Nurses pushing on stomach after birth - help. - Page 7

[fruitfulmomma]

It is a ridiculous oversimplification as well, that does not take into account laws governing each state and *who* is allowed to practice midwifery nor the background of every single "lay" midwife. Not a few of whom are former L&D nurses or etms or some other medical background.

And you're right Holly, I don't give a hoot what the who has to say (I don't vax my kids either!) merely pointing out the irony that you cling so tighly to what you claim they say but are in total contrast to a man who worked there as director for many years. Guess he didn't listen to his own advice???

[holly6737]

Originally Posted by fruitfulmomma 

It is a ridiculous oversimplification as well, that does not take into account laws governing each state and *who* is allowed to practice midwifery nor the background of every single "lay" midwife. Not a few of whom are former L&D nurses or etms or some other medical background.

And you're right Holly, I don't give a hoot what the who has to say (I don't vax my kids either!) merely pointing out the irony that you cling so tighly to what you claim they say but are in total contrast to a man who worked there as director for many years. Guess he didn't listen to his own advice???

Well then they should have no problem doing the work required to be a CNM/CM and passing the AMCB certification exam.

[slmommy]

Quote:

Originally Posted by holly6737 

I'm not understanding how I am denying women agency and informed consent in their maternal care? Is this because I practice active management of third stage?

Yes exactly. I never want a hcp who I would have to fight with to "let" my body do something it is meant to do (birth placenta), especially in absence of problems. 

From everything you have said it sounds like you do not allow your patients the option of delayed cord clamping, birthing the placenta themselves, or even waiting 5,10, 15 minutes before using traction?, foregoing pit, fundal massage, etc?

[holly6737]

Originally Posted by slmommy 

Quote:

Yes exactly. I never want a hcp who I would have to fight with to "let" my body do something it is meant to do (birth placenta), especially in absence of problems. 

From everything you have said it sounds like you do not allow your patients the option of delayed cord clamping, birthing the placenta themselves, or even waiting 5,10, 15 minutes before using traction?, foregoing pit, fundal massage, etc?

What are you talking about? I said that I prefer to delay clamp. You can delay clamp and practice active management of third stage.

If a woman were to say to me, "No! I do not want you to touch my fundus!" I wouldn't force fundal massage on her. That's assault, I can't do that. However, I would HEAVILY document her refusal as well as the amount of her blood loss, as would all of the RNs working with me, in the event that it comes up in court.

When you hire a hcp, you need to look at it like going to a restaurant. You wouldn't go to Outback, for example, and try to order Chicken Marsala. Outback doesn't make Chicken Marsala. If you want Chicken Marsala, go to Carrabas or Olive Garden. You come to me at your first prenatal and you say, "I dont' want an induction at 42 weeks gestation". I say, "Our policy is to induce at 42 weeks gestation. Nothing good happens to your placenta after 42 weeks gestation and that's evidence based practice." If you can't get on board with that, you need to think about going to find another hcp. Same as if you come to me and say, "I want a waterbirth". And I say, "Hospital policy does not allow for you to birth in the water. You can labor in the water, but you can't birth in the water." In other words, waterbirth is not on this menu. Perhaps you should go somewhere else where waterbirth IS on the menu or alter your preferences.

[slmommy]

Quote:

Originally Posted by holly6737 

What are you talking about? I said that I prefer to delay clamp. You can delay clamp and practice active management of third stage.

When you hire a hcp, you need to look at it like going to a restaurant. You wouldn't go to Outback, for example, and try to order Chicken Marsala. Outback doesn't make Chicken Marsala. If you want Chicken Marsala, go to Carrabas or Olive Garden.

Sorry, I guess you did say you do wait for pulsations to slow or cease. Couldn't get passed your deliver, clampclamp cut, pull, pit, massage list for EVERY birth. 

I agree about hiring hcp/restaurant analogy... but you just went on a huge rant about how incredibly bad Olive Garden is... no highschool diplomas, all for finding the highest risk woman possible and ignoring every.single. problem that might arise... Maybe you should just practice how you see fit, and try to have maybe a shred of respect for other hcps who practice differently or women who view birth and risks differently?

