Posts tagged ‘maternity’

Aug 11

Not your Usual Birth Plan

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A birth plan is usually a written plan from the mother to her caregivers describing her wishes, what type of options she’d like to take advantage of, things she would like to happen thru out her labor and birth, what things are important to her as she experiences birth. There are various resources out there to help a new mom explore options and formulate a plan.. especially for a hospital birth. It is important that the mom review this with ALL her care providers AND especially the L&D nurses…. the advocates who help you actually realize the goals with in your plan. I have a fellow L&D nurse blogger who has done extensive research on the topic and wrote a 2 part series on Writing Your Birth Plan- Tips from an L&D Nurse over at nursingbirth. I would highly recommend you check it out especially if you plan on a hospital birth.

Many times these birth plans accompany a mom’s prenatal chart weeks in advance of her birth. Over the years there has been a gradual acceptance of the plans in my facility where historically, there had been much resistance for the mother’s input what so ever. Much like the attitudes towards homebirth…. The doctors or nurses would casually peruse the plan then toss it aside and have a good laugh…. saying…. ” oh- she’ll end up a section for sure!” Unfortunately, they were often right about that– many of those early birthplans never seemed to go as mom wanted, giving the staff fodder for snide comments and remarks. Sad but true. 😦

Recently, we recieved a birth plan that was not at all like any other. Maybe some of you have seen plans like this… maybe some of you actually wished for births like this…. Hey~ who am I to judge? …. I am only here to help, it isn’t my birth.

Her Birth Plan requested:

Pain medication as soon as possible….. I prefer to have an epidural as soon as possible
Please do not try to make me have breathing patterns through contractions… I’m afraid I’ll be too nervous
If a Cesearean is needed, please put me to sleep
I want only my mother with me in the labor and delivery of my baby
When the baby is born, I do NOT want to touch him until you clean him off
You can do his eye ointment and Vitamin shot, bath and all procedures before I hold him
I want to hold him wrapped in a blanket, not skin to skin
I want the baby to be in the nursery as much as possible at night so I can rest
I want to feed my baby formula from a bottle. I don’t want to breast-feed
I want to stay in the hospital for the whole allotted time so I can rest

My first thoughts were… Sweetheart, you could have ALL THIS without even asking!” ……..

Sadly, despite all efforts to improve, … things still happen exactly like this for many births. We just don’t usually see it written out as a formal request or plan! At least this is how this mother wanted things to happen.

This little mommy came in and delivered vaginally. Her plan was very easily carried out. 😉 I am very happy to report that she and her son were healthy and she displayed very postive interaction with him. Very loving and caring. She was very very happy with her birth and with being a mother!

That is all that really matters in the end. Options– and what you as an individual would like to have for your birth. How much education she had before chosing these options… I’ll never know.

Now I am asking the rest of cyberspace world.. have you ever seen birth plans like this???

Aug 7

10 Comments

A Formula Rep turned my Maternity Leave Injury into a new career as an IBCLC? Really?

My contribution to this fabulous Carnival of Maternity Leave , is a story of how during my maternity leave, an injury occurred leading to a career change specializing in Lactation… ! It starts with the birth of my third and last baby…… A girl….. (after 2 boys) was also born by C-Section.. a first for me.

Well– first, let me back up a few years… I’ve had a potpourri of maternity leaves. I have been a Maternity/L&D/Nursery since the mid 70’s. I always worked full time and had never entertained thoughts of staying home with my children once they were born because the USA didn’t assist in providing any type of viable option for families who rely on two incomes or single moms with one income. Prior to FMLA, maternity leave was pretty much up to the employer as far as I understand it. The USA doesn’t offer any paid leave (unless offered by individual employer). For my first baby in 1979- I took 7 .5 weeks and went to a weekend 12 hr shift job which at least allowed me 5 days each week with him.

When my next baby was born in 1985, I worked at the same facility I am now. We were allowed to save up ALL Vacation, Holiday, and Sick time to be used collectively with your hospital allowed 12 weeks off. I was able to have 5 1/2 months total, partially paid time to be with my new baby. Since he had to have surgery at 3 months, I needed that time and could have used more.. My leave was actually supposed to end on Christmas day (YUK).. however, they graciously allowed me to come back on the 26th… also his first day in Day Care. 😦

So back to my third baby in 1988~I had had a C/S — (that’s another story). I had to be hospitalized for 10 days after the surgery with a whopping infection. A fresh incision and chills with a temp of 103.8 do not go well together! [Nurse Curse] Anyway, I made it thru–> healed and returned to life as a mother of three. The same type of collective accumulated paid hours were allowed withthe hospital’s offered 12 weeks. I didn’t have as many hours saved up as last time but was hoping for the best length of time. One day in church, I held my little 2 month old baby girl on my shoulder with one hand, while using the other to hold the hand of my active 3 yr old boy as we made our way down the aisle. Suddenly, my boy squealed with delight and whipped over in a different direction. I held my daughter and did a sudden twist and reach for my son as he squirmed away. I immediately felt something “give” in my back.

It took a few days for me to feel the true extent of the injury. I thought it was just a little pulled muscle. After a 5 hour drive to my sister’s for a family visit, I ended up writhing on the floor with the unstoppable intractable “fire hot poker” pain of full blown sciatica…. all down my right side. I had to go to the hospital ER away from home, unfamiliar doctors, for help and drugs! Boy, I needed relief. As explained to me by the doctors… this was not the same as sciatica from many other causes. This was a swollen inflamed sciatic nerve… we didn’t know why yet. The only thing helping at that point was medication and ice.. a lot of ice. I still insisted they give me meds I could take while breastfeeding, so they weren’t too strong.

