Zzzzzz

I was at the most wonderful labor and delivery. My cousin Susan did great, and kept a great sense of humor. I was blown away by how fantastic the obstetrician was (and patting myself on the back for recommending him and his practice.) I am hoping to write a post about it soon. But, for now, back to bed.

Zzzzzzzzz

Birthin and babiez!

I am on my way to one cousin Susan’s labor tonight. (Wheeeeeeeee!). She’s a first timer and things are looking wonderful so far.

Another cousin Susan of mine has had totally horrid luck when it comes to secondary infertility. Well, the urban legend happened. She experienced a bunch of barriers and complications, it seemed impossible, they just gave up, and it happened naturally. They heard a heartbeat in the right place today. Big deal!

So, good things are brewing. I have a big smile on my face. I am headed to a birth. Not sure if I will be checking in any time soon, but I hope this is indeed as much of an upswing as it seems.

Desperately needed comic relief

I link to this study(pdf) by Berghella et al about evidence based labor interventions at least once every few weeks, it seems. I always seem to be looking it up. Like I did yesterday for this post, and last week for the comments section of this post.

Well, after I looked it up yesterday, the search string I used was still in the search box on top of my browser when I released my laptop from its hibernation. I had apparently used “Berghella evidence based medicine”, but all that was showing, due to the size of the box and alignment of the search phrase was

hella evidence based medicine

That’s what I want to practice some day.

Reply turned post, do I have a Kick me! sign style?

So, considering the last few days and weeks I have had, I shouldn’t be surprised that I was the recipient of a flurry of referrals from Dr.Amy’s blog to mine. She apparently didn’t have enough sarcastic and dismissive things to say about this post I wrote giving what I thought was non controversial, balanced advice to my cousin Susan, who is pregnant for the first time, about things to ask a potential obstetric provider. So, she wrote a whole post about it, how I am “obsessed” with birth, thinks everyone else should be, and how wrongity wrong I was to supposedly ignore “skill level” of the provider in my list of interview questions.

I am sure I am not doing much for my image posting my reply on here, but I am really starting to wonder what is going on. I do honestly try to avoid conflict in most areas, and usually only object to what I think is truly objectionable. I seem to be very unpopular this week with the online medical establishment. I hope this doesn’t seal my reputation as a trouble maker. I am really making an effort to walk the high road when I reply, but I do refuse to stand by silently when I am linked to or talked about. I don’t have higher standards for myself than I do the other people who are engaged in these discussions. I sometimes feel like they do for me, but, oh well.

Here is my reply on her site:

Dr. Amy, you don’t say how to measure this skill level. I asked you several times. How about avoiding complications of a vaginal delivery, since you mention avoiding complications? OK, what would those be? Well, a common one would be a third or fourth degree tear. What is the greatest risk factor for that? Well, an episiotomy.

I am glad more people are going to my blog and reading the whole post than are commenting on here, based on my referral numbers. I don’t see a lot of consent here, either. Even in the cherry picked statements, I think I don’t look all that bad. But hey, Dr. Amy readers, I link to an entire task force position statement on labor and delivery interventions(pdf), among other things, in the original post.

I also must object, again, to your sarcastic and dismissive tone. I am not “obsessed” with the birth process – I am researching obstetrics at medical school, and plan to be an obstetrician. Is Dr. Fogelson “obsessed” with the birth process when he leads off an article about evidence based delivery interventions with a paragraph on episiotomy, and how it should be unthinkable to recently trained physicians?

Evidence based care is the only way I can think of to judge practitioners, and I gave many specific examples of how to ask your practitioner about evidence based practices. Evidence based care comes from researchers like me being interested, not “obsessed”, with birth. Using evidence based standards would be the best way to prevent complications, don’t you think?

