Nurses pushing on stomach after birth - help. - Page 10

[lilikoi]

Holly- They really should offer a class in your program on how to interpret scientific literature. It doesn’t look like you can actually do this on your own. People here have posted a few scientific studies that clearly show that this is not black and white and you refuse to answer their questions. What the WHO, the ACNM and the ICM do is interpret data that they see fit, and come up with a series of recommendations that may apply to the majority. Some of us don’t live in Africa. Most of us are well nourished. If I want to be treated like cattle, I will look for a vet.

I want evidence based practice to be used when I look for a provider. I want someone who is capable of understanding original research and can keep up with new literature, not just pointing to recommendations that may not apply to me as an individual or relying on outdated recommendations. As others have pointed out here, if you really follow evidence based practice, you should read the original peer review literature. Come on, you can do it! And if you need access to those pdfs people have mentioned, just pm me. I will be happy to share them with you. 

[Storm Bride]

Originally Posted by stik 

ACOG has issued a statement opposing using court orders to force women into specific treatment protocols.  It has happened anyway in a few cases, but I think it's worth noting that the broad medical consensus is that it's poor practice, it reflects horrible doctor/patient relationships, and doctors who do that are asshats.  

Holly has a protocol.  She's been taught it.  It's evidence-based.  It has good results.  She's comfortable with it.  She's honest about it, so if you don't like it you can easily not hire her.  There are other CNMs and OBs who don't automatically use cord traction or pit, and the fact that a bunch of people here are shocked by the existence of fundal massage is clear evidence that not everyone does that either.  

I don't actually give a crap what ACOG (or the SOGC, for that matter) say about anything.  I see the court orders as a natural extension of the attitude the medical profession, as a whole (yes - there are exceptions) has towards pregnant/birthing women.

I personally have no idea what third stage protocols my medical professionals might have - one has to get to third stage to find out that kind of thing. If Holly's honest about her protocol, that's great (she says she is, but I've never had a licensed provider who actually told me much, and moms don't always know what questions to ask). Women can choose to go elsewhere if they don't want "gentle cord traction". As long as licensing boards are forbidding anyone from providing care without said traction, the woman still has choices.

[stik]

You can find another provider, even late in pregnancy.  Or, you can show up at the hospital in labor and sign AMA forms for procedures you don't want.  They cannot turn you away.  They are unlikely to seek a court order for treatment.

If you feel you need that particular doctor, then you have some reason to feel that doctor's advice has value, and you should probably consider taking it.  

[holly6737]

Yes, your choices are to either 1) refuse or 2) not refuse. It's the providers choice to either keep you as a patient or not. Both of you have agency. Both of you have the right to choose. But I believe at 39 weeks patient abandonment would begin to be a legal issue, which is why it is so important to have these conversations at the beginning of pregnancy while you both have time to determine if it's a good patient/provider match.
 

Originally Posted by Plummeting 

That's not "consent". In order to give informed consent, you cannot be coerced. If a doctor is threatening to drop you as a patient in your 39th week if you don't do what (s)he wants, then you no longer have the ability to give "consent". All you can do is either refuse or give in to her/his demands. That's not consent.

[holly6737]

Picking individual pieces of literature that support your viewpoint does not determine evidence based practice and it does not determine standard of care. It takes more than one (or two) pieces of literature to create practice protocols. If you have a problem with how the WHO, the ACNM, ACOG or the ICM interpret the vast body of literature, then by all means, please write to them and inform them of their errors.

Originally Posted by lilikoi 

Holly- They really should offer a class in your program on how to interpret scientific literature. It doesn’t look like you can actually do this on your own. People here have posted a few scientific studies that clearly show that this is not black and white and you refuse to answer their questions. What the WHO, the ACNM and the ICM do is interpret data that they see fit, and come up with a series of recommendations that may apply to the majority. Some of us don’t live in Africa. Most of us are well nourished. If I want to be treated like cattle, I will look for a vet.

I want evidence based practice to be used when I look for a provider. I want someone who is capable of understanding original research and can keep up with new literature, not just pointing to recommendations that may not apply to me as an individual or relying on outdated recommendations. As others have pointed out here, if you really follow evidence based practice, you should read the original peer review literature. Come on, you can do it! And if you need access to those pdfs people have mentioned, just pm me. I will be happy to share them with you. 

[holly6737]

Originally Posted by stik 

You can find another provider, even late in pregnancy.  Or, you can show up at the hospital in labor and sign AMA forms for procedures you don't want.  They cannot turn you away.  They are unlikely to seek a court order for treatment.

If you feel you need that particular doctor, then you have some reason to feel that doctor's advice has value, and you should probably consider taking it.  

