Doulas Are Awesome

You will often hear moans and groans from many L&D nurses from coast to coast when a woman shows up with a birth plan and/or a doula. Many nurses (and doctors, even midwives…or shall I say med-wives) believe that any woman who writes out specific plans as to how her labor shall occur are subconsciously asking for a c-section. They hate the thought of someone else trying to take control of the birth. The hospital is the doctors’ and nurses’ home turf and the best results occur when the away team (aka Mom and Dad) follow the rules. Birth plans challenge this, and are quite threatening to those who like full control on their own turf.

But actually, what I meant to get into was doulas. Doulas are trained in labor support. They provide support and assistance continuously while a woman is in labor, and some may also provide help after the baby is born. Many times doulas like to meet their future mothers during the pregnancy to get to know them, and make sure that there isn’t something that would inhibit the doulas work (like the mom and doula not liking each other). Just about anyone can call themselves a doula, but don’t be fooled. Doulas must be certified by either Doulas of North America (DONA) or Childbirth and Postpartum Professional Association (CAPPA).

I personally love doulas. Unfortunately, very few women have doulas where I work, and there have even been some women who were denied their doula. Apparently there aren't many doulas in my area and the one that most go to is “not allowed” in the labor rooms per the medical staff. She was accused of interfering. My feeling is that she probably is an outspoken advocate of her clients, and therefore challenged some of our old school thinking docs.

The reason I love doulas at work is because it frees me up. Isn’t that terrible? Traditionally labor and delivery nurses were meant to provide the continuous labor support to women. However, this has historically not been the case. When childbirth was moved to the “safety” of the hospital, nurses were to assist the obstetricians. I have a nursing textbook from 1922 that gives a litany of duties the nurse was to perform.

Many of the duties have changed, but 2007 is essentially no different for a labor and delivery nurse than for the 1922 labor and delivery nurse. The difference is in what we have to do. There are monitors to maintain. Paperwork and charting to kept on top of and meticulous in case we have get deposed. Interpretation of fetal heart tones and maternal vital signs. And many times one nurse is caring for 2 or 3 woman at once. I am totally simplifying what L&D nurses do as far as our “tasks”, but my point is that very little of our time is left over for actual contact with the woman. So as you can see, doulas do what I wish I could be doing. They do what the woman deserves during her childbirth experience.

Research also shows that women who have continuous labor support have shorter labors, fewer interventions, less pain medication, to name a few. Most importantly, most women will report a greater satisfaction with their experience, even if they ended up having a c-section or epidural. I’ve done a cursory review of the literature and have come up with some titles that might be helpful. I’d link directly to the articles, but I’m told this is illegal. Find Articles might be helpful, or just google it.

This is a meta-analysis demonstrating some of the positive effects that continuous labor support has:

Zhang, J., Bernasko, J. W., Leybovich, E., Fahs, M., & Hatch, M. C. (1996). Continuous labor support from labor attendant for primiparous women: A meta-analysis. Obstetrics and Gynecology, 88(4), 739-744.

This article is interesting for many reasons. It has a small section on continuous labor support but I think you will find other pieces of it interesting:

Leeman, L., Fontaine, P., King, V., Klein, M. C., & Ratcliffe, S. (2003). The nature and management of labor pain: part 1. Nonpharmacologic pain relief. American Family Physician, 68(6), 1109-1112.

I found this one interesting because they trained student nurses to provide doula care, and the researchers imply that institutional changes should occur to allow more nursing support of the laboring woman:

Van Zandt, S. E., Edwards, L., & Jordan, E. T. (2005). Lower epidural anesthesia use associated with labor support by student nurse doulas: Implications for intrapartal nursing practice. Complementary Therapies in Clinical Practice, 11(3), 153-160.

If you were going to read only one of these articles I list, then this is the one. It’s a case study that is discussed by several different professionals from different perspectives, while reviewing the benefits of doulas.

Stein, M. T., Kennell, J. H., & Fulcher, A. (2004). Benefits of a doula present at the birth of a child. Pediatrics supplement 3 of 3, 114, 1488-1491.

For those interested in having a doula but don’t know where to start I would suggest DONA’s website. They have a search feature to find doulas in your area. Meet with potential doulas to get a feel for her (or his) style. Also, talk with your doctor or midwife about doulas. You’ll learn a lot about his/her philosophy of birth by what they have to say about doulas.

