Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

How one mom “Walked, moved around, and changed positions” to a successful hospital VBAC! October 23, 2009

Filed under: Birth/Inspirational Stories — NursingBirth @ 10:20 AM
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Science and Sensibility’s Healthy Birth Blog Carnival #2:  Walk, move around, and change positions throughout labor

 

This month’s Healthy Birth Blog Carnival is “Walk, move around, and change positions throughout labor.”  This is a repost from a story I wrote back in March however, I feel like it is a really great example of how important movement and position changes are to a successful labor and birth, especially a vaginal birth after cesarean (VBAC)!  This story has been a popular posts with my readers in the past and I hope by participating in this blog carnival it reaches and helps empower more and more expecting women out there!!  In reposting this story I have highlighted all the times where Alyssa used upright positions and movement to cope with pain, help her uterus contract more efficiently, help her baby find the best position in her birth canal, use gravity to her advantage, and be an active participant in her labor!  And there is no doubt in my mind that all of these things helped her have a safe, positive and empowering VBAC experience!

 

 

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Last week I had the honor to be a part of one of the most beautiful VBAC(Vaginal Birth After Cesarean) hospital births I have ever witnessed. I would like to share that couple’s story with you today as both a feel-good tale of personal triumph and a story of inspiration for all those moms planning a VBAC out there that might stumble upon my blog. Since this is a blog about “a nurse’s view from the inside” this story is probably much different than any other birth story you might have read from the mother or father’s point of view. But then again, maybe that isn’t so bad! Enjoy!

 

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It was ten to 11 o’clock am as I walked through the lobby doors of the hospital I work at, rushing towards the elevator so I could punch in on time. As the elevator doors started to close, a hand shoved through the crack, forcing the doors back open. “Please make room!”said the woman, a phlebotomist who works in the hospital, in a shaky voice, “Woman in labor here!!”Following behind was a very pregnant woman, huffing and puffing as she waddled into the elevator, followed by what looked like her husband and her mother. “Don’t touch any buttons!”said the phlebotomist, “We’re going right up to labor & delivery!” Since that was where I was headed too, I smiled at the husband and said, “Don’t worry, you’re here now and she won’t have the baby in your car! I work up on L&D so I’ll show you were to register.” Something told me that if this woman was truly in labor then she would be assigned to me since I was just starting my shift. But she had to “pass” triage first, so after helping the family to the registration desk, I hurried into the locker room to change into my scrubs.

 

 

 Fifteen minutes later the triage nurse came to the main desk, “I’ve got a term mom, 40 weeks 5 days, who’s five centimeters,” she said, “We’re gonna need to put her in a room…. And she’s a VBAC with a ‘birth plan’.” “I’ll take her!,” I said excitingly, knowing that I have my bestdays when I can assist a woman through labor, as opposed to getting stuck on the OR team or in the high risk ward running magnesium. (Not that those women don’t need a lot of TLC too, it’s just that I like labor the most!) Birth plans, natural unmedicated labor, and getting my patients out of bed…those are my specialties!

 

 I quickly set up the room across the hall as the resident finished the patient’s history and physical in the triage room. Then I quietly knocked on the triage room door and let myself in. The patient, Alyssa*, was standing by the bed, rocking her hips back and forth, as the continuous monitors strapped to her abdomen traced the baby’s heart rate and her contraction pattern. It looked like she was contracting every 3 minutes, and the baby’s heart rate was beautiful and reassuring. Her husband, Jared, was leaning nervously against the wall and her mom, Deb, was sitting quietly in the corner. I could really tell that Alyssa was lost in “Laborland” and I wanted to make the transition to her room as seamless as possible as to not break her rhythm and concentration too much. I quietly introduced myself and with the help of Jared and Deb, moved all of their belongings across the hall as Alyssa waddled behind.

  

 I could tell that Alyssa was coping well with the contractions while standing but a quick glance at her prenatal summary revealed that she was Group B Strep positive and would need IV antibiotics (our hospital’s policy and the midwife’s order) and hence, and IV. Now I feel that I am pretty skilled at starting IVs, but I have not yet mastered starting an IV with the patient standing and swaying! So in the two minutes between the contractions, I explained to the Alyssa what I needed to do before the admission process was complete: get 5 more minutes of continuous monitoring on the baby (to equal the “20 minute strip” my hospital’s policy requires before we can switch to intermittent auscultation), take a set of vital signs, draw three tubes of blood, start an IV, and ask a few more questions. “Give me 8 minutes sitting on the bed,” I said, “and I can have everything but the interview done. The rest of the admission can be done with you standing up.” “Okay,” she said, “I can do eight minutes.” Eight minutes later the IV was in, antibiotic running, labs drawn and sent, vital signs done, monitors were removed, and the patient was helped out of bed (Phew!! That was close!! J). And it wasn’t a moment too soon because Alyssa was having a lot of back labor and sitting in bed was just making it worse!

 

 

 

Then there was a knock at the door. Here’s how the subsequent conversation went down…

 

Me: “Who is it?”

Med Student: “It’s just the medical student,” (said as he walked right into the room)

(I hadn’t yet gotten a chance to ask Alyssa if she was okay with medical students so I just kind of looked over at her and Jared and tried to judge their reaction.)

Med Student: “Hi I’m Michael. I have to ask you a few questions.”

(Have? How about “Is it okay if I ask you a few questions? Sheesh!!)

Med Student: “Are you being induced today?” (asked as he stared down at his paper)

Alyssa: “INDUCED! DOES IT LOOK LIKE I AM BEING INDUCED!”

Med Student:“Okaaaaay. Umm, any problems with this pregnancy?”

Jared: “Do you really need to ask these questions right now? The resident already asked her that stuff.”

Med Student:“Umm yeaaaah, I do. There is a lot of repetition but we have to ask again.”

Deb: “Doesn’t her prenatal summary tell you all of that?

Med Student: “Ummmmm….”

Me: “With all do respect, Michael. But I think they are trying to tell you that they do not want any medical students. Or anymore residents for that matter. Okay? So I think we are done here.”

Med Student:“Ummm, what am I supposed to tell the resident?”

Me: “Tell her I said that the next induction that comes in is all yours.”

 

As the med student left, Jared, Deb, and Alyssa all looked at me simultaneously and said “THANK YOU!” “I don’t think he was getting the hint,” said Jared. “Yeah,” I said, “I figured he needed it spelled out.” In hind sight, I think this was one of the moments that really helped me to bond with this family because after all, I understand how difficult it must be for families to come into the hospital and have to work with a nurse that they have even never met during one of the most intimate experiences of their lives!

 

I spent the next fifteen minutes finishing up the patient’s admission assessment as quickly as I could. I told Alyssa that if she was having a contraction to just ignore me, and asked Jared to help answer any questions he knew the answers to. (Unfortunately, our hospital’s pre-registration does not include performing an admission assessment and hence, it has to be done on arrival to the hospital. Usually, if a patient comes in for false/early labor a time or two, it gets done then but Alyssa had not been to the hospital her whole pregnancy, which is great, but it meant that I did have to bother her with some silly questions during labor. Kind of a bummer, but with the help of Jared, it went pretty smoothly.) It was during the admission interview that I found out some of the details of Alyssa’s pregnancy and prior cesarean section. Alyssa had an unremarkable health history and a normal, healthy, uncomplicated pregnancy. She was a G2P1, but since her first baby was born by cesarean section, she technically was considered to be a “primip” (healthcare slang a woman who is about to deliver her first baby) regarding a vaginal delivery.

 

Jared told me that when their son was born two years ago, Alyssa was persuaded into an induction at 39 weeks for “LGA” (a.k.a. large for gestational age, which by the way is NOT recognized as an appropriate indication for induction of labor by ACOG), was first given a few doses of misoprostol to “ripen” the cervix, followed by pitocin to stimulate contractions and continuous external fetal monitoring to monitor those contractions, then given a couple doses of Stadol and eventually an epidural for the pain, followed by artificial rupture of membranes to place a fetal scalp electrode after the epidural dropped Alyssa’s blood pressure and caused a prolonged fetal heart rate (FHR) deceleration, then an intrauterine pressure catheter to assess if the pitocin induced contractions were “adequate”, and eventually a cesarean section after 1 hour of pushing in a back-lying position for “failure to descent & cephalopelvic disproportion (CPD).” Thirty minutes later baby Kevin was born at approximately 2:00am, weighing in at 7lbs, 5 oz.

 

In my opinion, Alyssa was a victim of the “cascade of interventions.” Many maternity interventions, including elective induction, pain medication, artificial rupture of membranes, epidural anesthesia, back-lying positions for labor or for birth, etc. have unintended effects. Often these effects are new problems that are “solved” with further intervention causing a domino effect that ends up creating yet more problems. This chain of events has been called the “cascade of intervention” and unfortunately often leads to vacuum extraction/ forceps delivery, episiotomies or 3rd or 4thdegree tears, and even cesarean section. Many of these women are often also then mislabeled with diagnoses like “CPD,” “failure to progress,” “failure to descent,” and at the end of it all, the obstetricians turn around and say, “Thank God we were in a hospital; look at all the technology we needed! So when will your repeat cesarean be??”

 

This time, however, things were different. After the birth of their son, Alyssa and Jared started to research more about labor and birth, VBAC, and natural birth. They interviewed and chose a doctor (Dr. Z) that was supportive of natural birth and VBACs, with the statistics to prove it! And here they were now, at my hospital, ready and rearing to go! Alyssa said that for the past few days she had been having contractions “on and off” but that they really started to get going at 8:00 am. When the resident had checked her on admission, her water spontaneously broke during the vaginal exam at 11:15am. It was now 11:45am and Dr. Z’s midwife entered the room. Although it had only been 30 minutes since her last vaginal exam, the midwife decided she would check Alyssa again since she seemed pretty active. And boy was she ever! The midwife’s exam showed that Alyssa had progressed to 7-8 centimeters! “I don’t think I can do this anymore,” Alyssa softly whimpered to the midwife. We all reassured her that she was doing so well and that things were getting more intense for a reason and to stick with it!!

 

The midwife then offered to help Alyssa into the shower to help alleviate her back pain. Alyssa seemed skeptical at first but we assured her that if it wasn’t helping, that we could get her right back out. So Alyssa agreed and the midwife and I, along with Jared, helped the patient into the shower. What happened for the next hour was one of the most beautiful displays of love, perseverance, hard work, and dedication I have ever witnessed. Alyssa turned her back to us and rested her hands on the grab bar on the shower and her head on the shower wall. Her cadence was this: Between contractions she would sway side to side, as if she was slow dancing. During contractions she would squat up and down, up and down, moaning in a low tone as she carried out her ritual. She just moved with the rhythm of her labor, listening so instinctively to what her baby and her body were telling her to do.Jared used the hand held shower head to spray Alyssa gently with a stream of warm water up and down her body, concentrating mostly on her lower back. I quietly entered the bathroom a few times that hour to check the baby’s heart rate with the portable doptone, trying hard not to disturb Alyssa’s concentration. Mostly, however, the midwife, her mother, and I stayed outside the bathroom door as to give Alyssa & Jared the privacy they needed to facilitate the progress of her labor.

 

At 12:35pm Alyssa told me that she was starting to feel a strong urge to push. The midwife entered the room and as Alyssa knelt in a hands and knees position in the tub, the midwife checked her cervix. To everyone’s surprise Alyssa only had an anterior lip of cervix left to go (this means she was about 9 ½ centimeters dilated)! After the next contraction, Jared and I helped Alyssa out of the shower to the toilet where we both used warm towels to dry her off. Then Alyssa walked over to the bed, “Can I kneel on my hands and knees?” she asked. “Sure!” we all said in unison, as we helped her up onto the bed. “I feel like I have to push!” Alyssa said convincingly and when the midwife checked her cervix, the anterior lip was gone…Alyssa was fully dilated at 12:45pm, only 1 hour and 55 minutes after arriving at the hospital! “You can start to push anytime,” said the midwife.

 

One of the best things about being a part of this experience was the fact that it was one of the only times that I have been present at a delivery where that a birth attendant has allowed the mother to use spontaneous or mother-directed pushing, as opposed to directed pushing. I knew that Alyssa was interested in using a variety of pushing positions for the second stage of labor from her birth plan and for the next hour and a half the midwife, Jared, Deb, and I helped Alyssa get into a variety of positions including right/left side lying, squatting, hands and knees, and kneeling.

