Shenanigans

I still owe a VBAC Summit post, but in the meantime I want to link to some photographic evidence of the total goofiness that happened in and around the conference.

VBACitivist of the Year and Birth Activism Diva Jill Arnold stayed with me for the conference, and within about, oh, two minutes of meeting in person we figured out that we were two peas in a very, very twisted pod. In between talking like Foghorn Leghorn and giggling, she had some time to take some pictures. Some of them involve me, some are very silly, and some have made it onto her blog.

February Travel with Pictures

From Supine to Lupine

Proof that we feminist activist aren’t humorless.

Defensive medicine series

Please hop on over to The Unnecesarean for an outstanding series on Defending Ourselves Against Defensive Medicine. I am sorry to say I was invited to contribute and didn’t manage to get a piece ready. I am very impressed with what has been released so far.

So, I’m still here

Again I find myself apologizing for the blog silence. There are a few reasons I have been quiet.

First of all, my ex has been reading my posts and complaining to players in our divorce about what I write on here. So, I am not writing more about our divorce on here.

Secondly, I have been pretty busy. I have been doing the holiday thing with the kids, family and friends. I did get a few days off work. I am actually pretty happy to get back. I am enjoying pulmonology, and may look into doing a 4th year elective with the same attending physician. I am getting pretty good at ABGs.

I am not so good at EKGs. I did a module on EKGs using this ECG Wave-Maven, and I am really confused by a 5:4 AV Wenkebach. I could spot the MI’s, which is a relief, I guess.

So, there is more stuff I wish I had the energy to talk about. Mtv had an episode of “16 and Pregnant” called No Easy Decision in which one of the teen moms gets pregnant again, and decides to terminate the pregnancy. I have not seen it, but I think there are actually three young women who discuss choosing abortion. From what I have heard, it is a well put together show. Exhale has put together a site called 16 and loved that supports her coming forward with her story.

California Watch published a report entitled “As early elective births increase so do health risks for mother, child”. Thanks to Jill at The Unnecesarean for covering this.

CNN had an article on CNN.com called “Mom defies doctor, has baby her way” about a woman who had a home birth VBA3C (vaginal delivery after 3 cesareans). She was alternately painted as reckless and also as having no other option. How is a woman supposed to have a VBAC in a facility “with staff immediately available to provide emergency care” if practitioners who deliver in these facilities refuse to attend VBACs?

Anyway, I’m back, at least for the time being. I hope my son’s guardian doesn’t tell me he got an earful about my blog again. I am not airing all of our dirty laundry on here. Believe it or not, this is reticence.

Reply turned post, a VBAC reality check

I am a huge fan of RH Reality Check. However, I was recently a little troubled by a post about choosing elective cesarean over attempted VBAC (vaginal delivery after cesarean). I am a little, OK way behind on my blog reader. The original article, I’ve Made My Birthing Choice, and It May Surprise You was published in September, but I just got around to reading it tonight. I had a gut reaction similar to the reaction I have to many blog entries I have read defending a common, mainstream choice that is disguised as an underdog, against the system, authority challenging choice. But, I was more troubled by the many medical inaccuracies in the piece.

So, I wrote a reply. One I am upset to see has a bunch of html fail in it. I guess RH Reality Check doesn’t support hyperlinks. So, here is the prettier version:

I want to support you and your decision to have a repeat elective cesarean instead of a VBAC attempt, and your choice is indeed valid.

I have to join in the chorus challenging some of your points, however. On the one hand, I am hesitant, since I cringe at the thought of how judgmental people are towards pregnant women and their choices. However, there are a few reasons why I am choosing to do so. First of all, I think you have some statements in your article that are medically inaccurate. And, this isn’t a personal blog. This is presented as journalism / advocacy. Journalism on medical topics needs to be held to a higher standard.

Secondly, you are defending a choice, elective repeat cesarean, that is really not in need of defense – it is presented as the most reasonable choice, and in many cases only choice, for the vast majority of women in the U.S. The power balance is dramatically tilted against women being able to choose VBAC. How is it surprising that it was your choice? Of course it’s valid – it’s almost guaranteed!

Let’s start with some of the inaccuracies.

I am in medical school and just completed a research fellowship on labor interventions. I think the exercise you did in your childbirthing class was atrocious. We do not need to choose between a healthy baby and evidence based, women centered medicine. Avoiding non-evidence based interventions that have worse outcomes for the mother and baby makes it more likely that we can have healthy babies. They should not be presented as competing priorities.

