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Discussion Starter #1
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<p><span style="font-size:12pt;"><span style="font-family:'times new roman', serif;"><span style="font-family:'times new roman';">Any doulas have a homebirth client that had a balloon induction at home done by her homebirth midwife?  </span></span></span></p>
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<p><span style="font-size:12pt;"><span style="font-family:'times new roman', serif;"><span style="font-family:'times new roman';">Do any of the homebirth midwifes on the list do this?</span></span></span></p>
<p><br><span style="font-size:12pt;"><span style="font-family:'times new roman', serif;"><span style="font-family:'times new roman';">Thanks</span></span></span></p>
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<p>I had a doula client who had a Cytotec/Folly Catheter (sp.) induction done at home by her homebirth midwife.  In my opinion forcing the cervix open seems like a very bad idea.....</p>
 

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<p>I have no personal experience with this, but I wanted to link to a blog post I read a while ago about the topic:</p>
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<p><a href="http://www.glorialemay.com/blog/?p=324" target="_blank">http://www.glorialemay.com/blog/?p=324</a></p>
 

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<p>Wow.  I have been hearing various other things also in the past couple of years--pitocin and cytotec inductions at home.  I simply cannot fathom this behavior, it rubs me wrong on so many levels.  Informed consent is the first thing (re the letter posted on Gloria's blog)...I have been shocked to discover that so many mws do not provide solid, thorough informed consent (about much of anything, not just referring to induction methods).  To me it is the cornerstone of sane care anywhere and with any practitioner; and informed consent, for me, is among the best of what homebirth midwifery can offer that med care does not (in most cases med care does not--I've seen exceptions).</p>
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<p>Something else that really really bothers me is this dread of utilizing med care when it is either truly indicated, or is simply the prudent thing to do.  I don't hate the hospital, or doctors, so much that I would go to such unwise lengths (unwise on various levels) to avoid them.  It's not a competition, it's not 'losing' to seek med care in some cases, it's not inadequate skill, courage or patience or anything like that.  No homebirth fam or mw wants to go to the hospital, of course not.  And it just doesn't have to be such a terrible ordeal.</p>
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<p>As for the survey monkey, I imagine that not every mom who has had home foley induction posted there.  I imagine that if we could count ALL the births where this was tried, we'd see that there has been some success with it.  Yet that success rate must be very small, if 100% of women who posted on the survey had failed foley inductions followed by csecs!</p>
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<p>What are we thinking?</p>
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<p>"We"--the midwives using such med stuff at home, without evidence and without providing real informed consent.</p>
<p>"We"--the families accepting such care without making sure they really understand it, and are making an informed decision. </p>
 

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<p>Foley or Balloon inductions are one option I offer when induction is indicated.  I've never done one, though.  I wouldn't consider Gloria Lemay an acceptable research source. </p>
<p>No pitocin or cytotec inductions, tho.  Shudder. </p>
 

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<p>Jane--</p>
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<p>Since you are in the state under discussion in Gloria's post...a couple things.</p>
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<p>What about the idea that foley cath is 'not covered by mw-license'?  Is it something that seems to be a grey area?  (that was my impression from that letter)</p>
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<p>Also, what do you think of the survey monkey results?  I see that you have not yet done an induction this way; do you know mws who have been successful w/foley induction at home? </p>
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<p>I agree that Gloria is not necessarily a good 'research source'--and want to say that I don't see her as such.  I just tend to agree with her general position about homebirth and midwifery, in most ways.  And while I think her use of the word 'assault' is unnecessarily offensive, I can see why she chooses it.</p>
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<p>thanks!</p>
 

