Homebirth MWs...about transport and what follows

[MsBlack]

Hello all you wonderful MDC homebirth midwives (and friends)

This year I have had more transports than ever before in my practice (which only recently resumed after a long hiatus). This past week I actually had 2: one of which I accompanied, and the other was done and done without my presence at all by parental choice (see my post on Pros and Cons of ultrasound thread in Homebirth forum, this past week on MDC). Oy vey. Anyway, this leads to some pondering/questions about how to manage self and mw/client relations in the immediate post transport days; I also have a question for you about how you view and advise upon breastfeeding neonates in the earliest pp days. This is kinda long, I'll try to separate into discrete questions/areas:

1. We all know that in the hospital, especially with the dreaded 'macrosomic' baby (over 4000gm), that hypoglycemia is an issue for NICU leading to lots of needle sticks for baby, formula feeding and so forth. Ugh. But when a baby is born at home after a normal delivery, do you concern yourself with blood sugar issues? Other than observations of s/s, that is, as we would observe, and help parents know how to observe, for s/s of any issue--respiratory, temp, feeding and eliminating, etc. For instance, do you insist that mom must wake baby ever 2hrs to eat, even in first 24hrs? Do you ever see perfectly normal healthy babies who want to spend quite a bit of time sleeping in that first 24-48hrs--who do wake to feed but who sleep, at least a couple of times during that transitioning time, for 4-6hrs...and if so, do you consider this 'normal' and not a cause for worry and forced feeding? Tell me, in short, your basic suggestions/protocols relating to neonate's blood sugars in first 72hrs for bf-ed babies. In spite of the trail of healthy babies behind me, I'm starting to wonder if I'm just TOO 'normal oriented' and not vigilant enough or something!

2. How do you carry on with the family after transport--at least, after a transport that is a fairly normal birth with 24-48hr discharge of both mom and baby? When allowed, I do accompany transport and give whatever I can toward a good birth/pp time. And I tell families that we are still under contract, that I am available and want to see them on the usual schedule for pp visits, that they should know I'm still on call 24-7 for first weeks..don't hesitate to call...that, in short, while place of birth has changed, our basic relationship and arrangements have not. Of course, I also tell them that while I will check in as I would if birth had happened at home, they are free to utilize as much or as little of my time/services as they choose. Anyway--do you find that transport disrupts the connection that was forged among you during pregnancy and labor--that families may be confused/conflicted about your relationship now that birth did not happen at home (even if there are no 'hard feelings', birthing in hosp definitely introduces a whole nother worldview and reference point for families to contend with--like, widely varying info on the potential for harm from hypoglycemia and how to manage early days feeding! among other things....). Is there anything you do/say to help avoid/manage the potential for this disruption and confusion?

It's clear to me that all of this is highly dependant on just who the family is, what their personalities are like and how much they respect/adhere to 'med thought' vs 'natural thought'. Not like I think the above issue could be nailed down for every fam with one 'formula'. Still--I have to wonder if there is something I could be doing, or not doing, that might help in future cases. Your insights and input will be much appreciated.

thanks womyn!

[Reha]

Originally Posted by MsBlack

1. We all know that in the hospital, especially with the dreaded 'macrosomic' baby (over 4000gm), that hypoglycemia is an issue for NICU leading to lots of needle sticks for baby, formula feeding and so forth. Ugh. But when a baby is born at home after a normal delivery, do you concern yourself with blood sugar issues? Other than observations of s/s, that is, as we would observe, and help parents know how to observe, for s/s of any issue--respiratory, temp, feeding and eliminating, etc. For instance, do you insist that mom must wake baby ever 2hrs to eat, even in first 24hrs? Do you ever see perfectly normal healthy babies who want to spend quite a bit of time sleeping in that first 24-48hrs--who do wake to feed but who sleep, at least a couple of times during that transitioning time, for 4-6hrs...and if so, do you consider this 'normal' and not a cause for worry and forced feeding? Tell me, in short, your basic suggestions/protocols relating to neonate's blood sugars in first 72hrs for bf-ed babies. In spite of the trail of healthy babies behind me, I'm starting to wonder if I'm just TOO 'normal oriented' and not vigilant enough or something!

