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Posts tagged ‘ethics’

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and unfortunately, because these things aren’t monitored, many practitioners go back to their own comfort zone of past [outdated] practices.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.

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.”
  • America Scores a “D” on the Premature Birth Report Card

    _

    Hello Everyone

    I haven’t disappeared… I’ve just been too busy outside for computer time!

    This is a copy of a letter I received today trying to

    spread the word

    about Prematurity in this country……

    Today is the release of the second annual Premature Birth Report Card, and I wanted you to hear the news from me: America receives a “D.” As a country, we are failing to give our babies the healthy start they deserve.

    Your state has received its own report card. I’m afraid you’ll agree we have a long way to go. In fact, before the end of this year, more than half a million babies will be born too soon, some very sick.

    It’s Prematurity Awareness Day® — the day when we’re all focused on the terrible toll of premature birth on babies and families. The report card reminds us how urgent the problem is. But with the support of people like you, we can continue to fund lifesaving research and programs.

    If you haven’t already, I hope you’ll visit our Web site and join the fight for preemies.

    Warmly,

    Dr. Jennifer L. Howse

    President

    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!!

    **ROAR** on Breastfeeding Guilt

    10_Lioness-with-Cub-Feeding

    (Image found at Google Images)

    **ROAR**

    The Mommy Wars over feeding babies continue..I guess it won’t ever be truly over. I’ve been following a discussion over at NursingBirth on  “Why Educating Our patients is a Professional Responsibility and Not about Guilt.”

    I thank her for quoting me and including thoughts I wrote on what I have learned over the years talking to, educating and helping mothers.

    I have re-posted this earlier segment  “Breastfeeding, Bottle-feeding and Somewhere In-between… Why the Guilt?” This post is about what I have learned speaking from a professional point of view. As a professional, it is inappropriate for any of us to imply directly or indirectly to any mother trying to make feeding choices that breastfeeding and formula feeding are equal.  They are not. Human milk is the superior species-specific food for Human infants. The recommended feeding hierarchy from the experts (AAP,CDC, WHO) is Breastfeeding, expressed mother’s milk, expressed donor milk then properly prepared infant formula. That’s why NursingBirth’s post is so important to understand. Reading the comments……

    There are STILL moms out there confusing the issue.

    All or most of this discussion is NOT directed at any mother who tried to breastfeed under any circumstance and wasn’t able to at all or wasn’t able to fulfill her individual goals. I applaud all your efforts for trying to give your baby the best food you could. I am so sorry that you experienced the difficulties you have. Your situation is not what this discussion is about. I think it’s very possible that advocates and some professionals lack sufficient skills to help you deal with the loss of a breastfeeding relationship. If breastfeeding is important to you then you would truly go through a grieving process and guilt would most likely come into play somewhere along the line. We do that to ourselves a lot as women anyway. I did personally experience that guilt. I had wanted to breastfeed my last baby for a full year and was unable to because of personal health problems. I had a lot of guilt. This discussion is NOT about these situations. Let’s stop making it about that. Please!

    This mommy war guilt discussion as I see it is one where a mother who chooses to formula feed defends her choice and lays claim that those who are promoting or advocating breastfeeding make her feel guilty.

    Guilt comes from within an individual if they feel they haven’t done what they “should” or wanted to. Guilt is a very strong emotion. NursingBirth has a great description of guilt as does The Feminist Breeder in “Mommy Guilt- Its all about Perspective.” It would be a good idea for guilt-ridden moms to read these articles. Those professionals or advocates who I have mentioned here or in my re-post are trying to do a good job of making sure people have the information to make educated decisions about health care issues.  Any professional who intentionally tries to make a mother feel guilty isn’t being very professional. If there is an advocate out there continually finding moms feeling guilty, perhaps you should change how you deliver the message. I said in this earlier post about how one single word can make a difference:

    “She needs to be comfortable and confident with her decision. Perhaps her guilt comes from how one single little word or sentence was said, even if what was said is accurate and true. Perhaps her guilt is coming from her own internal struggles. I don’t know.  She needs to come to terms with that herself,  and not punish herself and or publicly criticize the advocates saying they are causing the guilt.  Although there are some very zealous advocates out there, I feel in my heart they are not trying to make any individual mother feel guilty. I read a comment from a mom somewhere that said something like… “perhaps if moms knew it wasn’t all or nothing, maybe more would try breastfeeding.”  My first thought was..why do they even think that..are there really mom’s who feel it has to be all or nothing? Is this causing the guilt because they don’t think they can breastfeed exclusively for the first 6 months as the experts recommend??”

