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Nurses pushing on stomach after birth - help. - Page 11

post #201 of 229

Originally Posted by holly6737 View Post



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.


Quote:
Originally Posted by holly6737 View Post

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

 


Ok. I guess on top of having extremely different views of birth and the ncb community, we are also speaking different languages.

post #202 of 229

Nope. Not what I said. You can read into what you will, but that's not what I said. I will never concede that point as I would never say that. It's a ridiculous assertion and I don't make ridiculous assertions. ;)

 

You should get fundal massage if you don't want to hemorrhage, as fundal massage prevents PPH. It's a simple concept. Fundal massage prevents PPH. If you dont' want a PPH, you should get fundal massage. That does not mean 100% of people without fundal massage will PPH.

 

You are focusing on this part of the argument in order to distract from the greater issue, which is the fact that fundal massage is recommended by every major medical organization as a part of active management of third stage and is evidence-based practice. (What you are doing is called a red herring. It's a logical fallacy and I'm not going to waste my time on it further.)
 

 

Quote:

Originally Posted by BroodyWoodsgal View Post




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.



 

post #203 of 229
Quote:
Originally Posted by holly6737 View Post



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.



CPMs can't bill Tricare. They aren't authorized providers.

post #204 of 229
Quote:
Originally Posted by holly6737 View Post


But no one said you weren't allowed to birth at home with anyone you wish in attendance. No one wants to get the laboring woman in trouble. The laboring woman can do whatever she wants. It's the dangerous "provider" that should be regulated and fined for pretending to be something they are not.



 



Have you any idea how paternalistic this sounds? You're essentially saying that the poor, pitiful, laboring women are essentially too dumb to be active participants in something you think is wrong. It's like the old idea of jailing abortion providers, but not the women who get the abortions. Well, it's nice and all that you don't want to punish pregnant women - I appreciate the sentiment - but the idea that it's only the providers at fault really DOES suggest that the women were gullible and stupid. If midwives don't misrepresent themselves, then the women know what they are getting. If they do, then that's another issue entirely, and surely worthy of punishment, but if they don't, then why should they be punished over the women? Honestly. I know this is a difficult idea for people to wrap their minds around, because it sounds so nice, and friendly, and caring to not punish the poor, pitiful, pregnant women, who were just too dumb to know better, but the fact of the matter is that if a woman knowingly hires a midwife with whatever background, then that woman is complicit in whatever "crime" you think it is that the midwife is committing. If you disagree, you are essentially assigning the mentality of children to pregnant women - saying they aren't intelligent enough to know better. You really can't get more paternalistic than that. (And remember, I specifically stated that this applies only when women are well aware of their midwife's particular background, education, etc. It's a different story when a midwife misrepresents herself, so please don't try to conflate the two issues and pretend that they're all the same. They aren't.)

post #205 of 229


If there were a man going around calling himself a "lay surgeon", removing the appendix's of people in your neighborhood in their living rooms, do you think he should be charged with practicing medicine without a license?

Quote:
Originally Posted by Plummeting View Post



Have you any idea how paternalistic this sounds? You're essentially saying that the poor, pitiful, laboring women are essentially too dumb to be active participants in something you think is wrong. It's like the old idea of jailing abortion providers, but not the women who get the abortions. Well, it's nice and all that you don't want to punish pregnant women - I appreciate the sentiment - but the idea that it's only the providers at fault really DOES suggest that the women were gullible and stupid. If midwives don't misrepresent themselves, then the women know what they are getting. If they do, then that's another issue entirely, and surely worthy of punishment, but if they don't, then why should they be punished over the women? Honestly. I know this is a difficult idea for people to wrap their minds around, because it sounds so nice, and friendly, and caring to not punish the poor, pitiful, pregnant women, who were just too dumb to know better, but the fact of the matter is that if a woman knowingly hires a midwife with whatever background, then that woman is complicit in whatever "crime" you think it is that the midwife is committing. If you disagree, you are essentially assigning the mentality of children to pregnant women - saying they aren't intelligent enough to know better. You really can't get more paternalistic than that. (And remember, I specifically stated that this applies only when women are well aware of their midwife's particular background, education, etc. It's a different story when a midwife misrepresents herself, so please don't try to conflate the two issues and pretend that they're all the same. They aren't.)



