frustrating at the same time. To understand the process of change, we have to sometimes remember where we’ve been. I wrote about Medical Science vs Natural Childbirth a year ago because I feel history IS important to help us move forward. Often it is about control… but many times nurses and doctors are simply task oriented/focused and not patient centered. They want to complete all their procedures and charting and move on to the next task. I understand this, there is always a lot to do and document. I work there too! The environment provided to us, the health-care workers, is one in which regulations are abundant and staffing is not always optimal. Flexibility is needed. I know there is a way. This culture just has to change. And it happens in small little doses.

SO–> Skin to Skin immediately after a C/S? I have been told by coworkers, doctors and anesthesia:

“It’s impossible, “

“It can’t be done”

“There’s not enough room”

“This patient (the mom) is in the middle of major surgery!”

“The baby needs to be under the warmer, it’s too cold in the OR.”

Really? Seriously? Watch Me………

I have actually been working on this issue for the past few years…… Ever since I began staff education for World Breastfeeding Week 2007′s theme “Breastfeeding: The first hour — Welcome Baby Softly”. The focus from ILCA was: ‘Establishing a welcoming environment that keeps mothers and babies together.’ It was then that I gently tried to introduce the concepts for C-Sections as well as all vaginal births. I was getting a lot of positive response for vaginal births…not so for C/S.

Anesthesia is our biggest barrier. The chest area of the mother seems to belong to them somehow. The arms too.. I always politely ask the doctor for permission to have at least one arm released so she can touch her baby. (they are secured on armboards to her sides.) Really the OB’s didn’t mind what was happening outside of their draped domain. The Pediatrician is the next barrier because they want to finish a complete exam…. in the nursery…. before they returned to the office or whatever.  So I started with the Peds… hoping they would stop expecting the baby to be quickly removed from the OR. I started with just simple requests for prolonged “bonding”… because they all get that. “Look how well this baby is transitioning.. so alert and PINK! ” “I’ll write all the measurements in your exam note…. I’m fine… I know you’re busy….” I’d say.   Sometimes mom and baby got to stay together. Soon, for some of the doc’s, the expectation of baby leaving mom was gone. They got tired of waiting around and would leave. More moms and babies got to stay together…even if it was dad doing the holding. My co-workers were not always so understanding because of the work flow on the unit. It would work best when the birth happened any time other than first thing in the morning when it’s busy everywhere. Isn’t that sad? Sitting here writing this I’m thinking of ways to work on that….. another time…..

Anesthesiologists or Nurse Anesthetists are all different. There are some wonderful ones who are releasing both arms and pushing things out of the way for the baby and others who are constantly telling moms they are “under” anesthesia and can’t hold the baby, or they have given meds to mom right after baby is born so mom is now groggy. I talk to each of them respectfully and differently depending on their own approach. I have discussed my plans for STS if baby stable ahead of time. I have discussed how it is up to us to provide this protected environment for moms etc…  I have used the patient satisfaction discussion, the scientific evidence discussion, the patient centered care discussion, and the increased patient numbers due to higher satisfaction talk.  I have let them know that when a mother requests that–> we must do everything possible to help her experience this.

Slowly, over the last few months, I was able to facilitate some babies really getting skin to skin in the OR for short periods before going to the nursery. There were a variety of factors for why it wasn’t very long each time but at least it was happening!! It’s not a standard of care yet and I’m the only one working on it but others are getting interested… Communication has been very important to create the environment and reduce barriers. We still have a long road ahead. But we did pave a path for this mom….

She came in with an unknown double footling breech presentation in active labor and the doctors wanted to do a C/S right away. She was really upset and had a beautiful birth plan that was already getting discarded. “STS until first breastfeed accomplished” was on her plan and I was determined to help her with that! Things were happening fast. The anesthesiologist wasn’t my best STS supporter.. “oh well” I thought, “I’ll do what I can to help.” The baby was crying and pink when born and without thinking about it, the doctor, nurses and myself had him on the baby unit drying him. Mom went panicky! “Give him to me, give him to me! He has to be ON me! You just took him OUT of me, now he HAS TO BE ON ME!”  She was literally trying to sit up. Anesthesia was drawing up meds for her (that was his answer).  I said “OK here he comes!”. So I didn’t ask anyone’s permission this time….. just held that naked baby in one hand, snapped open her gown with the other and helped him move in. I asked for a warm blanket and looked up to see the other nurse and doctor staring at me. I said “Seriously… she’s exactly right, he does belong ON her!” Anesthesia saw the immediate transformation of his frantic patient to one with calm maternal bliss, admiration and cooing. He was then helpful to let her other hand out. This little boy stayed with mom, breastfed before he was 15 min old and went to the PACU with mom. She was so incredibly happy. I never got to see her after that since it was near the end of my shift and I wasn’t on shift the next few days. I saw that she exclusively breastfed in the hospital and without complication went home on day 3. At least part of her birth experience went according to plan!