I got home, went thru an MRI and diagnostic process, different doc’s, different opinions. I had a disc “blow-out” with”free extruded disc fragments” at L5-S1. Some felt surgery was needed immediately, others said to wait. After careful consideration, we decided to wait and do some conservative type treatments with oral and epidural steroids. I still had to heal well enough to work, though. I spent many nights crying and wondering HOW I could work ??? How could I go and be on duty…running all over to keep up with the pace, helping people thrulabor and delivery…respond to emergencies…how?? I could barely care for my family! I called many friends while I was on periods of bed-rest and had various treatments during the time I had left of maternity leave. (I eventually did have to extend the leave a couple weeks for more recovery. I ended up witha 5 month leave altogether). I was searching for ideas.. visions of something less physically taxing which could combine my knowledge of labor/delivery/postpartum and neonatal care….. and allow me to continue working. I was, after all, the major bread-winner in our family!

Finally, a friend came up with an idea. He was actually a formula and drug rep for Ross labs.. TRUE!! But he was a friend, had heard I was hurt and stopped by the house to see how I was. He was a rep to many hospitals in the NorthEast and had exposure to what else was going on– what other hospitals were doing. This was 1988, only a few years after the emergence of the Lactation Consultant profession. I had never heard of it. Sometimes word traveled slowly (by pony express) and things changed slowly in my little neck of the woods. He encouraged me to check it out and gave me phone numbers of LC’s at some of his other hospitals. I was really excited! I called a few and found out more about the lactation profession and the relatively new Board exam given every year in July to gain the credential of IBCLC. I was actually naiveenough to think I could take the exam with my current knowledge base! HA! (Unfortunately, this is what many nurses with a little experience think…we think we already know it all! Ha!)

I called one of the LC’s at a hospital not too far from me. We talked a while and I had my eyes opened as to the extensive and vast knowledge base needed to become a lactation professional. I launched a quest for the best way to gain this knowledge. I joined LLL and went to meetings. I made home visits with the local LLL leader. I wrote many letters, made many phone calls searching for some type of education program. (remember– no Internet back then!)

Finally I found the perfect program for me. There was a correspondence course offered to be done all through the mail and phone calls designed to be an 18 month course. It was a Lactation Consultant Course offered by BSC Breastfeeding Support Consultants! (the link shown is for their current course) Back then, you could be called a Certified Lactation Consultant after completing the clinical practicum and final exam. Because of continued back problems, I started this course in early 1989, had to take a few months leave from the course and completed it in early 1991. I then went on to continue studying and sat for the IBLCE exam in 1993 earning my IBCLC status!

I have always continued to work as a staff nurse. I found a corset style back brace and found the best balance possible between family, back pain, work and more pain. I was able to get the pain subdued with steroids to carry on with life. In 1992, during a particularly gruesome relapse, I eventually consented to a myleogram… something I had previously NOT wanted. They also did a CT scan while the dye was in place. These tests showed my right Sciatic nerve had been pushed way up out of place by the disc material. I consented to surgery by a fabulous neurosurgeon the very next day. It turns out, the disc was actually adhered to my sciatic nerve!! He had to meticulously excise it off the nerve!! My post-op pain was minimal compared to the pain I had before surgery. I was able to go back to full duty in 8 weeks!

Over 20 years later, I am still working as a staff nurse and am now a CLC… Certified Lactation Counselor. Becoming a breastfeeding professional has enhanced and fortified my life! I am immensely happy I have gone down this road. To think it all came about as a suggestion from a Formula Rep!?!?!

Hope all had a great WBW 2009!!

Jun 16

9 Comments

I’m Proud of my Hospital….~ this week ~

~I’ve reason to be a little proud of the care given this week.

I hope this is a continuing trend of attention to detail, utilizing evidence-based practices and compassion, listening to our patients and providing them with options and the best possible care…. I’ll give you a few details about each as you read on… In summary, this week we have had the following situations:

A 25 week-er walk-in with a precipitous delivery stabilized & tranported quickly
Twins! Vertex/vertex –turned breech– turned vertex~ delivered vaginally
A Heroin/Cocaine addict identified, baby able to be treated appropriately so comfortable transition
Safe Haven newborn about 1 day old.. placed up for adoption
Homebirth Transfer handled with great respect overall and most importantly, the mother is happy with her experience.

Whew! We have a lot of busy weeks but they don’t always have this intensity or variety! I feel proud because there may have been a few things done differently due to recent conversations I’ve had…Plugs I’ve made… and I keeping putting in little plugs to try to gently increase awareness & educate. I am an Instructor in Neonatal Resuscitation and Lactation.. sometimes the troops listen when I talk about other topics…. I’m no expert but I try to be current, correct and compassionate in care. (My 4 c’s)

Okay… the details for the first 3… stay tuned for the others…..

~25 Week gestation walk-in~

She came in with mild cramps and pressure. She didn’t report any fluid leakage but did C/O pink vaginal mucus. We had her in an exam room pronto. She had a gentle speculum exam which revealed hour glassing membranes thru an approximate 4-5 cm cervix..visually. Hour-glassing means that the intact amniotic sac has protruded thru the partially dilated cervix and expanded like a bubble in the vagina. She went right into trendelenburg. The transfer teams were called. It was soon clear she would deliver here and the baby would need to be stabilized and transferred. The NICU team contacted us back they would be flying up to retrieve. The nurses caring for her were tremendously supportive. All procedures explained, options offered and decisions honored. They got her records faxed over from her OB’s office so we had a little history.