Maternal Deaths Rising

Today on my internet provider’s homepage there was a news headline that said something like: “US maternal deaths on the rise”. The headline was only up for several hours this morning. It was likely removed to make room for more important news like Lindsey Lohan’s latest drunken caper, or Britney Spear’s latest shave job.

I read the AP article and found that the most of the experts quoted didn't think this stat was correct. According to the WHO, UNICEF, and the United Nations Population Fund, the United States is only the 28^th best in the world when it comes to moms dying. Denmark, Finland, Canada, Austria, Belgium, and Japan do better than us, to name just a few. Mind you, none of this was mentioned in the article. What was mentioned was that we have the technology to save women now, and so the rise in maternal deaths is surprising. Oh, really?

Does anyone notice the increase correlates with the rise in our c-section rate? With about 1 in 3 women giving birth by surgery, it seems only natural to see this increase in maternal death. Surgery is surgery, even when there is a birth involved, and it comes with risks. One of those risks is death. Now before someone jumps all over me because I mentioned death as a risk with c-sections, I will say that most c-sections (and surgeries in general) are done in a controlled environment with skilled care takers. But death can happen. It does.

There will be others that are not surprised at all. I’m one of them. And then there are some who are debunking this rise in maternal deaths (I believe it is now 13 in 100,000 births, up from 11) because we are just reporting these deaths differently. This may be true, I don’t know, but even if it is how many more deaths are we actually having? How long will it take us to see how many maternal deaths are occurring to rethink how we care for women?

I'm here, I'm there

Rachel from Women's Health News has posted a new interview series on her blog. I'm her first interview, go check it out.

Change of Shift is up over at Nurse Ratched's Place. My mucous plug discussion is in this week's carnival.

Charge Nurses

If there is one thing I hate more than anything, it would have to be lazy nurses. In particular, lazy charge nurses. When I worked at Posh City Medical Center, I became one of the frequent charge nurses on the unit. Although it was not a labor and delivery unit, there still was shit that needed to be addressed in any given shift. It was the charge nurse’s responsibility to ensure that the shift was running smoothly, that one nurse wasn’t running around with like a chicken with her head cut off while the others languished in the back room eating chips and dip.

Enter my current unit. I’ve been there several years and have never been assigned charge nurse. I normally would have been miffed at any other hospital, but the place I work now is not like the other places I worked. Obviously this is good and bad. I actually would not want to be charge nurse in my current job. Most shifts include three ring circuses, whining physicians, crying nurses, and some huffing and puffing. I don’t want to be in charge of that.

There are some really good charge nurses, I have to admit. I particularly love when Nurse M is charge. She’s funny, she’s fair, and she doesn’t take shit. She also was very supportive and protective of me when I was new, so perhaps I am a little biased. Either way, I prefer her over most.

Today, on the other hand, was Lazy Ass Charge Nurse day. I actually try to avoid working days that she is on. Here’s why in a nut-shell: you get shit on for 8 to 12 straight hours. It’s the one thing in life that you could always bet money on and win. Trust me. I can’t even begin to count the times that she has pushed several patients on me so that she would not have a single one. But I’m certainly not special, it happens to all of the staff nurses under Lazy Ass Charge Nurse.

For instance, I was caring for two active laboring women. One was doing very well, was very pleasant, and was understanding that I was busy. The other was highly anxious, difficult to please, and made me feel uncomfortable for some unknown reason. I anticipated both of them needing epidurals around the same time. I went to Lazy Ass Charge Nurse to inform her of my prediction, and could we put a plan in place? There is no way that I can safely assist with an epidural in one room while monitoring the other woman. I’d be tied up in one room for at least 45-60 minutes, unable to leave to help the other if she needed me. It’s all well and good that we have central fetal monitoring so I can watch the other’s strip while in the opposite room. But what happens if I see a decel? I can’t exactly go running from Mom #1 during an epidural placement to do what needs to be done with Mom #2 having decels. This is why I was trying to plan ahead.

Of course, I got a non-committal plan of which I left wondering if one was even in place. And what do you know? Mom #1 wants an epidural. Fortunately all goes smoothly, the immediate recovery period was cake, and so I was able to go see Mom #2.