 

(Side Note: I would like to digress for a moment to point out how important it is to be physically fit during your pregnancy whether you are planning for a natural birth or not. Many a woman I take care of blindly fills out a “birth plan” they find online where they can click on the boxes for options that sound “good” to them, without actually researching or thinking over what they are writing down. For example, they say that they want to try squatting during labor and birth, but couldn’t even do a squat at the gym pre-pregnancy. Although it is definitely true that a woman can sum up and realize an incredible amount of strength during labor and birth related to not only hormones but also sheer will power, it should also be known that labor is HARD WORK and pushing out a baby is HARD WORK which both require a great deal of physical strength and stamina. This is yet another reason why it is so important to follow a modified exercise plan and eat a healthy well balanced diet rich in protein and omega-3 fatty acids before, during, and even after your pregnancy.) Let’s continue with Alyssa’s story…

 

What was so amazing was that although there were plenty of times during the labor and pushing phase that Alyssa would doubt her ability to go on (“I can’t do this anymore!” “The baby isn’t moving?” “Is the baby moving?” “I am so tired!”), she never gave up on herself. Each time she made a comment like that, we all took it as a request for more support. And every time we gave her more encouragement, cheers, and reminders of her progress and goals, (“Keep going!”, “You are doing so well!”, “We can see so much more of the baby’s head!”, “She has lots of hair!”, “Just a few pushes more”, “You are so strong, you are going to do this!”, “You can do this!”), she found the ability to keep going! Towards the end of the pushing stage Alyssa was (understandably) exhausted and was pushing in a modified lithotomy position while Jared and I supported both of her legs. Then all of a sudden Alyssa popped up and said (and I quote)…

 

“I need GRAVITY! I need to be UP!” as she sat upright into a full squat and

PUSHED her baby’s head out with one gigantic ROAR!

 

“Whoa, whoa!” the midwife and I said almost simultaneously, “Easy, easy, baby pushes.” “Blow like you are blowing out birthday candles,” I said. The midwife checked for a cord around the neck (which there was none) and cleared the baby’s mouth and nose. And with only a few more “baby pushes” Addison Joy was born at 2:27pm!

 

The room erupted into cheers of excitement and tears of happiness! I put the baby skin to skin on mom as I dried her off with warm blankets and cleared her mouth and nose with the bulb suction. A quick palpation of the baby’s cord revealed that her heart rate was nice and strong and she was pinking right up! Jared and Alyssa kept hugging and kissing each other and talking to their new baby girl, “Hi Addison! Hi baby girl! I am so glad to finally meet you!”  The midwife waited until the cord stopped pulsating before she cut it (per mom and dad’s birth plan) and then checked Alyssa for any tears. Except for some swelling, she only had a small tear on her right labia that didn’t even require any stitches!! We kept mom and baby skin to skin for a full hour after birth and baby Addison nursed almost the whole time. When she was an hour old, I weighed her to satisfy mom’s curiosity and to everyone’s surprise the baby weighed 9 lbs 3 ozs!!!

 

So much for “cephalopelvic disproportion” huh!!

 

And it was as I handed baby Addison back to Alyssa that she looked up at me and said softly, “I needed to know my body could do it. I knew my body could do it! I really needed this. Thank you.” So as you can imagine, I started to well up. I have never felt so honored to be a part of something so special. What a privilege to have a job where I witness the miracle of birth and the miracle of motherhood every week!

 

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So let’s recap shall we. Alyssa, after having a cesarean section for her 7 lb 5oz son two years earlier for “CPD” and “failure to descent”, pushed out a 9lb 3oz baby after a 6 hour and 27 minute labor, including 1 hour and 42 minute of mother-directed pushing, without any pain medications or an epidural, monitored by intermittent auscultation, needing not a single stitch to her perineum! Her tools included good and relevant labor & birth preparation, appropriate and helpful family support, sheer strength, determination, and will power. The midwife’s arsenal included extensive knowledge of and experience with natural birth and labor support, a doptone, a trust in birth, and a belief in Alyssa’s ability to do it! No medications, no vacuums, no scalpels, no scissors, and no doubt!

 

Boy how I love my job sometimes :)

 

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*As always, names and any identifying information have been changed to protect privacy.

 

For more information on VBAC please visit: International Cesarean Awareness Network and Childbirth Connection

 

For more information on how you can move and groove through your labor check out: 

  • The Healthy Birth Practice Paper, written by Teri Shilling, MS, CD(DONA), IBCLC, LCCE, FACCE

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  • The Healthy Birth Your Way handout on movement in labor(PDF), produced by Lamaze International and InJoy Birth & Parenting Videos

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  • Companion tip sheets, “Maintaining Freedom of Movement” (PDF) and “Positions for Labor” (PDF)
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    The Good, The Bad, and The Icky on Vomiting in Labor October 19, 2009

    Filed under: Ramblings,Super Comments! — NursingBirth @ 11:46 AM
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    vomiting logo

     

    Submitted on 2009/10/18 at 9:43pm

    Comment left at: Top Ten Things Women Say/Do During Labor (And trust me… they are totally normal!)

     

     

    Dear NursingBirth,

     

    Hello, I know this is an old post, but I’ve been searching information on vomiting during labour for a few hours (lol!) and can’t quite find what I’m looking for.  So with the housework waiting I thought I should just come out with it and ask!  Your post is very informative and you seem lovely so I hope you are able to help me! (Or others who have been through it!)

     

    I have emetophobia (fear of vomiting), and find I am able to calm myself about the potential of vomiting (because I have had to face that fact that I can’t just escape it!), if  I

     

    #1: Know that “everything will be ok” if I do vomit. (i.e. Mainly that people won’t be disgusted, or freaked out and that someone will be able to deal with, well, the result, if I’m not able to.  Even though I’ve never vomited anywhere except in a toilet, it’s just the potential that terrifies me!  My husband is a wonder, and it’s only actually since being with him that I’ve begun to get over the phobia because he’s not scared about it, and not fazed by it).

     

    And

     

    #2: Remember that I can handle vomiting much better if it isn’t preceded by hours and hours of painful nausea.

     

     

    SO, I find myself trying to prepare mentally for the possibility of throwing up during labour, and I have some questions stemming from this for you (I know it is an irrational fear, and these questions seem trivial but they are things that really stress me out – I actually lose sleep over them – so I appreciate your answers):

     

    #1 Will the midwives be ok if I throw up all over the place? Will the staff get disgusted or freaked out?

     

    #2 Will the staff clean it up or will I or my husband have to?

     

    #3 What happens if it gets in my hair?

     

    #4 Will I choke because I might be lying down?

     

    #5 Will everything be okay if I do vomit?

     

    And, finally

     

    #6 Is it a different kind of vomiting – one that just kind of happens, rather than following hours of terrible nausea?

     

     

    Anyway, I don’t mean to waste your time, and many thanks in anticipation of any answers – I’m just trying to mentally calm myself so I can focus more on the really important things about labour – like my baby!!

     

    Sincerely,

     

    NervousMumToBe

     

     

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    Dear NervousMumToBe,

     

     

    First of all I am sending you one MAJOR cyber *HUG* right now complete with back patting and me saying “You can do this!!”  :)

     

     

    Second, you are NOT wasting my time so don’t mention it!!  I have written before about worrying, that is that “WORRY is the WORK of pregnancy!”  In her book Birthing From Within, certified nurse midwife Pam England tells the story about a patient of hers (Hannah) that worried a lot about having a natural birth experience after having had a highly medicalized birth with her first baby.  She writes that Hannah longed to hear her say things like “Don’t worry” and “Everything will be alright” but instead England encouraged her to face her fears.  She instructed Hannah to write down all of her worries and explore each of them with questions like “What, if anything, can you do to prepare for what you are worrying about?” and “If there is nothing you can do to prevent it, how would you like to handle the situation?” 

     

     

     England lists the “Ten Common Worries” of Labor as:

     

    1)      Not being able to stand the pain

     2)      Not being able to relax

     3)      Feeling rushed, or fear of taking too long

     4)      My pelvis not big enough

     5)      My cervix won’t open

     6)      Lack of privacy

     7)      Being judged for making noise

     8.)      Being separated from the baby

     9)      Having to fight for my wishes to be respected

    10)  Having intervention and not knowing if it is necessary or what else to do

    I would like to add #11:

               11) Fear of pooping in labor/Fear of embarrassment regarding bodily functions

     

     As you know I am a labor and delivery nurse and have estimated that I have been present at over 300 births during my career and still, I would have to say that when it is my time to give birth, #1 through #6 are top on my list of worries!!  And I witness the amazing power of women everyday!!  So NervousMumToBe, don’t *worry* about “worrying” about vomiting!  I am so happy that you are FACING YOUR FEARS!!  If vomiting is something that you are really concerned about, no matter how trivial it might seem to others, it is important to you and that is all that matters!  So I applaud you! 

      

    Okay now that the most important thing is out of the way (i.e. the hug) lets get down and dirty about the #2 thing on every pregnant woman’s mind…VOMITING IN LABOR!!  (If you are wondering what the #1 thing on every pregnant woman’s mind is it is POOP.  Don’t believe me?  Check it out here.)  I want to preface the following post with a few things in the interest of full disclosure:

     

    • I am drawing from both my experience as a labor and delivery nurse (as well as a medical/surgical nurse and nurse’s aide) and the research I have read on this subject to write this post as I do not have any personal experience with going through labor myself.  That being said…

     

    •  I have thrown up a time or two myself (I did go to college after all :) ) and know how it feels to do so.

     

    • Some readers might have personal experiences that are different than what I describe.  However it is important to remember that if I make a statement like “In general I have found most women in labor to do x, y, or z” I do not mean to say that there isn’t anyone out there that had a different experience.  There are exceptions to every rule. 

     

    • Although I have only been working as either a nurse or nurse’s aide for approximately 5 years (which I understand does not make me the most experienced nurse out there) I have certainly been working directly with patients for long enough to know a thing or two about bodily functions, including when they are likely to happen, how to make someone feel better, and how to clean them up.

      

    • I cannot speak for every labor and delivery nurse and midwife out there.  After all, I have only worked in one labor and delivery ward (not counting nursing school clinical).  But since you asked me I will answer your questions as if I was your nurse or midwife.  I will also take into consideration what the other nurses and midwives I work with on a daily basis would do and how they too would react to the situations you present.   

     

     

    Now to some answers!!  I will take your questions one at a time:

     

     

    #1 Will the midwives be ok if I throw up all over the place? Will the staff get disgusted or freaked out?

    Yes and No!!  YES!  The midwives and the labor and delivery nurses will be okay if you throw up all over the place and actually, they probably will not even bat an eye if you throw up!  And NO!  The staff will not get disgusted or freaked out if you throw up!  If bodily functions bothered us, we wouldn’t be working in healthcare!  I have been thrown up on before…more times than the average person for sure!  I have been splashed with blood, amniotic fluid, pee, spit, and mucus.  I have also cleaned up my fair share of explosive diarrhea.  And if I do get splashed with something I just kept on doing what I was doing until I have a break where I can go change.  (Remember L&D nurses usually have to wear hospital scrubs just in case they end up in the operating room.  The other bonus to this set up is that if you get splashed with something gross then you just go in the locker room and change into a new pair of hospital scrubs!)  I am sure over the course of time there has been some burnt out nurse that has said something really nasty or insensitive to a mother if she has thrown up but in reality, it’s all part of the job and the vast majority of nurses and midwives don’t get bothered by vomit!

     

     

    #2 Will the staff clean it up or will I or my husband have to?

    This question is assuming two thing:  #1 That you are going to vomit (remember not all women vomit in labor) and #2 That if you do vomit that you will make a mess (remember not all women who vomit miss the bucket or don’t have a chance to throw up in a bucket).  That being said…

     

    I know I can’t speak for every single nurse out there but I would NEVER EVER expect a husband (or any coach for that matter, including the mother herself) to clean up something like that.  After all it is the husband’s (or partner, coach) role to support the mother and if the mother did throw up, say, on the floor, I would ask the husband (partner, coach) to stay with the mother while I went to grab some towels to clean it up.  And then I would clean it up quickly.  And then it would be a non issue!  Done! 