Like a well oiled machine (from all of our drills), all the emergency equipment was readied, pediatrician in attendance, roles clarified. Once he was born almost without warning, precipitously, all at once, about 30 minutes later. He was quickly assessed, wrapped in plastic, ventilated, then intubated. We had a peripheral IV in place in case he needed meds or fluid volume. He had a chest xray and a blood culture/blood count sent. He was kept warm, ventilated and appropriately oxygenated and had stable glucoses. He weighed in at about 700 gms (about 1 1/2 lbs). The team arrived when he was about 30 minutes old. They checked all labs, xrays and his IV line. They gave him Surfactant and pretty quickly and carefully, loaded him in the transport incubator then got him out to his mommy for a visit before he was transferred. They answered all her questions before they left and we helped her deal with it all. The doctors discharged her shortly after that so she could get down to her baby. At last report, he was doing just as expected for 25 wks, no other complications often seen at that gestation, for ELBW (Extremely Low BirthWeight) had come up. He was actually improving each day! So happy for everyone!

~Twins!~

She came in to the hospital already in very active labor at 37.5 weeks gestation. Her twins were both head down (vertex/vertex). She labored quickly, uneventfully and delivered Twin A at about 1 pm. With the ultrasound machine in the room, they scanned over her still pregnant belly to see where Twin B was and if he was still in position. Turns out that once Twin A had vacated the womb, baby B had a lot of room and he had moved into a transverse/breech position. That means he was more bottom first than head first anymore. Most Ob’s now don’t attempt a breech delivery even with the second twin. They are quick to do a C/S…. This day, however, …. the Ob in charge called over an associate to ask his opinion. They brought the mom into the OR and prepared to do a C/S if they were unable to get the baby in proper position. The point is they were at least going to TRY! With the U/S scanner and 2 assistants, they did an external version and worked Twin B back into a head down vertex position without complication. He delivered vaginally about 1 hour and 45 minutes after his brother! The staff kept the first twin in the room the whole time so they could all be together. I spoke to the Ob later and congratulated him on a great job.. he said to me that he remembered what we had talked about awhile ago (when I had written the post about a C/S for the 2nd twin), and had researched it himself. I was happy that any little plug I had made had sparked interest in researching the topic and possibly even influencing a decision towards better care! I am happy to report that both babies went home with mommy on day 2!

~A Heroin/Cocaine addict~
We are attempting to put together some consistant protocols for drug screening so that we don’t miss the opportunities to protect a newborn in need…. Some may not understand how important it is to sometimes screen the healthy and innocent to weed out those with problems…. They don’t always present in an obvious way. From my perspective, those individuals who are hiding something are very difficult to identify from outward appearance only. We identified a heroin/cocaine addict recently who was a very beautiful, well groomed, well nourished, affluent (seemed wealthy) woman who stated she was just visiting in our area, and had no prenatal care info or records with her…. she was in rip-roaring very active labor at 36 1/2 weeks with heavy vaginal bleeding and fetal distress. We thought we were headed to the OR but the baby had other ideas. We had little time to get more information before the baby was born. There was a small abruption but luckily, the baby was vigorous and did not seem to have suffered blood loss. The admitting nurse had collected a urine sample with a catheter insertion and sent it for drug screen. It came back positive for Opiates, Cocaine and THC. The baby’s urine also tested postive for Opiates, Cocaine and THC. Because we knew, we were able to start the NAS (Neonatal Abstinence Scoring) for signs of drug withdrawal and identify the signs quickly. If the baby is unable to be comforted by swaddling or holding or if we had 3 scores of 8 or higher, there are protocols set up for medicating the baby. The baby did require medication within 24 hrs. Once medicated, she was such a happy sweet little girl. The nurses named her “Molly” and we all loved her. She stayed with us all week until the pediatrician released her andChildren’s Services placed her in a foster home experienced with this kind of care. Unfortunately, some of the big drug problems have hit my area. Our local paper just did a big series of stories on local Heroin addiction problems. Apparently it is cheap and accessible.

I am going to publish this part tonite and tell the other two stories soon…

Jun 3

52 Comments

No Prenatal Care? …..What are YOU Hiding??

No Prenatal Care is usually a symptom of something--hiding some type of underlying problem. Sometimes it's very ugly. The most common encounters we have involve illicit drug use during pregnancy. We need to develop a comprehensive Maternal and Neonatal Drug Screening protocol to protect the newborn.

May 28

21 Comments

**OB Docs and Nurses Scoff at Homebirth**

My community hospital’s views have never been in favor of any type of home-birth… whether it’s with a skilled professional practitioner or a skilled lay midwife. There could have been some free unassisted births going on but we were not aware…. As I grew-up in this profession, I learned first from my experienced counterparts…then I began to educate myself and learned a lot from mothers and babies. The doctors and nurses I worked with were all stagnant in their knowledge in my early years. They were satisfied with how things were. I was young, I had an open-minded philosophy and an eager quest for knowledge.

In the later 70’s, just when we began to have mothers speak out and request a more natural childbirth, I had a few friends who enlisted the aid of some lay midwife in the region and arranged for homebirths. They all had a really nice birth experience without a single complication. Perhaps that was why I was open to the idea even though I was not personally involved. Besides some of the truly prepared couples who came in and had incredibly beautiful births….. that had been my first exposure as an alternative option to the knock’em out–pull’em out births I had been working with on the job. I knew my friends were very low-risk and had done their homework.