By this time Mom #2 is losing it, unable to cope with her 20 second contractions. She is begging and pleading for an epidural. And so an epidural it is. Except…. all hell breaks loose. She has one of the most extreme hypotensive reactions I’ve ever witnessed. Her blood pressure was 50/24 after the epidural loading dose. I was thinking that I might be pressing the Code Blue button. Fortunately I didn’t have to, but needless to say it took 2 hours to stabilize her. I didn’t get a chance to call out and ask for someone to keep an eye on Mom #1 until over an hour into this debacle.

Lazy Ass Charge Nurse said that she had no idea that I needed help.

Say what? Or should I say, Say Fucking What????

I was fuming mad. When I was able to leave Mom #2 for a minute I went to Mom #1’s room. There I found our most motherly of nurses, Nurse F. Despite having a full assignment of her own, she somehow became aware of my situation and stepped in to watch Mom #1 without having been asked. To say I was grateful is an understatement. I felt terrible that Mom #1 had some random nurse coming in and caring for her, but she was totally cool with it.

Now did I mention the reason I had these two patients was so that Lazy Ass Charge Nurse could have an empty plate? I already was assigned one patient when an hour into the shift she decided to dump her one and only patient on me. And as the day went on and more women came into our triage room (and of course all were admitted) she conveniently dumped each and every one of them on other staff nurses. Each of the other nurses already had 1 or 2 patients to begin with. Nurse H got the shortest end of the stick as she was given one patient after the next because she just happened to get the only patients that were delivering. No sooner would a placenta pop out would Nurse H be told that she had to take yet another woman.

This sort of laziness is more annoying than stupidity. I don’t dare go to management about this, although I wonder if anyone has. The problem with going to management is that Lazy Ass Charge Nurse is well entrenched with the management crowd, and so she is well protected. It’s funny how such people can’t manage to do much work, but work real hard at making the right connections.

Falsies Vs. The Real Thing

I can’t begin to tell you how many first time mothers make trips to the labor and delivery unit thinking they are in labor when in fact they are just having a spell of Braxton-Hicks. The look of excitement and anticipation is universal to each mom, while their husband has their 6 suitcases and bags piled up beside their triage bed. We can spot these women a mile a way. They smile nervously and hold their bellies while they have a contraction. They’ll say to the nurse, “Oh, this is a strong one!” while carrying on a conversation on their cell phone to their friends and family to inform them that they are at the hospital.

And we (the nurses) think, “Ya, right sista!” Many times our report to the resident will be something like “Here’s another wannabe primip (first time mother)”. After their evaluation, you can see their hearts sink. Some will fight to stay. Some will leave with their bags with embarrassment.

Here are some ways to help distinguish real labor versus false labor:

• False labor will have no distinguishable pattern. Contractions may come and go at different intervals. Contractions may go from 6 minutes apart, to 12 minutes, to 20 minutes, then back to 6 minutes apart. They may even stay at a specific interval for a while, but eventually will peter out after a while, or at least space themselves.
• False labor contractions will not typically increase in intensity over time. Your contractions could last 2 hours, but none of them will get stronger than the previous. Sometimes they will lessen over time.
• If you eat, drink, or go for a walk and the contractions space out or go away, it’s false labor.
• If you lay down to rest, contractions will lessen in intensity or go away if it’s false labor.
• True labor contractions will become longer, stronger and closer together over a period of time (for some over an hour while others over many hours).
• No matter what you do, contractions just keep on coming. The walking, eating, drinking, and resting don’t do diddly squat for what you are feeling.
• Real labor will not pass you by. Trust me. Even if the beginning of your labor starts off like false labor it will change and you won’t miss it.

Every provider has their own preferences as to when you should call them if you think you are in labor. In my classes, we use the guideline of contractions that are every 5 minutes apart for the last hour OR if the contractions are so intense or painful that you are having a hard time talking or breathing during them. But again, make sure you know what your provider wants you to do. There can be other variables that would determine when you go to the hospital, like any pregnancy complications or potential problems, distance to the hospital, or if you’ve had a very quick labor previously.

I Hate You

Today I cared for a woman who I cared for during her first childbirth. This was the first time I have ever had this happen. Actually, it was the first time I cared for a mother during her birth for both her children. When I walked onto the unit the nurse I was taking over for said to me, “You know her; you were her nurse for her first baby.”

