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Posts tagged ‘homebirth’

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!

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Mama needs “ME” time…. How do you guys do it all?

Birth and Breastfeeding Blog? I haven’t been doing much blogging.. Hmmmm……I feel somewhat guilty…….I mean I feel like I have a lot going on in my life… but ~

I don’t have small children….. mine are grown and gone… for the most part.

I don’t work 5 days a week….I work 3..but they are 12 hour shifts

I barely cook… at least no really complicated meals… I’m not a crunchy (didn’t even know what that word meant) organic earthy person.. I try to eat well but — the easier, the better…or frozen ūüėČ is ok with me!

I don’t scrub-clean my house….. I like things orderly so I straighten, manage the dishwasher, blow the dust off frequently used areas, but hey, I gotta clean the bathroom.. that’s a must.

My husband does all my floors and his own laundry….. everyone in my house has always done their own laundry. My husband is just NOT a needy guy at all! He’s my dreamboat.

I’m not really married to my work… so to speak — but I’ve always taught my family that I have to care for people all day long at work…so they need to be independent where they can and help care for all their own needs. Mama is always available for the important stuff or talks.

Mama simply needs “ME” time..and a lot of it! It renews my spirit and rejuvenates my energy. Sometimes I feel like a selfish be-otch.. but I KNOW I need it. I’m worse with out it.

Today I worked on several work projects here at home… ¬†Some PowerPoint, outlines for projects in my Clinical Expert Applicant Curriculum…. Specifically on Evidence-Based Practice and research; ¬†Project participation within my organization… (searching for compelling ideas to stir up others enthusiasm); Community involvement; Cultural Diversity; Service Excellence and Preceptor/Mentoring of new nurses. Just a little somethin-somethin.

Oh and I forgot to mention a little thing called.. WORLD BREASTFEEDING WEEK !!   August 1-7  (more on that very soon)

A lot of the¬†blogs¬†I read contain regular well researched posts. I have over a hundred posts still to read in my reader! I want to tell my stories but I don’t always have the energy to figure out ways to tell the essence of the story and change enough to protect the identities.

So I do a lot of thinking and dreaming about what I’ll write on this blog — without really writing. Don’t give up on me yet. ¬† ¬†If you are looking for something really cool or inspiring..I have it inside me head.. I do… it’s in there — still waiting to be gracefully typed with two fingers….

BUT

I’m probably watching a movie, reading a book or going out to lunch.
Fellow Bloggers… How do you pour it out on to the pages? I have a fairy tale impression of you all.

JUST HOW do you guys do it all?? Come clean with me.. are you all magical self-less supermom wizards?

HomeBirth Transfer~ Doc says NO to C/S~

I wrote a few stories a few weeks ago because I was proud of my hospital that week– sorry¬†I didn’t finish the stories until now……

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~She lived about 8 -10 miles outside of town.¬†“Ellie” was having her first baby at age 32.¬† First baby, first pregnancy, no risk factors…. an easy uncomplicated pregnancy. She had done some research, not extensively, judging from some of my conversations with her and her husband…but she knew what she wanted. She had made¬†a beautiful¬†plan with a CPM¬†for a water tub home birth. This particular midwife has been doing home-births in my area for a long time.. (She was the one cowering in the L&D hallway in this story…).¬†The story of how things progressed up to transfer to the hospital was told to us by both the mother, father and¬†midwife.¬†

~Her labor started with regular contractions at 39 weeks. They progressed from early labor which lasted around 6 hours to a more active labor with contractions about every 2- 3 minutes.¬† Her cervix had dilated to 6-7 cm. This pattern of contractions continued for hours. Ellie was in and out of the tub, walking, dozing, in and out of the shower, squatting, doing many different position changes throughout the next 6 to 8 hours. When she was re-examined by her midwife, she had made no cervical change in all that time. This can happen sometimes, things can stall out and pick back up again. Ellie reported that the contractions may not have been as strong at that, so she wanted to wait it out, maybe nap. The baby’s heart rate checks were all good.