However, the hospital’s exposure to a homebirth in those days was only if the homebirth went awry for some reason or another and they came in our doors seeking help… here’s what the docs and nurses would say to one another :

“Can you believe she planned to deliver at home???”
“How could she take take a chance like that with her baby?”
“The reason people started coming to hospitals to give birth was because mothers and babies were dieing at home….she must be crazy or totally insane!!”

We’ve had planned homebirths come in for various reasons, as I am sure other facilities did…. (keep in mind that in my area, the usual birth attendant was a lay midwife). The situations bringing the mother to the hospital were often scary and upsetting for her. The most common were:

Fetal heart rate decels with or without meconium stained fluid
Lack of progress with pushing mostly after many hours..
Higher than normal bloody show or bleeding–possibly abrupting
Breech, brow or face presentation
Retained placenta

Often the OB’s didn’t handle themselves well.. certainly not professionally. We had this one OB who would call for the OR to be opened before he even examined the patient or evaluated the situation…..regardless of why they came in. And he often actually yelled at the mother, in the middle of her scary situation.

“Your baby will die if we don’t do an emergency C/S right now, why did you let this happen!”

Most often the backlash was directed at the midwife who cowered in the hallway- uninvited by the staff, left alone detached from her patient. She never left the unit though until she was afforded the opportunity to visit and speak to her patient.

The two significant situations I remember which would fall in to statistical data for morbidity were:

An abruption which resulted in a crash C/S upon admission and a neonatal resuscitation with good response….(final apgars 3@one min then 7@ five min) positive overall outcome, no long term sequelae.
A birth where the father (a chiropractor) was the birth attendant for his wife, a multip, encountered a shoulder dystocia and the baby ended up with a displaced fractured left humerus. That baby was in a crib with traction to realign the bone. The child went on to be an honor student at a local university after homeschool.

I feel that instead of the midwife or mother receiving hostility (or even the mother being wisked away to the OR without a trial of something if the baby was deemed stable..)~ the staff should have behaved in a compassionate professional manner, acting on any urgent situation with consideration that this mother is now experiencing not only labor but fear and grief over the loss of her beautiful planned birth.

Despite all the negativity from the staff, we never had a seriously bad outcome from attempted homebirths arriving on our doorstep. We still have attitude problems, probably always will~ just as we do with breastfeeding. I wish they could look at it from my perspective. Those who choose homebirth today have better information to hopefully make an educated informed decision about their birth options and choose wisely. I really like Ricki Lake’s “The Business of being Born” among other’s. I hope those choosing homebirth are truly investigating all these options, deciding what is best for them and not making any decisions out of “anger at the system” or any sort of revolutionary zeal.

There is so much out there for medical professionals to be aware of other than what goes on in their tiny little realm, their little part of the world. My co-workers and doctors need to be better informed.

Any one bad outcome (which most certainly happens in the hospital) does not mean that every homebirth is a bad idea.

May 21

15 Comments

Cesarean Delivery of the Second Twin… Why?

029 I was talking to one of my on-line Twitter friends @onefinebreeder about twin delivery. I was telling her about how things used to be.. how vertex-nonvertex twin gestation’s were always delivered vaginally ….. and she commented on how it was sad that some of the old OB skills have been totally lost to surgery… So Very True!

I got to thinking about the first combination Twin delivery I had witnessed back in the very early 80’s. This was actually one of our own (hospital employee) nurses . She was a multip…. around 37-38 weeks and healthy…no complications during pregnancy. Twin A delivered spontaneously, vaginally with a generous episiotomy as they often performed at that time… The baby , a girl, was about 6 pounds, vigorous and had no problems. We were all marveling at the first baby, checked fetal hearts on the second twin and started waiting for him to get in position. Still before consistent ultrasound, we were not worried. However, we had a newer doctor who was attending this birth. He began to get concerned after 5- 10 min when contractions slowed and he was worried that if this baby was breech, he would have difficulty with the “after-coming” head. Up to this point, all I had learned was this can be a real concern if the smaller feet or buttocks present through a cervix which is not fully dilated. Much research was done later on but at the time, I did not know about it. He began to ask us to call the OR for a C/S. This was unheard of in my limited experience at the time…. my 70’s world. I thought.. how can they do a C/S now when one baby was already born??? I tried to be an advocate… (my early days… )”We have Piper forceps…” I said meekly… “Have you tried to grab a large part and help bring the baby down… ?” This was my limited knowledge… all I knew to suggest. I kept wishing one of the other doctors was on duty that day.. or maybe we could call them???

In front of the mother, he said to me “I’m not going to have a bad outcome here!” By now it was 20 minutes or so. There was no cord prolapse, no drop in fetal hearts, no evidence of immediate trouble… the baby was seeming to work itself into breech position…. To the mother he said “Your baby is in serious danger and the best thing to save him is to take you for a Cesarean now!” “I’ll sew your episiotomy together while we are in the OR.”

I was in shock. She signed, scared to death of course. So we prepped her for the OR. She went up for a C/S of her second twin and repair of her generous episiotomy. Her second baby was delivered frank breech… a beautiful boy about the same size and was also vigorous and healthy. I remember I felt as though she was almost assaulted. I remember feeling that this was a true rare event if it every happened before. There was no immediate access to information like today.

Luckily mom and babies did fairly well in the postpartum period even though healing from both the episiotomy and the C/S was difficult for her.

" Psst-- How can I get out if I'm not head 1st ??"

I wanted to see how much research I could find on this topic. I had gone to the green journal (OB & GYN) website but then it locked me out. (You can only look at abstracts anyway unless you want to purchase the article. You are on your own for that.) I had some luck with the abstracts at PubMed so I have put a few here.

I decided to take a look across time…….