The name didn’t look familiar at all. But I can barely remember names even while I care for people, so I couldn’t rely on that. The night shift nurse said to me that the patient absolutely hated me.

Say what? What the hell am I getting assigned to her now? My puzzled look gave the nurse a case of the giggles, and she further explained that she hated me when I first came in to care for her and thought that I was going to leave her. Apparently the nurse I had taken over from back then didn’t provide much support. But I had stayed with her the entire time, holding her hands, giving her sips of water, putting cold cloths on her forehead. And she loved me from then on.

I still didn’t remember who she was. Hopefully I would when I walked into her room.

Sure enough, it all came back to me as soon as I entered the room. As I stood at the foot of her bed, we stared at each other. It was quite bazaar actually, like we were sizing each other up. Not in a bad way, just weird. Kelly, the patient, broke the silence.

“Did Nurse B tell you that I hate you?”

“Yes.”

“But you know I absolutely loved you!” She stopped to breathe through a contraction. Watching her was like watching a childbirth education video. She was perfect and controlled. Very unusual. Very unlike the first time. She ended the contraction with a calm breath and opened her eyes. “I had several false alarms this pregnancy and every time I came in I asked for you.”

No one informed me of this (which was not unusual because it seems that I work with people who don’t like to pass on compliments). But I was so flattered. Kelly had remembered me, remembered my name, and asked for me to be her nurse. Hearing this makes me feel like what I do really is important, that I am not just a cog in the wheel.

And so we fell into the old routine. I talked her through her contractions. I gave her sips of water. I made hot packs for her back. I told her how impressed I was with her breathing and ability to calmly cope with her labor. I sat on her bed and held her hands or rubbed her legs. When she wanted to push when she was only 8 centimeters I breathed with her to get her through the urge. And I wished that I could bond with all my patients like this. I provide labor support to all of my patients, don’t get me wrong, but there was something different about my nurse-patient relationship with Kelly.

When her baby was born, I helped to place him on her chest. Kelly talked to her new little boy in some secret baby language. Her son looked wide eyed and calm. When all was said and done, Kelly said to me, “I didn’t hate you one bit this time.”

I laughed. “Good.”

“I hope you’ll be here in ten years,” she said.

“Why’s that?”

“Because that’s when I’ll be back.”

Check Check Check Check, Check It Out!

No, I'm not stuttering. I'm quoting the Beastie Boys.

I was made aware of a website that matches women with care providers that share similar philosophies and beliefs in childbirth and women's health. You have to register, but it's free. The providers who participate in this website pay a fee, so they want patients who also share their practice style. There are forums for women to connect, although the website looks fairly new so it's not as active as others like iVillage.

Anyhow, it's worth checking out: My Birth Team

Troll Baby

Think that ugly babies don’t exist? Think again. There is plenty of them, and I think I have seen the ugliest of them all. The ugliest baby was born well before I even graduated from nursing school…yet I remember this baby as if it were yesterday. (Sorry I am referring to this baby as “it” but I can’t remember if it was a boy or girl).

Think troll. Thick black long hair stuck straight up as if it was just twirled between someone’s hands like one of those troll doll pencils. Think squat little hairy creature. Big flat ears that came out at the sides. And it’s parents weren’t ugly. Go figure.

There have been others that are not so attractive, but in general I find really big babies unattractive. Typically babies over 9lbs just don’t do it for me. It’s like giving birth to a 2 or 3 month old. And an eleven pounder? Call the pre-school! Most of these large babies look like little obese people. Babies shouldn’t resemble obese adults.

The most recent large baby I cared for weight in at 11lbs 10oz. His face actually wasn’t fat looking, but the rest of him was obscene. His thighs were as thick as my forearms. His fingers looked like pigs in a blanket (the cocktail wieners). His abdomen was big and round like he’d been guzzling beers for 9 months. And he was covered in dark black hair. Needless to say, he was the talk of the unit for a while.

(photo credit)

More on the Plug

So I was grocery shopping the other day and hear my name being called out. I turn to find a couple that was in my most recent childbirth education class. The wife was looking tired and swollen. The husband looked eager and excited. I began with, “Oh, how nice to see you!” but was quickly cut off by the wife.