~Everyone rested about 2 hours¬†…¬†Ellie’s water broke (clear fluid)¬† about¬†1 am and her contractions got more intense. The CPM checked her cervix about 3 am and felt no change. She still was 6 -7 cm dilated and the head was at about -2 station. The midwife then brought up the idea of possibly transferring to the hospital. Ellie said NO! Is my baby alright? “Yes….” said her midwife.. “Then No..I’m staying here, — I can do this.”

~Back to the tub… In and out of the shower, total body massages.. contraction pattern the same with increased intensity…next cervix check at 730 am… still 6-7 cm. Now Ellie was tired. Really tired. Exhausted! The baby was great on all checks. Her midwife again brought up the transfer to hospital idea, talked to her about the possibilities of pitocin, epidural etc… Ellie was now wanting anything, agreeing with anything–to get this over with.

~She arrived at the hospital around 8- 830 am very upset. Her husband and midwife were with her and her CPM had all her prenatal care info. Some of the first words out of¬†Ellie’s mouth were that she wanted an epidural and a Cesarean! The nurses on duty this morning were awesome! They calmed her down, had her hooked up to the fetal monitor and observed her contraction pattern and the fetal heart rate pattern response. The baby looked excellent! The midwife and hubby coached her through the contractions while the nurses gathered their admission data.¬† The doctor checked her and she was still about 6-7,¬† swelling of the cervix noted, about -1 station. Ellie asked him if he would please do a C/S and he said no… (yeah!).¬† He said that he felt the best option at this time was to do the epidural she was asking for and observe her contraction pattern… possibly add Pitocin. He talked to her so nicely and non-judgmentally. Many of the other docs would have taken her right into the OR with very little discussion of options. She had been 6-7 cm dilated for some approximate 16 hours.

~After the epidural, Ellie and¬†her husband and midwife all¬†slept. The doc did NOT start pitocin right away, he said that she may need to rest and the contraction pattern couldstart to become of better quality once she rested and was better relaxed. WOW! Where did this guy come from? I’m so amazed and happy and quite frankly, shocked. This was a newer OB here.. I wanted to ask him where he’d been all my life! I went in to talk to Ellie and introduced myself. I told her¬†I was so sorry thingsweren’t progressing the way she had hoped and sorry she didn’t get to stay home. She thanked me and said at this point, she was ready for it to be over! I told her she was really quite fortunate to have this particular doctor on duty today. Except for one bad apple from the night shift just leaving when Ellie arrived, everyone was wonderfully supportive and accommodating. Ellie’s contractions indeed did start up in a better intensity pattern on their own….. however their continued to be a lack of progress.¬† Once again, she asked the doctor to get it over with now and please do a C/S.¬†

~The doctor said NO again! He explained that her uterus was probably tired and the quality/intensity of contractions just¬†may not be what was needed for the job to get done. He explained that the fetal heart rate tracing was beautiful and her membranes had been ruptured less than 12 hours. No baby risks… ¬†He felt it possible the baby merely needed to get in better position and the contraction quality needed to improve.. and then he would re-evaluate. Ellie agreed with renewed optimism. The pitocin drip was started. She didn’t need much before the contraction pattern got much stronger, longer¬†and better quality.¬† He came to re-evaluate her only after these better contractions had been consistent for 2 hours. The vaginal exam revealed the cervix was the same ..still the same and possibly more swollen.¬† He said he felt the head was not as well applied to the cervix as it had been.. but still at -1 station. He examined her with and without a¬†contraction. Same in his opinion. Ellie lost all her fight. Her support people rallied to help her, but she was now insistent.