This first one is from 1981. . Quoted abstract from the PubMed site:

Cesarean Section for Delivery of the Second Twin

Evrard,JohnR.; Gold, Edwin M.

Obstetrics & Gynecology. 57(5):581-583, May 1981.

Four cases of combined vaginal-abdominal delivery of twins are presented, and an additional 5 cases from the recent literature are discussed. Malposition, malpresentation, and contracted cervix were the main indications for cesarean section for the birth of twin B. In the 9 cases presented, there were 2 perinatal deaths.

Interesting that this research was done during the same time frame as my experience above. I’d like to know more about those poor outcomes 😦

The next interesting article I found was researched over a 10 yr period, somewhat close to here in a larger facility, published 1997. THIS study examines the delivery of the second twin by utilizing external version vs breech extraction . 😉 The results are showing in favor of breech delivery vs version (those meeting exclusionary criteria ).. Versions were associated with higher a incidence of Cesarean and fetal distress. Neonatal outcomes no different and are stated below:

Method of delivery of the nonvertex second twin: a community hospital experience.

Smith SJ, Zebrowitz J, Latta RA. J Matern Fetal Med. 1997 May-Jun;6(3):146-50

Abington Memorial Hospital, Pennsylvania, USA.

The purpose of this study is to examine the incidence of cesarean section and fetal distress complicating the delivery of the second twin in vertex-nonvertex twin gestations in which the second twin underwent either breech extraction or external version. The intrapartum courses of 510 twin gestations delivered at a community hospital over a 10-year period were retrospectively analyzed. All vertex-nonvertex twin gestations were identified in which the second twin underwent attempted breech extraction or external version. Exclusion criteria included birthweight < or = 1,500 g, fetal anomaly, intrauterine demise, and monoamniotic twins. Of the 76 twin sets that met inclusion criteria, 33 underwent external version and 43 underwent primary breech extraction. The two groups had similar demographic characteristics. External version compared to breech extraction was associated with a significantly greater incidence of cesarean section (8/33 vs. 1/43, P = .008) and fetal distress (8/33 vs. 1/43, P = .008). There was no difference between groups in neonatal outcome for the second twin as measured by length of stay, 5-minute Apgar < 7, intensive care unit admissions, hyaline membrane disease, intraventricular hemorrhage, and traumatic birth injury. In conclusion, the increased incidence of cesarean section and fetal distress in patients undergoing attempted external version suggests that breech extraction may be the preferable route of delivery for the nonvertex second twin weighing more than 1,500 g

The next study was published a little later in 2001 and covered a 20 year span of time… during the 80’s and 90’s at a larger center in Nova Scotia, Canada. They noted an increase in their combination vaginal/cesarean twin births and documented some statistical data, looked at reasons for an operative second twin birth. I wish to read this study further some day to see if there is mention pertaining to mother/baby outcomes other than statistics outlined (even though that wasn’t their objective) in this abstract:

Combined Vaginal-Cesarean Delivery of Twin Pregnancies

Persad, Vidia L.; Baskett, Thomas F.; O’Connell, Colleen M.; Scott, Heather M.

Obstetrics & Gynecology . 98(6):1032-1037, December 2001.

Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.

OBJECTIVE: To estimate the incidence and factors associated with combined vaginal-cesarean delivery in twin pregnancies. METHODS: We studied all twin births weighing 500 g or more during a 20-year period (1980-1999) at a tertiary care center. Major anomalies, monoamniotic and conjoined twins, and antepartum fetal deaths were excluded.

RESULTS: During this 20-year period, 105,987 women delivered, of whom 1565 (1.5%) had twins. Of these, 1151 twin sets fulfilled the study criteria. The mode of delivery was vaginal in 653 (56.8%), cesarean in 448 (38.9%), and vaginal-cesarean in 50 (4.3%). During the 20 years there was a statistically significant increase in combined vaginal-cesarean and elective cesarean deliveries, with a decrease in vaginal deliveries. Parity, gestational age, and birth weight discordance (>25%) were not associated with combined delivery. Compared with vaginal delivery, the nonvertex second twin was associated with a twofold higher risk of cesarean delivery (relative risk [RR] 2.3; 95% confidence interval [CI] 1.3, 3.8; P =.002); and an interdelivery interval of over 60 minutes with an eightfold higher risk (RR 8.2; CI 4.6,14.6; P <.001). Vaginal-cesarean delivery had a 22-fold higher use of general anesthesia compared with vaginal delivery (RR 21.8; CI 5.4, 88.5; P <.001). CONCLUSION: There has been a significant increase in combined vaginal-cesarean and elective cesarean deliveries among twin gestations, with a decrease in vaginal births. Vaginal-cesarean delivery is associated with nonvertex second twin and a prolonged interdelivery interval.

Now we come to 2008! There is a study here from Texas. This study looked a twins born by C/S after labor and twins who had cesarean birth of the second twin. they campared outcomes to see if the twin of a combined delivery had more problems. The most important pieces of information I gather from this abstract of results…. (again, having NOT read the entire study):

“Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.” Hmmm

Cesarean Delivery for the Second Twin

Alexander, James M.; Leveno, Kenneth J.; ….et al:for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU) Obstetrics & Gynecology . 112(4):748-752, October 2008.

Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75235-9032, USA. james.alexander@utsouthwestern.edu

OBJECTIVE: To examine maternal and infant outcomes after a vaginal delivery of twin A and a cesarean delivery of twin B, and to identify whether the second twin experienced increased short-term morbidity as part of a combined route of delivery. METHODS: Between January 1, 1999, and December 31, 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 university centers. This secondary analysis was limited to women with twin gestations who experienced labor and underwent cesarean delivery. We compared outcomes of the second twin in women who had vaginal delivery of the first twin and a cesarean delivery of the second twin to those who had cesarean delivery of both twins. RESULTS: One thousand twenty-eight twin pregnancies experienced labor and underwent cesarean delivery; 179 (17%) had a combined vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in both groups (P=.97). The rupture of membranes to delivery interval was longer in the combined group (3.2 compared with 2.3 hours, P<.001). Endometritis and culture-proven sepsis in the second twin were more common in the combined group, respectively (n=24, odds ratio 1.6, 95% confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence interval, 1.0-3.4). These differences were not significant after logistic regression analysis. There were no statistically significant differences in an arterial cord pH of less than 7.0, Apgar score less than or equal to 3 at 5 minutes, seizures, grade III or IV intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death. CONCLUSION: Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.

I gather from these studies that a combined delivery route leads to more problems.. however…there are probably more problems than breech presentation alone to lead the provider to make that choice. I believe that many newer providers of obstetrics in a hospital setting are more apt to do a scheduled C/S for any vertex-nonvertex twins they encounter. That is what is done in my facility today. The same for all breech presentation singleton gestation.

Where is that old-fashioned nurse when you need her?? How ’bout the old fashoined doc??? 😉

I am very interested in anyone’s story or experience either in healthcare or your personal birth. Please let me know if you know anything about this!

Thanks for reading!

May 19

16 Comments

Breastfeeding Barriers

Barriers~

Even the word itself is foreboding.

Breastfeeding advocacy, lactivism, promotion are important to combat what is really a public health problem and should be a public health priority. ~Breastfeeding should simply be the norm.

“Today’s medical community recognizes what their

predecessors knew a century ago—that the

American propensity to shun human milk is

a public health problem and should

be exposed as such.

“Today’s medical community recognizes what their predecessors knew a century ago—that the American propensity to shun human milk is a public health problem and should be exposed as such.”

American Journal of Public Health | December 2003, Vol 93, No. 12

It should be SIMPLE~

It is one thing to talk or write a lot about breastfeeding advocacy and promotion… but WHAT does that really do to break down the hospital barriers. Even with some good ideas or some well-written plans & protocols(ie. as recommended by The Academy of Breastfeeding Medicine)…. I’m here to tell you, all that does very little to actually change an individual health-care professional’s actions. There is a critical void in the practice of appropriate breastfeeding management strategies and breastfeeding support from the health-care arena.

Working with barriers day-in and day-out can really open your eyes to what some of us, as lactation professionals or advocates, are dealing with on a daily basis. Many of us are ill-equipped to attempt to enforce evidence-based management guidelines. There must be better support from the management of each facility, organization or Health-System. It needs to start at the top…. to say we now have an evidence-based breastfeeding policy is NOT enough. I believe it starts with each individual being responsible and accountable for their own practice.

Action Taken~

I have written about how Breastfeeding was taught to me in nursing school and what our scary hospital policy looked like when I got started in this profession.

I have written an article published in a local parent magazine to coincide with 2007 World Breastfeeding Week supporting practices to keep breastfeeding SOFT and SIMPLE.

I have been working on so many different ways to try to keep it SIMPLE… trying to reduce barriers. I have written countless competencies at work while trying to gently re-educate my co-workers. I have developed several PowerPoint presentations, poster in-services, poster displays etc.. to try to help my fellow staff members AND physicians fully UNDERSTAND the superiority & importance of breastfeeding and the use of correct evidence-based management advice, assistance or feeding plans. I have learned to be gentle and patient in the process….one step at a time.

I want to keep it simple for the mother…I’ve tried to work on a simple bottom-line approach to eliminate any maternal barriers of feeling overwhelmed or confused with too much or conflicting information.

I don’t want mothers to think they have to “study” to pass the breastfeeding test….to “perform” correctly!

I encounter a variety of moms from vastly different backgrounds. There are huge differences in their own individual breastfeeding expectations and goals. We have a large breastfeeding/bottle feeding combination population at my facility. I’ve struggled to balance quality promotion and proper education to both mother’s AND the staff. I continue to to educate with acceptance of all individual mom’s actions. I have written about my approach and maternal guilt.

I wrote:

Never overestimate a mother’s desire to breastfeed her infant.

Never underestimate a mother’s desire to breastfeed her infant.

Listen to the mother; help her define her true desires and goals.

Support the mother, support the mother, and support the mother.

This is what I have learned and how some of my approaches and strategies have evolved over the last 20 years so that moms and staff alike will listen. I have written these same things at work…. They are hearing me now. I have to say that at least they are listening and some are talking the talk. How do I get them to walk the walk? Only a select few truly care to try. The following is some of what we still deal with…