If she hadn’t have been so vocal about what she wanted, so adamant… she would not have experienced what she did.

SPEAK UP AMERICA…. MAKE IT HAPPEN

Want to see more? This stunning video of a baby skin to skin then breastfeeding at birth in the operating room via @MothersUtopia @Laura_Keegan. What were your experiences? Please don’t forget to head on over to Breastfeeding with Comfort and Joy on FB to comment on your experience or opinion about this important topic!! Calling for women to share their experiences with skin to skin here, to help give a voice to the real need to make skin to skin in the OR routine practice in all ORs.






“Breastfeeding is a Health Preventative Behavior” ILCA Press Release

Please send this press release too any local media companies!

United States Lactation Consultant Association Announces

Date: May 14, 2010
Contact: Scott Sherwood                                                      For immediate release
Tel. 919-861-4543
Email: ScottSherwood@uslcaonline.org

National Woman’s Health Week

Morrisville, NC- The United States Lactation Consultant Association (USLCA) joins the US Department of Health and Human Services in celebrating National Woman’s Health Week. The week of May 9th to 15th is dedicated to empowering women to make their health a top priority. In honor of this week the USLCA reminds women that breastfeeding is a health preventive behavior that reaps benefits for a lifetime. Avoiding or abandoning breastfeeding increases a woman’s risk of developing premenopausal breast cancer, ovarian cancer, type II diabetes, hypertension (high blood pressure), hyperlipidemia, and cardiovascular disease.

The decision to breastfeed is a health promoting public health behavior that benefits not only infants but also their mothers. During National Women’s Health Week, communities, businesses, government, health organizations, and other groups work together to educate women about steps they can take to improve their physical and mental health and lower their risks of certain diseases. Women are often the caregivers for their spouses, children, and parents and forget to focus on their own health. But research shows that when women take care of themselves, the health of their family improves. Health care providers are urged to remind the childbearing population of women that they work with of the importance of breastfeeding as a method of reducing diseases and conditions that can rob them and their family of a healthy mother. Heart disease is the number one killer of women in the US. Epidemiological data suggest that women who do not breastfeed or wean too early face a higher risk of diease and early death.

USLCA president, Laurie Beck, RN, MSN, IBCLC would like to celebrate National Woman’s Health week by wishing all moms a Happy and Healthy Mother’s Day. “USLCA urges all mothers and health care providers to view breastfeeding as a health promoting and disease preventing behavior just like nutritious eating and physical activity.”

Knowledgeable professional breastfeeding support can be obtained from lactation consultants with the IBCLC credential (International Board Certified Lactation Consultant). To locate a IBCLC for assistance with breastfeeding go to http://www.uslca.org


Mission: To build and sustain a national association that advocates for lactation professionals

Vision: IBCLCs are valued recognized members of the health care team.

The United States Lactation Consultant Association (ULSCA), is organized exclusively for the advocacy of Lactation Professionals.

For Expectant Families… your “Due Date”…

Hi everyone! Happy New Year!

I have been very very busy over these past months and I’ve spent very little time on the computer….. many of you have had the same situation. Thanks to all of you who keep checking my blog anyway!

I’m here now to talk about one of my big concerns.

Your due date…

Every single year around the holidays, we have a surge of elective, social induction requests.  Here are some comments we occasionally may hear each year around this time on an L&D unit:

“Please, please induce me so I can have the baby and be home for Christmas…please!”

“I’m only 2 1/2 weeks from my due date anyway so I’m ready…”

“I can’t have this baby on Christmas day..I just can’t…you HAVE to help me!!”