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Discussion Starter #8
<p> I have lots of trouble philosophically with this type of intervention at home from a homebirth midwife.  Espically when there is was no clinical indication the women needed to have the baby out NOW it was just 41 weeks. I cannot comprehend the midwives rush to have the cleint give birth this week.  It just felt like a OB's rush to do something  unrelated to the pregnant women becase he was getting ready for vacation, or holiday.</p>
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<p>Makes me think the midwife did not want her Thanksgiving interrupted?  What else can you think at 41 weeks and this midwife was all hot and bothered about inducing this perfectly healthy homebirth client.</p>
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<br><br><div class="quote-container">
<span>Quote:</span>
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Originally Posted by <strong>MsBlack</strong> <a href="/community/forum/thread/1280382/homebirth-balloon-induction#post_16060900"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a><br><br><p>
What about the idea that foley cath is 'not covered by mw-license'?  Is it something that seems to be a grey area?  (that was my impression from that letter)</p>
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Also, what do you think of the survey monkey results?  I see that you have not yet done an induction this way; do you know mws who have been successful w/foley induction at home?</p>
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It has been put into practice under the expansion of practice guidelines.  It's not really a gray area.  There are some very black and white areas, ie, pitocin and misoprostol allowed, but ONLY post partum.  Inductions are already part of the scope of practice, and this is an expansion of that through the official mechanisms.  The protocols are in place. </p>
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All uses I've seen have been followed by induction with another agent, castor oil, homeopathy, AROM, acupuncture, in combination, usually.  It usually works, from my discussions with collegues. </p>
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Originally Posted by <strong>sweet.p</strong> <a href="/community/forum/thread/1280382/homebirth-balloon-induction#post_16061783"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a><br><br><p>
 I have lots of trouble philosophically with this type of intervention at home from a homebirth midwife.  Espically when there is was no clinical indication the women needed to have the baby out NOW it was just 41 weeks. I cannot comprehend the midwives rush to have the cleint give birth this week</p>
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I would say most inductions with foley are for unripe, low bishop score women at 41 weeks, 6 days.  The hospital community will take these women for induction at 42 weeks, but the physicians doesn't want to sit and watch and monitor after 42 completed weeks.  Us midwives generally care for women until the 42nd week, and then they are out of scope on our malpractice carrier, and their health insurance won't pay without the malpractice cover.  So, they are facing transfer to a hospital provider offering induction or induction with the midwife. </p>
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I think dating is SO important here.  Most instances of post-dateism is really bad-dateism, IMO. <br>
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Here is the official response to the letter.  It's public, so I do not believe I am violating any copywright on posting it. </p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Kelly Meinig, President</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Citizens for Safe Birth</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">                                                                                                                                       October 19, 2010</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Dear Kelly,</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">I’m writing in response to CSB’s letter of July 7, 2010 regarding the use of Foley catheters as a cervical ripening method in the midwifery community.  I apologize for the delay in responding—it took a good deal of time to gather information.  We were hoping to be able to provide CSB with a more representative account of this practice than was captured by the informal and highly biased sampling your organization conducted.  Given CSB’s commitment to promoting evidence-based practice, one would expect a greater understanding of what constitutes “evidence.”  Unfortunately, I was not able to obtain information from every out-of-hospital midwifery practice in the state, although I was able to gather data from 4 of the larger midwifery practices (45-100 births/year) and am happy to be able to provide information below that, I hope, will alleviate some of CSB’s concerns about safety and outcomes.  Of course, one cannot draw definitive conclusions from such a small sample size (n=35), even though the number of cases is considerably higher than the 5 cases which CSB reported to MAWS.  </span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Before I present the data we collected, I’d like to address some of the points raised in your letter:</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">1)      </span></span></span><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Regarding your assumption that the MAWS practice mechanism for introducing expanded clinical procedures into midwifery practice was likely not followed—in fact, MAWS has a protocol on file for the use of Foley catheters to encourage cervical ripening.  Midwives who are following this protocol, therefore, are <strong><em>not</em></strong> engaging in unprofessional conduct or practicing outside the scope of midwifery practice as CSB contends they might be.  Your point, however, that midwives <strong><em>should</em></strong> be following this protocol is well-taken.</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">2)      </span></span></span><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Contrary to your allegation, midwives <strong><em>do</em></strong> appear to be presenting this procedure to their clients as a cervical ripening strategy; and while it is often true that additional methods may be needed to stimulate labor following a Foley catheter insertion, that is not always the case, as you will note from the data we collected.  Furthermore, it appears to be more the exception than the rule that a hospital transport for induction or augmentation with Pitocin was necessary; most of the time, the additional method used to stimulate labor was castor oil, AROM, or homeopathy.</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">3)      </span></span></span><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">The midwifery practices we surveyed were all using Foley catheters, not Cook catheters—recent evidence indicates that the Foley is just as effective as the Cook catheter for this purpose and costs considerably less.</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">4)      </span></span></span><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Postdates was not the only indication for the use of this procedure—rising blood pressure, borderline oligohydramnios, severe PUPPS, and a history of macrosomia with a shoulder dystocia were other reasons that midwives offered this procedure to their clients.</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">5)      </span></span></span><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">The law does <strong><em>not</em></strong> require a consent <em>form</em> for every procedure offered, although it does require that an informed consent <em>process</em> occur. Given the responses to your survey, it would indeed be prudent for midwives who are offering Foley catheter procedures to their clients to have forms that describe the procedure’s risks, benefits, and alternatives.  </span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">And now, the data.  </span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Of <strong>35</strong> Foley catheter procedures reported on:</span></span></span></p>