That's a good point. You are always covered under EMTALA if you are in active labor.

[Storm Bride]

Originally Posted by stik 

Fundal massage is a low-risk method of treating pph that has a long history of working and has few side effects.  If you gave birth with any kind of care provider, someone checked your fundus after the placenta was delivered.  If it felt huge and floppy, that person probably proceeded to pummel you in the stomach for a while, because that it what care providers do to encourage the uterus to clamp down so that bleeding stops faster, really no matter what their philosophy is on active management of the third stage.  If you had a c-section, they probably did it before stitching you up.  Fundal massage is described as a treatment for PPH in all the UC materials I have seen.  I'm kind of boggled that fundal massage has been viewed with such skepticism in this thread.

A treatment is something one uses when a condition is present. If there is no PPH, then performing fundal massage isn't a treatment. As for side effects...the OP described is as torture. Putting pregnant and post-partum women through hell "just in case" is absolutely standard of care, in all kinds of ways. That doesn't mean it has few side effects. It just means that excess pain for the pregnant/post-partum woman isn't considered to be relevant. The only time the medical profession cares about what a pregnant/labouring/post-partum woman is going through is when they sell you on the epidural.

I have no objection to fundal massage as a treatment for PPH...but PPH doesn't occur in 100% of births.

[Storm Bride]

Originally Posted by slmommy 

Quote:

It was her original assertion that fundal massage is absolutely.necessary.in.every.single.birth or the mother will always lose an "uncommon amount" of blood.

Like I said, Holly can practice however she wants, but speaking in these absolute terms is simply not true. 

You know...I missed that. WTF? How can it be the loss of an "uncommon amount' of blood, if every woman would lose it without fundal massage? That doesn't even make sense.

[Storm Bride]

Originally Posted by holly6737 

Yes, your choices are to either 1) refuse or 2) not refuse. It's the providers choice to either keep you as a patient or not. Both of you have agency. Both of you have the right to choose. But I believe at 39 weeks patient abandonment would begin to be a legal issue, which is why it is so important to have these conversations at the beginning of pregnancy while you both have time to determine if it's a good patient/provider match.
 

There's a reason that the expression "bait and switch" is so prevalent in NCB/VBAC circles. I've never experienced a full on bait and switch, but one of my OBs sure seemed to have a different perspective as my pregnancy progressed. The only thing he stayed constant on was his repetitious "offer" of a tubal.

[lilikoi]

Oh, no. I don't think you understood what I was trying to say. I apologize. I was trying to tell you to read the papers other have provided and also the ones you also provided.  It didn't seem like you understood them since in some of their recommendations were misinterpreted by you. Please read them! Others here have already tried to tell you this but I don't think you are open minded enough. And no, I don't think these organizations are wrong. Their recommendations are just not right for every women on earth and I am grateful for that! Evidence based means reading the original literature, understanding it, and applying to real situations.
 

Originally Posted by holly6737 

Picking individual pieces of literature that support your viewpoint does not determine evidence based practice and it does not determine standard of care. It takes more than one (or two) pieces of literature to create practice protocols. If you have a problem with how the WHO, the ACNM, ACOG or the ICM interpret the vast body of literature, then by all means, please write to them and inform them of their errors.

[slmommy]

Quote:

Originally Posted by Storm Bride 

You know...I missed that. WTF? How can it be the loss of an "uncommon amount' of blood, if every woman would lose it without fundal massage? That doesn't even make sense.

post 28 and 29
 

Holly:  "It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood."

[holly6737]

No, I read them. And I read that woman's post. I didn't acknowledge it because it seems that she picked studies that supported her viewpoint as opposed to looking at the overall spirit of the body of literature. To get an idea of what the entire body of literature conveys, one looks to recommendations and meta-analysis. These are much more worthwhile to determine practice standards as opposed to individual studies, as one can find an individual study to support one's viewpoint if you only look hard enough.

Cochrane: http://www.ncbi.nlm.nih.gov/pubmed/10908457

"Routine 'active management' is superior to 'expectant management' in terms of blood loss, post partum haemorrhage and other serious complications of the third stage of labour. Active management is, however, associated with an increased risk of unpleasant side effects (eg nausea and vomiting), and hypertension, where ergometrine is used. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal delivery in a maternity hospital. The implications are less clear for other settings including domiciliary practice (in developing and industrialised countries)."

National Guideline Clearinghouse:

http://www.guideline.gov/content.aspx?id=15263

"Active management of the third stage of labour (AMTSL) reduces the risk of PPH and should be offered and recommended to all women. (I-A)"

And that is rated the highest level of evidence and is based on RCTs.