Also, I very clearly mention several times that each woman should determine her own priorities when interviewing a practitioner. I, in no way, suggest they need to share my “obsession” priorities. I have been to many vaginal deliveries (probably more than you have in the past decade, anyway) and currently research birth full time. I can tell you what the worst sequalae of these deliveries are – complications due to iatrogenic unnecessary interventions. As for skill, I have seen a recently graduated midwife handle shoulder dystocias with calm skill, and have seen a seasoned ob/gyn handle it like a first year medical student.

Here are your questions:

HOW should a newly pregnant mother rate a physician based on his or her skill? HOW does she find this information? What SPECIFIC parameters should she use?

Mortality rates are obviously not good, even if they are available, for reasons your commenters have already pointed out. Patient characteristics, along with physicians characteristics, can contribute to mortality rates. Also, in our developed country, mortality rates are not good indicators, since maternal and infant mortality is very rare, and is usually indicative of an underlying pathology or birth defect, not poor skill of the practitioner.

I gave many examples of specific evidence based standards as examples, and some practical and yes, atmospheric issues (like, can my partner spend the night in the post partum room. May be atmospheric, but a first time mom might not even know to ask and probably cares a lot), and made it clear the priorities of the person interviewing were obviously personalized and flexible.

Also, one more question, which I have asked before. What is SPECIFICALLY wrong with using the interventions I suggest as a guide to the practitioner’s adherence to evidence based care? Is that really such a horrid way to judge a practitioner that you need to scold me on my blog and on yours? Just scoffing and calling me naive is not answering this question.

Reply turned post, that’s a nice welcome style

A reply to Own Worst Enemy, on Mothers in Medicine.

Here is my reply:

I think feminism has made us more supportive of women’s various choices and roles in life. I think women who work outside the home, go to medical school, get divorced, use birth control, have babies when unmarried, wear pants, etc. are judged a lot less now than they were a few decades ago, due to feminism.

I have been hurt by men and women alike. I think sexism and hurt in general isn’t doled out by a single gender.

Yes, women (and men) are very judgmental of women’s choices. Women definitely play along with the patriarchy and tear other women apart. “Female Chauvinist Pigs” by Ariel Levy is a really good book on the subject.

That’s why feminism has a lot more to do.

I am sorry I flounced away from your blog with a seething comment. I am just not a fan of Glenn Beck’s. You linked to a long letter of his I had serious problems with.

I think Glenn Beck is a destructive force in our country, one of those same fringe elements you seem to criticize in this post – like overly judgmental breastfeeders (most of us weren’t or aren’t) or stay at home moms who judge moms who work (most I know don’t). And he isn’t even a woman.

I hope it is less baffling to you now.

What do *I* think we should do?

I think we should be introspective and supportive. I think we shouldn’t give support to hostile fringe elements – whether it be med school friends who talk about someone’s eyebrows needing to be waxed or political pundits who stoke hatred.

I think we should support each other as best we can.

Advice to a mom to be, who do you ask? style

So, another cousin Susan of mine who is planning on having a baby soon also asked me about choosing a practitioner. I wrote about questions to ask a practitioner, but the comments section (except for some glaring nonsense) went in the fantastic direction of who else in the community to ask about opinions on practitioners (namely, physicians).

RealityRounds, a NICU nurse, recommended asking the nurses. Rachel, from Women’s Health News, points out this may be difficult for some people, and also agrees with me that the online sites that rate doctors may be problematic and biased. Except for NursesWhoRatOutUnskilledDoctorsAnonymously.net, which is an excellent resource. But top secret and not available to the general public, as of yet. (Snort!)

So, there is the Birth Survey, which I am embarrassed to say I was unfamiliar with until Jill from The Unnecessarean pointed it out. I’ll have to check that out some more, but it looks interesting and potentially helpful. Jill also mentions ICAN. If there is a local chapter, they may be a good source, especially, of course, if someone is seeking a VBAC.