     

    One time I had a mother who was taken off guard by her need to vomit and accidentally threw up all over her bed.  She was very apologetic but apologies were not necessary.  I knew that she didn’t mean it!  With the help of her husband I walked her into the bathroom and had her sit down on the toilet to pee.  Her husband stayed in the bathroom with her.  Within 5 minutes I had the completely remade the bed with clean sheets.  Then I helped her into a fresh, new, warm gown and then back to bed.  It was like it never happened!  We all moved on and no one mentioned it again.  After all, who was thinking about a little vomit when there was a BABY about to be born! 

     

    I learned from that experience and ever since then I always make sure that I give every mom a bath bucket when she is admitted and I put it right on her bedside table so that if she needs to throw up, it is right there for her.  Because I do this, I have rarely ever had a mother throw up in labor and not use the bucket.  Since you have a concern about vomiting, I would recommend that you ask your nurse for a bucket when you get to the hospital, just in case.  And when I say bucket I mean bath bucket (or wash basin), not those ridiculous kidney shaped “emesis basins” that wouldn’t even be helpful to catch ladybug vomit!

     

    emesis basin and wash basin

     

    Remember, although it is not rare for a mother to throw up in labor, it is rare that she throws up all over the place, or has no idea that it is coming.  In my experience the vast majority of moms who vomit in labor do indeed make it into the bucket and therefore, there is nothing to clean up!  Also remember that labor vomit is different that “stomach flu” vomit.  That is, there is no risk to me as the nurse of getting sick from a laboring woman’s vomit because it is not caused by illness.  I’d rather clean up your labor vomit over my own stomach flu vomit any day!

     

     

    #3 What happens if it gets in my hair?

    If you were my patient and you started to vomit I would hold your hair back.  And I am sure that your husband would do the same for you too.  That way you wouldn’t get any vomit in your hair at all.  Have you considered putting your hair into a pony tail or clip while you are in labor?  If your hair was up it would be very unlikely that it would get any vomit in it.  Perhaps you can pack a few extra clips or elastics into your hospital bag just in case you need them.  If you don’t usually wear your hair back you may want to consider wearing a few hair elastics around your wrist so that they are readily available if you need them to tie your hair back if you feel nauseous.  I also have been known to cut the opening off a rubber glove and use it as a make-shift hair tie for just this type of circumstance! 

     

    However if a little bit of throw up did get in your hair and if I was your nurse I would probably wet a warm washcloth and clean it out.  And then I would put your hair into a pony tail or clip for you to get it out of your face.  If it was really bad (I have never seen this but I suppose that technically it could happen) and if your midwife allowed, I would help you into the shower.  After all, many women find laboring in the shower to be extremely soothing and helpful!

     

     

    #4 Will I choke because I might be lying down?

    NO!  You will not choke, even if you are lying down.  Only people that are unconscious, have an impaired gag reflex, or are debilitated in some other way have a risk of choking on their own vomit.  I have never seen a conscious laboring mother choke on her own vomit…NEVER.  Why?  Because every single healthy, able-bodied, conscious person sits up or leans over automatically when they start to vomit.  I have never even seen a mother who was positioned flat on her back and numb from the breasts down for a cesarean choke on her own vomit.  Why?  Because every single healthy, able-bodied, conscious mother in that situation automatically turns their head to the side to vomit. 

     

    If necessary every hospital room and operating room has (or at least should have) a suction canister in it with a yankauer suction set just in case a mother does lose consciousness and her mouth needs to be suctioned.  You might not have seen it when you toured your hospital because most birthing suites keep that kind of equipment behind pictures or in cabinets so that the room doesn’t look too “hospital like.”  But they are there.  I personally have only had to use the yankauer suction set ONE TIME as a labor and delivery nurse and I used it because my patient had an eclamptic seizure (a rare complication of preeclampsia) and when she came too she was really out of it (“post-ictal”) and her mouth needed to be suctioned because it was full of secretions.  That’s it, one time only.   

     

     

    #5 Will everything be okay if I do vomit?

    YES!  In fact, labor and delivery nurses get excited when they see a patient vomit because vomiting is usually a sign of transition which is the last stage of active labor (usually 7-10 centimeters) right before a women begins the pushing phase.  Remember whether or not she has been eating throughout early labor, a woman may still vomit when she enters transition so it is not necessary to starve yourself on purpose because you are afraid to vomit later on.  In fact, some women vomit because they have done just that!  (I know I personally get very nauseous as well as get a headache if I haven’t eaten anything all day).  I always think of it as a way the body is “making more room” for the baby! 

     

    Also since vomiting, like holding your breath or making a bowel movement, is a vagal response, it inadvertently helps your cervix dilate and hence, is a great sign to a labor & delivery nurse!  The body does awesome things to help the process along!  So really it is not just okay if you vomit, it is GREAT if you vomit because it may help you cervix dilate!  I also want you to know that you will not hurt anything if you vomit, including the baby or your cervix.

     

     

     

    #6 Is it a different kind of vomiting – one that just kind of happens, rather than following hours of terrible nausea?

     

    In my experience as a labor and delivery nurse most women who have a natural, unmedicated, spontaneous labor do NOT have hours and hours of nausea before they vomit.  Instead, once there labor really starts to ramp up for the last few centimeters they get a feeling of nausea that gives everyone enough warning to grab the bucket and then they throw up.  After throwing up, the vast majority of women have told me that they feel better.  It is very rare that I have taken care of a woman who continues to throw up once they are 10 centimeters dilated and begin to push or is nauseous for hours and hours before they vomit.  That being said…

     

    Nausea and vomiting are very common side effects of narcotic pain medications (e.g. stadol, nubain, demerol, morphine etc.) as well as ALL forms of anesthesia (including labor epidurals as well as spinal blocks often performed for cesarean sections).  Because of this, some physicians and midwives prescribe an anti-emetic (aka anti-nausea medication) like Phenergan, Zofran, or Reglan to be administered with the narcotic, epidural, or spinal to counter act this side-effect.  Sometimes it helps, sometimes it doesn’t.  Because you have such a fear of vomiting I want you to be aware of this fact.  

     

     

    So there you have it: the skinny on vomiting in labor!  I hope this has helped calm your fears and worries however if you have any more questions about this topic please feel free to leave a comment!! 

     

    Thank you for writing in to me.  You are certainly not alone in your fears!!!  I know that your question will help other women out there who experience the same fears as you!  GOOD LUCK with your upcoming birth and CONGRATULATIONS to you!!!  And remember, although birth might be one of the messiest experiences of your life, no amount of fluids, cursing, farting, pooping, striping naked, howling, crying, peeing, bleeding, or vomiting will take away from how honestly empowering, mind blowing, and touching this experience can be for you and your family!!

     

     

    Sincerely,

     

    NursingBirth

     

    No Doula in the Name of Privacy? Oh Come On! September 26, 2009

    Filed under: Ramblings,Super Comments! — NursingBirth @ 9:35 AM
    Tags: , , , , , , , , , , , , , , , , , , ,

    This comment was recently left by a reader named Jessica under one of my older posts.  Since I read every comment that is posted on my blog I happened to stumble upon it this morning.  When I read it I couldn’t help but think “I Hear Ya Sister!!!”and felt that it was so well stated that it needed to be its own post!  I know that there are quite a few doulas out there that read my blog and I just wanted to take this opportunity and give a shout out to them all and say thank you for all you try to do to educate women before they get to me on L&D!  Unfortunately, they don’t all listen but I hope you know that there is at least one L&D nurse out there that appreciates your efforts, both before and during labor!!!

     

    For all you expecting moms out there please check out DONA’s website to learn a bit more about what a doula is, how you can find one, the effects a doula can have on your birth outcome and experience, and how a doula can advocate for you!

     

    And just for the record, there is NOTHING private about a hospital birth experience.  Even in the most well meaning hospitals with the most well meaning birth attendant and the most well meaning nurse(s).  Albeit some women’s hospital births might be more private than others and I personally have had the priviledge to be a part of a few totally amazing hospital births.  But to not hire a doula for your hospital birth (especially at a university hospital!) because you want a “private” experience is a very VERY naive and misguided idea!  I am not saying that to hurt anyone’s feelings and I am certainly not judging anyone out there who decided not to hire a doula for one reason or another.  I am just telling it like it is.  Some food for thought…

     

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

     

    Hi NursingBirth!

    I am a certifying doula and have recently had an interview with a perspective client. She is 36wks pregnant with her first. She was strongly considering a doula, but everyone else in her family was on the fence, and pushing a “private” birth experience. However, they are planning a delivery at a university hospital, she has yet to see the same health care provider throughout her prenatal care, she has no idea which one will be at the birth, or if it will even be someone she has met. They are planning a natural birth. She assured me that the hospital she is birthing at offers a multitude of birth options, including water birth, birth ball, position changes, etc… and the childbirth education from the hospital has given them confidence in their ability to get what they want from this birth. After much “deliberation” they decided that they were not going to hire a doula, based solely on their confidence in the hospital to give them what they want, and their desire for privacy. While I can completely respect their privacy request, I fail to see how birthing in a university hospital will give her much if any privacy…AND if she doesn’t even know who will be her health care provider at the birth…how is she confident that the hospital will give her what she needs? I wish there was some way to help open her naive eyes to the reality of birth in hospitals today. Her chances of getting to work with a mother friendly doc that understands and respects natural birth have got to be low! Reading your blog was comforting (because I know there are others who struggle with this) and depressing(because we have to struggle with this). I don’t want to have her hire me for her VBAC next time around. I want her to have the birth she desires now. I realize there isn’t much I can do for her at this point, which is why I am here, leaving my frustration with a bunch of like minded individuals. I am hoping things will go well for her and in the mean time, I’ve let her know that I am and will be available until the baby is born. just in case. Thanks for the space to rant.

      

    Sincerely,

    Jessica

      

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    Jessica, you can rant here anytime!!!  I Hear Ya Sister!  Loud and clear!!

     

    And now I leave you with one of my FAVORITE Monty Python skits of all time.  I have seen it a million times but it is still as hilarious (and eerily true) each time I see it.  Notice how the doctor invites in an army of people to watch.  It often feels like that where I work no matter what I do!!!

     

     

    The WORST Idea Since Routine Continuous Fetal Monitoring for Low Risk Mothers September 7, 2009

    Filed under: In The News,Ramblings — NursingBirth @ 9:33 PM
    Tags: , , , , , , , , , , , , ,

    My husband (being the techie cutie that he is) reads CNET news, a website about computers, the Internet, and groundbreaking technology as part of his morning routine.  The other day, while I was enjoying my Kashi cereal and checking out the latest blog posts on my Google Reader, my husband hollered over to me from his office and said,“Hey Melissa, have you heard of LaborPro?”  Until that moment I was having a pretty good Sunday morning.  I mean, I woke up refreshed and smiling, the sun was shining, and I was looking forward to what I felt was going to be a “good” day at work.  But my attitude quickly turned from happy-go-lucky to blinding rage when he uttered those eight little words. 

    (Okay, okay, so I think I am being a bit dramatic.  Maybe blinding rage is a bit strong.  But I was pretty upset!!)

    So what is LaborPro and why did it put me into such a tizzy you ask?  According to Trig Medical’s website (the Israeli company that is developing and recently won a Frost & Sullivan Technology Innovation of the Year Award for this GARBAGE), LaborPro is “a novel labor monitoring system that using ultrasound imaging measures continuously and objectively fetal position, presentation and station along with cervical dilatation. LaborPro quantitatively assesses and records vital labor parameters in real-time to enable obstetricians to make informed and accurate decisions throughout the labor process to improve both the quality and cost of obstetric care.”

     

     

     

    The website lists LaborPro’s capabilities as able to:  

    • Determine continuous station & position of fetal head by ultrasound imaging,
    • Provide radiation-free pelvimetry & birth canal modeling.
    • Perform one-step computerized “non-invasive” trans-vaginal digital examination (I’ll touch on that in moment)
    • Determine intermittent or continuous accurate measurement of cervical dilatation
    • Record comprehensive labor data recording

     

    It also toutes its “unique benefits” as the following: 

    • Non-invasive, precise measurement of station & position
    • Improves assessment of non-progressive labor
    • Supports decision-making before operative delivery
    • User friendly, on-screen display of all labor parameters
    • Enhances patient comfort and sense of security

     

    Okay okay okay….Just HOW does it do this you ask?  Well it’s EASY!  (*rolling eyes*)  Well according to the website’s one mintute educational video (check it out here, it’s worth it).  FIRST you have to place “just four little electrodes” externally on the mother’s pelvis in order to continuously assess fetal station and position and also enables the user to ”recognize CPD early”.  SECOND you just have to clip (or screw) “just a few position sensors” to the woman’s cervix to accurately and continuously measure cervical dilation.  And THIRD you just have to screw “just a small little electrode” into the baby’s head.