Research has shown that testing and treating neonatal hypoglycemia is only warranted when you see s/s, so doing exactly what you are doing is right on, and totally evidence based. I think a lot of babies are sleepy in the first 24 hours or so, and I would just be wanting to see baby nursing more often by the end of day 1, regardless of being a "big" baby or not. In fact, it is the tiny babies (6lb and under) that I would encourage mom to wake baby and encourage her to be nursing more often; those babies are so much more susceptible to not having enough reserves (brown fat, glucose reserves) to get them through the first few days and too often get sleepy, won't wake to nurse, which just makes them more sleepy.

The fact of the matter is that we simply don't really know what is normal and physiological blood sugar levels in newborns. Dr. Jack Newman (the amazing breastfeeding-supportive ped.) talks some about this as well. He is also an advocate for only treating hypoglycemia if there are s/s.

[MsBlack]

Thanks, Lennon!

I think I have my head on straight again ;-) Had a good conversation with a dear friend who has been an LLL leader for years--yes, she agreed that the hospital in this case was just being silly, and also affirmed the way I understand things. Plus, apparently Jack Newman was just here in my town, giving a talk to the local hospital, and told them the same things. Huh, I guess none of the nursery nurses attended--or at least, didn't listen!

I guess the hospital got under my skin more than I realized. Suddenly, I needed a reality check. It's been quite a week....

[Reha]

[Jane]

Not exactly related to transport, but I recommend feeding as baby desires for 24 hours, especially respecting that 4-6 hour sleep that sometimes occurs a few hours after birth (It's GOLDEN if it happens). After 24 hours, feeding at least every 4 hours, totaling 8 feedings per day. Yes, I know that doesn't add up. Evidence has shown that mothers who feed at least 8 times per day typically have successful breastfeeding relationships. 7 times = sometimes successful. 6 times = less likely to be successful.
I find that lets first time parents relax when the baby wants to feed every 90 minutes, and have the appropriate amount of concern when waking a baby after 4 hours - if they don't wake the sleeping baby now, they won't get 8 feedings in 24 hours!

For hypoglycemia - I look at baby's weight, but more they size and shape of the baby. If the chest is an inch or TWO inches bigger than the head, I have a lower threshold to worry about blood sugar. Other than that, I do everything I can to have baby nurse 20 minutes in the first hour - latched by 40 minutes of age. Usually that just means giving them space and respecting the nursing that's happening (no cold stethoscopes on nursing babies!).

[Reha]

Apricot, I am just curious about the chest vs head measurement thing. Where did you learn that? How do you account for moulding in the head measurment?

[Jane]

I think in my pediatric class - that diabetic babies pack weight on in the shoulders and chest, rather than proportionally, for a football-linebacker "look". I do chest and head measurements on all babies, and they are usually within 1/4 inch of each other. I measure a bit above the eyebrows. I haven't found moulding to change the measurement much - at least when measured 2 hours after birth.
I googled a few links: Shoulder Dystocia and Varney's

[wumanh]

1. I have had a lot of sleepy babies in the first 24 hours. One even took 4-7 days if I recall to really get it together. Mom pumped her milk. The baby's dad did the same thing when he was born.
I know what you mean wondering if you are too normal oriented. Our definition of normal is much broader and you find yourself wondering- should I be worrying about something? Most times I find I am right. Trust your gut instinct.
I am sure you've also had those times when everything looked fine by measurments or tests and you had that niggling feeling something wasn't quite right and you were correct.
2. I do the same as you. Accompany with the transport, visit in the hospital and follow up at home. Most couples are happy to have the support. Also gives us the chance to process together which is so important.

[Lynnette]

I try not to let transports interfere with the postpartum routine as long as client allows.

After a run of big babies this summer (none transported, thankfully) I had this conversation with midwife friend about blood sugar. She suggested that maybe because we don't clamp the cord right away, we will be less likely to see hypoglycemia. No evidence, but something to research.

[amyro]

Also, the recent Cochrane review of early skin to skin contact found an 11 point difference in the average blood sugar between babies held skin to skin and those who were separated from their moms (these were healthy term or nearly term babes). 11 points is highly clinically significant! A lot of the hypoglycemia they're getting in hospitals may be an iatrogenic effect of separating moms and babies (or of other practices, such as glucose-containing IV fluid, etc.)

-Amy

[MsBlack]

Amy--

That is SOOOOO funny! Because NICU found this baby's blood sugar to be 39, and told parents it had to be at least 50...exactly 11 points lower than 'norm', AND, this test was done without allowing mom to hold or nurse the baby at all!