~This time the doctor¬† said she certainly had reason to feel this way, had given this a great try. He told her he still felt she could try longer… that we could alter positions with the pitocin, keep her comfortable with the epidural and keep going… the baby was handling all this just fine. He did say that there was a possibility the baby had his head in a tilted position making it difficult to descend the birth canal. He then let it up to her and told her if she wanted the C/S, he would do it at this point.

~YES I want a C/S! Ellie exclaimed. We did the C/S about 3 pm… some 7 hours after transfer and approximatelyclose to 24 hours of being 6-7cm dilated. Her gorgeous 7 lb baby boy was delivered operatively with apgar scores of 9 and 9. Pink and vigorous! Beautiful. I was able to get him skin to skin in the OR.. that was one of the first times all the players didn’t object and¬†I went with it! (It won’t be the last….and next I’m trying for breastfeeding on the OR table!) Upon delivery, the OB noted the baby had been acynclitic¬†. This is when the head is tilted to the side, ear towards the shoulder.¬† It is probably¬†responsible for her long stall in labor. The OB still felt she could have delivered vaginally given time and good management. I am just so happy he was there.¬† I am proud of this mom, her partner and midwife and of our whole team! This mom was able to make good educated choices about her care despite dealing with the stress of a transfer.. and was able to feel so very very proud of how hard she tried.

In the end it was her…… who gave in to the C/S … not her doctor.¬†

Of that we can be proud

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I’m Proud of my Hospital….~ this week ~

~I’ve reason to be a little proud of the care given this week.008

I hope this is a continuing trend of attention to detail, utilizing evidence-based practices and compassion, listening to our patients and providing them with options and the best possible care…. I’ll give you a few details about each as you read on… In summary, this week we have had the following situations:

  • A 25 week-er walk-in with a precipitous delivery stabilized & tranported¬†quickly
  • Twins! Vertex/vertex –turned breech– turned vertex~¬†delivered vaginally
  • A Heroin/Cocaine ¬†addict identified, baby able to be treated appropriately so comfortable transition
  • Safe Haven newborn about 1 day old.. placed up for adoption
  • ¬†Homebirth Transfer handled with great respect overall and most importantly, the mother is happy with her experience.

Whew! We have a lot of busy weeks but they don’t always have this intensity or variety! I feel proud because there may have been a few things done differently due to recent conversations I’ve had…Plugs I’ve made… and I keeping putting in little plugs to try to gently increase awareness & educate. I am an Instructor in Neonatal Resuscitation and Lactation.. sometimes the troops listen when I talk about other topics…. I’m no expert but I try to be current, correct and compassionate in care. (My 4 c’s)

Okay… the details for the first 3… stay tuned for the others…..

~25 Week gestation walk-in~

She came in with mild cramps and pressure. She didn’t report any fluid leakage but did C/O pink vaginal mucus. We had her in an exam room pronto. She had a gentle speculum exam which revealed hour glassing membranes thru an approximate 4-5 cm cervix..visually.¬† Hour-glassing means that the intact amniotic sac has protruded thru the partially dilated cervix and expanded like a bubble ¬†in the vagina. She went right into trendelenburg. The transfer teams were called. It was soon clear she would deliver here and the baby would need to be stabilized and transferred. The NICU team contacted us back they would be flying up to retrieve. The nurses caring for her were tremendously supportive.¬† All procedures explained, options offered and decisions honored.¬† They got her records faxed over from her OB’s office so we had a little history.

Like a well oiled machine (from all of our drills), all the emergency equipment was readied, pediatrician in attendance, roles clarified. Once he was born almost without warning, precipitously, all at once, about 30 minutes later. He was quickly assessed, wrapped in plastic, ventilated, then intubated. We had a peripheral IV in place in case he needed meds or fluid volume. He had a chest xray and a blood culture/blood count sent.  He was kept warm, ventilated and appropriately oxygenated and had stable glucoses. He weighed in at about 700 gms (about 1 1/2 lbs). The team arrived when he was about 30 minutes old. They checked all labs, xrays and his IV line. They gave him Surfactant and pretty quickly and carefully,  loaded him in the transport incubator then got him out to his mommy for a visit before he was transferred. They answered all her questions before they left and we helped her deal with it all. The doctors discharged her shortly after that so she could get down to her baby.  At last report, he was doing just as expected for 25 wks, no other complications often seen at that gestation, for ELBW (Extremely Low BirthWeight) had come up. He was actually improving each day! So happy for everyone!