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<strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">16</span></span></span></strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">were for nulliparous women</span></span></span></p>
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<strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">19</span></span></span></strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">were for multiparous women</span></span></span></p>
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<strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">6</span></span></span></strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">(5 nullips; 1 multip) had c-sections (a rate of <strong>17.1%</strong>) </span></span></span></p>
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<strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">29</span></span></span></strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">had vaginal births</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Of the <strong>29</strong> who had vaginal births:</span></span></span></p>
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<strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">26</span></span></span></strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">were able to have their babies at home or in a birth center</span></span></span></p>
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<strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">3</span></span></span></strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">were transferred to the hospital for either an induction, augmentation, and/or pain relief</span></span></span></p>
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<strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">12</span></span></span></strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">had additional labor stimulation: <strong>3</strong> had AROM; <strong>7</strong> used castor oil; and <strong>3</strong> used homeopathics (1 used both AROM and castor oil)</span></span></span></p>
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<strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">14</span></span></span></strong><span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">went into labor without ANY additional stimulation following cervical ripening with the Foley catheter</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">These numbers are obviously <strong><em>very</em></strong> different from the numbers you reported.  I can certainly understand, given the complaints that CSB received and the data that emerged from the informal survey you conducted, why CSB raised its concerns with MAWS.  From our data—again acknowledging its limitations—it does <strong><em>NOT</em></strong> appear to be the case that the use of Foley catheters is contributing to a high </span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">c-section rate in the licensed midwifery community.  Indeed, it would seem that this tool is being used quite effectively in most cases to enable women who had planned to have their babies out of the hospital to do so.</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">In closing, I have to say, Kelly, that I continue to find CSB’s communication with both MAWS and the Midwifery Advisory Committee inflammatory and I just want to express my frustration with CSB for persisting in its attacks on the licensed midwifery community.  There are so many more constructive ways that your organization could use its time and energy to improve the care of mothers and babies in Washington State.  We wish you would work with us rather than against us. </span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Respectfully,</span></span></span></p>
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<span style="color:rgb(31,73,125);"><span style="font-family:calibri, sans-serif;"><span style="font-size:11pt;">Audrey</span></span></span></p>
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<em><span style="color:rgb(31,73,125);"><span style="font-family:'calisto mt', serif;"><span style="font-size:11pt;">Audrey Levine, LM, CPM</span></span></span></em></p>
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<em><span style="color:rgb(31,73,125);"><span style="font-family:'calisto mt', serif;">President, Midwives' Association of Washington State</span></span></em></p>
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<p>Gosh Jane....sorry to speak so strongly of things I really didn't understand at the time.  <span><img alt="blush.gif" height="15" src="http://files.mothering.com/images/smilies/blush.gif" width="15"></span></p>
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<p>I can see that the picture is quite different than what that original letter would have anyone believe.  And I'm very glad it is!</p>
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<p>Also, I think you're right--the Informed Consent <em>process</em> should probably always include an Inf Cons <em>document</em>.  That way, no one can 'forget' that they went through that process, or forget the details of it...families disappointed with their birth can at times have faulty memories about such things.  Heck, even a mw can remember things differently in retrospect, once the blame/avoid-blame dance gets started.</p>
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<p>thanks for sharing all of that.</p>
 

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Discussion Starter #11
<p>Very fascinating, I had no idea what was going on, seems like such a hot topic.</p>
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<br><br><div class="quote-container"><span>Quote:</span>
<div class="quote-block">Originally Posted by <strong>MsBlack</strong> <a href="/community/forum/thread/1280382/homebirth-balloon-induction#post_16062863"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a><br><br><p>Also, I think you're right--the Informed Consent <em>process</em> should probably always include an Inf Cons <em>document</em>.  That way, no one can 'forget' that they went through that process, or forget the details of it...families disappointed with their birth can at times have faulty memories about such things.  Heck, even a mw can remember things differently in retrospect, once the blame/avoid-blame dance gets started.</p>
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This obviously doesn't apply to everything, but if you're wanting to document informed consent for something "small," you can always make a note in the chart and have the client initial it. It's not perfect, but it's better than no documentation.</p>
 
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