Oh, I tried to help some nursing/bonding happen...because this birth was managed as a 'suspected' or 'potential' shoulder dystocia (large head, no wait, CNM just started applying firm continuous head traction--gah!) and baby's color was not too good at birth--BUT, within about 2-3 seconds he wiggled, cried and pinked right up--still, cord clamped cut baby handed to nurses, 02 applied continuously for 20 min (to a screaming red baby)...and every minute nurses kept finding more reasons to keep baby from mom: he needs 02; he needs weighing and banding; he's cold, we need to warm him up (he was naked on the warming table); now he's jittery, we need to test his blood sugar....and so forth. After 30 min of this crap, they finally bundled him in 2 layers of blankets and handed him to mom for 2 min before stealing him to nursery for testing, warming, bottle, etc etc bloody damn etc.

I don't suppose you have a link for me on this skin to skin thing? That would be so super, but in any event I'll look into it today.

Apricot--thanks for this thought on head to chest proportions. I'll look into this too, tho it makes sense of a sort to me. This baby was normally proportioned, by the way--not just 'fat' (not to mention that mom had had and passed gtt just fine).

appreciating all input here, it really helps--

[amyro]

Sorry - I'm just seeing your reply. Sounds like a mess and lots of treatment of iatrogenic problems they created themselves!

You need a subscription to see the cochrane review, but here's a summary that I wrote about it: http://www.lamaze.org/Portals/0/Rese.../2007-9.htm#A1.

I hope that helps! You can also PM me and I'd be happy to send you the paper itself.

-Amy

[MsBlack]

Amy--

Awesome, thanks SO much!

[amyro]

My pleasure - glad it was helpful.

[riomidwife]

Originally Posted by MsBlack

2. How do you carry on with the family after transport-..... I tell families that we are still under contract......that, in short, while place of birth has changed, our basic relationship and arrangements have not......do you find that transport disrupts the connection that was forged among you during pregnancy and labor--that families may be confused/conflicted about your relationship now that birth did not happen at home..... Is there anything you do/say to help avoid/manage the potential for this disruption and confusion?

yes, i do find that the relationship changes somewhat and often has some tension around it. i think sometimes this is the result of parent's having encountered numerous care providers in the hospital, all claiming some kind of authority. it's overwhelming. i find that the relationship with clients who tend to perceive allopathic medical providers as the utmost authority on their baby (yes some homebirthers are in fact this way), these relationships can be particularly chalenging pp.

in any case, i do my best to continue with frequent contact and follow-up, making hospital visists as often as i would do home visits (if appropriate) and checking in with phone calls etc. i know some mws only do phone check ins, but imo that is lousy care.

Originally Posted by Apricot

I recommend feeding as baby desires for 24 hours, especially respecting that 4-6 hour sleep that sometimes occurs a few hours after birth..... After 24 hours, feeding at least every 4 hours
For hypoglycemia - I look at baby's weight, but more they size and shape of the baby. If the chest is an inch or TWO inches bigger than the head, I have a lower threshold to worry about blood sugar..

same here, although i advise after 24hrs nursing at least every three hours, with a slightly longer stretch at night if baby goes for it. and i advise parents that most babies will want to nurse more than every 3 hours.
we talk about this prenatally too, as i find that most new parents are totally flabergasted at just how often newborns nurse.

also, for some reason i have had my share of moms come in for pp visits with babies that are clearly rooting, fussy and hungy, and they are perfectly happy to put a pacifier in the baby's mouth and bounce her while she sits there desperate for a nipple. it's heartbreaking! so yeah, we talk prentally about how some newborns will nurse every hour.

[MsBlack]

elriomw--

thanks for your post. I especially found this passage about post-transport relations quite apt and helpful:

"yes, i do find that the relationship changes somewhat and often has some tension around it. i think sometimes this is the result of parent's having encountered numerous care providers in the hospital, all claiming some kind of authority. it's overwhelming. i find that the relationship with clients who tend to perceive allopathic medical providers as the utmost authority on their baby (yes some homebirthers are in fact this way), these relationships can be particularly chalenging pp.

in any case, i do my best to continue with frequent contact and follow-up, making hospital visists as often as i would do home visits (if appropriate) and checking in with phone calls etc. i know some mws only do phone check ins, but imo that is lousy care."