As pps already said, birth care should not be one-size fits all.

[holly6737]

Originally Posted by slmommy 

Quote:

Sorry, I guess you did say you do wait for pulsations to slow or cease. Couldn't get passed your deliver, clampclamp cut, pull, pit, massage list for EVERY birth. 

I agree about hiring hcp/restaurant analogy... but you just went on a huge rant about how incredibly bad Olive Garden is... no highschool diplomas, all for finding the highest risk woman possible and ignoring every.single. problem that might arise... Maybe you should just practice how you see fit, and try to have maybe a shred of respect for other hcps who practice differently or women who view birth and risks differently?

As pps already said, birth care should not be one-size fits all.

Here's the thing. I respectfully believe that we should have a standard of education for who is a midwife and who is not in this country that mirrors that of other developed countries. In GB, for example, a CPM certified through the PEP process would not be able to practice. We lose credibility in the US when we say anyone with any degree of education can be a midwife, be licensed by the state, bill insurance and medicaid, etc. It's too radical (in a bad way). There should be a standard. The CPM credential does not meet that standard- not according to the ACNM, not according to the ICM, not according to any developed country other than the US. You are legally allowed to birth at home with anyone you desire in attendance. I do not want to make it illegal for you to birth in your home- even birth in your home by yourself. However, the state is not obligated to endorse whoever you want to endorse as a licensed provider. We regulate many things in this country. We should regulate midwifery similarly. Look, my husband is in medical school. If he were to just say, "Eh, I don't need this "education". I want to perform orthopedic surgery in my shed! What do I need a license or a medical degree for?" that would be illegal. Why is it legal for untrained, uneducated "midwives" to attend birthing women- many of whom have complications such as PIH, previous c-section, GD, Type I or II diabetes, GBS +, breech, twins, etc.- (and if you don't believe me, just read these boards) in their home? Why should the state endorse that practice? Why should they be able to bill medicaid and Tricare for such services? Standards are important. Education is important. When you say it's not, you're making yourselves look like anti-intellectualists.

[slmommy]

I have no interest debating cpm standards/licensure/legality here. This thread was originally about the necessity of fundal massage and then turned to something somewhat on topic - the necessity or not of active management vs. intervention free, and validity of informed consent to that decision.

I don't ever recall saying that education is not important.

Funny how I see posters on mdc getting called out all the time here for making over-generalizing statements about the "big bad obs" and "medwives" but then it's ok to crap all over cpms and make really gross over-generalizing statements. This is not the first thread to that end either.

As to your husband performing orthopedic surgery in his shed... I mean really, you can't see how some people would view birth as a slightly less medical even than orthopedic surgery? 

[holly6737]

Originally Posted by slmommy 

I have no interest debating cpm standards/licensure/legality here. This thread was originally about the necessity of fundal massage and then turned to something somewhat on topic - the necessity or not of active management vs. intervention free, and validity of informed consent to that decision.

I don't ever recall saying that education is not important.

Funny how I see posters on mdc getting called out all the time here for making over-generalizing statements about the "big bad obs" and "medwives" but then it's ok to crap all over cpms and make really gross over-generalizing statements. This is not the first thread to that end either.

As to your husband performing orthopedic surgery in his shed... I mean really, you can't see how some people would view birth as a slightly less medical even than orthopedic surgery? 

The only way you really know that birth is slightly less medical than ortho surgery is by ruling out pathology. If you don't do any ultrasounds, don't properly monitor bp, don't dip urine, don't do the GTT, don't test for GBS, how do you know that it's a normal low risk birth? For all you know, it's not any less medical than ortho surgery.

[slmommy]

You know I did most of those things and others based on my own situation and needs with a whole range of hcps... I understand even low risk can even turn out badly and have issues, obviously... but still, I'm willing to bet that the vast majority of births need be much less medical than orthopedic surgery... 