    None of this changes the facts. Like it or not, breastfeeding is and will continue to be a major Public health Issue to the point of a public health crisis! As professionals and advocates, our work is not finished. I think sometimes that those speaking out against advocates get in the way of facts and put their personal opinions or views out in front and totally distort the issue. I read on someones blog this week (TFB) a great quote by Daniel P. Moynihan: “You are entitled to your own opinion, but not your own facts.” and I loved it!

    According to this article from the American Journal of Public Health:

    “Today’s medical community recognizes what their
    predecessors knew a century ago—that the
    American propensity to shun human milk is
    a public health problem and should
    be exposed as such.”

    I am still going to promote breastfeeding. I am still going to provide appropriate factual information to the mothers in my care and support whatever feeding decision they make. I will never be pushy. I will gently encourage those on the fence to give breastfeeding a try. I always support the mother.

    But more people need to talk about the importance of breastfeeding.

    Because it is

    Important.

    Don’t be guilty

    Stop it

    *ROAR*


    Repost~ The Guilt trip~ Breastfeeding, Bottle-Feeding and…. Somewhere In-between…. Why the Guilt?

    There has been so much discussion circulating in the blogosphere right now about breastfeeding.  I thought I’d add my 2 cents because….I have an opinion and….. I have just a little experience in this field both in study (2 year Lactation course, IBCLC for 10 years, current CLC) and in practice (35 years).

    I thought I knew so much in 1988 after nursing 3 babies and assisting others for nearly 15 years. I actually thought I could just take the IBLCE exam based on my experience!

    I was so ignorant and naïve!

    I started to talk to some IBCLC’s and my eyes were opened wide to the real world. Up to that point, at that time, (I sadly and guiltily admit) I had no idea about the volume of study and research in the field of lactation. I had NO idea just how wrong we were doing things at my hospital.

    I launched into a lactation course, soaking up all I could, 3 years of study preparing for certification. I set out to change the world… at least my world. I wrote big proposals for the hospital. I applied for grants to fund a lactation program. I developed education competencies for the staff. I started breastfeeding classes. I thought everybody shared my passion, that they too would want to learn …. because I was right!!

    Instead I was the target of all the boob jokes you could think of and I had almost no support. My ideas were rejected left and right.

    Long story short…it took me a long time to come to terms with accepting small changes, taking baby steps…..continuing to do the best job I could with each mother-baby couple and to keep a positive outlook. I needed to remain realistic about how much I could actually accomplish one step at a time. Slowly I began to have people under my wing trying to learn. Yeah!

    I learned a lot about how to approach physicians, co-workers, managers and most of all …. mothers.

    I am not an expert in journalism or critical analysis so this is my opinion of what is going on right now.

    There have been some irresponsible journalists, those who have a bigger platform than most of us, writing negatively about something they have not studied or truly researched. They are expressing their opinion and including an emotional component which has, in my opinion, gotten the reaction they hoped for from breastfeeding advocates as well as those who concur with the authors. More hits, more readers. I feel they have twisted the facts to benefit or support a point they want to make. I read some of them.. other’s I really just scanned then brushed off so I don’t know everything that’s been said. On the positive side, these articles possibly give us a larger platform to provide correct information to a larger public in reply.

    I read a lot of blogs and I really respect and admire all the research that many breastfeeding advocates put into their fabulous posts. These are educated women who are trying to provide current accurate information! (@phdinparenting, @bfmom, @MommyNews , @JakeAryehMarcus, @blacktating ,@AmberStrocel, and so many more). I applaud their passion and breastfeeding advocacy. They are doing a very important job. Breastfeeding IS very important and deserves advocacy, protection and support! There are still large scores of women out there making choices with only tiny bits of information, who really do not know the important benefits of breastfeeding. It is because of this, and because we still haven’t met the US Dept HHS Healthy People Goals for 2010, that breastfeeding advocacy needs to continue. I have been there, advocating in a time where I faced great adversity and a lot of negativity. I am bothered that it still exists…and exists now in so many new ways.