“I’m having a funny colored mucous plug, I think.”

Oh, jeez… here we go. Those damned mucous plugs!

“Oh, really?” I replied. I was secretly hoping my lack of specific questions would change the topic.

“Ya, it’s like this bright orange. And then some brown mixed in it.”

Sounds like a 1970's plug to me. Perhaps we could add some avocado green.

“Have you talked to your doctor?” I asked.

“Yes, I called them during the night and the doctor on call said I was fine.” Oh, how the on call doctor must have loved getting that call at 3AM!

And so she continued on with every ache and pain, every symptom, every twitch. I tried to gently remind her that she was in the last days of pregnancy and most women experience unpleasantness. I reminded her that the mucous plug couldn’t specifically predict when labor was to begin.

Her reply was, “But my due date is 11 days away. Could I really lose a mucous plug now?”

My answer began as I started pushing my cart. This could turn into an hour long consultation if I didn’t make my move. I felt bad trying to cut this short, but could I really triage her symptoms at the grocery store? Did the other customers want to hear all of this (she was mighty loud)?

And so as tactfully as I could, I said, “Well, some women lose the mucous plug very early. Some don’t. But I hope to see you soon! Take care!” I could see the disappointment in her eyes, which made me think that she probably wasn’t getting many answers from her doctor and that she was getting very scared.

Perhaps I will have her in labor so I can work my magic!

What Happens Before Labor

Here is the last of the childbirth ed posts from Life and Times. Don't worry, though, there are tons more to follow in this series.

What Happens Before Labor?

Everyone wants to know: "How will I know it's labor?"
And every time I answer: "Because you can't mistake it!" I get looks of frustration and confusion. Labor won't pass without you knowing it. Trust me.
Here's a known fact among labor units everywhere: if you can easily talk through a contraction, like you can tell us you're having one while smiling with excitement, means you are either not in labor or in very early labor. And if you come to the unit like this, you'll likely be going home.
Other things that women frequently ask is what signs can I look for to tell me when labor is going to happen? Well, hate to burst your bubble here but there is no specific sign or scientific formula that is going to tell you that either.
There are things that can occur that tell you that your body is preparing for labor. They don't occur in any specific order nor do they occur in every woman.

• Braxton-Hicks Contractions: these are contractions that occur in the third trimester of pregnancy that are irregular and mild. These contractions do not change the cervix like true labor contractions do. Think of them as practice contractions on a very small scale. Some women can be bothered by them and others never seem to experience them. These contractions will typically subside with rest and fluids.
• Lightening: You've heard the saying, "The baby has dropped", right? This is lightening. It's when the baby engages it's self into the pelvic cavity and you can suddenly catch a good breath. And you pee like every 22 minutes.
• Nesting: Ya, this really happens. This is when you get an urge where everything must be ready. Clothes must be washed in Dreft, folded, and placed in the cute little baby bureau in the nursery. Diapers must be stacked in the changing table. The suit case must be packed. The house must be cleaned. You've mustered up some new found energy that just must be put to use.
• GI Changes: Here's everyones favorite! That nausea and vomiting you finally got rid of? It's come back. And that diarrhea? Ya, its to empty out the system and triggered by prostaglandins (more on the hormones later).
• Dilation and Effacement: I hate to even put this in here because everyone wants to hang on to their cervical exam at 39 weeks like it's their ticket to the labor room. But dilation and effacement can occur before labor. Typically the changes in the cervix prior to labor are minimal at best, particularly in a first time mom. There is no formula that says if you are 1 centimeter dilated at 38 weeks then you will go into labor in 16.23 hours. Sorry, there just isn't. I've told this to countless women, but everyone wants to hang on to that damn exam! Why are they done, anyhow, is what I'd like to know! But that's beside the point. So many get hung up in this and just make themselves frustrated and disappointed with each passing day that the stork passes them by. Here's what I've seen happen: cervical exam at prenatal appointment is 2 centimeters. You think labor will hit you at any moment. And then you find that your doctor is booking a postdates induction. OR cervical exam at prenatal appointment is zippo. Cervix closed tighter than Fort Nox (Knox?). You think you'll never go into labor but end up having a baby hours later. So either way, you just never know. I've seen women walking around at 4 centimeters for several weeks and not go into labor; and I've seen the disappointed mom with the closed cervix go into labor later that night. So I guess the take home message here is that dilation and effacement of the cervix can happen before labor, but it won't tell you when labor is going to occur.
• Loss of the infamous Mucous Plug: Here is another event that can't really tell you diddly squat. Well, other than your body is doing all the right things and labor will occur at some point in the future. And the mucous plug doesn't come out looking like a cork. Typically its seen as an increase in mucousy vaginal discharge over a couple of days. Sometimes the cervix does spit it out in one big glob. I can tell you that the big event of the mucous plug has doctor's offices rolling their eyes when someone calls in a panic thinking that at any moment labor will strike them down like Kryptonite. I can attest that no one cares but you about the mucous plug. We'll care if there's bleeding associated with a mucousy discharge... but otherwise you can just make note of it in your scrapbook. Well... I mean write about it...don't scrapbook the actual plug.