Jill P. gave a good example of how parenting groups can be helpful, but that would most likely be for a child after the first one. I was thinking going to a La Leche League meeting would be a good idea. And Pinky agrees that residency sites aren’t an ironclad guarantee of a good practitioner, but has an interesting suggestion of calling the local birthing center and asking them about the local practitioners. I would also recommend considering hiring a midwife, of course! But, if you don’t think a midwife is the best choice for you, you can call and ask who their back up physicians are, who they would refer women who are risked out of a midwife attended birth (and this may not be their back up physician – collaborative care is different than a back up physician, and that is different than a referral.)

No matter who you are talking to, ask why they recommend someone. Their priorities may be different than yours. And, ask if there is anyone they would recommend avoiding, too!

Advice to a mom-to-be, on caffeine and from home style

OK, I am home today with a not-so-sick five year old and my new 12 cup French Press coffee maker. So, sorry about the overabundance of posts today. I have super caffeinated typey fingeritis.

I wrote some more advice to my mom-to-be cousin Susan:

There are a few questions you can ask practitioners when you interview them. I would pick a few things you are particularly concerned about and use them to judge your practitioner choice (along with your gut feeling about your rapport with them, of course). It’s really up to you what these things are but here are a few examples:

1. Episiotomy: Do you employ them? Routinely? Under what circumstances?

It is up to you, but this would be my main litmus test. Episiotomy is not evidence based, at all, and there is a HUGE effort to restrict and/or end their use. It causes lasting harm to the mother, and the practitioner should at least show some hesitation, and boast about a low to non existent rate. In my opinion, the only time an episiotomy should be used would be if forceps had to be applied, and it facilitated that. And, forceps are rarely applied.

2. Cesarean section: What is your cesarean section rate? Under what circumstances do you do them? (Specifics, like…how long would someone have to be stalled in labor? 4 hours? 12? 24? What if my water breaks? How would you define a non reassuring fetus during labor?)

3. Induction: Do you do elective inductions on your first time moms? What percentage of your first time moms do you induce? Is it at their request, or is it the routine practice to do them at a certain gestational age? What are your guidelines for doing them? What are your guidelines of letting a pregnancy run past its estimated due date?

Again, your priorities in this situation are up to you, but I wouldn’t recommend an elective induction unless your Bishop score was 10 or more, which is a score of how ready your cervix and the fetus are for delivery. Inducing someone who is post dates is more understandable, but most guidelines say not to do so until at least a week post dates, even two if the fetus has reassuring status. Many practices starting pushing inductions at 39 weeks with an unfavorable Bishop’s score.

Those are the big three. Now, there are other points you may want to discuss, based on your own priorities.

During labor, can I eat and/or drink? Can I have access to a tub for labor, or a shower, or walking, or a birth ball, or my own clothing, or (fill in the blank)? Can I bring a doula to my labor? How many support people can I have, and what are the visitation rules in general? Can my support person spend the night with me in labor and after the baby is born? Do you require an I.V.? Do you require continuous external monitoring? Can I get intermittent monitoring if I am low risk and in early labor? Do you routinely do an artificial rupture of membranes in early active labor? What are your guidelines for ruptured membranes, do you have a time limit for how long they can be ruptured before you move to cesareans section, if everything else seems low risk? Do you routinely administer pitocin to strengthen contractions, or do you have a guideline for stalled labor before you use it? Can I have (whatever accommodation you may need, such as a vegetarian meal, or a kosher meal, or a disability accommodation, or religious accommodation)? Can I have access to an epidural at any time, or only during certain hours? What other pain relief options do you offer, and how are they offered? Are you supportive of patients not wanting to use epidural pain relief or IV pain medication? When do you show up to a labor? Who will show up to my labor? (It may depend, if it’s a large practice). What sorts of situations would you show up to the hospital for, and what ones do you expect the nurses to handle? For example, if I thought I was in labor, do you want me to come by the office? If I was admitted to the labor floor, do you do show up in early labor? (Most docs in this area don’t, but some do in other areas. As for the other complications and issues, you’d be surprised. I would love to hear this question asked. I wouldn’t dare when I was pregnant, but hey, why not throw it out there? I would hope that I’d be happy to ask that when I am an ob/gyn).