    I am more disturbed that some mother’s out there are upset. I always try to understand just WHY a mom feels guilty if she chooses to formula feed or do some combination of formula and breastfeeding. I always hope she’s made her choice with good information and that it is her own true choice. Then good for her! I am not to judge. She needs to be comfortable and confident with her decision. Perhaps her guilt comes from how one single little word or sentence was said, even if what was said is accurate and true. Perhaps her guilt is coming from her own internal struggles. I don’t know.  She needs to come to terms with that herself,  and not punish herself and or publicly criticize the advocates saying they are causing the guilt.  Although there are some very zealous advocates out there, I feel in my heart they are not trying to make any individual mother feel guilty. I read a comment from a mom somewhere that said something like… “perhaps if moms knew it wasn’t all or nothing, maybe more would try breastfeeding.”  My first thought was..why do they even think that..are there really mom’s who feel it has to be all or nothing? Is this causing the guilt because they don’t think they can breastfeed exclusively for the first 6 months as the experts recommend??

    Over the years, I have learned this:

    • It is inappropriate for a health care professional to indicate to a mother directly or indirectly that formula feeding and breastfeeding are equal. Human breast milk is the superior food for human infants. Properly prepared infant formula is an acceptable substitute for those who cannot or choose not to breastfeed.
    • The first approach is probably the number one factor in gaining a mother’s interest in what you have to say.
    • The education process to a mother needs to be in small doses, sensitive to her unique learning abilities, her cultural beliefs and practices and most importantly, her choices and individual breastfeeding goals.
    • With that in mind, try to provide her with the information she needs to make her decision.
    • Never overestimate a mother’s desire to breastfeed her infant.
    • Never underestimate a mother’s desire to breastfeed her infant.
    • Listen to the mother; help her define her true desires and goals.
    • Many times, the first question she asks may not be what she really wants to ask.
    • The mother’s individual breastfeeding goals, how she defines them, how important they are to her and how she relates them to her actual breastfeeding experience all help define how she measures success.
    • Support the mother, support the mother, and support the mother.

    Here are the top 3 responses to the feeding choice question pertaining to breastfeeding at my facility on admission:

    • “Breast and Bottle”
    • “I’m going to do both”
    • “I’m going to ‘try’ to breastfeed”

    To each of these I respond very positively with something like… “Great! Tell me what you’ve learned about breastfeeding.”     I will then ask the mom a few questions to somehow find out her true wishes.

    Then I say  “We will support and honor however you wish to feed your baby.  I’d like to give you some information so you can really understand and then tell us what you’d like to do.”

    I explain some things,  i.e.: how the milk production works, the importance of early feeds etc.. and how formula introduced at that time could  interfere with the process of production, the baby’s ability to latch properly and so on… I usually end with..”We usually recommend to  focus on breastfeeding for now and then offer bottles later after milk supply is established if that is how you’d still like to manage feeding”. ETC…ETC….  Here’s what I then see:

    • There have been so many mom’s who — after a little  bit of information decide they would like to focus on breastfeeding. There have been many who totally fell in love with it.
    • There have also been many who really didn’t want to breastfeed after one single feeding.
    • There are many many still that like to breastfeed and bottle feed in combination right from the start. If they have the right info and understand how things may progress… I still say “Good for you!”
    • I have seen many continue that way for months and they are very happy with that.
    • I’ve seen many mom’s “partially” ( I don’t like to say it that way) breastfeed and feel very proud. I say “good for you!”  They don’t think of it in terms of “exclusive” or “partial”… It’s more like any breast at all…. is breastfeeding vs. no breastfeeding at all.
    • There have been many who also never wanted to try until all of a sudden they see milk leaking!
    • I’ve worked with mom’s where I can see tremendous improvement in her situation, I think she’s going to keep going…but she decides to totally quit. I simply praise her for all her efforts and help her feel proud of herself.
    • I’ve worked with mom’s who have hardly put forth any effort to overcome small obstacles, I think they will probably quit outright… Then..I find out they are the ones exclusively breastfeeding down the road.

