Rant.

Can I just rant for a minute?

Breast feeding does not = moral goodness. 

Nor does being vegetarian, voting democrat, eating all local organic humanely slaughtered meat, or birthing at home.

What makes you a good person is...well, being a good person. Little things like caring about others and understanding that we are all part of a larger social contract.

(Disclaimer: I fully support exclusive long term breast feeding, and feel strongly that we should mold our culture to fit this biological imperative. However, I don't think that if you did you are in any way superior to those that didn't. At least not because of that.)

In future installments:

New cool research

What the heck am I doing anyway?

Dr. George Tiller

I know, I know. This is a midwifery blog. BUT midwifery is rooted in my commitment to reproductive freedom. Where to birth, with whom, and when.

PLEASE READ THE POST AT OuR BODIES OUR BLOG ABOUT THE LATE DR TILLER> HE WAS AN AMAZING MAN.

http://www.ourbodiesourblog.org/

I HAVE MANAGED TO DOWNLOAD A VIRUS SO I WILL POsT My ThOUGhts WHEN IT IS RESOLVEd!!

Takin' it to the bank..or, The Bottle Let Me Down.

In other news, I was able to attend a roundtable with a rep. from the(not quite up and running) Northwest Mothers Milk Bank.

Did you know:
-All milk banks are not-for-profit organizations?
-The closest milk bank to us(Northwesterners) is in San Diego?
-There is a protocol ranking so that the neediest babies get milk first. The premie in the NICU will get milk before the adoptive mom.
-Human breast milk is considered a prescription medication.
-Some, but not all, of the nutrients and immunologic factors are lost during pasteurization; it still retains much of its protective value.
-Some hospitals stock BM, so that it is always available regardless of the ability of parents to pay for it.
-Most of the cost of the milk is attributed to processing fees. There is no profit made on the sold milk.

Breastmilk is only accepted up to 6 mos. postpartum, and there is a high need for the milk of preterm babies moms, since the composition is different enough from term mommies milk.

So, donate milk if you can, spread the word to your clients(there is a depot, or drop off site in Newburg, Or for locals), help set up a depot at your local hospital or clinic, or send a donation!
I was able to get a stack of brochures that I am sticking in my charts and giving to each client.
It can mean the difference between life and death for many of the babies receiving it.

NWMMB
3439 N.E. Sandy Blvd. #130
Portland, Oregon, 97232

www.nwmmb.org

(503)297-3664

Also check out Human Milk Bank Association of North America @
www.hmbana.org

The Week in Review.

It has been a very, very busy week. Two conferences in Portland, plus the usual prenatal/postpartum/domestic tasks to be fit in around them. I learned a lot, was challenged some, and was completely inspired. So here it is, my week in review:

Let me start this off by saying that I am pro-choice. I am completely unashamed by my stance, and think that as adults(you know...grown ups) living in the world that we live in, no one should get their panties in a bunch whether they agree with me or not. We can agree to disagree and still be friends. If you come across something here that you don't like, for goodness sakes, just skip over it.

The first interesting thing that I came across this week, goes like this:
A social scientist did a study where a American parents and Dutch parents were asked a question: "Would you allow your teenagers boyfriend/girlfriend to have a sleepover at your house?" Apparently, not a single American parent said that they would allow it, while their Dutch counterparts had a much more intriguing answer. The Dutch parents ALL said that they would allow it if their teenager was ready, and then they went on to qualify what would make them ready, things like emotional maturity and the ability to use contraception responsibly were on the list. Something to think about...

Next, I was able to attend a session titled 'Trauma Stewardship' after the book of the same title by Laura van Dernoot Lipsky. A co-worker laughed when I told her I was going to attend this session, but I promised to leave if hand-holding-teary-confessions/and or crystal charging started. I admit, it was a gamble! I can not even begin to tell you how pleasantly surprised I was. I take that back. It wasn't pleasant. It was alternately side splitting and sobering, and I loved every minute of it. It completely changed my life, and I urge you all to run out and BUY HER BOOK. Or google it. Or whatever. She has created a system to help professionals of all kinds cope with secondary trauma. This is the kind of trauma that comes from working with people in difficult life circumstances, or very heightened emotional states on a regular basis. As opposed to the kind of primary trauma that you are in say, after a shoulder dystocia(although I suspect that it could be useful for that as well). It is endorsed by the likes of Thich Nat Han, and is very, very relevant to midwives. Feeling cynical? Feeling like a martyr to your work? Don't have anything left over at the end of the day for your own kids? Trauma Stewardship. Check it out.