“I’m so tired of being pregnant and I have so much to do…can’t you do SOMETHING and make me have this baby today??” (37weeks)

“I really really need another tax deduction this year… ” (heard quite often!)

“Please do something so this baby is born by the end of December…I’ll even have a C/S if you want.”

“Can you induce me while my family is all here?? Please??”

Young pregnant women~ Please don’t do something crazy for a special delivery date.

Please!

Please educate yourself about the risks of induction and the risks of late preterm births.

PATIENCE

“A little patience now adds up to long-term health benefits for your new baby.”

I have received this following information from the Mother-Friendly childbirth community.

I felt it was well worth sharing……..

This is an excerpt from a newsletter from the CIMS ~ Coalition for Improving Maternity Services.

Please read, check out their website link above and the other resources listed below the letter.

Thanks so much!

“For Expectant Families

What you need to know about your due date and late preterm birth

A little patience now adds up to long-term health benefits for your new baby.

You’re not alone if you’re secretly (or openly!) hoping that your baby will get here sooner rather than later.  But when it comes to your due date, it’s important to understand what it represents, what it does not represent, and the potentially serious consequences of agreeing to an induction or c-section before your baby is ready to be born.

Mayri Sagady Leslie, CNM, MSN, clinical faculty at Yale University School of Nursing, recently penned an insightful post for Lamaze International’s Science and Sensibility blog.  In “Beyond Due Dates: How Late is Too Late,” we’re reminded that, despite widespread belief that EDD stands for ‘due date’, it actually stands for ‘estimated date of delivery’!  Mayri writes, “No matter what you call that date on the calendar, it is nothing more than a formula derived from statistical averages which says that sometime within a range of 4-5 weeks your baby will probably be born.  Smack dab in the middle of that range is one of days on which the labor may start.  Yet when it comes to dates in our life, few take on more significance than this one.”

Appreciating this fact is something of considerable consequence when it comes to the immediate and long-term health of your baby.  There is mounting evidence that only the baby should have the right to choose her/his birthday.  Two recent reports add to this evidence.

The CDC’s National Center for Health Statistics recently reported a 20% increase in the nation’s late preterm (34 to 36 weeks ) birth rate from 1990 to 2006.  The report also cites alarming increases in the number of late preterm births among births for which labor was induced as well as among births that were delivered by c-section.  The report cautions, “…it is becoming increasingly recognized that infants born late preterm are less healthy than infants born later in pregnancy.  Late preterm babies are more likely than term babies to suffer complications at birth such as respiratory distress; to require intensive and prolonged hospitalization; to incur higher medical costs; to die within the first year of life; and to suffer brain injury that can result in long-term neurodevelopment problems.”

March of Dimes 2009For the March of Dimes, prematurity is an extremely important public health issue.  The March of Dimes launched a multimillion dollar, multiyear campaign in 2003 to prevent premature birth and raise awareness of its serious consequences.  Last month, the March of Dimes released its annual Premature Birth Report Card.  Sadly, for the second consecutive year, the U.S. earned only a ‘D’ grade, “demonstrating that more than half a million of our nation’s newborns didn’t get the healthy start they deserved.”

We know you’re anxious to meet your baby.  It’s perfectly understandable too if you’re just plain tired of being pregnant.  We just want to remind you that a little patience now adds up to long-term health benefits for your new baby.

Learn more:

  • Beyond Due Dates: How Late is Too Late” by Mayri Sagady Leslie on Lamaze International’s Science & Sensibility blog.
  • Born a Bit Too Early: Recent Trends in Late Preterm Births” a NCHS Data Brief from the CDC.
  • U.S. Gets A “D” For Preterm Birth Rate” press release from the March of Dimes.”
  • Our Cesarean Section Rates still Below the National Average

    002I had checked out a post by Jill from Unnecesarean reviewing ICAN’s Press release on the rising Cesarean Rate and how mom’s really don’t realize or recognize how they can reduce their risk for a surgical delivery. It is very good informative post. It’s just totally shameful and pathetic that one third of our nation’s babies are brought in to this world with a surgical delivery! I’ve been present for thousands of births. I remember when the doctors were under pressure to keep their C/S rates down under 20%!! They had to go under peer review when they hit individual rates over 16%. Those days are over.