I haven't really met anyone who contracts cpm for at-home c/s... or any ucers who attempt that. 

[holly6737]

How many times on here, even, do you read that women aren't doing the appropriate screening tests- at least one ultrasound in pregnancy, appropriate bp management, GTT screening, GBS screening, etc? How many times do you see a woman attempting a breech homebirth/UC, a twins homebirth/UC, a homebirth with + GBS or unscreened GBS, a homebirth/UC with a type I diabetic, a UC/homebirth after c-section, etc? It's all over the place. Just scroll through a couple of pages. It's like saying, "If I never get a colonoscopy, I'll never get colon cancer." No, whether you get a colonoscopy or not, you could still get colon cancer. The difference is it will happen and you just won't know about it. YOU may be a responsible homebirther who births with a CNM who has good back-up and YOU might do the appropriate screening tests to determine that you actually are low-risk, but many of your peers do not.

[slmommy]

Originally Posted by holly6737 

How many times on here, even, do you read that women aren't doing the appropriate screening tests- at least one ultrasound in pregnancy, appropriate bp management, GTT screening, GBS screening, etc? How many times do you see a woman attempting a breech homebirth/UC, a twins homebirth/UC, a homebirth with + GBS or unscreened GBS, a homebirth/UC with a type I diabetic, a UC/homebirth after c-section, etc? It's all over the place. 

About as many times as I see women complaining that their obgyn/mw/hospital policy messed up their labors, coerced them into induction, augmentation, c/s, did something border-line abusive, failed to give informed consent, performed procedures against their will, etc. 

We each don't have to like or personally agree with every birthing decision made by every individual. Like you pointed out, it is still legal for women to birth in some of these situations you deem terrible.

[holly6737]

Originally Posted by slmommy 

About as many times as I see women complaining that their obgyn/mw/hospital policy messed up their labors, coerced them into induction, augmentation, c/s, did something border-line abusive, failed to give informed consent, performed procedures against their will, etc. 

We each don't have to like or personally agree with every birthing decision made by every individual. Like you pointed out, it is still legal for women to birth in some of these situations you deem terrible.

That's a red herring.

No, I don't have to personally agree with every birthing decision made by every individual. However, when I have my practice philosophy attacked as being too "medical", I am going to explain why my practice philosophy is what it is, and that is because of the number of irresponsible homebirthers and lay midwives and the deaths that occur as a result and the superior outcome data for hospital based CNMs. It's very clear that my management style has superior outcomes. You can see that with the CDC Wonder data. it's not difficult to do. Homebirth with a DEM has a much higher mortality and morbidity rate compared to hospital birth with a CNM. Why is that? You tell me! Lay midwives don't treat you at your peril. Just look at the posters here who have had deaths. "Hands off" leads to worse outcomes- statistically speaking (and that's what counts). And I"m not for every test in the book. I'm for evidence-based practice- which means appropriate interventions when necessary. But sticking your head in the sand and not doing the tests that might indicate an intervention is needed is not the same thing as not needing an intervention. You say, HOmebirth is safe for low risk women. I say, How do you know that you are low risk if you don't actually do anything to show that you are low risk. For all you know, you are high risk. Or, you know you are high risk, as is the case for women who have breech births or homebirth after cesarean (especially multiple cesarean), and choose to proceed anyway in spite of every piece of worthwhile evidence out there that states that what you are participating in is a dangerous situation.

[slmommy]

eh. I'm in a country with 50% c/s for all and 80-90% for women with private health insurance in metro areas. I don't think those numbers are the result of evidence based medicine. I don't think uc is the safest way to give birth, but with the options I had, it was the best option for me. I'm gonna throw out the Wagner quote one more time because I can't really express my thoughts to this end any better in regards to unnecessary interventions.

Scientists can measure the efficacy and risks, midwives and doctors can inform the woman of the data on these two chances (better or worse) but the person taking the chances (the patient) is the only one who can legitimately decide whether one chance outweighs the other.