For example, we can have a healthy baby AND not have an episiotomy. Episiotomies should be avoided at all costs, according to substantial research. They do not make babies more healthy. There is not one situation in which they save a baby’s life. It is even recommended that they be avoided for operative vaginal delivery (when an intervention such as vacuum extraction is needed) – they lead to more maternal and neonatal morbidity. I consider episiotomy use to be a litmus test for an obstetrical health care practitioner.

As other people have pointed out, non medically indicated inductions, especially those in a first time mother, carry more than double the risk of cesarean. In fact, some hospitals are now banning elective inductions on first time moms as a quality assurance measure. Rixa has a good synopsis of links on this topic at Stand and Deliver. The Bishop’s score is an important indicator of whether an induction is likely to be successful, as opposed to a several day long ordeal that ends with a cascade of interventions, leading to an emergency / iatrogenic cesarean. If there is a compelling medical indication that one would get a cesarean for anyway, that is one thing. But, in our society, many women are told to get induced before their baby gets to big, or because the baby is looking a little small, or because the obstetrician is going on vacation, or the calendar year is changing, or because they have a certain amount of time off from work and they really want to plan their maternity leave. These psychosocial factors for induction are all indeed valid, and birth is not the only medical decision in which psychosocial factors are weighed, but they do sometimes increase the risk of not having as healthy a baby or as healthy a mom. More than an episiotomy would.

Or an epidural. Epidurals are associated with maternal fever, especially longer lasting epidurals, such as those associated with inductions. If a mom’s membranes break, or more likely, are artificially ruptured during active management of labor or an induction, and she subsequently develops a fever, many practitioners will consider that to be an indication for cesarean section.

Group B Strep is present in up to 40% of healthy women – a cesarean is not the recommended intervention for prevention of transmission of group B strep to a baby. The current standard of care is to administer antibiotics during labor.

As for the VBAC vs. elective repeat cesarean issue – it is obviously a highly personal choice, and one I am happy you were able to make without apparent pressure from your hospital system or your chosen practitioner. Please don’t present VBAC as higher risk, however. The larger risks of an emergency situation are very, very uncommon in a VBAC. In fact, they are identical to the risk of perinatal mortality in a primary vaginal delivery. There is a definite imbalance of risks to the mother (increased risk of hemorrhage, need for transfusion, and infection, as illustrated by your anecdotal experience) with a cesarean, and increased risk of neonatal trauma or morbidity with a VBAC. But, these risks are vanishingly small. One set of risks is not large and uncontrolled and scary, compared to one set being small and manageable and acceptable.

Anyway, I wish you a safe and uneventful birth, regardless of your chosen method of delivery. I am always happy when this site steps out of the zone of reproductive choice just being about preventing birth. And, you were very brave to put your personal decision our there. Just, please remember that when you are writing for a site such as RH Reality Check, a little reality checking may be in order.

More prenatal humor

It’s a good day for prenatal humor. Yes, I know this is over the top and sarcastic, but it is also hysterical. (Yes, pun intended again)

The “Emergency” C-Section

(I can’t get it to embed. Boo.)

This was written by a local midwife. A doula isn’t a rash. It’s a person. But it’s just as annoying. LOL!

I’m in print!! *link fixed*

I have an article published in the Journal of Perinatal Education:

Social Media, Power, and the Future of VBAC

Squee!!!!

Special thanks to Amy Romano, who was the lead author and did almost all of the final version of the piece, and to Desirre Andrews, who was the other co-author.

Edited to add: I fixed the link, but now they are asking for pay-per-view. I think if you register for a free trial of Ingenta you can read it for free. If not, let me know.

Reply turned post, what a doula can do

Well, Rixa wrote an entire post about the physician who trashed birth plans and doulas on her blog. I tried to write a reply to it, but I was got an error message that said it was too long. So, I have published it here. I guess that’s how the reply – turned – post was born.

Aha! Here it is. Well, I answered this travesty of a comment on my blog.

I have a few other things to add. The grammar and spelling are irritating to me, but irrelevant. Don’t even bother expecting good grammar. I see spelling errors everywhere in the hospital where I am training right now. Worst of all, I see meds misspelled in charts! If there’s anything you want to spell right, it should be the name of a med! I see right and left mixed up all the time also. I am doing a tumor board presentation tomorrow, and the pathology report mixed up the right and the left. Scary.