Makes labor signs clear as mud, huh?

Yet More Wasted Time

I knew within the first three minutes of today’s staff meeting that it was a waste of my time. Again. It didn’t start on time (it never does), it didn’t end on time (it never does), and it kept going off course with the usual bitching, whining, and complaining.

I have noticed that the last few staff meetings I have attended that false promises were not made. Perhaps management is being called on their lack of fulfillment. I can think of several things they said they would either implement or address well over a year ago that I’ve yet to see. But I’m not holding my breath.

What surprised me was that management wants to hire more per diem staff. Hello! The current per diem’s get canceled or shit hours! What are they thinking? Oh well, at least I get paid to sit at these meetings.

Don't Do This On A Date

This is so not blog related, but I just had to share this with you. I'll never forget the first (and only) time I saw this commercial about 9 years ago. It's classic!

Rising C-Section Rates

The American College of Nurse Midwives (ACNM) brought to my attention an article on the rising cesarean rates in our country. Here is the link to the Childbirth Connection’s page on c-sections. Go read it then come back and finish this post. I’ll wait for you.

………..ok……..so what stuck out for me was the myth of maternal requested c-section. I have to say I wouldn’t have called it a myth. With many famous women having such surgeries and hearing about this trend in the media I assumed that this was in fact part of why so many women now have surgical birth. If just 1 in 16,000 women surveyed by Childbirth Connection (I’m assuming via their Listening to Mothers II survey) requested and had a c-section for non-medical reasons, then why has this been portrayed as a major cause of the rising c-section rates?

I have two theories. As I’ve mentioned, celebrities are having c-sections just because they want them. One of the most notorious of them is Britney Spears. She had c-sections because she didn’t want to experience the pain of childbirth. (What a dope! Surgical pain for days, if not weeks, is a better alternative?) Then there is Too Posh To Push, aka Victoria Beckham, Kate Hudson, and Elizabeth Hurley to name just a few. I'm sure we'll be adding Nicole Ritchie to this list because, frankly, she'd need to eat in order to have enough strength for a vaginal birth. Because these famous women chose surgical birth the media hypes it as the “in thing”. Just like Botox.

My other theory is that it is being propagated by obstetricians. I’m certainly not saying that all obstetricians support or perform maternal requested c-sections but if there is an internal dialogue movement within their profession then word will get out. The American College of Obstetrics and Gynecology (ACOG) is a powerful organization, and if they place this on their agenda you can bet more obstetricians will open their practice to mom’s wanting surgical birth for non-medical reasons. This topic is quite popular among our residents and attendings right now, and it appears as though it’s a 50/50 split.

I am very worried about the climbing c-section rate. When I first began working in this field seven years ago 1 in 5 women had a c-section. Now it is 1 in 3. Firstly, I believe that we perform too many unnecessary surgeries created out of our own doing. As the Childbirth Connection article mentions, some labor interventions have been linked with higher c-sections rates. Secondly, I don’t think we are going to see a stabilization of this rate any time soon. More and more obstetricians are denying women the VBAC option and there is worsening litigious practice underlying medical decisions. Thirdly, I have a personal fear that I will be one of the three women giving birth by c-section. There are some obstetricians who would consider me a c-section waiting to happen….I’m obese, short, have PCOS (a nice set up for gestational diabetes), and will likely be advanced maternal age (35 and older) when I do have children.