I don't even really know what we are arguing about anymore? You are allowed to practice whatever medicine you want. You can also judge your superior outcomes however you would like, and continue to make gross generalizations about anyone you disagree with. 

[SimonMom]

I'm still interested in your evidence for your evidence based practices. :p I'm a scientist, I am capable of reading the literature. Show it to me. :) You totally glossed over any of the studies I pointed you in the direction of. You want to be believable? :p Then show us the evidence. That should be easy. 

[womenswisdom]

Taking a chance and jumping in here. I have read the whole thread and been following along. Something you said, Holly, stuck out at me. I agree that you have the right to make decisions about how you practice, but what happens if a woman desires something other than what you have to offer? What if she goes into the community and finds that there are no options for hcps who will "allow" her to do what she believes to be best for her and her baby? There are areas in which, even though something is "evidence-based", or even more dubious, the "standard of care", the alternative choice is still a reasonable one. If a woman cannot find a hcp who will provide care, then she either has to consent to something she doesn't really want (not exactly "informed consent" if the alternative is to be dropped from care, right?) or take a chance with a type of hcp that might not be optimal for her situation but will respect her ability to make her own choices.

For example, in many parts of this country, there are vbac bans in all hospitals within a reasonable driving distance (I'm talking within, say, an hour). So what is a woman to do in that circumstance? Either she consents to surgery that she may not feel is the best and safest choice for her and her baby or she hires someone that you might consider to be inadequate to provide care for her. Another example would be antibiotics for GBS, frank breech presentation, induction at x weeks, the list goes on. The issue becomes that when most or all of the available providers in an area make a decision about what they will do, it directly impacts what choices are available to the women in that area.

There are benefits and risks and the only person who should get to say what course of action is appropriate is the patient, with full information. What you as a health care provider would consider the optimal choice for you, in your evaluation of the risks and benefits, may not be what your patient believes is the right choice for her. All testing and interventions come with both benefits and risks and a health care provider should not be allowed to dictate the course of care for the patient, even if the hcp truly believes that what the mother is choosing is detrimental to herself or her child. That's not their job. If you, as a midwife, do not offer space for women to make their own decisions, then they will find someone who will support them, and the person who will do so may not be the best choice for their situation. And the responsibility for that will be partly on you.
Edited by womenswisdom - 4/16/12 at 6:45pm

[Storm Bride]

Originally Posted by holly6737 

I'm not understanding how I am denying women agency and informed consent in their maternal care? Is this because I practice active management of third stage?

Originally Posted by holly6737 

I'm not here to take away anyone's right to birth at home. I just want a system in place that allows women who are low risk enough to birth at home to do it in a safe, supported environment. To me, that means CNM (or equivalent) care, proper OB back-up and strict criteria for risk status. That's how you get good outcomes. You don't get good outcomes by going "Oh, yeah, you're a HBA4C's with a history of shoulder dystocia and PPH and you're a type I diabetic with + GBS a breech baby and your membranes have been ruptured for over 4 days with mec, a homebirth (Or god forbid a UC) sounds like a great idea for you!" Right now, the homebirth community is it's own worse enemy because no one wants to admit what I've been saying. Not everyone is a candidate.

This is where you're denying women agency and informed consent. Right here. I was attempting an HBA3C when I lost my son. People jump to a lot of conclusions about that. I discussed my case with my lay midwife, and she wasn't even remotely "rah, rah, rah - this is a fabulous idea". She discussed the risks of both options (more than any doctor I've seen has ever done). She also believed that it was my decision to make - not hers, and not a licensing board's. You obviously disagree. If you want to deny women agency and informed consent, then that's your stance. Be honest enough to admit that it's your stance.

Also - "good outcomes" is subjective. I've never had one - not once. I have four living children, and they're wonderful, but they're only part of the outcome of my pregnancies. My children had good outcomes. I, as their mother, had good outcomes. I, as a woman, did not.

I know for me, personally, there were 2 notable deaths here on MDC several years ago prior to me going to the dark side, and I remember thinking, "If homebirth is so safe, why did those babies die from preventable complications?" and then the wheels started turning.