I also wanted to add that one major purpose of a doula attending a hospital birth, at least when I am a doula, is to inform the woman what to expect when she is traiged and admitted to the hospital. Also, to give informed consent, hopefully prior to labor, on typical labor interventions, and to help the woman decide where her priorities are before she is in labor, and what she may want to discuss with her practitioner. If the practitioner doesn’t show up until the end of the labor, how is she supposed to discuss an order given over the phone to break her water and give her pitocin when she’s at 4 cm? I was clueless about what would happen to me, and most women are not informed at all about what it is really like.

Many women don’t know that your doctor most likely won’t be there until you are completely dilated (that is the standard of care in my area – not sure if it is in all areas, but it is something the woman can ask her practitioner about once the doula brings it up.)

Many women don’t know that they will need to have labs drawn when they show up – they think they are “preadmitted”. They will be asked the same questions about their history over and over again by multiple hospital employees. They will be asked invasive questions about their sexual histories, drugs, smoking, prior abortions, including exact dates. In front of their partner, mother, doula, whoever is there. Even women who want an epidural immediately will not be able to get one (see below), and will be asked these questions during contractions, regardless of if there is an issue that is concerning her about the way her labor is progressing (such as the baby being premature, there being blood, her blood pressure being high, etc.) No one will reassure her or care that she was just asked all the same questions, or that she is scared, or in the middle of a contraction, or doesn’t want to answer a question about an abortion in front of her mother. It may be a good idea to inform her doula or partner the answer to some of these questions, such as if she has ever had a reaction to anesthesia, or if she has false teeth, etc.

Nurses may be brusque and insist that she removes all of her jewelry and not wear any of her own clothing, and tell her it will risk her and her baby’s life if she doesn’t remove them. (Seen it).

If they are planning on an epidural, they WILL NOT GET IT RIGHT AWAY. This is a HUGE issue. Many women seem to think the anesthesiologist will meet them in the parking lot. My cousin Susan was told by her obstetrician that she “didn’t deserve to feel any pain.” Well, she needed to have labs drawn, and run, and then needed to have 2 liters of IV fluid infused before they would even consider giving her an epidural. Considering her entire labor was 4 hours long, she felt the pain for half of it the first time. The second time, the epidural only took on one side. Was she only half as deserving? Did she even know that epidurals don’t always “take”?

I have seen epidural informed consent that consisted of “it won’t effect your baby”, and then the baby crashed immediately after, since the woman already had low blood pressure and was flat on her back. I got the honor of explaining to them what happened. I have seen an anesthesiologist storm off angrily when another couple asked about the blood pressure drops associated with epidural and spinal anesthesia (she was there on a birth center transfer and was most likely getting a spinal and a cesarean) – again, I was left to reassure them.

I have seen women told that stadol will “take the edge of and help you relax a little” as the entire informed consent. This poor women effectively missed her delivery because she was too busy hallucinating, moaning, and drooling on herself. The baby was born depressed and had to be given narcan to cancel out the effects of the drug. I have learned from these experiences to inform all women, regardless of their professed desire to avoid meds, what the pros, cons and side effects are BEFORE we are there and someone tries to talk her into it.

Also, I didn’t know, and many women don’t know, that their baby is likely to be whisked away immediately following the birth, and most likely will not be returned to her until after a four hour “observation”. I was simply devastated when that happened, and cried until they returned the baby. Even women I have warned about that have cried with me while the baby is gone.

Anyway, this went on longer than I planned, but needless to say, doulas can provide information in a way that tends to be seriously lacking in standard hospital labor and delivery.

Physicians’ attitudes and knowledge influence their practices – who knew?

My data from the KALI questionnaire is shaping up nicely. I guess it isn’t a big surprise, but, at least in the group I have interviewed, their knowledge about and attitudes toward labor and delivery interventions do seem to influence their reported practice patterns. And, as recent research indicates, practice patterns don’t necessarily follow the current body of evidence, expert opinion, or professional organizational guidelines, although many do. As of right now, I will most likely be looking at the associations between obstetricians and gynecologists’ knowledge, attitude, practice, professional guidelines and existing evidence on four interventions: episiotomy, elective cesarean, doulas, and upright positioning in the second stage.

I have more data on more aspects and more interventions, but I think this will make for the cleanest, most easily explained and supported outputs (e.g. poster and paper). I may use some of the other data on barriers, autonomy, VBAC, litigation, demographics, etc., in the future in other projects.

And, since I promised more poop jokes, I’ll have you know I was wandering around the house today singing Surfin’ Bird by the The Trashmen with the word “turd” substituted for bird. Yeah, I’m mature. At least the kids weren’t home, so I won’t be getting that phone call from school.