Continued Problems …. Persistent Barriers ~

Getting the baby skin to skin in the birthing or delivery room–very inconsistent
Accomplishing the first breastfeeding in the delivery area (I even revised the nursing form to REQUIRE documentation of a reason WHY not breastfed….) Most common reasons..attempted, mom tired or mom declined. I have to wonder how often it’s really encouraged…and are they trying to help?
Some staff still thinking they have to give that “test” feed of water
Keeping a healthy baby in the nursery for hours under “observation” while nurse gets all adm paperwork done
Giving handouts to mom but not talking to her, not listening, not helping
Telling or directing mom firmly, like it’s an order… often with incorrect info- “you really need to feed that baby, wake him up every 2 hours no matter what”
Inconsistent observation of latch and feeding progress (At least some are really good at this!!)
Giving partial bits and pieces of correct info mixed with misinformation and not accompanied with actual assistance…… then reporting to me “I said just what you taught me, Melissa!” (A challange to gently correct)
Keeping babies away from mother’s…esp at night so “she can sleep”
Incorrect use of formula— given for so many many reasons that are most often because of all the problems above…… sometimes mom asks for formula…. but a little detective work, proper evaluation, assistance and education can possibly help avoid the formula
Not understanding the unique characteristics and needs of the ‘near term’ infant.
Being understaffed when busy… we always have a mom/baby dyad with some need for frequent breastfeeding evaluation and assistance when we are crazy busy….they often get lost in the shuffle
Staff members not helping a mom because they tell them to wait for me… I am a staff nurse with multiple duties who happens to be a lactation professional.
The discharge diaper bag from formula companies. ***SIGH***
Doctors giving conflicting out-dated feeding management advice
Doctors scheduling the first baby F/U visit for 2 weeks on first time breastfeeding moms
Persistent Lack Of Management Support and Enforcement of Exsisting Evidence-Based Policies and Protocols which I feel leads to staff apathy

I have been patient, really patient. I have seen progress…real progress. I feel so frustrated to be still dealing with some of these barriers. It is overwhelming and exhausting. I haven’t been trying to do everything alone. I have “duplicated” myself several times. Some of those individuals are still here, others move on to other jobs, others become apathetic over time. Then we get new people who look at things differently with comments like… “This is what we did at __blank___ hospital..”

What do you suggest could help with the real change……the implementation process??

How do I get them to walk the walk???

Please comment and make a suggestion… Do you have a good one I haven’t tried?

May 5

29 Comments

Scary 1975 Breastfeeding Policy

This story is about

VINTAGE Breastfeeding information

NOT Current Information

1979 Father wearing gown and mask to attend feeding

I have attempted to give an overview of our Maternity Ward as it was when I started to work there. I mentioned how “Once delivered, the baby went to the nursery and became the immediate property of the nurses, only to be seen from a window and allowed to be with the mother at token intervals. The poor little baby was often keep without food/ only water for the first 12 hrs. (Breastfeeding was something only the hippies did.)”

The thought process, as I was instucted even in nursing school, was that most newborns needed to rest after birth, and didn’t require food for 4 to 24 hours. They felt that postponing food would allow time for the mucous to be cleared from the throat and the baby would be allowed ample rest after the exertion of birth and all that handling by doctors and nurses as they provided the necessary care. My nursing school textbook (Marlow, Pediatric Nursing, 4th ed. 1973) even goes so far as to say that this lag time would allow the mother sufficient rest before giving her infant the breast because….. this first offering is…… difficult. ( Oh… You’d better rest up, dear…)

Another thought process that unfortunately is still around today was that the nurse should not encourage the mother to breastfeed over bottle feed…. least she arouse or cause any maternal guilt feelings. My old textbooks all did list some basic benefits of breastfeeding and proclaimed this as the ideal food. Ie: easier to digest, natural diet for the newborn, convenience, availability AND the provision of identified and unidentified substances which may be protective. The nurse should provide the information to the mother but not encourage her. They felt prepared formulas (Evaporated or whole milk formulas with added carbohydrates) OR the newer commercially prepared formulas were an “equal” substitute. We did have a full formula preparation room in the nursery with a refridgerator, range, sterilizing equipment etc. When I started, the Similac and Enfamil reps had already just hooked up the hospital with the marvelous free individual bottles of their products which were piled high on top of the former work area for formula prep. I don’t know when they actually stopped making it themselves.

Our 1975 Hospital Policy & Procedure *

We start with NPO (nothing by mouth) for 12 hours. Then feed one feeding of sterile water to confirm the infants ability to swallow.
If the baby has excessive mucus secretions, he should be fed 5% glucose water (G/W) every 4 hours for the next 12 hrs before his first breast feeding.
The father may be present for feedings provided he is properly gowned, wearing hat and mask and has scrubbed hands.
For the first breast feeding, teach the mother to cleanse her nipples with the cotton ball (soaked in a Benzalkonium chloride solotion) and teach proper latch-on techniques where-by the mother should cradle the baby near her breast, stroke his cheek so he turns and assist him to “grip” the nipple when he opens his mouth. Place the baby at both breasts for no longer than 2-3 min each side to avoid sore nipples. Feed the baby 5% G/W if he is still hungry when removed from the nipple.
Feedings should be every 4 hours, the mother should cleanse her nipples as above before each feeding.
If the baby should cry within 3 hrs of his last feed, he may be offered more 5% G/W.
The time spent at breasts should gradually increase to 3-5 min each feed for the first 2 days then continue to increase up to 10 min each side by the 4th day. When her milk begins to flow and the baby will actually be receiving milk.
Instruct the mother to pay close attention to which side she began and ended each feeding so she can alternate which side to begin the next feed.
Babies will usually require 6 feedings a day for the first several weeks.
Once lactation is established, she should be instructed to limit a feeding to 20 – 30 minutes total per feeding. The baby gets 90% of his milk in the first 5 minutes, any additional time is for his enjoyment. Some babies may “cling” to the breast after feeding and may need to be removed. Teach the mother to use her finger gently in the babies mouth to break the suction and remove him.
Babies may be taken to the mother for a breast feeding “on-demand” if so written on the chart by the physician

(*This is a combination of information I have from a scanty old policy,

what I remember

and interviewing some older former colleages about what we all actually did.)

If we were unable to get a baby to latch on, we had one tool available to us at the time. We had a hard rubber nipple on a glass base shield that we placed over the breast/nipple and we used the same timing of feeds. We would only help a mother pump her breasts if she was engorged. The only tool we had to assist her with this was a bicycle horn hand pump.