I don't know if my son is one of the deaths you're talking about or not. The "notable" (I know my pregnancy and birth were discussed here a lot, as this was - I thought - one of my only safe places to discuss it) and "several years ago" make me think it may have been. If mine was one of the ones you were talking about, please fill me in on what  preventable complication caused his death. I don't know what killed him or if it was preventable and the doctors didn't know, either, so if you do have the answer, please share it with me.

[Storm Bride]

Originally Posted by holly6737 

How many times on here, even, do you read that women aren't doing the appropriate screening tests- at least one ultrasound in pregnancy, appropriate bp management, GTT screening, GBS screening, etc?

What makes those "apppropriate"? I had GBS screening with my doctor (not in my last "birth", as that was a schedule c/s) for two babies. Both times, she commented that it was protocol, but she was unconvinced it was necessary or useful, and wasn't really supported by research. So, the doctor did screening I didn't like, that she didn't believe was necessary, because that screening was "appropriate".

GTT? I've had the GTT with all my hospital babies. I've passed with flying colours every time. Three of my babies have been over 10lbs. and my last was 9lb. 15oz. I'm obese. I've heard comments about "missed gestational diabetes" multiple times. So, the doctors apparently don't trust that test, either. Why is it appropriate? What is appropriate bp management? I have a friend who checks her own blood pressure regulary and it's fine. When she goes to the doctor, it's through the roof. White coat hypertension  - most doctors know, intellectually, that it exists in at least some people. So, is it "appropriate bp management" if a woman gets a blood pressure reading at every prenatal, but never checks it otherwise? Is it "appropriate bp management" if she checks it regularly herself and shows it to her doctor, but refuses to check at the doctor's, because she knows she's prone to white coat hypertension? (The only high blood pressure reading I ever had - during a pregnancy or otherwise - was when the doctor was discussing labour management with me, and when she re-checked it 10 minutes later, when she wasn't piling on stress, it was back well into the normal range. At least she was smart enough to realize that one reading didn't necessarily mean anything.)

I've done all the tests, because I'd given up caring about myself at all by the time I had dd2, and when trying for my VBAC and VBA2C, appearing to be a good patient was important.

And, the woman I know irl (from outside the NCB community, I mean) who had the worst time of it, medically was doing everything "right", by your standards. None of the screening tests caught anything - she showed up at the ER (in the hospital where she worked - she's a nurse) because she had symptoms that concerned her. She had her c-section that night, once her HELLP syndrome was diagnosed. (Her second baby was in the care of an OB, and they thought she'd go full term...but she had another emergency c/s a month early when symptoms flared again.) So...what good did all those "appropriate" screening tests do for her? Her condition was caught, because she noticed symptoms...both times. She probably would have had exactly the same birth experience if she'd been planning a UC.

[slmommy]

Originally Posted by SimonMom 

I'm still interested in your evidence for your evidence based practices. :p I'm a scientist, I am capable of reading the literature. Show it to me. :) You totally glossed over any of the studies I pointed you in the direction of. You want to be believable? :p Then show us the evidence. That should be easy. 

SimonMom, here are some a pp put in post #68 (which I responded to a bit already)

http://www.sciencedirect.com/science/article/pii/S0140673697094099 :done in the UK

http://onlinelibrary.wiley.com/doi/10.1111/j.1471-0528.1991.tb10364.x/full done in the Netherlands, and it's a randomized, double blinded, placebo controlled study

http://ukpmc.ac.uk/abstract/MED/22071837 A 2011 Cochrane review. 6 of the 7 studies they used were in "high income" countries

also this was referenced by another poster I think:

http://apps.who.int/rhl/reviews/CD000007.pdf

but maybe Holly knows of more.

[fruitfulmomma]

If you go to the who website then guidelines (on right) and then maternal and reproductive health you can find their publication on pph. It is pretty long, I've only skimmed through, but for what is worth their recomendation is that active management should be *offered* to all women.

[slmommy]

nm