Crunch on these while I crunch numbers

I am working on getting my data analyzed by a friendly professor who knows more about that stuff than I do. Chi square mumble mumble. Then, I am going to be hunkering down and working on my paper and/or poster.

I also have other stuff going on in my personal life that is keeping me occupied, to say the least. I’ll try not to be so mysterious forever, but I am not ready to dump it all out on here just yet. Especially when I get comments calling me a broodsow, and wishing a fatal disease on my children and me. Nice. So, I pat myself on the back for keeping a lot of my personal life off this blog.

In the meantime, here is some stuff to check out:

Dr. Fogelson discusses cesarean closure at Academic Ob/Gyn

The Female Patient(pdf), which I just discovered. That particular paper is on estrogen pharmokinetics and delivery.

Last but not least, Drunk History, Vol. 3. This one is about President Washington’s runaway slave Oney Judge.

I get mail!

I got two emails on the same day, asking me for advice! I feel like mighty Isis. I’m not going to start call you “my little muffins”, but I am going to answer them on the blog, like she does.

Since the letters are so similar, I am going to answer them both together.

Letter writer #1 writes:

I’m just curious what made you decide to move from an education in midwifery to medical school. I’m at a bit of a crossroads. I’m about to finish my MPH and had been planning on applying to medical school this summer. I already have the MCAT and all prerequisites under my belt. However, I recently became really interested maternity care and midwifery. Now I’m confused about whether I should pursue an education in midwifery or go into medicine as an OB and support natural birth practices and midwives.

Letter writer #2 writes

I am currently a doula and CBE and the more I get involved with birthwork, the more I see that overall we need way more options out there for respectful, compassionate, Care Providers who practice evidence based medicine.

So naturally I thought, OK go be a midwife. … There’s a great program in Chicago for those of us with generic Bachelor’s degrees to jump right in get the RN and then do a master´s in midwifery in 2-3 years after that. So with another year of pre-reqs at a community college, it will take me 6 more years (at least) to finish.

Now we are moving to Oregon which opens up the CPM route if I wanted (just means I can’t move back to IL and practice legally if that’s what I choose)….

I see how regulated and pushed around midwives are here in IL. There are only about 5 in the Chicago area who will do home births and even then b/c they work all over the Chicago area it’s difficult for the to build up a rapport with the staff at the hospitals b/c there are so many and a necessary transport can be difficult which puts moms and babies at risk.

So then I was thinking about medical school to go the OB or the GP who also delivers babies route. But then that means at least 2 more years of pre- reqs before I can even apply for medical school. And then med school plus residency. (And I haven’t even mentioned the loans I’d have to take out).

One other option my aunt threw out there was a Physician’s assistant. I have never heard of them delivering babies, but she seemed to think that might be a possibility…I know this has been a huge ramble, and I guess I’m writing b/c I’d like to get some slightly objective input. What factors influenced you to dive all-in to med school instead of midwifery? What kind of practice do you think you’d like to be part of?

Ha, well, I don’t know if I am a good example when it comes to planning a career in medicine. Not unless you want to be the non-traditional student everyone else seems to think they are. (Not that there aren’t other non-trads, but most students seem to think they are non-trads even when many of them seem really trad to me).

I didn’t choose to train as a midwife. It is one of the best things I ever did, but it kind of happened to me. I had my first son with a CNM at a hospital. I was not a birth activist at the time. I was the first of my friends to become pregnant. It wasn’t a particularly great birth, and it certainly didn’t make me want to be a midwife.

I was interested in natural medicine originally, after helping diabetics in the health food store where I worked right after art school. I originally considered going to Bastyr University to its naturopathic physician program, but, much like the CPM dilemma mentioned in letter #2, an NP can only get licensed in a dozen states, which is even less than a CPM/LM. Considering how tenuous that seemed, I decided going for a conventional medical degree would be more safe, and then I would be able to practice as holistically as I chose, while also able to be the primary care physician, regardless of where I ended up living.

I had both of my children during my pre-medical journey. I had to take a significant amount of prerequisites, and I only went to school part time. If I had it to do over again, I would have taken more classes and taken out loans. I was five months pregnant with my second son when I interviewed for medical school for the first time. I had no clinical experience, and talked about using natural supplements for diabetes in my interview. I also was wearing a much more casual suit than the other applicants, and stood out like a sore thumb in many regards. I didn’t get a spot.