    I got a comment from a breastfeeding mom @TheFeministBreeder that I absolutely have to share. She describes her own experience in the full comment and on her new blog post.  She comments:

    “Yes, I think that’s the most important part – informing a mother of any and ALL benefits/risks to supplementing, and helping them work through the option they choose.  But to tell a mother to supplement without explaining that it could undermine her efforts is just plain mean.  And too many medpros are doing it.  I’m glad there are more nurses like you who will give out the real information to empower a woman to make her own choice.  My smart friend always says ‘It’s not really a choice if you don’t have all the information.’ “

    For those mom’s really trying to breastfeed and struggling, there’s more than I can say right here to cover that. I’m sorry for your struggles and hope it gets easier for you. It is important to have a skilled competent support person assisting you who listens thoughtfully and helps you get to the root of your problem… and helps you define and realize your goals. If you are experiencing guilt from your struggles or from not being able to fulfill your goals, desires to breastfeed….I think that kind of guilt is different from what I’m trying to discuss here. I am not a an expert on that. It is valuable to get the best help out there that you can as soon as possible.

    I’m adding this after reading some comments on other blogs.. When approaching a mom to observe or assist with the latch process…. Permission is a must! I ALWAYS ask the mother if she would like any assistance with the latch or if  I may observe how well her baby is latching….. If that answer is yes… The next question is ALWAYS.. May I touch your breast? (if that needs to part of the process). I prefer to help moms by having the mom and BABY do the latch. I try to keep my hands out of it.  All nurses and LC’s should practice this. I am sorry for the mom’s who aren’t asked permission to be helped or touched.  😦

    One of my favorite things I like to say to any breastfeeding mom is:

    “Try not to make any final decision when it’s dark outside”.

    On another note, regarding some reader comments on various blogs about public breastfeeding, a skimpy bikini or the bathing-suit issue of a favorite sports magazine show more skin in a provocative, sexy way than any mom breastfeeding. Even the movie stars in their gowns with plunging necklines are showing almost the entire breast! Somehow, that is OK. There are volumes of video footage and photos all over the place… even on billboards. It is sad that the public opinion of a baby breastfeeding (the most natural way for him to eat) is something that should be done in private … yet young girls are encouraged by media to bare more and more skin. Of course being discreet while feeding is important, but I can assure you, most girls in a tiny bikini are thinking more about “tacky exhibitionist behavior” than a mother breastfeeding her baby. Why aren’t law-makers focusing on any of that?

    Webinar~ WHO CODE ~ “The Code, Companies, and LC’s”

    This is a reprint of an email invite I received today and wished to share with all those interested.

    Brought to you by the USLCA

    ON

    Wednesday October 14th 2009

    United States Lactation Consultant Association

    “The Code, Companies, and LC’s” by Marsha Walker

    Marsha Walker
    Participants will be able to describe the LC’s manufacturing or distributing products within the scope of the Code.
    Participants will be able to discuss the elements of the WHO Code as they relate to companies that manufacture or distribute products covered within the scope of the Code.The Code within lactation consultants practice.  LC and ethical Practice within the Code.

    • Use of company products
    • Use of educational materials
    • Exhibiting at conference
    • Attending company sponsored education programs
    • Accepting meals or free items

    How does a company meet its obligations under the code

    • Company websites
    • What violates the Code and what does not
    • Pictures-where and how are they acceptable
    • Idealizing language
    • Marketing vs Selling


    Course Details
    60 Min program
    1 E Cerp Awarded for participating
    (Certificates are emailed to attendees)

    Price:
    USLCA Members $20,   Non-members $30, Groups 2-10 $45, 10 or more $65

    Click here to sign up “The Code, Companies, And LC’s”

    Here’s how to sign up for a USLCA Webinar1. Down load the sign up sheet for the appropriate webinar.Click here for list of scheduled webinars.