    Fetal Scalp Electrode (notice the little corkscrew tip)

    Close up of a fetal scalp electrode, or FSE (notice the little corkscrew tip, that screws into the baby's scalp.)

    According to Frost & Sullivan, the organization that awarded Trig Medical for the LaborPro technology writes, “The LaborPro is staff and mother-friendly and requires only basic training in ultrasound usage, obviating the need for an obstetric ultrasound expert,” adds Ms. Prabakar. “Moreover, the technology employs non-invasive, radiation-free pelvimetry as well as a single-step computerised digital examination. All labor progress tracking data including the fetal heart rate monitor are integrated in the LaborPro display and automatically recorded by the system, which helps reduce staff workload.”

     

    Oh great!  We only need “basic ultrasound skills” to work it!  (*double eye rolling*)  Here’s a novel idea!  How about every hospital (including my own) in the United States that has a L&D floor actually provide labor support training to their nurses instead!  That would go a lot farther for us than freaking ultrasound skills!! 

    (Just for the record, my hospital does NOT include labor support training as part of orientation and we are NOT alone.  At my hospital, if you want to learn how to provide labor support you have to seek out other learning opportunites on your own, like I had to.  But we do get extensive training on how to work and interpret the fetal monitor.  Oh and about 1/3 of our three month orientation is dedicated to learning how to care for a patient who is being induced.  In fact, I had to teach myself how to do intermittent auscultation and hence, I am one of the only nurses that I work with that isn’t “scared” of intermittent auscultation and will actually advocate for it!) 

    The most terrifying thing is that although at this time LaborPro is not available in the United States (Oh Hallelujah!!!) there is another company called Barnev based out of Andover, MA that has developed an almost identical product they call BirthTrack™ Continuous Labor Monitoring System which they describe as “a revolutionary continuous labor monitoring technology that provides obstetric caregivers invaluable, precise, objective, real-time information about the physical progress of labor. The BirthTrack System provides tools for a more informed decision making process through which hospitals can reduce the risks and costs of childbirth and assure the safety and comfort of mothers-to-be and their babies.”  I remember hearing about this product a couple of years ago when it was still in “development.”  Well guess what?!  Development is over!!  Marketing here we come!!  (GAG me!)

     

    So now there are at least TWO companies that are actively marketing this HORRIFIC, INHUMANE, and OUTRAGEOUS product.  Just wait  until LaborPro makes it to the United States (which according to their website they are actively persuing).  Then they will probably start to compete with eachother!  Now now only will labor & delivery wards around the country have to deal with Similac and Enfamil representatives competing for our money and attention in house (which already makes me sick to my stomach), but now I have to worry about this??!!  THIS IS TERRIFYING!!!

     

    I’m telling you right now, I will UP AND QUIT my job and never look back if either LaborPro or BirthTrack EVER  appears in even just one, JUST ONE of my hospital’s labor rooms.  QUIT ON THE SPOT!  And I will make a Hollywood exit too!  A HUGE scene!!!  Hooting and hollering!  You just wait!!  LOL!  As if our moms aren’t already strapped down enough with the often unnecessary and sometimes downright harmful technology we already have.  This is just TOO MUCH TO BEAR!

    I have taken care of MANY a laboring woman (often as a result of an induction, mind you) who are connected to:

     (1)  an IV line with IV fluids and Pitocin running through,

    (2) an electronic fetal monitor to measure fetal heart rate,

    (3) a tocodransducer to measure contraction pattern

    (OR a fetal scalp electrode to measure fetal heart rate and an intrauterine pressure catheter to measure contraction frequency and strength),

    4) an epidural catheter in the back giving a continuous flow of anethetic and narcotic medications into the spinal column,

    (5) a foley catheter in the bladder since it is very rare that one can empty their bladder with an epidural,

    (6)  a pulse oximeter to continuously measure blood oxygen level (necessitated by the epidural),

    (7) a blood pressure cuff to record one’s blood pressure every 15 minutes since an epidural can drop your blood pressure dangerously low, and finally

    (8) if the baby has shown any signs of distress, an oxygen mask for your face!

     

    Well I have a message for both Trig Medical and Barnev, LABORING WOMEN DO NOT NEED ANY MORE THINGS SHOVED UP THIER VAGINA!!!!  And furthermore,  CLIPING ANYTHING TO A WOMAN’S CERVIX OR SCREWING ANYTHING INTO A BABY’S HEAD DOES NOT COUNT AS “NON-INVASIVE”!!!  LABORING WOMEN AND BABIES ARE NOT ROBOTS THAT DON’T FEEL ANY PAIN OR DISCOMFORT!!!!  RESEARCH HAS SHOWN TIME AND TIME AGAIN THAT LESS IS MORE WHEN IT COMES TO LABOR FOR HEALTHY MOMS AND BABIES!!!  CONTINUITY OF CARE IS MUCH MORE EFFECTIVE, LESS PAINFUL, LESS INVASIVE THAN ANY “COMPUTERIZED FINGER.”

    Furthermore, LaborPro and BirthTrack are a slap in the face to every labor and delivery nurse that cares about giving appropriate, effective, competent, physiological, and compassionate care to childbearing families.   Unfortunately I would bet my hard earned money that at least half of the doctors I currently work with would think that this is a good idea. 

    Okay, okay, now that I am all riled up again I have to go to work  :(    Please check out Rixa’s post over at Stand and Deliver about BirthTrack.  It was written about a year ago and I stumbled upon it when I was searching for a picture of a fetal scalp electrode!!

    Change has GOT to come!  It’s GOT to!  For the health and wellness of our mothers and babies!!  Remember ladies, YOU actually have more power than ME and all the other L&D nurses out there!!  That’s right!  If you do not hire birth attendants that do not support evidenced based medicine and physiological birth and do not patronize hospitals that do not support a family-centered approach to maternity care then and only then will they start to listen.  You know why?  Because when the customers aren’t comin’, it hits them where it hurts… in their WALLET!!

     

    Believe! A Tear-Jerkin’ Inspirational Midwifery Ad September 4, 2009

    Filed under: Birth/Inspirational Stories — NursingBirth @ 8:01 AM
    Tags: , , , , , , , , , , , , , ,

    The other day I stumbled upon a YouTube video advertisement for a midwife in Albuquerque, New Mexico via a friend’s facebook page.  You’d think that I must get sick of watching videos of births and babies since I am, after all, a labor and delivery nurse but alas, I am a true birth junkie and just can’t get enough!!  I don’t know anything about the midwife in the movie but I have to say that not only do I BELIEVE everything she quotes in the video but I wish that every health care professional that provides care for childbearing familes felt and practiced the same way as she does! 

     

    I believe that every mother DESERVES a midwife and that every baby DESERVES to be born into gentle hands!

     

     

     

    The following is from Citizens for Midwifery:

     

    The Midwives Model of Care

    The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes.

    The Midwives Model of Care includes:

    • Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
    • Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
    • Minimizing technological interventions
    • Identifying and referring women who require obstetrical attention

     

    The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.

    Copyright (c) 1996-2008, Midwifery Task Force, Inc., All Rights Reserved.

     

    Natural VBAC Hospital Birth: One Reader’s Empowering Experience September 3, 2009

    Filed under: Birth/Inspirational Stories — NursingBirth @ 9:18 AM
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    Dear NursingBirth,

      

    I wanted to share with you my birth story.  I thought since I did an all natural VBAC, it might be something you would want to share.  Thanks for the posts.  YOUR blog helped me get though my second birth! Your stories of inspiration that you have are amazing, and just your general  tone.  The fact that there are nurses out there like you made me have the confidence to trust the nurse with me, but also not be totally trustworthy. It helped me realize that I am the final decision maker.

     

    In preparing for my VBAC I read your Injustice in Maternity Care Series and your story “I Needed to Know My Body Could Do It!”: A VBAC Story over and over.  I also read Active Birth by Janet Balaskas which I think helped me a lot, and with our first daughter (my c-section) we took Bradley classes so we both thought we were so prepared.  This time I had my mom, a friend and my husband as my birth team and we took control, which reading about it from your point of view gave me the courage to do so!!!


    Thanks for all you do!  I love the blog!

     

    Sincerely,

    Katie C.

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    Dear Katie C.,

     

    I would LOVE to reprint it and am honored that you would even send it to me!  Thank you for reading and THANK YOU for being such an awesome and empowered woman and mother!!  It is women like you that are an inspiration to ME!

     

    I just love everything about your birth story!!  First off, CONGRATULATIONS on your VBAC and on the birth of your daughter!!  What a wonderful time for you and your family!  It also must be really nice to NOT have to recover from major abdominal surgery and take care of a newborn and 3 year old!  Second, one HUGE pat on the back to you for choosing to go back home during your initial trip to the hospital when you were found to be 2 centimeters.  That took A LOT of courage and trust in your body and your abilities, especially since the on-call doctor was pressuring you to stay.   And I completely agree with you; choosing to labor at home until you were more “active” most definitely had a significant impact on your successful unmedicated VBAC.  Thirdly, KUDOS to you for being an active participant in your birth!!  It no doubt helped your labor progress to be upright and moving during your labor!  I am so proud of you!!  While it’s true that no one can really “plan” their birth, you did everything you absolutely could to stack the cards in your favor!!  Yay!  Yay!  Yay!!!

     

    Thank you again for reading and sharing!

     

    All My Best,

    NursingBirth

     

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    Katie C’s VBAC Birth Story

    College Station, TX

     

    Starting on Friday, May 22, I started having very mild but consistent contractions at 5 minutes apart at lunch time.  The rest of the day they came and went, some getting farther apart but stronger slowly as the day went on.  I also had a lot of brownish and pinkish spotting.  Figured that maybe I was in very early labor.  Did my usually stuff that day and went to bed about 9:00pm, just in case this was it. Saturday morning I woke up about 1:00am with contractions strong enough that I couldn’t sleep.  I got up and ate some peanut butter toast and drank a bunch of water and tried to go back to sleep.  Contractions were about 7 minutes apart but stronger and enough so that I was having a hard time sleeping.  Likely because I was excited.  Got up and took a bath but that didn’t help.  Tried to go back to sleep.  Got up and ate 2 huge bowls of apple cinnamon cheerios.  Finally fell back asleep about 4:30 am.  Woke up at 7am and was just very tired.  Contractions were completely bearable but figured that we were starting (maybe) and so I had Madison go to Jaxson’s (and George and Amie) house for a few hours while my mom and I stayed home to see if anything would progress.

     

    Lamaze International's Tips for a Normal Birth #5: Eat and drink as your body tells you to. Drinking plenty of fluids during labor will keep you from getting dehydrated and give you energy.

    Lamaze International's Tips for a Normal Birth #5: Eat and drink as your body tells you to. Drinking plenty of fluids during labor will keep you from getting dehydrated and give you energy.

     

    As the day went on they got stronger but not really closer.  I called L&D and she said 3-5 minutes apart, not able to talk through them, so I just figured I would wait.  Wasn’t ready to go to the hospital yet anyway.  I called Meredith (a friend), who was working about 2 hours away, to let her know that she might have to come back that night. We decided that she would come back that night instead of waiting for a call at 2:00 am and have to drive then.

     

    Lamaze International's Tips for a Normal Birth #6: Think carefully about who you want to give you support during labor and birth. Consider hiring a doula or other professional labor support person to give you, your partner, and any other support person who's with you, continuous emotional and physical support.

    Lamaze International's Tips for a Normal Birth #6: Think carefully about who you want to give you support during labor and birth. Consider hiring a doula or other professional labor support person to give you, your partner, and any other support person who's with you, continuous emotional and physical support.