There were some pediatricians who were starting to be flexible and improve the approach to breastfeeding in a more natural sense, encouraging initiation earlier and more frequent feeds “on-demand”. There were more professionals opposed to that train of thought and continued their same practices. When the women started coming in and requesting a better approach to feeding…. they were sabotaged by the nurses who then fed their infants “white water” while in the nursery so these babies would sleep until the next designated feeding time.

This was 34-35 years ago and I still work with nurses today who have some of these thought processes behind what they do. Many of the older physicians, if taught anything in Med school, were taught similar management protocols. It is such a difficult retraining, re-educating process that some of us face.

Just last week.. a brand new RN/BSN asked me how the newborn was supposed to survive on colostrum alone?

She was blank faced dead serious.

I started my answer with…”You are not the first nurse to ask me that very same question and it’s a good question. Here’s why etc……..”

I hope I answered her well enough so she can someday teach the next one and the next…..

We really need much better Lactation Education

for our Doctors and Nurses.

They should not be so uneducated or ill-equiped

to properly care for and advise the mother’s in their care!

Apr 7

2 Comments

Tuesday Twins

A Few 70’s Twins Tales

It was Autumn 1975 when she arrived on the unit in labor. She stood close to 6 feet tall and was very very pregnant. She knew she was having twins. Twins were usually diagnosed after a mom grew larger than dates and by finding two fetal heartbeats. I had never seen someone that big! I was amazed she could even walk. She was taken to a labor room for the standard prep and SS enema (3H..High-Hot and a Hell of a lot). They did an abdominal girth: 60 inches…. that’s 5 full feet! We did not have any U/S to check fetal position. We relied on our exam and assessments. If the first twin was head down (vertex), that was all that mattered for the moment. Labor progressed and when she was close to crowning, she awkwardly and with a great deal of difficulty, maneuvered over to the stretcher and then once again, across the hall, moved onto the delivery table. She was asking for anesthesia. They provided that with some nitrous oxide or something by mask. The first baby was born spontaneously. A boy!! a BIG BOY! He weighed 9 LBS 6 oz! Wheeh! The doctor checked the 2nd baby’s position and it was vertex and moving down. I think they used some low outlet forceps and within 3 minutes, the 2nd baby was born. A girl!! An even BIGGER GIRL! She weighed 10 LBS 7 oz! Both were strong, vigorous and pink.
The placentas were delivered and Pitocin IV given (a Pit Drip we called it). She had no complications I can remember. These babies were just the biggest twins I had ever seen or ever did see so far…;-)
How about you? I have a poll on this page…please answer! I’m interested in your twin stories.

The young wife of a prominent local attorney arrived with her mother-in-law to be admitted to the labor room for delivery of her second child in the late 1970’s. She was about a month early, 35 – 36 wks. Her husband was away at a conference. Her belly was pretty big for her small frame. The doctors were all quite concerned about the size of the baby and how it would fit through the birth canal. They decided to send her to X-Ray for Pelvimetry. They would take films and measure the internal size of the bony pelvic inlet, spines and outlet, the compare those with biparietal diameter of her baby’s head. The film showed TWO baby’s heads, not one! Surprise! I’ll never forget the phone call the dad’s sweet refined little mother had to make to her son. She maintained her composure…”Thurston dear, we are at the hospital. Elizabeth is in labor, dear……..yes dear, I am quite aware that she isn’t due yet….Thurston dear, there’s more….. You are having twins darling……..Are you alright dear?? Yes..they are all fine…. we’ll call you back soon. See if you can come home, dear.” Elizabeth and Thurston (names changed for this story) became the proud parents of identical twin girls by vaginal delivery later that morning.

One of our OB staff nurses, Sue, had a sister having her third baby. She had 2 boys at home and everyone was hoping for a girl. Nobody ever knew the baby’s sex before the birth back then, unless you had an amniocentesis for medical reasons. Even then, many moms did NOT want to know and it was written on the chart that way. The mom’s labor progressed very quickly and soon she was in the delivery room, her sister Sue at her side. I was designated to wait outside the DR and let all the anxious staff know if it was a girl..
I couldn’t wait after I heard the baby crying. I peeked in- there was a little 5 pounder squirming on the Kreiselman! It was a boy! The doctor was saying “Check the belly—check the belly, I think there is another one!” Sue was huddled over her sister trying to help calm her while reaching back to hold oxygen oven the baby’s face. I came in to help. Quickly after that, another baby was born! Again, a squirming 4 or 5 lb baby boy! Surprise twins! Everyone was quite shocked! Sue was then holding the one oxygen mask over both babies together while hugging her sister. The boys turned out to be identical and quite handsome young men as they grew up.

Apr 2

1 Comment

Childbirth Evolves “You say you want a revolution”

The young pregnant women in the 70’s began to realize they wanted and deserved a better form of childbirth than what was available to them at their local hospitals. They wanted a more natural approach. The Lamaze techniques which started in France in the 50’s (from observations of the Russians) came to the US in the 60’s and made it into the mainstream of “flower children”. Although it wasn’t unheard of, that movement didn’t quite reach our neck of the woods in full force until the 70’s. Many medical staff were solidly unwavering in their principles and still wished to control the entire event.

The fathers were wanting.. and some rightfully so… demanding to be involved and included. The connection that was often witnessed between the couple was no short of amazing to me. I was young, very interested and eager to learn about this “natural childbirth”, so I often let the couples do what they wanted or had prepared and I offered help and support when I could.