    I have seen many different changes in the field of obstetrics, I am embarrassed that our national rates are now this high! I don’t feel that this is an advancement in maternal fetal obstetrical care. It feels like such a cop out most of the time when you are there in the trenches experiencing the “call” for a C/S time after time for “failure to progress”; “failure to descend”; “arrest of dilitation” etc…etc..

    I came across the perinatal statistics and thought I’d share.

    Here are our Actual Cesarean Section Rates so far this year January thru September

    for nearly 750 births:

    • Total C-Section Rate =   25.8% (monthly range 16.9% to 34.4%)
    • Primary C-Section Rate =  16.4%  (monthly range 12.5% to 23.6%)
    • Primary Rate in labor =    13.4%  (monthly range 8.9%  to 20.0%)

    Our average is about a quarter of the births falling below the national average of a third… for now. Can we keep this up?? I hope so. I really hope so. I hope we can even lower it! With a NICU coming in and sicker patients to go along with that… I am hopeful to just keep it where it is. I will do my best to help educate women, co-workers and the doctors I work with.


    We Deliver? How about we make it a better delivery?

    permission from CartoonStock

    permission from CartoonStock

    Our Maternity Services

    Need Help!

    The Maternal Child care delivery system in this country as a whole needs vast improvement. All of these 10 steps as well as the 10 steps to ensure optimal successful  breastfeeding are very important.

    These items are sadly grossly misconstrued or ignored by many facilities offering maternity services in this country. I have been having the same discussions and occasional arguments with co-workers  lately on this battle of the newborn baby staying in the moms room overnight!!! I know~ it is a no brainer to those of you who read, research and understand. Many of my co-workers still defend their philosophy that the baby needs to come into the nursery at night so the mom can sleep!!  Many argue with me about labor positions and inductions!! AARRGGHH! I won’t get into our details right now…….

    What I have here for you today is NOT new info but I recently reviewed it again as I was searching for evidence to back my discussions with staff. If you haven’t placed this information in your workplace to nudge some resistant peers, I urge you to do so!

    This document : THE COALITION FOR IMPROVING MATERNITY SERVICES:
    EVIDENCE BASIS FOR THE TEN STEPS OF MOTHER-FRIENDLY CARE
    can show you research studies or data which support the ten steps below.

    The 10 steps for Mother-Friendly Care from CIMS {Coalition for Improving Maternity Services} taken from their website…..are:

    Ten Steps of the Mother-Friendly Childbirth Initiative
    For Mother-Friendly Hospitals, Birth Centers,* and Home Birth Services

    To receive CIMS designation as “mother-friendly,” a hospital, birth center, or home birth service must carry out the above philosophical principles by fulfilling the Ten Steps of Mother-Friendly Care.

    A mother-friendly hospital, birth center, or home birth service:

    1. Offers all birthing mothers:
      • Unrestricted access to the birth companions of her choice, including fathers, partners, children, family members, and friends;
      • Unrestricted access to continuous emotional and physical support from a skilled woman—for example, a doula,* or labor-support professional;
      • Access to professional midwifery care.
    2. Provides accurate descriptive and statistical information to the public about its practices and procedures for birth care, including measures of interventions and outcomes.
    3. Provides culturally competent care—that is, care that is sensitive and responsive to the specific beliefs, values, and customs of the mother’s ethnicity and religion.
    4. Provides the birthing woman with the freedom to walk, move about, and assume the positions of her choice during labor and birth (unless restriction is specifically required to correct a complication), and discourages the use of the lithotomy (flat on back with legs elevated) position.
    5. Has clearly defined policies and procedures for:
      • collaborating and consulting throughout the perinatal period with other maternity services, including communicating with the original caregiver when transfer from one birth site to another is necessary;
      • linking the mother and baby to appropriate community resources, including prenatal and post-discharge follow-up and breastfeeding support.
    6. Does not routinely employ practices and procedures that are unsupported by scientific evidence, including but not limited to the following:
      • shaving;
      • enemas;
      • IVs (intravenous drip);
      • withholding nourishment or water;
      • early rupture of membranes*;
      • electronic fetal monitoring;
      • Has an induction* rate of 10% or less;†
      • Has an episiotomy* rate of 20% or less, with a goal of 5% or less;
      • Has a total cesarean rate of 10% or less in community hospitals, and 15% or less in tertiary care (high-risk) hospitals;
      • Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal of 75% or more.
    7. other interventions are limited as follows:

    8. Educates staff in non-drug methods of pain relief, and does not promote the use of analgesic or anesthetic drugs not specifically required to correct a complication.
    9. Encourages all mothers and families, including those with sick or premature newborns or infants with congenital problems, to touch, hold, breastfeed, and care for their babies to the extent compatible with their conditions.
    10. Discourages non-religious circumcision of the newborn.
    11. Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital Initiative” to promote successful breastfeeding:
      1. Have a written breastfeeding policy that is routinely communicated to all health care staff;
      2. Train all health care staff in skills necessary to implement this policy;
      3. Inform all pregnant women about the benefits and management of breastfeeding;
      4. Help mothers initiate breastfeeding within a half-hour of birth;
      5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated from their infants;
      6. Give newborn infants no food or drink other than breast milk unless medically indicated;
      7. Practice rooming in: allow mothers and infants to remain together 24 hours a day;
      8. Encourage breastfeeding on demand;
      9. Give no artificial teat or pacifiers (also called dummies or soothers) to breastfeeding infants;
      10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from hospitals or clinics

    † This criterion is presently under review.

    I endorse these steps. You can visit their website to also endorse.

    Kathy from Woman to Woman Childbirth Education wrote about the CIMS press release on the Need for Transparency regarding the rising C/S rates. Excellent information is discussed here by the CIMS and I enjoyed the discussion between Kathy and RealityRounds.

    I also would urge you all to visit and give information to The Birth Survey.

    How is your birth place measuring up to these initiatives?

    Let’s all continue to make this a better world

    in which to give birth!!

    No VBAC’s Banned: So Far so Good

    iStock_000004564778Small My little hospital is not one of those hospitals which has banned VBAC’s.

    We’ve been doing VBAC’s since 1984. Here is our first VBAC story. You may have read and heard that some places had specific policies against a mother attempting a VBAC.  There is really only a small percentage of women who truly are not a good candidate for a vaginal delivery after a cesarean. (Having a previous vertical incision in the uterus for example). There are several places a mother can go to for facts, scientific research, honest information and support if her provider or hospital has denied her an opportunity to VBAC. If this has happened to you, it will be important to do your homework, get the facts and have a really good conversation with your provider. It is important to make an informed choice weighing your benefits and any potential risks.

    We do just under a thousand deliveries a year.

    From January through July 2009~

    We had a 100% successful VBAC rate!!!!

    We had 2 mom’s last month that ended up having to go for a cesarean after labor began. I don’t know all the numbers but I had looked over the perinatal data sheets yesterday and I was so very happy to see how we were doing.

    Let’s hope we keep it up!

    😉

    A Wonderful Day in the BirthingHood

    What a great fun day in the world of birthing.
    The first words I heard at work today were words that I just love to hear when used in this sequence….

    “Section’s Canceled”

    Hooray!

    Her Cesarean had been scheduled because her baby had been in a transverse lie position…. for weeks.  However–> this smart little genius baby had positioned his little self into a beautiful head down position before arriving at the hospital this morning! Mom was also contracting regularly and was 3 cm dilated. This was her second baby, first exam of the day, so she hung out for a while until it was clear she was continuing to make cervical changes and labor was underway.

    A few others decided it was their time to make an appearance today. One baby boy was a couple weeks early and another a few days over 41 weeks.

    Ever hear that things sometimes happen in 3’s ??

     As luck would have it, 3 young men decided to be born within 15 minutes of each other! All 3 were spontaneous vaginal deliveries. All 3 boys were breastfeeding within that first hour and 1/2 … not bad!

    All the moms were so happy with their birth experiences. All the babies were healthy. The staff worked really well together. Our midwife was awesome! The doctors were fun, funny, thoughtful and kind and made really good patient centered decisions.

    It was just an all around wonderful day in the birthinghood!