     

    My back started hurting and I called another friend of mine who does massage. She wanted me to come to her studio, but I really didn’t want to leave the house, so I decided to stay home. Rob called his mom and went to meet her and take Madison to her house so that we wouldn’t have here with us. By the time Rob got back, about 6:30pm, contractions were 5 minutes apart and getting stronger. I could still talk and walk, but it took effort. I called Meredith back and she said she was on her way to my house. At 7:30pm I started to panic.  The contractions seemed very strong to me, I was concentrating on them and they were consistently 5 minutes apart, so we decided to head to the hospital.  I called Meredith and told her to meet us there.  Once I got there, my contractions stopped pretty much, likely due to my nerves.  They got me into a room and set and checked me and I was 2cm and 80% effaced.  I was devastated!  I told them I wanted to go home.  The doctor on call was leery of that since I was a VBAC and they said they would really like me to stay but I refused and we packed up and came home.  (In hind site, this was the reason it all worked out!! Best Decision!!!)

     

     

    I went to bed disappointed and tired, since I had been contracting for nearly 30 hours at this point and I just wanted to either be in labor or not.  I ate a snack and went to bed.  At about 3:00am I was woken by very strong contractions, 7 minutes apart, strong enough that I would flip to hands and knees in bed and rock and moan through them. Rob decided I was in labor, though I was still not sure!  LOL!  I started just sleeping in between them.  (Must have been some natural coping mechanism, since I did it until about 6:30 am!)  We started timing for real at 7:00am.  Meredith came over and she helped my mom.  My mom would time the start to start and Meredith would time the duration. They were about 5 minutes apart with about 30 seconds of what I would call pain.  The actual contraction would last about a min or longer.

     

     

    As the morning went on, I could no longer do anything during the contractions except hang onto Rob and moan.  Contractions got stronger and longer.  They were 4-5 minutes apart, and lasting (pain) about 70 seconds.  During one contraction while I was hanging on to Rob I had a huge rushing feeling, almost like a pushing sensation (or so I thought) so I just said, “We have to go NOW!” We packed up and went up to the hospital.  I had 4 contractions in the car, which were the hardest ones!  [At that point I preferred to be standing during them, since sitting or lying down was excruciating.] We got back to the hospital and I was moaning and hanging on Rob and everyone in the ER was looking at me funny.  It made me laugh.  They probably all thought I was crazy!  

     

     

    I went back up to L&D and they put me in the same room and got me all set up again.  The nurse said, “We were waiting for you!” I was so nervous that I would only be 3 centimeters and they wouldn’t let me go!  She checked me (about 11:00am) and I was 6cm, fully effaced!!!  I cried when she told me, I was so happy!!  Rob, Mom and Meredith clapped!  LOL!  They told me I had to stay.  I said that was fine!  They put me on the monitors and said I would be able to get off of them, but then the Dr. on call said “NO!” so I was worried I would be stuck in bed.  The nurse said, “You can move as much as you want, so long as the cord is long enough,” so I got out of bed and stood next to it for most of the day.  We said I didn’t want to be checked again except by the doctor or if they thought I was complete (i.e. pushing) so when the doctor got there at 1:00pm she checked me and I was a stretch 8!! I was still concerned that it wasn’t going to happen, but everyone else was excited.

     

    Lamaze International's Tip #4 for a Normal Birth: Plan to move around freely during labor. You'll be more comfortable, your labor will progress more quickly, and your baby will move through the birth canal more easily if you stay upright and respond to the pain of your labor by changing positions. Try rocking, straddling a chair, lunging, walking and slow dancing.

    Lamaze International's Tip #4 for a Normal Birth: Plan to move around freely during labor. You'll be more comfortable, your labor will progress more quickly, and your baby will move through the birth canal more easily if you stay upright and respond to the pain of your labor by changing positions. Try rocking, straddling a chair, lunging, walking and slow dancing.

     

    Transition for me was the second hardest thing I have ever done.  I refused pitocin (which they really didn’t push since I was a VBAC) and did not let them break my water. I stayed at a 9 centimeters for almost 3 hours, then at 9 ½ centimeters for a while until I begged them to stretch my cervix!!  LOL!  I was on the bed with the back raised on my hands and knees and suddenly had a contraction that felt better when I kinda of pushed at it. My mom went to get the nurse and she tried to check me like that but said I really needed to lie down.  I said I didn’t want to push lying down and she said, “Sweetie you can push however you want, but I need to make darn sure you are complete so you don’t swell.” I knew that was true so I got down and she checked me and then had the doctor come in and doctor said, “I’d call that complete!” I was so freaking happy! However I was also exhausted and once I was lying down, though I was hurting, I just couldn’t get back up again.  They broke my water sometime in there.  [I think it was earlier when I was at a 9 ½ centimeters but I can't remember.]

     

     

    The first few pushes I really thought I was doing it but I think the contractions were just not strong enough.  I actually asked the doctor how far down Hana had to be to use the vacuum!  I was exhausted!  The doctor said that she wasn’t going to use the vacuum, so I was just going to have to push!  I started pushing about 4:45 pm.  She would come down (once I finally figured out just how freaking hard you have to push!!) and then scoot back in.  They explained to me that a little bit of pitocin would help to bring the contractions a little closer together, so I would be more effective in pushing, since I was having over a minute between them and Hana would just scoot back in.  I finally agreed to it at about 5:45pm.  The started it at about 6pm.  The doctor suggested a pudendal block, in case I needed an episiotomy (which while I wanted a natural tear, I wasn’t against at that point and I never thought I would come through it with no tear or cut).  I even got a mirror to see my progress, and knew right then that something was going to have to give! I made them put the mirror away!

     

     

    I started pushing 5-6 times per contraction and the doctor had been with me the whole time.  She had them break the bed and get all the stuff ready and I asked “Is she coming out this way?” and the doctor laughed and said, “I’m not doing a c-section today!” She asked me also if I wanted to feel Hana’s head, but I just couldn’t bear the thought for some reason.  I kept pushing and finally she said, “Ok, this next one you’re going to have your baby!” and so I hauled back and pushed harder than I thought possible and her head popped out and I kept pushing (oops!!) and Hana was born Sunday May 24th at 6:28pm!!!  It was the most amazing thing in my life and no doubt pushing was the hardest thing in the world.

     

    Lamaze International's Tips for a Normal Birth #10: Keep your baby with you after birth. Skin-to-skin contact keeps your baby warm and helps to regulate your baby's heartbeat and breathing. Keeping the baby with you in your room helps you to get to know your baby, respond to your baby's early feeding cues and get breastfeeding off to a good start.

    Lamaze International's Tips for a Normal Birth #10: Keep your baby with you after birth. Skin-to-skin contact keeps your baby warm and helps to regulate your baby's heartbeat and breathing. Keeping the baby with you in your room helps you to get to know your baby, respond to your baby's early feeding cues and get breastfeeding off to a good start.

     

    They gave her to me and after a few minutes (she was breathing but a little blue still) they took her over to rub her and clean her up some.  I was shaking so bad at that point that Rob had to hold her. I ended up with a 4th degree tear… not from her head, but her shoulder popped out when I pushed and the doctor wasn’t expecting it, and so that’s that.  But it isn’t so bad!  She stitched me up, and while it is sore, it beats the hell out of a c-section! Right after she was born I said, “I had a baby out of my vagina!” much to the amusement of the nurses and pretty much everyone in the room! But I can’t tell you just how amazing it was for me. I had been waiting 3 years for that.  And now I have it!  Hana was given back to me and she latched on right away and nursed like a champ for 15 minutes on each side (I was STILL being sewn up!) and finally Rob and Hana went off to the nursery.  To our surprise (and the doctor’s too) she was 8lbs 1 oz, 19 inches long.

     

    Happy Birthday Hana!!!!

    Happy Birthday Hana!!!!

     

     

    I am recovering very well and almost feel like new!!

     

    For more information on Vaginal Birth After Cesarean (VBAC) check out the International Cesarean Awareness Network's website at http://www.ican-online.org/

    For more information on Vaginal Birth After Cesarean (VBAC) check out the International Cesarean Awareness Network's website at http://www.ican-online.org/

     

    “Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions July 9, 2009

    Filed under: Ramblings,Super Comments!,Top Ten Lists — NursingBirth @ 4:31 PM
    Tags: , , , , , , , , , , , , , ,

    Yesterday in my post entitled “Pit to Distress: A Disturbing Reality” I wrote about a troubling way of administering the drug pitocin to augment or induce labor that some birth attendants are practicing in our country’s maternity wards.  Called “pit to distress”, the intention is to order a nurse (either verbal or written) to continue to turn up (or “crank” as is the current L&D slang) the pitocin in order to induce hyperstimulation/tachysystole of the uterus so that a women is experiencing more than 5 contractions in a 10 minute period.  This action, sooner or later, will cause fetal distress as research has shown that a baby needs AT LEAST a 1 minute break in between contractions where the uterus is AT REST in order for the baby to continue to receive adequate oxygenated blood flow from the placenta and not have to dip into his reserve. 

     

    Inspiration for my post came from two posts on the subject written by Keyboard Revolutionary and The Unnecesarean.  Since yesterday I have received many comments regarding this upsetting trend and one comment in particular has inspired me to address the topic again:

     

     

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

     

    July 8, 2009

     

    Dear NursingBirth,

     

    I really enjoy your blog and I learn a lot from all your posts. I am wondering if there is a way (as the patient) to know if something like this is happening and refuse it? Is the patient always told how much pitocin she is getting and can she say at a certain point that she doesn’t want it any higher if she is making progress?

     

    Sincerely,

    Zoey

     

     

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

     

     

    Dear Zoey,

     

    This is a GREAT question.  I love hearing from women who desire to learn more about their choices in childbirth and become more proactive in the care they are receiving.  KUDOS to you for doing both!!  I have thought a lot about this and I have come up with a list that I hope you find helpful.  Please pass it along to all of your friends, both expecting and not, so that we can both work to inspire more women to do as you do….that is, DO their research and DEMAND better care!!!

     

     

     

    TOP 7 WAYS TO PROTECT YOURSELF FROM UNNECESSARY AND HARMFUL OBSTETRICAL INTERVENTIONS (including “Pit to Distress”!)

     

     

    #1  Interview different birth attendants/practices before or during early pregnancy and CHOOSE a birth attendant that practices in a way that aligns with your personal childbirth/postpartum philosophy, is appropriate for your health status, and (optimally) who practices a midwifery model of care!

     

    I wish I could scream this from the roof tops!  Sometimes I feel like a broken record I say this so often but I say it so often because it is SO important!!  The bottom line here ladies is that if you think you can pick any care provider you want and then just write a birth plan that clearly states your philosophy and preferences and just get what you want…..THINK AGAIN!  Birth attendants are creatures of HABIT more than anything else.  If they cut an episiotomy on the majority of their patients then what makes you think that if you ask, they won’t cut one on you?  In fact, not only will they cut one on you but they will come up with some bogus reason why it was necessary.  Likewise, if your birth attendant induces most of their patients, what makes you think that he won’t start pressuring you to set up an induction date once you hit 37 weeks! 

     

    Think of it this way, if the birth attendant has a high elective induction rate, they probably feel more comfortable managing pitocin induced or augmented labors as opposed to spontaneous labors and hence, they will probably try to do everything in their power [including persuasion (e.g. the “convenience” card and the “aren’t you sick of being pregnant” card) as well as scare tactics (e.g. the “big baby” card, the “I might not be there to deliver you if you don’t” card, or my favorite the “if you don’t your baby might be stillborn/dead baby” card)] to convince you that your labor needs to be induced or augmented with pitocin.  Why?  It probably is a mix between how they were taught (i.e. medical model of maternity care), what they are used to (a self fulfilling prophecy), and a desire to be the one in “control.” 

     

    Writer Lela Davidson quotes professional childbirth educator and doula, Kim Palena James in her article Create a Better Birth Plan: How to Write One and What It Can and Cannot Do For You:

     

    “Too many parents create birth plans with the expectation that it will be the actual script of their baby’s birth. There is no way! Nature scripts how your child is born into this world: short, long, hard, easy, early, late, etc… The health care providers you choose, and the facility they practice in, will script how you and your labor are treated. The variations are vast. I wish every expectant parent spent less time writing birth plans and more time selectively choosing health care providers that align with their philosophy on health care, match their health status and their needs for bedside manner.”  (Emphasis mine)

     

    So PLEASE for the LOVE of all mothers and babies, PLEASE do your homework! 