    2. Submit your sign up sheet and payment information to the National office through mail (address located on sign up form), email ScottSherwood@uslcaonline.org or by fax 919-459-2075 Attn: USLCA Webinar

    3. You will then receive an email invitation to register for the webinar. Please complete this as soon as possible. You will not be able to sign on to the webinar until this registration is submitted, and approved.

    If you have any questions please contact us at any time for assistance

    Cerps are available only after payment is received.  If you are a member of the USLCA email Scott Sherwood to find out how to pay online.  Please feel free to forward this email to co-workers and friends. Thank you for your support!

    Frustrations in Obstetrical Care …Culturally Sensitive? Oppressive Male Partners?

    027 The drama  that went on here this weekend would be fodder for 10 or more Jerry Springer shows!

    ~Unreal~

    I kept thinking…

    “Please help me”

    I am not and never have been prejudiced or bigoted in thought process, personality or behavior towards others. I am actually on a campaign to help educate our staff on being culturally sensitive and delivering culturally competent care in relation to obstetrical, breastfeeding and newborn care…. I’m currently organizing a quick reference handbook so certain beliefs & cultural values are better understood by our staff.

    This type of sensitivity is very important to me.

    It may not matter how I say this. Despite me trying to convince you that I am not intending to offend any type of people…..someone will most likely get annoyed or upset. I don’t usually enter into this type of discussion. I am quite adept at diffusing anger. I am not singling out a problem with any specific culture, ethnicity, or country of origin. I am not attributing any certain behavior to any certain culture.

     

    This weekend, we had mother’s giving birth who have recently arrived in the United States from the following  areas: Argentina, Poland, Liberia, Egypt, Iraq, India, Dominican Republic and Nigeria. Sometimes their husband,  boyfriend or significant other was from yet another different country.  These are not unusual immigrants for our patient population. It is however,  unusual to have such diversity in a single 2-3 day period!

    My concern is this— As a health care provider– how do you even begin to try to understand another’s strong belief’s or values when you are treated with tremendous disrespect and confronted with attitudes which are unusually demanding of the caregivers to “provide” for any and all needs. Now this is of course what we do…. provide for the needs of those in our care. That includes our responsibility for understanding different certain religious beliefs, cultures and their various norms and values. But this should be done within an environment or culture of MUTUAL RESPECT.

    As  much as it is our responsibility to provide for those individuals in our care….. to be culturally sensitive. I feel there should at least be some responsibility on the part of the patient — and or their family- to learn what may be expected of them …. to communicate their history, needs and or wishes to the doctors and nurses~~ or at least to try to understand when it is explained to them at the time of birth and not lash out with anger or disrespect to their caregivers.  Is it too much to ask for a little bit of responsibility to understand at least a little something about what is involved in childbirth, postpartum, newborn care and the legal recording of birth in the facility, state and country in which they have come to and chosen to give birth!  {Many times I have been told they came here so their baby would be an American citizen.} Am I allowed to ask that those from other countries try to be somewhat sensitive to and try to understand our culture? I am not trying to victim blame here.  Really. Many of the patients exhibited rude entitled behaviors and were very disrespectful to staff.  We are all “others” to each other –> but one big blending of society. Lets ALL understand and respect each other.

    Some of the behaviors we dealt with include:

    • A mother is married, the father of her baby is NOT her husband. The FOB becomes physically violent that his name can not be on the birth certificate–yet– until there is an affidavit submitted that the husband is not the father…. This turned into an all out fist fight between the the 2 men. “SECURITY!!”
    • A husband refused to allow his wife to be examined in labor during his absence, yet left for hours at a time demanding the hospital provide for his transportation to and from his business 15 – 20 miles away.
    • This same father would not allow his wife to speak for herself…. then called our unit many times after the birth when he was not there to say he was sure his wife was suffering from post-partum depression and we needed to treat her!
    • An unmarried young girl had a PFO against the father of her baby — She did NOT want to see his family yet that FOB’s family demanded to be allowed to visit, displaying hostility, speaking loudly and threatening staff  in a non-English language outside the entrance to our unit!
    • Another mother delivered and the father of her baby was currently in jail on drug charges. She met the criteria (for other reasons) where she and her baby were screened for drugs…. Both were positive for cocaine and heroin… sadly.. 😦  This infant needed to be placed in protective custody of Children’s Services and treated for withdrawal. This is always difficult and heart wrenching. This mother spoke very little english, was ANGRY the tests were done and we were not able to help her understand a situation of this magnitude easily with the language line….
    • Frenzied inpatient banging on the window and yelling for the only nurses’s attention to simply ask a question or get more supplies for their infant even though she was involved in an exam with a doctor on a new very sick infant and had signaled she’d be there “in a moment’…
    • The family and multiple extended family members demanding minute by minute updates on a sick newborn, interrupting our care by knocking on the doors and windows to the nursery… after we have explained all  minute by minute updates to the parents of that baby who were at the bedside.  I have a feeling that culture may have placed a value on the elders decisions over the actual parents, but this mother did not want the father’s family to be in the nursery with her. They don’t understand HIPAA or even know what it is! My job is to support the mother and keep her informed and with her baby.
    • A family not wanting to answer most of the questions for the birth certificate because… it was simply an invasion of their privacy. Alright then.. it will remain blank and the Bureau of Vital Statistics can deal with it, right?
    • A father of a baby requesting then ultimately demanding to speak to the doctor ONLY for each and every one of his questions.. (I am just a nurse).. did I mention it was the weekend?? We don’t have doctors present 24/7 !

     

     

    There are times when these situations unfortunately occur. Many times the individuals involved are Americans who are 2nd or 3rd generation of mixed ethnic background or are of no discernable ethnic or cultural background, have lived in this country all of their lives and still exhibit the same type difficult personality traits.  Since they are more “Americanized” shall I say-or however is politically correct to discuss it— it isn’t so difficult to diffuse hostility’s, discuss options, assist with birth, newborn care, breastfeeding, do birth certificates…etc. It is my opinion that sometimes they understand things better simply from living here. We will ALWAYS encounter individuals with difficult personalities regardless of background who may be demanding in nature. They may not initially understand what’s happening but usually respond well to a gentle receptive approach.

    That was NOT the case this weekend!

    I only wish for strength and future guidance to help and support those who don’t quite understand.

    Don’t yell at me or treat me with disrespect.

    I ask those individuals new to our country to help themselves a little and learn some of our language and the framework for which we deliver our obstetrical care.

    Please.

    No Prenatal Care? …..What are YOU Hiding??

    No Prenatal Care is usually a symptom of something--hiding some type of underlying problem. Sometimes it's very ugly. The most common encounters we have involve illicit drug use during pregnancy. We need to develop a comprehensive Maternal and Neonatal Drug Screening protocol to protect the newborn.

    Read more

    Cesarean Delivery of the Second Twin… Why? 

    029I was talking to one of my on-line Twitter friends @onefinebreeder about twin delivery. I was telling her about how things used to be.. how vertex-nonvertex twin gestation’s were always delivered vaginally ….. and she commented on how it was sad that some of the old OB skills have been totally lost to surgery… So Very True!

    I got to thinking about the first combination Twin delivery I had witnessed back in the very early 80’s. This was actually one of our own (hospital employee) nurses .  She was a multip…. around 37-38 weeks and healthy…no complications during pregnancy. Twin A delivered spontaneously, vaginally with a generous episiotomy as they often performed at that time… The baby , a girl, was about 6 pounds, vigorous and had no problems. We were all marveling at the first baby, checked fetal hearts on the second twin and started waiting for him to get in position.  Still before consistent ultrasound, we were not worried. However, we had a newer doctor who was attending this birth. He began to get concerned after 5- 10 min when contractions slowed and he was worried that if this baby was breech, he would have difficulty with the “after-coming” head. Up to this point, all I had learned was this can be a real concern if the smaller feet or buttocks present through a cervix which is not fully dilated. Much research was done later on but at the time, I did not know about it. He began to ask us to call the OR for a C/S. This was unheard of in my limited experience at the time…. my 70’s world. I thought.. how can they do a C/S now when one baby was already born??? I tried to be an advocate… (my early days… )”We have Piper forceps…”  I said meekly… “Have you tried to grab a large part and help bring the baby down… ?” This was my limited knowledge… all I knew to suggest. I kept wishing one of the other doctors was on duty that day.. or maybe we could call them???