This has been a 'transport year' for me. Still processing the whys and wherefores of that, tho I am glad to say that of the 4 who transported, no mothers or babies were transported for emergencies and all came out just fine in the end. 3 of the 4 were indeed families for whom allopathic care is still 'utmost authority' as you mention. Prior to their births, I'd thought there was sufficient movement out of that mindspace and into a more empowered one...but I was wrong! One of those had an "OB scare-tactics induction" at 35.4 wks that turned out to be entirely groundless (as I knew it would be)--I didn't attend that birth, but have remained in contact. The others were labors I did attend at term, and accompanied transport. The first was the worst, because the parents got extremely angry with afterwards (long story--basically they refused to take my advice prenatally, and wound up choosing a transport and csec late in labor--blamed me for all, tho if they'd only followed my advice...sigh. It was so clear, the path from that refusal to their csec, really no doubt, and I think that pissed them off more than anything else!). But that one really impacted my initial emotional responses to the ones that followed--who knew what might be coming at me from the others, as those occurred.

In the end, with the others I just tried to remain aware of my own feelings so as not to let them get in the way, and kept on with calls, visits, etc as much as possible 'usual'. There was a certain amount of muddling through the pp time--and I think you are so right, families get so bombarded with 'authorities' in the hospital that it can't help but impact their relationship with their mw in some way. But now that those other 3 are behind me (the first happened early this year, the other 3 all in the last 2months), I'm glad I hung in there....and I now feel certain that the families all are, too.

In all cases, tho the immediate couple of days were the most difficult in terms of finding our way, in time we were able to move back to our former mw-client zone of comfort and communication. For 2 of them, I was especially glad that I did hang in there through those early pp days of tension and uncertainty about my role (and their feelings toward me!), because they needed me for neonate issues. Despite their histories of adherence to allopathy, both really wanted my pov and suggestions, as well as my support in general.

Anyway, when I first posted this thread, it was so recent for me (last 2 transports happened in 2days! just before I posted) that I was too full of my own worries to be able to see their side of things very well. As time went on, I did begin to see that each of these families did have their own worries/uncertainties about how to proceed w/me, whether or not they could still count on our prior contractual agreement re: pp care, etc. And of course, needed some time to adjust to their births occurring so very outside of original plans, time to de-stress and settle in w/baby at home again, etc. One of the moms later confessed that she hoped I didn't think they were just sissies who never really intended a homebirth (which is especially funny because they'd already had 2hbs before--they were the last I'd accuse of that of any of the 4). And there I'd been all worried that she would be thinking bad thoughts about me! We got to laugh together about that. She expressed a lot of appreciation for my ongoing labor support, as well as keeping in touch postpartum.

Anyway, I agree that it is important that we remain in touch and consider ourselves still obligated to pp follow up as much as the family allows/wants. It's mportant to realize the range of stressors on the family from a transport that might effect mw-client relations at least for a time...and important to work through our own (possible) feelings of uncertainty/upset as we go on giving care that is needed and that we earlier agreed to give. Some, I have seen, will just be angry and no fun at all....but the others make the effort worth it for sure

[riomidwife]

Originally Posted by MsBlack

There was a certain amount of muddling through the pp time--and I think you are so right, families get so bombarded with 'authorities' in the hospital that it can't help but impact their relationship with their mw in some way..... For 2 of them, I was especially glad that I did hang in there through those early pp days of tension and uncertainty about my role (and their feelings toward me!), because they needed me for neonate issues

. ......

even if the families do not, in the end, subscribe to a lot of the standard (and often fear-based) newborn care, i think it can be overwhelming and confusing when multiple care providers are encouraging differing courses of action, etc.....like you say, it really is important to hang in there with because often there is a newborn clinical issue, or BF problem, or something that needs ongoing support and attention that, in all likelyhood, they're just not going to get from hospital-based providers.

Originally Posted by MsBlack

It's mportant to realize the range of stressors on the family from a transport that might effect mw-client relations at least for a time...

yes, so true.

[mwherbs]

you support and suggest to people the best you can . sometimes you can see that your suggestions are just not going to go far- then go light and be prepared to pick up the pieces later-- I too really like Jack Newman's web site there are tons of down-loadable info sheets and some video clips too.
at home- symptomatic or babies you have resuscitated- I really want to see a baby that I have done some resuscitation on to nurse and nurse well- if they act sleepy, jittery, muscle tone not good- checking blood sugar comes to mind