     

    Of course there is always the chance that you do interview a particular birth attendant and they act one way in the office with you and then, WHAM!, are a completely different person when you step foot on L&D.  I see it happen ALL THE TIME where I work.  Just because a doctor gives you his home phone number and is sweeter than sugar in the office, doesn’t mean he won’t section you just to get to the company Christmas party!  (This actually happened to a patient I took care of!  NO lie!)  So what can you do about that! 

     

    Jill from Keyboard Revolutionary recently blogged about this:

     

    “Ya know, sometimes I feel bad for the good physicians out there. I know they exist. We all do. We’ve all shaken our fists in righteous indignation at the rants of Marsden Wagner. We’ve listened intently to the poetic, thickly accented declarations of Michel Odent. We’ve swooned over the tender ministrations of “Dr. Wonderful,” a.k.a Dr. Robert M. Biter. God bless those diamonds in the rough, particularly in the obstetrical field. It must be twice as hard to shine when the lumps of coal around you are so horrifically ugly.

     

    I was pondering just now in the shower how so many of us think we’ve got a real gem of an OB (or any other doctor, really) until show time, and suddenly we’re hit with the ol’ bait-and-switch. Sometimes there are warning flags along the way, sometimes not. Sometimes the flags don’t pop up until it’s too late. It sucks that for many women, we don’t realize what a crock we’ve been fed until we’ve already digested it. How do you know whether you’ve got a bad egg or your own Dr. Wonderful?”

     

    This leads me to my second point…

     

     

    #2  Ask the RIGHT QUESTIONS and the RIGHT PEOPLE when researching potential birth attendants.

     

    Two of my favorite posts from Nicole at It’s Your Birth Right! are her posts about choosing the right birth attendant entitled Choose Wisely I and Choose Wisely II.  She writes:

     

    “The decision about WHO is going to be your birth attendant should NOT be left to chance.  Where you deliver, how you choose to labor, what you chose to do while pregnant and in labor, while these things are definitely important, without the proper WHO, the plan will have difficulty coming together.

     

    I get questions, all the time from friends, friends of friends and even strangers.  They want my thoughts about pregnancy, labor and childbirth. I have spent HOURS talking with women providing answers and information they should be able to get from their prenatal provider/birth attendant.  I think to myself at the end of those conversations, “Why isn’t she able to get this information from her?  If  he doesn’t make her feel special, does not answer her questions, and doesn’t agree with her philosophy on childbirth and labor, why on earth is she allowing him to be her birth attendant?!”

     

    When I pose this question to the women themselves, the answers unfortunately never include “Because I did my research and I found him to be the best match for me and my desired childbirth experience.”  Most of the answers I receive fall into [one of] four categories, none of which are good enough reasons alone to choose a prenatal care provider/birth attendant.   They are: “She delivered my sister/girlfriend”, “She is my gynecologist,” “He is the best/most popular person in area,” and “Her office is so close and convenient to my office/house.””

     

    Now I am not trying to say that you shouldn’t trust your sister, sister-in-law, or best friend’s opinion about her personal birth attendant but if you are going to ask such a person for advice please remember that she probably has only had limited experience with that birth attendant as compared to, say, an L&D nurse or doula, and it is important to ask her exactly why she loves her birth attendant so much.  Does she love him because he trusts in birth and strived to facilitate a positive and empowering birth experience for her or does she love him because he was the only OB in the area that would agree to induce her at 38 weeks because she was sick of being pregnant?  There is a difference!!

     

    If you have done some research and found a birth attendant that you think you really like, I would recommend tapping into some community resources to get the “inside scoop” about your birth attendant.  Here are some ideas:

     

    1)      Contact your local grassroots birth advocacy group like International Cesarean Awareness Network (ICAN) or BirthNetwork National and try to attend a meeting.  The women that attend these meetings are often in tune with the birth culture in their community and can be GREAT resources for which birth attendants are true and which are really wolves in sheep’s clothing!  Also, don’t count out ICAN as a resource even if you have never had a cesarean.  We have a quite a few moms currently in my local ICAN group that are first timers and decided to start attending because they said they were learning so much about birth in general from our meetings!

     

    2) Sign up for a childbirth preparation class that is NOT funded/run by a hospital and ask the instructor for her opinion on different birth attendants.  It is the only way to guarantee that your instructor is not held back from speaking her true feelings since hospital based childbirth instructors are working for the interest and promotion of their hospital by the very nature of their job.  Independent childbirth instructors like Lamaze, Hypnobabies, Birthing From Within, Bradley etc. etc. can be GREAT resources as to which birth attendants follow which philosophies because often times their clients come back and tell them about their experiences.

     

    2)      Consider consulting or hiring a doula.  A doula is a great resource as to the true nature of a birth attendant because she is someone who is actually in the labor and delivery room with her clients and has as close to an “insider’s view” as you can get without actually working for the hospital.  If you hire a doula to be with you during your labor, they will also advocate for you, your needs, and your birth plan as well as provide essential labor support that (unfortunately) even the most well intentioned nurse might not have the time to do. 

     

     

    #3  Do NOT agree to an induction of labor unless there is a legitimate obstetrical, maternal, or fetal reason for delivering the baby before natural spontaneous labor begins!!  PLEASE Do NOT agree to an unnecessary elective induction of labor. 

     

    This might seem like a no brainier ladies but so many get sucked in!  They don’t call it “the seduction of induction” for nothing! 

     

    Bottom line is if you want to protect yourself from such an asinine, unnecessary, and dangerous intervention as “Pit to Distress” then DON’T agree to be induced unless there is a very important medical reason!

     

    BABIES AND MOTHERS HAVE THE BEST OUTCOMES WHEN THEY ARE ALLOWED TO BEGIN LABOR SPONTANEOUSLY AS WELL AS LABOR AND DELIVER WITH MINIMAL INTERVENTIONS!

     

    In the Lamaze Institute for Normal Birth’s MUST READ patient education bulletin entitled Care Practice #1: Labor Begins on Its Own, author Debby Amis, RN, BSN,CD(DONA), LCCE, FACCE, and editor Amy M. Romano, MSN, CNM write:

     

    “There is growing evidence that induction of labor is not risk-free. In 2007, Goer, Leslie, and Romano reviewed the entire body of literature on the risks of induction in healthy women with normal pregnancies and found that when labor was induced, the following problems may be more common:

    • vacuum or forceps-assisted vaginal birth;
    • cesarean surgery;
    • problems during labor such as fever, fetal heart rate changes, and shoulder dystocia;
    • babies born with low birth weight;
    • admission to the NICU;
    • jaundice;
    • increased length of hospital stay.”

     

    Okay, enough said!

     

     

    #4  If you have to be induced or augmented with pitocin for a true medical or obstetrical reason, be honest with your nurse about how you are feeling and have one of your labor companions keep track of how often your contractions are coming.

     

    And this does NOT mean for your labor companion to “monitor watch”!!  It’s not a TV for goodness’ sake!

     

    Research has shown that due to the risks of pitocin, continuous electronic fetal monitoring (CEFM) is a safety requirement for anyone being induced or augmented with it.  However, remember CEFM is a machine and machines have limitations.  The tocodynamometer or “toco” is “pressure transducer that is applied to the fundus of the uterus by means of a belt, which is connected to a machine that records the duration of the contractions and the interval between them on graph paper.”  However, depending on your body type, how “fluffy” your abdomen is, your position, and your gestational age, the toco might not be recording your contractions appropriately.  You might be having contractions every minute but the machine is not registering them.  This is why I always remind women that they have to tell me how they are feeling. 

     

    If you are being augmented or induced with pitocin your nurse SHOULD:

     

    1)      Be palpating (feeling) your fundus (top of your uterus above the belly button) before, during, and after contractions periodically throughout your labor to judge how strong they are (mild, moderate, or strong).  Palpation before and after contractions also assures the nurse that your uterus is actually coming to rest (is soft) between contractions, which assures that the baby (and mom!) are getting a break!  Remember, unless you have an IUPC (intrauterine pressure catheter) in, the toco can only tell the nurse how far apart and how long the contractions are NOT how strong they are!  That’s right!  Unless you have an IUPC in, the height of the contractions on the monitors is ABSOLUTELY MEANINGLESS!  So therefore the only way for the nurse to know how strong the contractions are is to TOUCH your belly and ASK you!

     

    2) Ask you about your pain level (for example to “rate” your pain on a scale of 0 to 5 or 0 to 10) regularly during your labor unless you have specifically asked her not to ask you about your pain.

     

    3) Give you periodic updates on your progress and the progress of the pitocin.

     

    [Note: I can only speak for myself here but what I do when I have a patient on pitocin is first and foremost to explain the process of titrating the pitocin and what the desired outcome is (and according to our hospital’s policy the desired outcome is moderate to strong contractions that are coming every 2-3 minutes, or 3-5 in a 10 minute period), as well as keep her informed throughout the process when I am increasing or decreasing the pitocin and for what reason.  For example, I might say “It looks to me like you are contracting every 4 minutes.  What is your pain level?  Do you feel like you are getting an adequate break?  Would you like to change position?  I would like to increase to pitocin to achieve a more regular pattern.  What do you think?” or “It looks like the baby continues to have variable decelerations in his heart rate despite all of the position changes we have tried.  I am going to give you a small IV fluid bolus and turn the pitocin down some to see if it helps to resolve the decels.  The baby’s variability is still very reassuring and she is still having accelerations so she is doing well.  I just would like to keep her that way!”  Your nurse should be keeping you “in the loop” so to speak and if she is not, it is your right to ask questions!]

     

    It is also important to remember that that running pitocin is much more of an art than a science.  Therefore you might think she is being “mean” if she is increasing your pitocin since you are only contracting every 6 minutes but remember, running the pitocin lower than is needed to cause cervical change isn’t going to help you either.  No nurse wants her patient to end up in the OR for “failure to progress” because she didn’t turn the pitocin up enough.  There is a happy medium somewhere that most nurses are trying to find.  So please, know that sometimes, even if you really feel like those “every 6 minute” contractions are strong enough already, it is important for the nurse to titrate the medication to achieve an effective labor pattern that promotes a vaginal delivery with a healthy baby. 

     

    If your nurse is NOT doing these things then it is your right to ask questions!!!  However, please remember for your own sake that when asking questions, one attracts more flies with honey than vinegar.  Don’t start yelling at her or demanding a new nurse.  Give her a chance and ask questions first!  She might just be so busy that day that she is in the zone.  Most nurses are happy to teach when asked!

     

     

    #5  Learn about and practice non-pharmacological methods of pain relief as part of your childbirth preparation and consider not getting or postponing an epidural until all other methods of non-pharmacological pain relief have been exhausted. 

     

    Okay, I know that this one is a bit controversial but please here me out first. 

     

    It is the truth that pitocin contractions, especially when the pitocin is being abused, are typically stronger and longer than spontaneous labor contractions.  Also, being that you have to be on continuous monitoring can also limit your movement and hence, one of your most effective and instinctual coping methods for the pain.  For this reason, many people feel that it is crazy for a woman to go though a pitocin labor without an epidural.  And when “Pit to Distress” is in play, it is truly unbearable to both experience and to witness.  However, if pitocin is administered compassionately and appropriately it is important to know that an epidural is NOT an absolute necessity.  I have seen many women do it without an epidural and many who have done it with an epidural.  So if you have to be induced with pitocin and you desire an “unmedicated” birth, your hands aren’t completely tied.  You CAN do it.  However, I have said time and time again, I would rather a woman have a vaginal delivery with an epidural than a cesarean section without.   That being said, the pitocin and epidural partnership has a dark side too. 

     

    While an epidural can help the woman relax and allow the pitocin to work more effectively, most birth attendants that practice “Pit to Distress” persuade and even bully their patients into getting an epidural specifically so the nurse can “crank the pit” without the woman objecting.  But I would like to remind you that even if you can’t feel those contractions, your baby IS feeling them.  Also, epidurals themselves CAN and DO cause fetal distress and anyone who tells you that epidurals pose no risk to the baby is being dishonest!  At my work, we nickname this the “ten by ten”.  That is, almost without fail, many women who get an epidural are is likely to experience a whopping fetal heart rate deceleration lasting approximatly ten minutes about ten minutes after she is put back to bed, which of course throws everyone into a tizzy. 