~Twins!~

She came in to the hospital already in very active labor at 37.5 weeks gestation. Her twins were both head down (vertex/vertex). She labored quickly, uneventfully and delivered Twin A at about 1 pm. With the ultrasound machine in the room, they scanned over her still pregnant belly to see where Twin B was and if he was still in position. Turns out that once Twin A had vacated the womb, baby B had a lot of room and he had moved into a transverse/breech position. That means he was more bottom first than head first anymore. Most Ob’s now don’t attempt a breech delivery even with the second twin.¬† They are quick to do a C/S…. This day, however, …. the Ob in charge called over an associate to ask his opinion. They brought the mom into the OR and prepared to do a C/S¬† if they were unable to get the baby in proper position. The point is they were at least going to TRY!¬† With the U/S scanner and 2 assistants, they did an external version and worked Twin¬†B ¬†back into a head down vertex position without complication. He delivered vaginally about 1 hour and 45 minutes after his brother! The staff kept the first twin in the room the whole time so they could all be together. I spoke to the Ob later and congratulated him on a great job.. he said to me that he remembered what we had talked about¬†awhile ago (when¬†I had written the post about a C/S for the 2nd twin), and had researched it himself. I was happy that any little plug I had made had sparked interest in researching the topic and possibly even influencing a decision towards better care! I am happy to report that both babies went home with mommy on day 2!

~A Heroin/Cocaine addict~
We are attempting to put together some consistant protocols for drug screening¬†so that we don’t miss the opportunities to protect a newborn in need…. Some may not understand how important it is to sometimes screen the healthy and innocent to weed out those with problems…. They don’t always present in an obvious way. From my perspective, those individuals who are hiding something are very difficult to identify from outward appearance only. We identified a heroin/cocaine addict recently who was a very beautiful, well groomed, well nourished, affluent (seemed wealthy) woman who stated she was just visiting in our area, and had no prenatal care info or records with her‚Ķ. she was in rip-roaring very active labor at 36 1/2 weeks with heavy vaginal bleeding and fetal distress. We thought we were headed to the OR but the baby had other ideas. We had little time to get more information before the baby was born. There was a small abruption but luckily, the baby was vigorous and did not seem to have suffered blood loss. The admitting nurse had collected a urine sample with a catheter insertion and sent it for drug screen. It came back positive for Opiates, Cocaine and THC. The baby‚Äôs urine also tested postive for Opiates, Cocaine and THC. Because we knew, we were able to start the NAS (Neonatal Abstinence Scoring) for signs of drug withdrawal and identify the signs quickly. If the baby is unable to be comforted by swaddling or holding or if we had 3 scores of 8 or higher, there are protocols set up for medicating the baby. The baby did require medication within 24 hrs. Once medicated, she was such a happy sweet little girl. The nurses named her “Molly” and we all loved her. She stayed with us all week until the pediatrician released her andChildren’s Services placed her in a foster home experienced with this kind of care. Unfortunately, some of the big drug problems have hit my area. Our local paper just did a big series of stories on local Heroin addiction problems. Apparently it is cheap and accessible.

I am going to publish this part tonite and tell the other two stories soon…

OB Docs and Nurses Scoff at Homebirth

My community hospital’s views have never been in favor of any type of home-birth… whether it’s with a skilled professional ¬†practitioner or a skilled lay midwife. There could have been some free unassisted births going on but we were not aware…. ¬†As I grew-up in this profession, I learned first from my experienced counterparts…then I began to educate myself and learned a lot from mothers and babies. ¬†The doctors and nurses I worked with were all stagnant in their knowledge in my early years. They were satisfied with how things were. ¬†I was young, I had an¬†open-minded philosophy and an eager quest for knowledge.