 

post #206 of 229

Performing surgery is not the same as attending vaginal births, and you know it....or maybe you don't. I have no idea. I kind of assume you do, since you know damn well your training, which is sufficient to prepare you to attend births, is not sufficient to prepare you to perform c-sections. However, if people are silly enough to have some neighborhood dude removing their appendixes, and they know he's not a real doctor and isn't licensed, etc., etc.,, then you either punish them ALL or punish no one. Otherwise, you are saying that the people who use him are morons, too stupid to understand what they're doing, and were therefore tricked. What you are saying right now is that EVERY woman who has ever used an unlicensed midwife in this country was too stupid to understand what she was getting, and therefore, while the midwife should surely be punished, the woman, who was obviously not intelligent enough to be considered an active participant in a crime, should not. She's essentially not mentally fit to stand trial for her participation in said crime.

post #207 of 229

Why is it that, in every other scenario, we punish BOTH parties involved in crimes? What's so different about buying drugs, for instance? If I go buy crack from some dealer on the corner, the cops don't assume that I was tricked. The law says I'm a criminal, too, because I was willfully engaged in criminal behavior. We prosecute johns just like we prosecute prostitutes. We don't say one was less guilty than the other (short of women who've been forced into prostitution). We assume that BOTH parties were mentally fit. However, when it comes to any sort of treatment of our health and/or bodies, suddenly all us patients are just idiots? We can't be guilty of anything because we're too stupid to know better? How come I'm smart enough to know whether I should buy crack, but I'm not smart enough to know whether I should use an unlicensed midwife? Makes no sense.

post #208 of 229

Not to stick my head into a hornet's nest here, but those laws regulating medical providers are because the state has an interest in making sure medical providers fulfil our duty to the public. As a medical provider, I am bound by certain laws if I want to continue legally practicing in my state, and I am subject to action if I break those laws. Patients are subject to no such laws, nor should they be. The "both parties to a crime" discussion isn't really relevant because patients are not legally held to any particular standard of conduct in an interaction with a medical provider that they aren't in other situations. The "crime" in question is committed by a medical provider who violates the rules of his/her profession, or by someone who hasn't met the standards to be called a medical provider but calls him/herself one anyway. Part of the reason that non-providers can't misrepresent themselves as providers is because they could do so in order to fool patients. The issue of whether a particular patient chooses that situation fully aware of the non-provider's qualifications isn't really relevant, because the legal smackdown is not about the patient, it's about the person who's calling themself a provider.

 

There are all sorts of instances along these lines where someone who is operating in a particular way has to obey particular laws, while those who use their services don't. If I own a restaurant and you come to eat there, then I get shut down for health code violations, you can't get in trouble for having eaten at my restaurant, even if you knew I was violating the health code and chose to eat at my restaurant anyway. That's because the law regulates me as the restaurant owner but not you as the customer. Etc.

post #209 of 229

 

“Evidence-based medicine is a systematic process of appraising and using current research findings. It is a step-by-step process that includes: formulating a clear clinical question of patient needs; searching the current literature; evaluating the literature, deciding which studies are valid and useful to the patient; applying the findings to the patient's care; and then evaluating the outcome.http://library.hsc.unt.edu/content/library-glossary (bolded mine).

 

I  have a hcp that follows this definition of evidence based medicine. I feel pretty lucky to have someone who can read the original research (not just meta-analyses and recommendations), understand it and together we can make a decision of care based on me. If my only choice was to be attended by someone like you, I would UC. I am glad I have a choice. I always think about women who don’t and it makes me sad.

 

post #210 of 229
Quote:
Originally Posted by lilikoi View Post

“Evidence-based medicine is a systematic process of appraising and using current research findings. It is a step-by-step process that includes: formulating a clear clinical question of patient needs; searching the current literature; evaluating the literature, deciding which studies are valid and useful to the patient; applying the findings to the patient's care; and then evaluating the outcome.http://library.hsc.unt.edu/content/library-glossary (bolded mine).