     

    All of a sudden mom finds herself with her face planted into the bed, her ass in the air, a mask of oxygen on her face, an anesthesiologist pushing adrenaline into her IV to increase her blood pressure and a doctor with his hands up her vagina screwing a monitor onto the baby’s head.  Most babies do recover from said decel and go on to deliver vaginally.  But it is NOT rare for the baby to NOT recover which lands mom…you know where….in the OR.  And guess what!  Since she already has that epidural in place, why they can just cut her open even faster! 

     

    Please know that I am not condemning any woman who requests an epidural in labor, especially if she is on pitocin.  I just want all you women out there to know that sometimes that epidural that they keep waving in your face is just a way for them to shut you up so they can CRANK the pit.

     

     

    #6  If you feel like you are contracting strongly at least every 2-3 minutes (3-5 in a 10 minute period) and the nurse or birth attendant desires to increase your pitocin, you might want to consider requesting a vaginal exam. 

     

    Now, I know limiting vaginal exams is very important to many women as they are invasive and uncomfortable/painful.  I completely understand!  However, if your care provider wants to increase the pitocin and you feel it is unnecessary, asking for a vaginal exam is a way to reveal if you are making any cervical change.  If you ARE making cervical change then there is no real need to continue to go up on the pitocin!  Remember the TRUE goal of pitocin administration is to stimulate an effective labor pattern that causes cervical change.  It is NOT (despite how many birth attendants practice) just about getting a patient to “max pit.”  Every woman is different! 

     

    Lastly,

     

     

    #7  You could always try writing something about pitocin administration in your birth plan. 

     

    For example: “If deemed necessary, I would like to try non-pharmacological methods of labor augmentation and induction including (blank) first before resorting to pharmacological methods.  However, if my birth attendant and I agree that pitocin will be administered to me, I request that the pitocin be administered following the “low dose” protocol and is increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each dose increase.”

     

    I will be very honest with you.  If your birth attendant or hospital does not practice in this way, it is doubtful that this request will be granted.  However, I suppose it can’t hurt and is worth a shot!  At least it can provide a sympathetic nurse with another platform on which to argue with the birth attendant if necessary (like, “But Doctor X, your patient has specifically requested a low dose pit protocol!”) 

     

    This should be a last resort!  Remember, writing something in your birth plan does not guarantee you it is going to happen if your birth attendant doesn’t practice that way!  Please refer back to point #1 about choosing the RIGHT birth attendant for you!!! 

     

     

    All My Best,

    NursingBirth

     

    New Study Shows C-Section Births May Increase Odds For Developing Diseases Later In Life June 30, 2009

    Filed under: In The News — NursingBirth @ 12:05 PM
    Tags: , , , , , , , ,

    A new study published in the July issue of Acta Pædiatrica, a peer-reviewed monthly journal at the forefront of international pediatric research, found that babies born by cesarean section experience changes to their DNA in their white blood cells (called leukocytes) which they believe could be related to negative stresses around birth, particularly the cesarean section.  The study, entitled Epigenetic modulation at birth – altered DNA-methylation in white blood cells after Caesarean section, was led by a team of Swedish researchers who sampled umbilical cord blood (collected at the time of birth) and venous blood 3-5 days after birth from a total of 37 newborn infants, 21 of which were born by spontaneous vaginal delivery and 16 by elective cesarean section. 

     

    According to the Medical News Today article, one of the authors of the study, Professor Mikael Norman, was quoted in saying:

      

    “Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks.  Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life.  That is why we were keen to look at DNA-methylation, which is an important biological mechanism in which the DNA is chemically modified to activate or shut down genes in response to changes in the external environment. As the diseases that tend to be more common in people delivered by C-section are connected with the immune system, we decided to focus our research on early DNA changes to the white blood cells. 

     

     Animal studies have shown that negative stress around birth affects methylation of the genes and therefore it is reasonable to believe that the differences in DNAmethylation that we found in human infants are linked to differences in birth stress.  We know that the stress of being born is fundamentally different after planned C-section compared to normal vaginal delivery. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after delivery than before. This is different to a normal vaginal delivery, where the stress gradually builds up before the actual birth, helping the baby to start breathing and quickly adapt to the new environment outside the womb.

     

     In our study, neonatal DNA-methylation did not correlate to the age of the mother, length of labour, birth weight and neonatal CPR levels – proteins that provide a key marker for inflammation.  However, although there was no relation between DNA-methylation and these factors, larger studies are needed to clarify these issues.”

     

     Although this study has its limitations (recognized by it authors) including its small sample size, it is fascinating to me as it is part of a growing sector of developmental biology dubbed “primal health” by French obstetrician Michel Odent in his book by the same name in 1986.  “Primal Health Research” explores correlations between the ‘primal period’ (from conception until the first birthday) and health in later life.  Since opening the Primal Health Research Centre in 1990, Odent has also created the Primal Health Research Database, available free online, which is a public collection of all the medical and scientific literature that belong to the framework of primal health research.

      

    In her book Pushed: The Painful Truth About Childbirth and Modern Maternity Care, author Jennifer Block writes:

     

     “[Odent] is interested in looking far beyond the 5-minute Apgar score to what we might call the 5-year, 25-year, 50-year Apgar.  He’s put a database online, where one can search studies that have connected narcotics at birth with addiction in adulthood; induction of labor with autism; and cesarean section with immune disorders.  The research is far from conclusive, but it points to the large, unknown territory of the impact of medicalized childbirth. 

     

    Odent places value on the process of physiological childbirth itself, of which we still have only limited understanding.  How can we fully appreciate the risks of intervention, he asks, if we don’t funny understand what is normal?  The mother’s body has spent 9 months growing and sustaining fetal life, and millennia of evolution have depended on spontaneous labor and its timed release of several hormones to transition the fetus from the womb to the outside world.  Odent has compiled scientific evidence that each one of these hormones serves as an important function in guiding the progress of labor and supporting the fetus—and that these hormones are interdependent.  ‘What we’re understanding today is that what happens at birth seems to be important,’ says Odent.”

     

      

    In my opinion, it should NOT be the case that the burden of proof lies on the supporters and proponents of unmedicated physiological childbirth (which is, as defined by author Jennifer Block, “[a birth where] labor begins and progresses spontaneously, the woman is free to move about for the duration, and she pushes in advantageous, intuitive positions.”) that “their” way is the safest and healthiest option for mothers and babies!  It SHOULD BE the responsibility of proponents of unnecessary inductions, unnecessary cesareans, and outdated and harmful labor & postpartum practices (i.e. routine episiotomy, early and frequent vaginal exams, early amniotomy, flat-on-back/lithotomy/recumbent pushing positions, separation of mother and baby, manual pressure on the uterus, and “directed,” hold-your-breath-and-count-to-10 pushing) to have to prove, beyond any doubt, that their way is superior.

     

     Because as far as I, and any credible research, is concerned it is NOT!  And if it ain’t broke, why fix it?!

     

    Preventing Maternal Deaths: An Interview with Ina May Gaskin June 23, 2009

    Filed under: Ideas & Information — NursingBirth @ 2:18 PM
    Tags: , , , , ,

    Today an avid reader sent me a link to a few short interviews with the great Ina May Gaskin conducted by Mindful Mama Magazine about a very sad, but very real phenomenon: maternal deaths in the United States.  I felt that these interviews were so well done that I just had to share them with all of you.

     

    Ina May Gaskin is a Certified Professional Midwife (CPM) and is the founder (along with her husband) and director of The Farm Midwifery Center in Tennessee.  She is the author of Spiritual Midwifery (1975) and Ina Mays Guide to Childbirth (2003), two incredible books that every woman who has ever had a child, is pregnant, or is thinking about becoming pregnant should read!!  

     

    Spiritual Midwifery is THE book that changed my life, my outlook on the birth process, and my career goals.  Ina May’s Guide to Childbirth is similar in style to Spiritual Midwifery, but has a much broader appeal and a more modern style.  Ina May has been a home birth midwife for more than 35 years and is the founder of the Safe Motherhood Quilt Project, a national effort developed to draw public attention to the current maternal death rate, as well as to the gross underreporting of maternal deaths in the United States, and to honor those women who have died of pregnancy-related causes since 1982.
    These interview clips are part of Rites of Passage, an exclusive video series and art/photo/ essay contest hosted by Mindful Mama Magazine that engages mothers across the country in a dialogue about childbirth and the transformation of new motherhood.  During the interview Gaskin speaks to the disturbing reality that 1) the United States lacks of a comprehensive, confidential system of ascertainment of maternal death designed to record and analyze every maternal death that occurs in the United States and 2) not all 50 states have questions on their death certificates that specifically ask about a woman’s pregnancy status (i.e. was she pregnant, postpartum, or within 1 year of delivering a baby) making our countries maternal mortality rates based solely on vital statistics data.  (And as an registered nurse who has had to fill out death certificates a time or two as a medical-surgical nurse I can attest to the truth of this!)  In reality the Center for Disease Control (CDC) estimates that our current maternal mortality rate is actually an underestimate and that our true maternal mortality rate could be as much as 3 TIMES HIGHER related to misclassification of the number of deaths that are truly happening. 

     

    Please also see my post: Super Comment!: Maternal Death in the U.S., or TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth

     

    So check out these videos and let me know what you think!!

     

    PREVENTING LOSS PART 1

     

     

    PREVENTING LOSS PART 2

     

     

    WHY CESAREAN?

     

     

    THE SAFE MOTHERHOOD QUILT PROJECT

     

     

    Don’t Let This Happen To You #22: Gina & Tony’s “Elective” Primary Cesarean Section PART 2 June 12, 2009

    Filed under: Don't Let This Happen to You!: The Injustice In Maternity Care Series,Nursing Notes — NursingBirth @ 1:16 PM
    Tags: , , , , , , , , ,

    Continuation of the “Injustice in Maternity Care” Series

     

    Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?!  Are you SERIOUS!?  Oh come ON!”  Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series.  If you are pregnant or planning on becoming pregnant, this series is dedicated to you!  If haven’t already read it, I invite you to check out part 1 of this post: DLTHTY #22: Gina & Tony’s “Elective” Primary C/S  PART 1.

     

     

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    And now the story begins…

     

     

    Not too long ago I was part of an absolutely outrageous and unnecessary cesarean section.  I arrived at work at 11:00am as usual and noticed that I had been assigned to the OR team.  My hospital averages about 10-15 births per day, and depending on the day, 4-6 of those births are by cesarean section…sometimes more.  Monday through Friday from 7am-3pm we have an OR team comprised of about 5 nurses or so, that handle all of the scheduled cases and even any emergency cases that happen during the day shift.  However, if there is a call in for the OR team or they have a particularly large case load (for example, a full schedule of scheduled cesareans plus some unexpected add-ons) I often get pulled off the floor to join the surgical team. 

     

    So after reading the assignment I moseyed on down to the surgical wing to get the scoop from the OR charge nurse, Linda.  Linda informed me that I would be scrubbing the 11:30 case (that is, assisting the surgeon by passing him/her instruments and keeping an accurate count of all instruments, sharps, and sponges).  Next I looked over the patient’s chart so I would better understand what to expect during the case. 

     

    The patient was Gina, a 24 year old G1P0 at 39.2 weeks with an unremarkable past medical history (tonsillectomy at age 6, mild exercise induced asthma) and a normal healthy pregnancy.  She and her husband Tony were expecting their first baby, a boy that they planned on naming Giovanni after her late grandfather.  Gina was about 5’6” and approximately 155lbs while her husband was about 5’10” and slender.  I scoured her admission assessment for a medical indication for her cesarean section.  Did she have active genital herpes?  Nope.  How about placenta previa?  Nope.  Was she breech, brow, or transverse lie?  Nope.  Problems with her first delivery?  Well no because this was her first baby.  Did she undergo previous extensive abdominal or uterine surgery?  Nope.  Was she abducted by aliens who sewed her vagina shut?!  NO!  NO!  NO!

     

    And as I shut her chart to go and find her nurse and get some answers, my eyes fell upon her name plate and everything started to make sense….she was Dr. M’s patient!!!!  She was an elective primary cesarean section!  Let me digress for a moment to explain a little bit about Dr. M so that you get a better idea of the situation and why I just knew that Gina was scheduled for an elective cesarean. 