    005

     

    Initial Low Milk Supply: A Breastfeeding Story – Case Study

    034     The History:

     One typical busy morning coming on shift, one of the couplets I received report on was a 3 day post-op C/S mom and baby who were scheduled for discharge this same morning.  She had been a long 3 or 4 day failed attempt to induce a vaginal delivery for fetal macrosomia (big baby) at 40 5/7 weeks before the C/S.  Lots of IV’s, lots of Pitocin… all before the birth.

    Her baby weighed 10 lbs 4 oz at birth. We got in report that his glucose sticks had all been over 60 initially so they were stopped early on. His exams were normal.  His total bilirubin this AM was 11.3 at over 72 hours of age. He was “breastfeeding only”  (*sigh*from the nurse giving me report).  She then expressed a concern that  he was down 10% from birth weight weighing 9 lbs 4.5 oz today.  When I asked her about the feedings, she said he’s been nursing beautifully all the time but nobody’s had time to stay in the room and watch him feed. I asked about the output and she reported he’s been voiding, the last stool was a couple shifts ago.  Then the nurse added “We told her you were here today, Melissa, she has a lot of questions for you. ”

    I was able to juggle some things around, have staff cover some of my other responsibilities temporarily to make this a priority. Since I am a general staff nurse, there are often more pressing situations. Fortunately, today I was able to manage the time to see her right away.

    I went in and introduced myself to Meg*, Brad* and their son Mikey* (*names changed). They had indeed been waiting for me.  Breakfast was underway and Mikey was asleep in his crib. I asked her a few general questions in a relaxed manner about breastfeeding first to try to establish some background: Mikey’s energy level, drinking pattern, feeding frequency, and diaper checks.  It is important to gather information and observe the feeding  in the process of  a full evaluation to determine adequacy of feedings.  The information I got was concerning.  He spends a lot of time at the breast, falls asleep quickly, not very energetic with every feed, not much change in her breasts at this point and no stool since yesterday. I did not tell her I was concerned at this point, nor did I mention the weight yet. I asked if I could check him now and if  it would be alright if I observed the next feeding.. We determined that should be with in the next hour. I talked about feeding cues and asked her to get me if  Mikey seemed ready to eat before I came back.  His vital signs were normal, jaundice not too significant for his age, diaper contained a small amt concentrated urine, and Mikey went immediately back to sleep.  I felt he was OK at the moment and needed to go do a few other  things with other patients.
     
    At this point I am feeling pulled in different directions because Meg’s situation could easily take hours of my already busy morning. I am upset that this has possibly been going on the last 3 days and hasn’t been evaluated properly, now it’s day of discharge! How do you do the proper evaluation, give the needed gentle support, make possible feeding plan arrangements in fragments of time? This is what I am trying to change…in my opinion, we the hospital, helped contribute to this situation of possible inadequate feeding and supply… we need to help her! I talk to the charge nurse and it’s cleared to keep my coverage the rest of the morning.. good thing L&D was quiet!
     
    Mikey’s doctor comes in and thankfully it is a partner who is very pro breastfeeding and open minded to try options a mom may choose. I gave her report on his physical status, VS, weight, earlier glucoses, and the Bilirubin. I summed up my plan to evaluate feeding quality but suspected he has been ineffective at the breast & milk supply/production may be delayed. I added that I was going to check his glucose if he had low energy level, and encourage pumping or expression for the mom and get that milk into the baby as well as encouraging her to stay for a few feedings to work with me. The MD was happy with these ideas but requested he be supplemented (complemented) with formula at all feedings now until his weight came up. She supports the theory (as I do) that the birth weight can be somewhat inflated with all the pre-birth IV fluids mom rec’d and some of what he lost may be fluid.  The MD said that if things were better by afternoon, he could go home. She went out to examine him at mom’s bedside.
     
    I went in for my feeding observation a little while later. Meg now knows his total weight loss and feels very upset. I give her a lot of support and agree with the doctor that some of that could be fluid. I then find out..Meg is an RN here at my hospital on another floor! It had not come up in conversation! So now I know she is even more worried because we nurses always think the worst! I do my best to think simple and encourage her to do the same… it is very early and we can turn this around quickly with a strong approach.
     