 

I  have a hcp that follows this definition of evidence based medicine. I feel pretty lucky to have someone who can read the original research (not just meta-analyses and recommendations), understand it and together we can make a decision of care based on me. If my only choice was to be attended by someone like you, I would UC. I am glad I have a choice. I always think about women who don’t and it makes me sad.

 

Thank you for posting this.

 

 

Quote:
Evidence-based practice involves the active participation of patients in making decisions about their care. Though foreboding in concept, the premise is simple: evidence-based decision-making requires that consumers comprehend their diagnosis and engage in a reasoned assessment of available treatment options and the benefits and risks associated with each.

I don't see how this is much different than the Marsden Wagner quote.

 

 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.

 

post #211 of 229

If your health care provider is picking out individual original research findings that only support their viewpoint and ignoring the recommendations and meta-analyses, then they are not practicing evidence based medicine. You can't just say, "I have found a piece of original research that supports the way I want to practice, and so I practice evidence-based medicine!" No. It doesn't work that way. You have to look at the body of literature as a whole. It may make YOU feel better, but it's not evidence based medicine. The recommendation to practice active management in all births is based on well-developed, large randomized controlled trials. That's the highest quality of evidence you can find. Not ONE RCT, but multiple. Just because your hcp can find one piece of original research that states that there is no significant difference in blood loss between active and expectant management of third stage, it would be foolish to discount all of those other pieces of high quality evidence that state that active management leads to superior outcomes. You have to take the body of literature as a whole. And further, current really is within the past 5 years. Just because a study is the most current (published in April of 2012 versus April of 2011), that doesn't make it more pertinent. Once again, you have to look at more than one study. More than two studies even. This is why homebirthers who cling to Johnsson and Davis like the Bible are so inherently flawed. They cling to this one study and ignore the VAST body of literature out there that contradicts J&D.
 

Quote:
Originally Posted by lilikoi View Post

 

“Evidence-based medicine is a systematic process of appraising and using current research findings. It is a step-by-step process that includes: formulating a clear clinical question of patient needs; searching the current literature; evaluating the literature, deciding which studies are valid and useful to the patient; applying the findings to the patient's care; and then evaluating the outcome.http://library.hsc.unt.edu/content/library-glossary (bolded mine).

 

I  have a hcp that follows this definition of evidence based medicine. I feel pretty lucky to have someone who can read the original research (not just meta-analyses and recommendations), understand it and together we can make a decision of care based on me. If my only choice was to be attended by someone like you, I would UC. I am glad I have a choice. I always think about women who don’t and it makes me sad.

 



 

post #212 of 229

I've been thinking about this more, and it seems that it must be very confusing to your hcp's patients who don't know what their hcp's protocols are going to be prior to coming into the office if they are constantly changing based on the whims of the most recent study. For example, the January 2012 Green Journal had an excellent study in it about mono twins and di twins. It was large prospective cohort study with a little over 1K twin pairs (sufficiently powered). The results of this study showed that mono twins should be seriously offered an elective preterm delivery at 37 weeks gestation as the rate of stillbirth dramatically increases after 34-35 weeks. Additionally, the study results demonstrated that it is acceptable to allow di twins to continue past 37 weeks, but only if there is "intensive ultrasonographic fetal surveillance". Otherwise, it appears to be unsafe to allow di twins to go past 37 to 38. The study starts on page 50. I'm sure your hcp has a copy, as she must subscribe to the Green, the Gray, JAMA and the NEJM in order to be up to date on her literature. You can just borrow a copy from her if you'd like to read it.

 

So, in light of this new study, did your hcp change their practice protocols in regards to management of twin births? If she did not, according to your own definition, she must not be following true evidence based practice!

 

As you can see, it is not tenable to change your practice protocols based on the results of one or two most recent studies q monthly. You must take the body of evidence as a whole. You can't pick and choose what studies you want to follow. This is why evidence based practice recommendations and large meta-analyses are important in creating practice guidelines. No provider has the time to read all of the journals that come out every month and no hcp would be so stupid as to change their practice protocols every month based on the new literature. It has to be taken in context. It can not be taken individually. That's not how science works.


Edited by holly6737 - 4/17/12 at 8:01am
post #213 of 229

Holly, can I ask, what exactly are you going to say to a client when she comes to you and says she wants to avoid active management?

post #214 of 229
Quote:
Originally Posted by slmommy View Post

Holly, can I ask, what exactly are you going to say to a client when she comes to you and says she wants to avoid active management?