In the later 70’s, just when we began to have mothers speak out and request a more natural childbirth, I had a few friends who enlisted the aid of some lay midwife in the region and arranged for homebirths. They all had a really nice birth experience without a single complication. Perhaps that was why I was open to the idea even though I was not personally involved. Besides some of the truly prepared couples who came in and had incredibly¬†beautiful births….. that had been my first exposure as an alternative option to the knock’em out–pull’em out births I had been working with on the job. I knew my friends were very low-risk and had done their homework.¬†

¬†¬† However, the hospital’s exposure to a homebirth in those days was only if the homebirth went awry for some reason or another and they came in our doors seeking help… ¬†here’s what the docs and nurses would say to one another :

  • “Can you believe she planned to deliver at home???”
  • “How could she take take a chance like that with her baby?”
  • “The reason people started coming to hospitals to give birth was because mothers and babies were dieing at home….she must be crazy or totally insane!!”

¬†¬† We’ve had planned homebirths come in for various reasons, as I am sure other facilities did….¬†(keep in mind that in my area, the usual birth attendant was a lay midwife). The situations bringing the mother to the hospital were often scary and upsetting for her. The most common were:

  • Fetal heart rate decels with or without meconium stained fluid¬†
  • Lack of progress with pushing mostly after many hours..
  • Higher than normal bloody show or bleeding–possibly abrupting
  • Breech, brow or face presentation
  • Retained placenta

Often the OB’s didn’t handle themselves well.. certainly not professionally. We had this one OB who would call for the OR to be opened before he even examined the patient or evaluated the situation…..regardless of why they came in. ¬†And he often actually yelled at the mother, in the middle of her scary situation.

“Your baby will die if we don’t do an emergency C/S right now, why did you let this happen!”

Most often the backlash was directed at the midwife who cowered in the hallway- uninvited by the staff, left alone detached from her patient. She never left the unit though until she was afforded the opportunity to visit and speak to her patient. 

The two significant situations I remember which would fall in to statistical data for morbidity were:

  1. ¬†An abruption which resulted in a crash C/S upon admission and a neonatal resuscitation with good response….(final apgars 3@one min then 7@ five min) positive overall outcome, no long term sequelae.
  2. A birth where the father (a chiropractor) was the birth attendant for his wife, a multip, encountered a shoulder dystocia and the baby ended up with a displaced fractured left humerus. That baby was in a crib with traction to realign the bone. The child went on to be an honor student at a local university after homeschool.

I feel that instead of the midwife or mother receiving hostility (or even the mother being wisked away to the OR without a trial of something if the baby was deemed stable..)~ the staff should have behaved in a compassionate professional manner, acting on any urgent situation with consideration that this mother is now experiencing not only labor but fear and grief over the loss of her beautiful planned birth.

Despite all the negativity from the staff, we never had a seriously bad outcome from attempted homebirths arriving on our doorstep. ¬†We still have attitude problems, probably always will~ just as we do with breastfeeding. ¬†I wish they could ¬†look at it from my perspective. Those who choose homebirth today have better information to¬†hopefully¬†make an educated informed decision about their birth options and choose wisely.¬†I really like Ricki Lake’s¬†“The Business of being Born” among other’s.¬†I hope those choosing homebirth are truly investigating all these options, deciding what is best for them and not making any decisions out of “anger at the system” or any sort of revolutionary zeal. ¬†

  There is so much out there for medical professionals to be aware of other than what goes on in their tiny little realm, their little part of the world. My co-workers and doctors need to be better informed.  

Any one bad outcome (which most certainly happens in the hospital)  does not mean that every homebirth is a bad idea.