    My Evaluation:
    • Good independent maternal positioning, holding and offering of the breast
    • Nipples erectile, breast tissue soft, pliable, small amts colostrum expressed–> mom reports her breasts were “swollen first 2 days”
    • Latch fairly adequate but not optimal-> improved greatly with football position and instruction on asymmetrical latch approach (I’d like to say here that I have a” if it’s not broke don’t fix it” attitude. I don’t correct a latch for a mom who has no pain and good milk transfer, we talk about it in case it may come up for though)
    • Mikey very sleepy at breast, difficult to maintain latch, no milk transfer observed–>breast massage during feed tried without improvement
    • Due to continued low energy level (suspected caloric deprived state causing sleepy ineffective feeding behaviors) a bedside glucose was checked. Result was 49.
    • Diaper dry–> the previous concentrated void was only his 2nd in last 24 hrs No stool last 20 hrs and that one was dark.
    The mother’s feeding plan:
    Many options and teaching points discussed with Meg including the need to boost caloric intake –>starting right now, methods to get her milk or formula into the baby avoiding bottles, a vigorous pumping plan to augment breast stimulation, alternate breast massage, how to observe for swallowing and milk transfer at the breast etc.. I also discussed with her how in my experience, sometimes it is like magic once the baby regains up to birth weight… they just take off!
    She chose:
    • Cup feed formula now while she pumped –>Mikey would not cup feed so we used a syringe, 18 cc, repeat glucose 62
    • Pumping round the clock, double pumping –> Meg rented a hospital grade pump for home use
    • Keep close eye on feeding cues, put Mikey to breast in football w/ latch process discussed earlier
    • Closely watch signs for milk transfer, correct feeding activity while at breast, sucking rythym 1 or 2 sucks /swallow ( Brad was very involved in this process of learning the observation techniques)
    • Use breast massage/ compression while baby @ breast through feed to increase milk transfer
    • Goal of min 8 effective feeds in 24 hr..wanted to try for 10 –>agreed to feed expressed milk or formula 1/2 to 1 oz after each feed first 24 hrs until re-weighed next day
    • Have as 1st 24 hr goal:  to see 3 -4 increasingly wet/clearer diapers and at least 2-3 good sized stools
    • Return to MD for F/U bili and wgt check next day
    • Call IBCLC for eval in next few days if weight not adequate and not independently breastfeeding/output  within safe parameters for age

    The follow up reports:

    • DAY 1 (In hospital) Mikey fed 3 more times in the hospital at 2 hour intervals.  Each time he had about 15 to 20 cc of formula by syringe. Each feed was improved but not adequate quality of milk transfer. Meg pumped 4 times before discharge not getting much first 3 times but 4th time she got almost 10 cc! Mikey had 1 conc wet diaper and a med sized dark stool. We re-weighed Mikey prior to discharge and he was 9 lbs 5.5 oz.  Meg left the hospital late that afternoon while I had been called to a STAT C/S. She was determined to go home after all the time she had been there! I called her later and she was on target with her plan.
    • DAY 2 (first 24 hrs home) Seen at Peds office. (reported to me from MD)  Bilirubin 10.6, weight–> 9 lbs 7.5 oz! Baby more energetic, better quality feeds reported. Meg still power pumping, now getting 1 -2 oz per pumping and giving to baby with syringe and only used formula occassionally if no breastmilk.  Had 3 wet and 2 stools since discharge, stools lighter in color. MD arranged F/U weight visit for 2 days, will arrange IBCLC if no strong improvement before 2 more days
    • AGE 6 1/2 days Seen at Peds office. (reported to me from MD) Weight–> 9 lbs 11 oz !!! Meg having fairly same routine but not always pumping if she feels Mikey had good milk transfer. She reported increased  breast fullness, 6 wetter, lighter urines and 4 mostly yellow stools in each of the previous 24 hr periods.
    • AGE 2 weeks  I don’t have MD office reports but Meg called me to tell me Mikey was 1o lbs 7 oz at his 2 week check up and nursing a lot better EVERY feeding!! She was still attached to her pump, gradually decreasing the sessions, just felt safer to keep going with that. If she gets milk she was still giving it to him. This was her security blanket and she was happy doing it. She was very proud of herself and crying happy tears! 🙂

    Meg’s case was a beautiful example of HOW a situation can turn around quickly.  An individual mother’s determination coupled with a productive plan can produce these results. All situations are different.

    Every mother and baby deserve our best!