Sure. I would explain what active management of the third stage entails. I would explain that active management does not interfere with delayed cord clamping, that you can still delay. Then I will explain that active management of third stage has been shown through numerous high quality trials to reduce the incidence of PPH. However, if she still wants physiological management of third stage, while it is not my preference, I would be comfortable waiting up to 30 minutes for the placenta to come on it's own before consulting with my supervising physician (and so long as her bleeding is within normal limits). If she is bleeding excessively or if her placenta does not deliver spontaneously within 30 minutes, additional measures would need to be taken to deliver the placenta expediently and/or stop the bleeding. Then, in the delivery room, I would again offer active management of third stage and if she still refuses I would just chart that.

post #215 of 229

Maybe I should've also just asked that in the beginning because you seem pretty reasonable here, whereas the rest of the thread you have been coming off as totally extreme, condescending and insulting.

 

Your constant replies only about superior outcomes and EBM seemed to deny any agency to the birthing woman... ("my way or highway"), that is what I think most people were reacting to, and ugh, I don't think it was just me... this thread is 11 pages long. Either this is epic communication fail or you are backtracking.

 

 

 

Originally Posted by Youngfrankenstein View Post

I'm not being snarky here, are you saying that gentle cord traction should be used if the placenta isn't out in X time?  Or are you saying that every single birth should follow with gentle cord traction?
Originally Posted by holly6737 View Post

It's my philosophy that every single birth should follow with gentle cord traction. I follow the WHO guidelines on active management of the third stage. I catch baby. Baby immediately goes to mom. Cord pulses. Cord pulsations slow or cease. Clamp, clamp, cut. Gentle cord traction with brandt-andrews. Deliver placenta. Pit running in IV (or injected IM if woman does not have IV). Fundal massage. Assess for bleeding. If uterus is not firm after delivery of placenta with fundal massage, follow with sweep of lower uterine segment to evacuate any remaining clots and consider other uterotonics such as cytotec, methergine or hemabate.

 


Edited by slmommy - 4/17/12 at 9:47am
post #216 of 229

"Either this is an epic communication fail or you are backtracking..."

 

 

OR you don't understand how patient/provider relationships work in practice. *I* prefer active management. That's what I prefer to do. When I go into a birth, that is my default. I believe that is evidence-based practice and I believe active management leads to superior outcomes. I also believe there are things that patients can (and should) be fired for. Rhogam is one of those issues for me. When I'm out on my own in practice and if I have the authority to do so, I would fire a patient for not accepting rhogam. I feel that strongly about the shot. Patients don't own me like I don't own them. But, there are fudge areas on some issues. Not everything is "do this or I fire you". I say, "This is what I want." The patient says "This is what *I* want." I say, "Well, I'm willing to go *here* with you, but no further. It's not what I want. It's not what I believe is the best management plan. But this isn't a make or break issue for me." They say, either "Ok, that's fine with me" or "Maybe I should find another practice". It's just like any situation with compromise, whether that be with your children or your spouse. I am the medical provider, I have delivered a lot of babies, I've been to a lot school, I know what I'm talking about. But sometimes patients just want what they want. You have to be able to give a little or you're being completely unreasonable. But if you give too much, then you're out of your comfort zone and that's not fair to you either.

 

Another example. Patient comes in with SROM x 24 hours. Temp 99.1. Vital signs stable. Reactive strip. Term baby. No medical co-morbidities. Cervical exam is 2/50/-2. UCs are rare and mild. Vertex. I want to start pit immediately and get this party started. It's been 24 hours and she's not going to be afebrile forever. The patient wants to do it all naturally and wants to wait for labor to start on it's own. I'm not comfortable with that. I want to get this baby delivered as she's going to get chorio, that baby is going to get flat, the persistent lates are going to start and then you have to go to section. So I say, "How about we give you another 6 hours. You can walk around the unit, but the RN is going to do intermittent monitoring and we're going to need to take your temp q 1 hr. Also, we're going to need to start some IV antibiotics as you're prolonged ROM. Otherwise, you could spike a temp on us and that would mean section for you. We want to avoid that scenario. Then, if labor doesn't start on it's own in 6 hours, we're going to need to start you on some pitocin." Now, that is not my preference. I don't want to wait 6 hours, I want delivery asap. I want pit asap. So I say, "I'm willing to go *here* with you, but no further." I have seen a very high success rate with this strategy.