I was privileged to hear Michele Goldberg speak about the Religious Right and Global Reproductive/Population Control politics. Her new book is The Means of Reproduction:Sex, Power, and the Future of the World. I am about half way through it, and promise a full review when I'm done. But suffice it to say for now, that wherever you stand (or waiver) on the issue of planned child spacing, it is a worthwhile read. I asked her to please someday write about midwifery and the religious right, so who knows?

Oh and by the way:
You should all know about Esure. It is a form of permanent sterilization where little coils (they look like the spring in a Bic pen, but are smaller) are inserted with the guidance of a hysteroscope into the fallopian tubes. Nice alternative to tubal ligation. I am intrigued ny it, but still think I prefer the IUD until I meet more women who have had it done. But be sure to add it to your contraception counsels for women interested in permanent solutions.

After a day home, dealing with my insanely engorged breast, spending time with my kids, and squeezing in appointments, I headed back up to PDX for the Swanman Lecture series.

Overall, I found it interesting but not challenging enough for my tastes. It was geared toward nurses, and I would say that 97.5% of the audience were RNs. And because there was plenty of interesting but not really relevant information, I had lots of time to sit around and think things like"Wow, midwives are the best!" and "We really do practice better maternity care." and "Shift work sounds sooooo amazing." Here's a recap:

Fist of all, let me say how heartening it is to see medical professionals pushing for evidence based practice and physiological birth. It feels really good. Really, really good. For example, the first session was titled Cesarean Delivery: Alarming Rates and Maternal-Fetal Complications.It gave me a nice warm and fuzzy feeling to see a room full of nurses get lectured on the dangers of primary c/s and their role in avoiding it. It was a beautiful thing. There was also discussion of the artificial foreshortening of gestational age, and Cesarean Delivery on Maternal Request(billed as CDMR). Did you know that 1/2 of all physicians surveyed by ACOG(2006) had performed at least 1 CDMR, nearly 60% reported an increase in requests, most practices have no protocol for dealing with requests, and that female OBs were more negative towards CDMR than their male counterparts. Also worth noting is that in a study(Obstet Gynecol Oct. 2006) looking at Urinary Incotinence at 6 mos. PP there was no statistical difference in the three categories(cesaren, vaginal, or sphincter tear group)! So many women have been frightened about vaginal delivery resulting in pelvic floor dysfunction that they are choosing major abdominal surgery to avoid it, and are getting it at the same rate as vag birthers! Ay-yi-yi. What a mess.

OK, moving on. Oxytocin is now one of only 12 High Alert Medications!! Please read Oxytocin: New Perspectives on an Old Drug AJOG 2009, Vol. 200, electronic page 35E. Some hospitals(like Swedish in Seattle) give IC on elective induction in the first trimester, and have a policy prohibiting elective induction!! Three cheers! Another interesting read is Clinical Disagreements During Labor and Birth: How does real life compare to best practices?(Simpson & Lyndon).

Duncan Neilson , MD lectured on the British concepts of labor and birth. Once again, midwives have it right. Other things he talked about were the value of turning the pit off at 5 cm(advocate for this if you can on your next transport...many mom's will kick over to endogenous oxytocin after the initial help) and Grading the sutures for molding. Do any of you do this? It looks like this:
Grade 0: sutures open
Grade 1: Sutures closed
Grade 2: Sutures over-riding. Reduced by digital pressure.
Grade 3: Sutures over-riding. Can not be reduced with digital pressure. (considered a red-flag)

Always refreshing to hear a Doc bemoan the loss of hands on obstetric skills. Guess we midwives are going to be the keepers of these skills, as it doesn't look like the trend is reversing.

When talking to your VBAC mom's you can now let them know that a prior VBAC is considered protective against uterine rupture.

One of the most compelling things that I learned was that there is a higher rate of Vasa Previa in the IVF population, presumably because of the artificial hormone profile. Please read Robin Lim's letter posted on RIxa's blog, and draw your own conclusion. Also, for those of you interested in the ability of the fetal head to tampenade a partial previa, this in much more effective if the placenta is posterior, and less if it is anterior.