    In front of the mother, he said to me “I’m not going to have a bad outcome here!” By now it was 20 minutes or so. There was no cord prolapse, no drop in fetal hearts, no evidence of immediate trouble… the baby was seeming to work itself into breech position…. To the mother he said “Your baby is in serious danger and the best thing to save him is to take you for a Cesarean now!” “I’ll sew your episiotomy together while we are in the OR.”

    I was in shock. She signed, scared to death of course. So we prepped her for the OR. She went up for a C/S of her second twin and repair of her generous episiotomy. Her second baby was delivered frank breech…  a beautiful boy about the same size and was also vigorous and healthy. I remember I felt as though she was almost assaulted. I remember feeling that this was a true rare event if it every happened before. There was no immediate access to information like today.

    Luckily mom and babies did fairly well in the postpartum period even though healing from both the episiotomy and the C/S was difficult for her.

    "How can I get out if I'm not head 1st ??"

    " Psst-- How can I get out if I'm not head 1st ??"

    I wanted to see how much research I could find on this topic. I had gone to the green journal (OB & GYN) website but then it locked me out. (You can only look at abstracts anyway unless you want to purchase the article. You are on your own for that.) I had some luck with the abstracts at PubMed so I have put a few here.

    I decided to take a look across time…….

    This first one is from 1981. . Quoted abstract from the PubMed site:

    Cesarean Section for Delivery of the Second Twin

    Evrard,JohnR.; Gold, Edwin M.
    Obstetrics & Gynecology. 57(5):581-583, May 1981.

    Four cases of combined vaginal-abdominal delivery of twins are presented, and an additional 5 cases from the recent literature are discussed. Malposition, malpresentation, and contracted cervix were the main indications for cesarean section for the birth of twin B. In the 9 cases presented, there were 2 perinatal deaths.

    Interesting that this research was done during the same time frame as my experience above. I’d like to know more about those poor outcomes 😦

    The next interesting article I found was researched over a 10 yr period, somewhat close to here in a larger facility, published 1997. THIS study examines the delivery of the second twin by utilizing external version vs breech extraction . 😉 The results are showing in favor of breech delivery vs version (those meeting exclusionary criteria ).. Versions were associated with higher a incidence of Cesarean and fetal distress. Neonatal outcomes no different and are stated below:

    Method of delivery of the nonvertex second twin: a community hospital experience.

     Smith SJ, Zebrowitz J, Latta RA.   J Matern Fetal Med. 1997 May-Jun;6(3):146-50

    Abington Memorial Hospital, Pennsylvania, USA.

    The purpose of this study is to examine the incidence of cesarean section and fetal distress complicating the delivery of the second twin in vertex-nonvertex twin gestations in which the second twin underwent either breech extraction or external version. The intrapartum courses of 510 twin gestations delivered at a community hospital over a 10-year period were retrospectively analyzed. All vertex-nonvertex twin gestations were identified in which the second twin underwent attempted breech extraction or external version. Exclusion criteria included birthweight < or = 1,500 g, fetal anomaly, intrauterine demise, and monoamniotic twins. Of the 76 twin sets that met inclusion criteria, 33 underwent external version and 43 underwent primary breech extraction. The two groups had similar demographic characteristics. External version compared to breech extraction was associated with a significantly greater incidence of cesarean section (8/33 vs. 1/43, P = .008) and fetal distress (8/33 vs. 1/43, P = .008). There was no difference between groups in neonatal outcome for the second twin as measured by length of stay, 5-minute Apgar < 7, intensive care unit admissions, hyaline membrane disease, intraventricular hemorrhage, and traumatic birth injury. In conclusion, the increased incidence of cesarean section and fetal distress in patients undergoing attempted external version suggests that breech extraction may be the preferable route of delivery for the nonvertex second twin weighing more than 1,500 g

    The next study was published a little later in 2001 and covered a 20 year span of time… during the 80’s and 90’s at a larger center in Nova Scotia, Canada. They noted an increase in their combination vaginal/cesarean twin births and documented some statistical data, looked at reasons for an operative second twin birth. I wish to read this study further some day to see if there is mention pertaining to mother/baby outcomes other than statistics outlined (even though that wasn’t their objective) in this abstract:

    Combined Vaginal-Cesarean Delivery of Twin Pregnancies

    Obstetrics & Gynecology . 98(6):1032-1037, December 2001.

    Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.

    OBJECTIVE: To estimate the incidence and factors associated with combined vaginal-cesarean delivery in twin pregnancies. METHODS: We studied all twin births weighing 500 g or more during a 20-year period (1980-1999) at a tertiary care center. Major anomalies, monoamniotic and conjoined twins, and antepartum fetal deaths were excluded.

    RESULTS: During this 20-year period, 105,987 women delivered, of whom 1565 (1.5%) had twins. Of these, 1151 twin sets fulfilled the study criteria. The mode of delivery was vaginal in 653 (56.8%), cesarean in 448 (38.9%), and vaginal-cesarean in 50 (4.3%). During the 20 years there was a statistically significant increase in combined vaginal-cesarean and elective cesarean deliveries, with a decrease in vaginal deliveries. Parity, gestational age, and birth weight discordance (>25%) were not associated with combined delivery. Compared with vaginal delivery, the nonvertex second twin was associated with a twofold higher risk of cesarean delivery (relative risk [RR] 2.3; 95% confidence interval [CI] 1.3, 3.8; P =.002); and an interdelivery interval of over 60 minutes with an eightfold higher risk (RR 8.2; CI 4.6,14.6; P <.001). Vaginal-cesarean delivery had a 22-fold higher use of general anesthesia compared with vaginal delivery (RR 21.8; CI 5.4, 88.5; P <.001). CONCLUSION: There has been a significant increase in combined vaginal-cesarean and elective cesarean deliveries among twin gestations, with a decrease in vaginal births. Vaginal-cesarean delivery is associated with nonvertex second twin and a prolonged interdelivery interval.

    Now we come to 2008!  There is a study here from Texas. This study looked a twins born by C/S after labor and twins who had cesarean birth of the second twin. they campared outcomes to see if the twin of a combined delivery had more problems. The most important pieces of information I gather from this abstract of results…. (again, having NOT read the entire study):

    “Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.”  Hmmm 

    Cesarean Delivery for the Second Twin

    Alexander, James M.; Leveno, Kenneth J.; ….et al:for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU)   Obstetrics & Gynecology . 112(4):748-752, October 2008.

    Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75235-9032, USA. james.alexander@utsouthwestern.edu

    OBJECTIVE: To examine maternal and infant outcomes after a vaginal delivery of twin A and a cesarean delivery of twin B, and to identify whether the second twin experienced increased short-term morbidity as part of a combined route of delivery. METHODS: Between January 1, 1999, and December 31, 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 university centers. This secondary analysis was limited to women with twin gestations who experienced labor and underwent cesarean delivery. We compared outcomes of the second twin in women who had vaginal delivery of the first twin and a cesarean delivery of the second twin to those who had cesarean delivery of both twins. RESULTS: One thousand twenty-eight twin pregnancies experienced labor and underwent cesarean delivery; 179 (17%) had a combined vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in both groups (P=.97). The rupture of membranes to delivery interval was longer in the combined group (3.2 compared with 2.3 hours, P<.001). Endometritis and culture-proven sepsis in the second twin were more common in the combined group, respectively (n=24, odds ratio 1.6, 95% confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence interval, 1.0-3.4). These differences were not significant after logistic regression analysis. There were no statistically significant differences in an arterial cord pH of less than 7.0, Apgar score less than or equal to 3 at 5 minutes, seizures, grade III or IV intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death. CONCLUSION: Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.

    I gather from these studies that a combined delivery route leads to more problems.. however…there are probably more problems than breech presentation alone to lead the provider to make that choice. I believe that many newer providers of obstetrics in a hospital setting are more apt to do a scheduled C/S for any vertex-nonvertex twins they encounter. That is what is done in my facility today. The same for all breech presentation singleton gestation.

    Where is that old-fashioned nurse when you need her?? How ’bout the old fashoined doc??? 😉

    I am very interested in anyone’s story or experience either in healthcare or your personal birth. Please let me know if you know anything about this!

    Thanks for reading!