Edited by holly6737 - 4/17/12 at 10:52am
post #217 of 229

Thank you for this. This is exactly why I get noxious every time I read one of her posts. And just for the record, they really should teach a class (maybe more than one), on ethics, patients rights, and analysis of scientific data. Maybe they already do but it didn't sink in.  If you don't know what kind of data go into a meta-analysis, you don't know what is coming out! I deal with this on the every day basis and it shocks me that someone would not read current literature. Maybe it is because it is easier getting fed like a baby bird. I think this conversation is done. There is really nothing to add here because Holly does not have an open mind for discussion and is changing her story as she goes along. She learned her ways in school and is going to practice just like she thinks is correct. Good luck, Holly. But for sure that is not evidence based practice!
 

Quote:
Originally Posted by slmommy View Post

Maybe I should've also just asked that in the beginning because you seem pretty reasonable here, whereas the rest of the thread you have been coming off as totally extreme, condescending and insulting.

 

Your constant replies only about superior outcomes and EBM seemed to deny any agency to the birthing woman... ("my way or highway"), that is what I think most people were reacting to, and ugh, I don't think it was just me... this thread is 11 pages long. Either this is epic communication fail or you are backtracking.

 

 

 

Originally Posted by holly6737 View Post

It's my philosophy that every single birth should follow with gentle cord traction. I follow the WHO guidelines on active management of the third stage. I catch baby. Baby immediately goes to mom. Cord pulses. Cord pulsations slow or cease. Clamp, clamp, cut. Gentle cord traction with brandt-andrews. Deliver placenta. Pit running in IV (or injected IM if woman does not have IV). Fundal massage. Assess for bleeding. If uterus is not firm after delivery of placenta with fundal massage, follow with sweep of lower uterine segment to evacuate any remaining clots and consider other uterotonics such as cytotec, methergine or hemabate.

 


 

 

post #218 of 229

Quote:

Originally Posted by holly6737 View Post

OR you don't understand how patient/provider relationships work in practice. 


I guess you have never been railroaded by a hcp in any situation, nor believe it to be possible. I've dealt with it several times recently, not birth related, so maybe I am overly sensitive. I think though that you had many times to clarify, had you thought about how your replies were being perceived or taken the time to do something other than throw insults at ucers, cpms, and anyone interested in making their own healthcare decisions.

 

post #219 of 229
Quote:
Originally Posted by slmommy View Post

Quote:


I guess you have never been railroaded by a hcp in any situation, nor believe it to be possible. I've dealt with it several times recently, not birth related, so maybe I am overly sensitive. I think though that you had many times to clarify, had you thought about how your replies were being perceived or taken the time to do something other than throw insults at ucers, cpms, and anyone interested in making their own healthcare decisions.

 



I am totally fine with patients making their own healthcare decisions! They just don't have the right to force their healthcare provider to be a part of their plan of care, (or at least they shouldnt' have that right). Make your own healthcare decisions, by all means. All you have to do is find someone to go along with them.

post #220 of 229
Quote:
Originally Posted by lilikoi View Post

Thank you for this. This is exactly why I get noxious every time I read one of her posts. And just for the record, they really should teach a class (maybe more than one), on ethics, patients rights, and analysis of scientific data. Maybe they already do but it didn't sink in.  If you don't know what kind of data go into a meta-analysis, you don't know what is coming out! I deal with this on the every day basis and it shocks me that someone would not read current literature. Maybe it is because it is easier getting fed like a baby bird. I think this conversation is done. There is really nothing to add here because Holly does not have an open mind for discussion and is changing her story as she goes along. She learned her ways in school and is going to practice just like she thinks is correct. Good luck, Holly. But for sure that is not evidence based practice!
 


 

 


You never answered my questions about how your hcp changed their practice protocols to be uniform with the most recent mono-twin, di-twin study or how their staff keeps up with protocols that change q monthly as new literature appears....

 

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