I could go on and on. Pretty much, ask them the questionnaire I am doing for my research project.

I would also see how they respond to being asked these questions. Hopefully, they will support your right to want to know the answers, and take the time to answer them. And, I think it needs to be done before a traditional birth plan is written, generally in the third trimester. That will be as important as what the answers are.

Guest post at Mothers in Medicine

A little toot toot of my own horn here, but I wanted to share that I have another guest post up at Mothers in Medicine. It is a repost of Advice to a Mom Starting Her Pre-Med.

Enjoy! And, if you’re so inclined, check out the other posters there, too. It’s a great site.

Reply turned post, no line to cross

I have a reply, currently in moderation, at Media Matters for America. On a post about Sarah Palin’s wavering condemnation and acceptance of the term ableist term “retard” as an insult. Rahm Emmanuel: he should resign over it. Rush Limbaugh: It’s satire! Glenn Beck: Silence. Family Guy: Heartless! A kick in the gut.

One commenter thinks that

The creator of Family Guy has used the program to poke fun at political figures, folks with disabilities, and people of fame and pop culture… funny enough this make Sarah Palin the equivalent of a Family Guy trifecta. There is no line to cross if you were on the otherside of the line to begin with.

I replied:

It is how we treat people we don’t agree with that is MOST important, not least important. There is a line to cross – with prisoners, with conservatives, with hypocrites, with the KKK. That’s what separates the good folks from the bad folks. We recognize the lines and respect them.

Reply turned post, reframing the pro-life debate

On hipmama.com, one of the posters complained about being asked if she BELIEVED in abortion. This has always been one of my pet peeves. I have been told that someone’s doctor “doesn’t BELIEVE in vitamins” and I replied “Well, you can assure your doctor they do exist. They have been photographed, even. It’s not like they’re Santa Claus.” I was also told by an ob/gyn that she “didn’t BELIEVE in midwives” before she stormed out of the clinic room and slammed the door in my face, when I told her I would be seeking a midwife for prenatal care.

Well, even when they are in the minority, many people think they can refuse to accept the reality of something just because they disagree with it, or wouldn’t choose something for themselves, even if it is a perfectly reasonable suggestion, such as taking a vitamin, like many people do and is arguably recommended by at least some reputable sources, especially certain vitamins like vitamin D, or choosing a midwife for your prenatal care and birth. Or, as 30% of women do, choosing to terminate a pregnancy at some point in their reproductive years.

Well, a commenter replied that some people “conclude abortion to be unacceptable under any circumstances.” And then, she goes on to describe herself as “pro-life” and “cool”, and having her reasons. She doesn’t say it’s unacceptable for her, she said it’s unacceptable. Period. As in, pretty much, she “doesn’t BELIEVE in it.” What me, and 30% of the woman around have done is unacceptable. She, like the person in the original post, thinks her convictions, regardless of how in the minority they are, some how cancel out the agency and ability of everyone else in the world to make a decision.

I wrote this reply:

It doesn’t matter if someone finds it “unacceptable under ANY circumstances”. Because that is an individual choice, not a public health choice, and not something one can dictate to others. That hard line approach is what leads to laws against abortion in many states and countries in this world. When abortion is made illegal, abortions don’t decrease at all, but they become more unsafe. So, 70,000 women die every year, and leave 200,000 orphaned children behind. Source for stats at Guttmacher.org

Saying “pro-life” does not mean being for life, but usually means for making abortion illegal, or thinking you wouldn’t choose an abortion if you got pregnant. What it usually means is that you support forcing your views as to what would be an unacceptable health choice for you on others. Which, to me, is unacceptable under any circumstances.

There are many people who strongly think that boys and/or girls should be circumcised, or that no one should accept blood products, or that organs cannot be donated, or vaccines are wrong or destructive, or that midwives are dangerous. Under any circumstances – it is an abomination before their god otherwise, or whatever secular reason they may have. Do they get to make the rules for everyone else in the majority, even if it jeopardizes lives?

No.