Dynamed:

"Active management of third stage of labor:

active management of third stage of labor should be used to decrease postpartum blood loss, length of third stage and incidence of postpartum hemorrhage

• active management of third stage of labor includes 3 components
  • uterotonic drug (for example, oxytocin) on delivery of anterior shoulder
  • controlled cord traction to deliver placenta
  • uterine massage"

Access to this is provided by institutions. It sounds as if you would have access to it, so to view it, just search "overview of labor & delivery" on dynamed and click on "management of third stage". It goes into much more detail, including references, for your viewing pleasure.

ICM Statement PDF, November 2006:

"Active Management of the Third Stage of Labour (AMTSL)

Data support the use of active management of the third stage of labour (AMTSL) by all skilled birth attendants regardless of where they practice. AMTSL reduces the incidence of PPH, the quantity of blood loss and the use of blood transfusion4, and thus should be included in any programme of interventions aimed at reducing deaths from PPH.
The usual components of AMTSL include:

• Administration of oxytocin∗ or another uterotonic drug within one minute after the birth of the baby

• Controlled cord traction∗∗

• Uterine massage after delivery of the placenta as appropriate"

[holly6737]

Originally Posted by slmommy 

Quote:

post 28 and 29
 

Holly:  "It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood."

That's right. Fundal massage is in imperative part of the birthing process. It prevents PPH. That's accepted by basically every major medical organization in the world, as I have noted.

[slmommy]

Quote:

Originally Posted by holly6737 

That's right. Fundal massage is in imperative part of the birthing process. It prevents PPH. That's accepted by basically every major medical organization in the world, as I have noted.

I guess I should've just asked a long time ago... can you show me the evidence that all women (particularly those with natural/non-augmented births) will always have pph or uncommon blood loss 100% of the time when fundal massage is not performed?

I am only objecting to your use of absolutes.
 

I stated many times in the beginning that I fully understand fundal massage can be very necessary in some scenarios.

[holly6737]

Where did I say that all women without fundal massage will hemorrhage? That's a ridiculous assertion. I don't believe that so I never would have said it.

What I said was that all women should get fundal massage unless you are okay with a PPH. You can't know who is going to hemorrhage and who is not. You CAN know that more women are going to hemorrhage without fundal massage as opposed to with fundal massage. So, if you don't want a PPH, you should get fundal massage.

It's the same concept as the pertussis vaccine. The pertussis vaccine prevents pertussis infection. So, if you don't want pertussis, you should get the vaccine. That doesn't mean that 100% of people without the pertussis vaccine will get pertussis. That means that the pertussis vax prevents pertussis, so unless you want to get pertussis, you probably should get the pertussis vax, since the pertussis vax makes that end result less likely.

Originally Posted by slmommy 

Quote:

I guess I should've just asked a long time ago... can you show me the evidence that all women (particularly those with natural/non-augmented births) will always have pph or uncommon blood loss 100% of the time when fundal massage is not performed?

I am only objecting to your use of absolutes.
 

I stated many times in the beginning that I fully understand fundal massage can be very necessary in some scenarios.

[slmommy]

Originally Posted by holly6737 

Fundal massage is standard protocol, and should be done in all births. It's a part of the "active management of third stage" which is encouraged by the WHO. It prevents uterine atony and PPH. It is an imperative part of the birthing process, unless you want to lose an uncommon amount of blood. It can hurt, but it's very important. Nurses and midwives don't push on your belly to hurt you, they push on your belly to control postpartum bleeding.

unless you want to lose an uncommon amount of blood, pretty much sounds like a gaurantee - that I will pph and/or want to.

[katelove]

Before I comment I just want to clarify something. When you talk about "fundal massage" are you talking about actively rubbing the fundus before there are signs of placental separation?

I'll comment further when I'm sure we're talking about the same thing.

[holly6737]

Originally Posted by katelove 

Before I comment I just want to clarify something. When you talk about "fundal massage" are you talking about actively rubbing the fundus before there are signs of placental separation?
I'll comment further when I'm sure we're talking about the same thing.

No, that's not what I'm talking about at all. Fundal massage prior to placental separation can cause partial separation of the placenta which can actually increase bleeding. Only massage the fundus after the placenta has been delivered. But I'm sure you already knew that. :)

[holly6737]

That's your interpretation, but that's not what was said.

Originally Posted by slmommy 

unless you want to lose an uncommon amount of blood, pretty much sounds like a gaurantee - that I will pph and/or want to.

[BroodyWoodsgal]

Originally Posted by holly6737 

That's your interpretation, but that's not what was said.

No...I think any reasonable person would say that is pretty much what you were saying there. I can't think of many other ways that could be interpreted. Or really even one other way.