     

     

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    During my first week off of orientation as an L&D nurse, I admitted a patient of Dr. M’s for a repeat cesarean section.  I asked a fellow nurse, Sarah, if she could tell me a little bit about Dr. M since not only had I never worked with her during a birth before, but I had never even seen her in the labor wing during my entire 12 weeks of orientation.  Sarah looked right at me and said, “Let me put it this way.  Dr. M performs so many c-sections that it is almost as if she finds it personally offensive for a woman to deliver vaginally.”  I almost spit out my juice when I heard that!  Turns out, however, that she wasn’t exaggerating. 

     

    Dr. M has the highest cesarean section rate out of any of the obstetricians that have privileges on our unit clocking in at a whopping 74% in 2007!  She has almost a 90% rate of vacuum assisted deliveries since she uses a vacuum on every cesarean and almost every vaginal delivery.  (And to be very honest, the only time she doesn’t put a vacuum on the baby’s head during a vaginal delivery is if the mother has a precipitous delivery and the nurse “accidentally” (*wink, wink*) forgot to bring a vacuum into the room!  Also whenever she uses a vacuum she cuts a giant episiotomy as well so you can do the math on her episiotomy rate!)  It is actually a joke among the residents and nurses on the floor (a really sad, sick joke, but a joke nonetheless) that Dr. M’s patients don’t ever have vaginal deliveries; they just have “failed cesareans.” 

     

    Dr. M is one of only two doctors on the floor that will do primary elective cesarean sections and even so, the other doctor that will attend them will agree to it only in very rare circumstances.  But what exactly is an “elective primary cesarean section?”  Is it the same thing as a “maternal request cesarean section?”  That is, if a patient is scheduled for an elective primary cesarean section, does it automatically mean it was because it was by the patient’s request?  Are they the same thing?  Interchangeable terms?  And what does elective really mean?  Before I discuss the answers to those questions let me finish Gina & Tony’s story.

     

     

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    At this point I’m pretty frustrated.  It has been my experience with Dr. M that if her patient does not have a true medical indication for a cesarean section that she will literally make one up in order to convince the patient that a cesarean is the best way to go.  Think I’m exaggerating?  Well when I finally entered Gina & Tony’s room to introduce myself I found out the real scoop straight from the patient’s mouth.  After introducing myself to Gina & Tony and explaining my role as the scrub nurse, we got to chatting about her family, her job, and her pregnancy. 

     

     

    Me:  “So how has this pregnancy been for you so far?”

     

    Gina:  “Great!  I mean I had a little bit of morning sickness in the beginning but other than that everything has been great! 

     

    Me:  “Is little Giovanni going to be the first grandchild for either of your parents?”

     

    Gina:  “Oh well not for my side, I’m from a big family.  But he’ll be the first grandchild for Tony’s parents.”

     

    Me:  “Oooh!  How exciting!!  It is so nice to hear that everything has been going well for you this pregnancy!  So what is the reason that you are having surgery today?”

     

    Gina:  “Well last week I had a sonogram to measure the baby’s weight and it showed that he was really big, like over 8 lbs!!!  Dr. M also did an internal exam and said that I didn’t have enough room in my pelvis to give birth to a baby that big.  And she was my sister’s doctor too.  My sister had to have a cesarean after like two days of labor.  Dr. M  tried to induce her but her cervix just wouldn’t dilate past 1 centimeter so she had to have a cesarean for her first baby.  And for her second baby Dr. M just recommended a cesarean because she just can’t dilate.  So we were figuring I’m probably the same way too.  And I mean, I can’t give birth to no 8 lb baby!  Oh lord no! 

     

    Me:  [dumfounded & speechless]

     

    At that moment the anesthesiologist entered the room to go over what to expect during the spinal and I just said “Well I’ll see you both back there!” and left the room. 

     

    I ran to the chart to find the sonogram report.  The estimated fetal weight per the report was 4025 grams (which is approximately 8lbs 14oz).  And sure enough in Dr. M’s admission note under “preoperative diagnosis” the following was written in black and white: elective primary cesarean section for suspected fetal macrosomia.

     

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    Okay, okay, okay, there are SO MANY things WRONG with what Gina was describing to me that I felt like I had been hit by a Mack truck.  Let’s take them one by one shall we!

     

     

    FACT #1:  Third trimester sonogram reports are imprecise and inaccurate since they can be off as much as 2 POUNDS and they notoriously overestimate the fetal weight.

     

    “Weighing the newborn after delivery is the only way to accurately diagnose macrosomia, because the prenatal diagnostic methods (assessment of maternal risk factors, clinical examination and ultrasonographic measurement of the fetus) remain imprecise. Leopold’s maneuvers and measurement of the height of the uterine fundus above the maternal symphysis pubis are the two primary methods for the clinical estimation of fetal weight. Use of either of these methods alone is considered to be a poor predictor of fetal macrosomia; therefore, they must be combined to produce a more accurate measurement. Ultrasonographic measurement of the fetus serves as a means to rule out the diagnosis of fetal macrosomia, which may aid in avoiding maternal morbidity, but is considered to be no more accurate than Leopold’s maneuver.” 

    ~American Academy of Family Physician’s (AAFP) publication of ACOG Practice Bulletin No. 22, November 2000, Obstetrics and Gynecology

     

     

    FACT #2:  You cannot accurately determine the size of a woman’s pelvis during labor by doing a vaginal exam before labor begins.  The human body naturally releases hormones as it prepares for and begins labor which act to relax the joints and ligaments of the pelvis, increasing the diameter and flexibility of the pelvic outlet.  This type of misdiagnosis of cephalopelvic disproportion (CPD) accounts for many unnecessary cesareans performed in North America and around the world annually.  Also the sutures of a baby’s skull are not fused at birth for the very important reason of allowing molding of the baby’s head through the birth canal. 

     

     

    FACT #3:  Labor induction increases a woman’s risk of cesarean section, especially if the woman’s cervix is not yet ripened and ready for labor (a.k.a. a Bishop’s score of less than 6 for a first time mom and less than 8 for a multiparous mom).  Therefore if a woman undergoes a cesarean section after a labor induction at 1 centimeter of dilation because she “can’t dilate anymore” it was the induction that failed NOT her body. See:

     

    1)     Bishop score and risk of cesarean delivery after induction of labor in nulliparous women.

     

    2)     Risk of cesarean delivery with elective induction of labor at term in nulliparous women.

     

    3)     Elective Induction of Labor by Henci Goer

     

     

     

    FACT #4:  According to the ACOG published practice guidelines, “suspected fetal macrosomia” should not be considered as an indication for cesarean section unless the estimated fetal weight is greater than 4500 grams (9lb 15oz) for a diabetic mother and 5000g (11lb 0oz) for a non-diabetic mother, and even so maternal risk factors and birth history must also be taken into account.  The ACOG committee (Practice Bulletin No. 22, November 2000, Obstetrics and Gynecology) provides the following recommendations for the management of fetal macrosomia:

     

    Recommendations based on good and consistent scientific evidence (Level A):

     

    * The diagnosis of fetal macrosomia is imprecise. For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold’s maneuvers).

     

    Recommendations based on limited or inconsistent scientific evidence (Level B):

     

    * Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.

       

    * Labor and vaginal delivery are not contraindicated for women with estimated fetal weights up to 5,000 g in the absence of maternal diabetes.

       

    * With an estimated fetal weight more than 4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery.

     

    Recommendations based primarily on consensus and expert opinion (Level C):

     

     * Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights of more than 5,000 g in pregnant women without diabetes and more than 4,500 g in pregnant women with diabetes.

       

    * Suspected fetal macrosomia is not a contraindication to attempted vaginal birth after a previous cesarean delivery.

     

     

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    So long story short, Gina had her cesarean section and I felt like I was going to cry the entire time.  (Sometimes I get myself really worked up about these types of injustices!  I know, I know, many of my colleagues tell me I need to learn to relax but turning the other way when this type of selfish and reckless obstetrical practice is going on in my community is just not something I can bring myself to do!)  Since I was the scrub nurse I was already scrubbed and in the OR before Dr. M even showed up to the case and since she blew out of that OR before we could even transfer the patient off the table to the stretcher, I unfortunately didn’t even get a chance to confront her about it.  And to be honest, I have seen her chew out so many nurses that I don’t know if I could have even stood talking to someone so irrational. 

     

    Oh!  I can’t forget to tell you the best part of the story!  Dr. M is notorious for cutting the smallest possible incision, which one would think is a good thing, however, she cuts them so small that she always “has” to use a vacuum to pull the baby out of the uterus (and there is often a lot of straining and pulling and tugging involved on that little baby’s head!  It makes my stomach turn.)  She then, of course, brags to the patient about how “cute” her small little “smile” is (referring to the bikini cut skin incision the patient is left with.)  It really makes me sick when I hear her say that. 

     

    So after the baby was delivered and Dr. M was suctioning her out with the bulb suction, I stared at the baby and thought to myself, “This baby is no where NEAR 9 pounds!”  And sure enough when the baby was weighed moments later, the red digital numbers burned into my brain as I saw them flash up onto the screen…

     

    7  POUNDS,  9 OUNCES

     

     

    And to top it off, as Dr. M saw the weight for herself as that little baby wiggled around on the scale, she poked her head over the drape towards Gina and said, and I quote, “Well she’s just a bit smaller than we first thought, but Gina, I think you really made the right decision.  You don’t have a lot of room in here.  You wouldn’t have wanted an emergency cesarean now would you?”

     

    AHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH!

     

    As if she could tell how much “room” she had in her pelvic outlet from staring at her uterus propped up onto her abdomen as she sewed it shut.  Wait?  What’s that smell?  Oh yeah it’s BULL CRAP!

     

     

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    In conclusion let us review the definitions of some of the terms I have been referring to throughout this post.  Although one of the problems in obtaining accurate research on the phenomenon of “elective primary cesarean section” is that there is no standard universal definition, I have decided to use the following definitions after extensive research on the subject which will be presented in Part 3 of this post.  So for the sake of discussion on THIS blog, I ask that the following definitions be considered:

     

    * Elective Primary Cesarean Section: A planned first or “primary” cesarean section in a healthy woman for the birth of a baby when there is no medical, fetal, or obstetric reason for the surgery.  May be influenced by non-medical issues, such as physicians’ personal beliefs (not facts) about safety, liability, insurance coverage, liability fears, hospital economics, efficiency, convenience, and reimbursement rates, as well as other factors not listed.  (American College of Nurse-Midwives, Position Statement: Elective Primary Cesarean Section & Citizens for Midwifery, News Release: “Patient Choice” Cesareans Almost Non-Existent)

     

     

    * Maternal Request Cesarean Section or Cesarean Delivery on Maternal Request (CDMR): A subcategory of elective primary cesarean sections.  A planned (before labor begins) first or “primary” cesarean initiated by the mother with the understanding that there is no medical, obstetrical, or fetal indication requiring cesarean delivery, and after a through review of the risks and benefits of cesarean delivery vs. vaginal birth by the obstetrician, the woman’s decision is to have a planned cesarean section.  The primary decision maker for a CDMR is the woman.  (National Institute of Health (NIH) Cesarean Conference definition, March 2006 & Childbirth Connection, Listening to Mothers II Survey)

     

    To reiterate, according to these definitions, it is misleading and inaccurate to assume that every woman who has an “elective primary cesarean section” actually had a “maternal request cesarean section.”  In order for a c-section to be truly considered a “maternal request” cesarean, the following FIVE criteria must be met:

     

     

    Necessary Criteria for Maternal Request Cesarean Section:

     

    #1  The request for the cesarean and the scheduling of the cesarean must have been made prior to the onset of labor.

     

    #2  The request for the cesarean must have been initiated by the mother.

     

    #3  The mother must have the understanding that there is NO medical, obstetrical, or fetal indication requiring a cesarean delivery.

     

    #4  The obstetrician must personally review and assure the mother’s understanding of the risks and benefits of elective cesarean surgery vs. planned vaginal birth.

     

    #5  The woman is the primary decision maker.

     

     

     

    So what do you think?  Does Gina’s cesarean section fit the definition for a “maternal request cesarean section?”

     

     

    TO BE CONTINUED…..

     

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    STAY TUNED FOR PART 3 WHERE I WILL REVIEW…

     

    * Types of cesarean sections and more differences between “primary elective” cesarean section and “maternal request” cesarean section.

     

    * How 13 major health care organizations and nonprofit childbirth/maternity advocacy groups weigh in on “elective” cesarean section.

     

    * An actual hospital consent form for “Elective Primary Cesarean Section.”

     

     
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