The second day was highlighted by three amazing lectures by my Lactation Hero: Marsh Walker. Seriously. This woman is amazing! One of my(many) favorite tips from her was to show parents worried about how much 'milk' their baby is getting in the first few days postpartum a medium sized walnut. Especially effective if it held up to a 4oz. bottle for comparison, since that is what most new parents think their baby should be getting in terms of volume. The walnut has the same volume as the babies stomach. This should also illustrate why they need to eat so often!!If a baby is doing that side to side head thing that they do, she suggests taking a syringe and lightly touching the mid line of their upper lip with it, leading them to the breast with it, and squeezing in a drop before they latch. She is a big proponent of Alternate Massage increases the pressure gradient allowing milk to flow more readily into the babies mouth. To do this, have the mom cup her hand around her breast and compress toward the nipple between suck/swallows. But the absolute best was the idea of Ventral Positioning(also called Biologic Nurturing) especially for Late Preterm Infants(LPI). I got a chuckle out of this, because our HB moms automatically do this, they never can get enough pillows t prop themselves up all the way! In the VP, mom is reclining at a 30 degree angle and the baby is draped across her chest belly to her belly. She recommended this for 'sleepy' babies, saying that even babies that appear asleep will BF in this position. In her lecture in Delayed Lactogenesis II she noted that moms with PCOS and other endocrine disorders may have had endocrine problems in adolescence that lead to insufficient or malformed glandular tissue, and that some of these moms may never be able to make enough milk. We have all probably seen this, but it does make me worry about plastics and chemical endocrine disruptor's and our little girls. Something to think about. There was so much more. She is brilliant. Read her books.

Phew! What a week! Take home message: Midwives Rock!!

Yes!

http://www.smar.info/article-30653416.html

'Mommy, What Did You Do In The Industrial Revolution?'
Brilliant feminist critique of current trends in surgical delivery by Lauren Plante, MD, MPH, FACOG. Read it and weep...I did.

Hang onto your ovaries!!

No, really. Hang onto your ovaries, if you can. Turns out that whole line that OB/GYNs feed women about their post-menopausal ovaries being shriveled up like raisins, and just hangin' around waiting to get cancerous is WRONG. Shocking, I know, but now we have the science to prove it. A study in May 2009 issue of Obstetrics and Gynecology titled "Ovarian Conservation at the Time of Hysterectomy and Long-term Health Outcomes in the Nurses Health Study" showed that women who had their ovaries removed had a higher risk of death from any cause, primarily heart disease and lung cancer. Furthermore, removing the ovaries at any age did not improve the life span.

My two moms have both had their ovaries removed. I say this with a heaviness in my heart, because I love and adore both of these women, and want nothing to stand in the way of a long and healthy life for both of them, and many, many years of their company. One mom had a hysterectomy for prolapse, and it could safely have been partial and her ovaries spared, had they not been cancer sprouting raisins. The other mom had really bad adhesions that were all over her ovaries, so who knows? But so it seems to go with our cavalier hacking up of our bodies. A little vaginal-bypass here, a little nip and tuck there, a little hysterectomy, and hey while we're at it let's just...I fully support womens, indeed all humans, rights to do what they will with their bodies(see suture post). But the verdict is still out on so much, and the level of informed consent so minimal, that it seems prudent to avoid it if you can. So, please, hang onto your ovaries!!!

Just Right...the Retrospective Diagnosis

One of the two April babies came. It was a much longer labor and push than we all anticipated, due to a posterior presentation. I hate to be a pessimist. I have a running dialog of silver-lining reassurances during times like these, but I was concerned about the outcome of this birth. When the head went from asynclitic and relatively evenly applied to posterior and ballotable at -1 with a consistently 6 cm cervix, I was wondering what the night would look like. In the end, the posterior resolved with some hard work on the part of the mom, and a little help from her midwives. The take home message, for me, was this: the diagnosis of dysfunctional labor is a retrospective diagnosis. Had the outcome of this birth been different, I would have termed it clearly dysfunctional. However, with the good outcome and 20/20 hindsight, I am able to clearly discern a pattern that made sense and contributed to the vaginal birth of the baby. Sure, it may have taken the better part of all of our lives had we not urged it along, but the change in the babies station and the sometimes easy going contraction pattern allowed for position change that resulted in a vaginal birth. I'm not sure that I will let my guard down about posterior, I've been stumped by it too many times. But was this woman's labor dysfunctional? Nope. It was just right.