I was devastated. For my pregnancy, I was seeing a direct entry midwife practice (in Florida, they are licensed as LMs, in other states, they are often licensed as CPMs) associated with a freestanding birth center and midwifery education program. I loved the atmosphere and the women-centered medical practice there. I was also adrift, not sure if I could or should reapply to medical school with an infant. I had planned on having two potty trained children by this point in my training, but a miscarriage, divorce, and remarriage postponed that a bit. I remember asking the director of the program if she would hire me as a physician’s assistant. She asked me why I wouldn’t just apply to the midwifery program.

I laughed and told her no. Honestly, and this will probably sound funny coming from people who know me now, I thought “Vagina and screaming all the time – who needs that??” Then, I went home, and reconsidered. Becoming a PA would leave my scope of practice very limited. Becoming a ARNP (or CNM) would take almost as many years as medical school, and I would have to be a disrespected and overworked nurse first. Becoming an LM would take 3 yrs, and the director told me I could bring my baby until he was crawling. I signed up for the midwifery program.

Studying to be a direct entry midwife was one of the best and most trying experiences of my life. I can’t and won’t go into all the details. I was attended more than 50 births, five of which were my own catches. Many of these were VBACs. I finished two of the three years of classes. I was trained and worked as a doula and as a lactation consultant. I loved the holistic atmosphere, the (usually) woman-centered care, the wonderful patients, the normalization and success of breastfeeding. I did not love cleaning the toilets and floors, doing “hell week”, or witnessing the ethical issues when it came to the gray areas of what was safe care within the legal limits of midwifery practice. I also wanted to be an abortion provider, which would not be legal under a direct entry midwifery license.

Amy Romano does a good job of describing what the legal and collaborative climate can be like for midwives. I replied on her post (and here), and described what it was like to be at a legally scrutinized birth center with problems getting doctor back up. One night, the director faced having five years of her records pulled, including all of her active clients, because of a compassionate delivery of a known intrauterine fetal demise (IUFD) because it was, technically, out of her scope of practice, based on the letter of the law. I know how hard it was for her and every midwife and student to stare at those 700 charts and wonder how many other technicalities could be found in them. I left that night knowing I couldn’t continue at the center, risk it being closed down, risk being implicated in any findings, and face being a marginalized and severely limited practitioner.

I had already been thinking about returning to medical school. The midwives and students had remarked how I seemed like I should be a physician and not a midwife, mostly due to my love of clinical research and academic journals, and my cynicism towards some of the more “woo” aspects of the midwifery community. I didn’t want to have to transfer every stalled labor. I didn’t want to have to have a physician back up my practice. I didn’t want to find out that a patient that I referred to a physician because she was risked out of my practice for something minor had been pressured into a non-medically indicated induction, episiotomy, or cesarean. I wanted to be able to deliver twins, and breech babies. I wanted to be able to practice like the physicians I observed in the hospitals and in the community – they seemed to have a wide level of autonomy, authority, respect, and freedom of practice.

I was afraid, and still joke about having a “midwife crisis” and “crossing over to the dark side.” It is hard not to adopt the paradigm of the system in which you are completely immersed. I am desperately searching out progressive residency sites. I am terrified of being stuck at a program in which I am ostracized or constantly in confrontations about standards of care and evidence based practices. I have to bite my tongue when interacting with some members of the medical establishment. But, I had to do that with some midwives. I adore some members of the medical establishment, and adore some midwives, too. I hope I can go to or even attend a homebirth every once in a while, but I can survive with just backing up midwives and working with midwives. There are physicians who attend homebirths. I have never heard of a PA delivering a baby, but I am not an expert.

Anyway, I ended up having to take the MCAT again. It had been 2 years and 3 months since I had taken it, and one of the schools, the closest one I applied to and the one I am now attending, wanted a score within two years (I have since heard of people getting around this, but I wasn’t able to, even though my score was more than decent for the program’s admission standards). Medical school has been challenging but doable. It has been far more enjoyable and varied than I thought it would be. I am only half way through, and would be a practicing midwife by now if I stuck with the midwifery program. A midwife who graduated after I would have has moved and opened a birthing center. I will not be practicing on my own, out of residency, for at least another six years.

I hope I would have made a damn good endocrinologist, or a damn good midwife. But, I have to say, despite how much of a runaround my training has been so far, I love having the direct entry midwifery experience and doula experience and think it is a definite advantage to me in medical school. I have had more than one physician look over his glasses at me and say “Aren’t you the one who was a doula?”, with a not exactly favorable expression, but for the most part, my knowledge and comfort with the subject, and experience with patient contact and basic skills has been nothing but a boon to my training.

Well, this post is about as long as it can be. I hope this helps! Please keep me up to date, letter writers!