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.

It's like she's lving my life.....

A little pregnant. Check it out, I promise you will laugh!

http://www.alittlepregnant.com/alittlepregnant/

In addition to struggling with similar questions about the Easter Bunny, I'm getting crazy amounts of gardening done(peas, beets, lettuce, potatoes, and broccoli in, most of the grass out...phew!), reading Farm Friends(about 60's Communal Farming, so far OK) and Devices & Desires (review to follow). Nursing Em through her four I teeth (literally and figuratively, she has breast fed baby poo again. This is not OK, *sigh*) and URI, and waiting on two babies that REALLY need to come before NAF in PDX and the Swanman Lecture Series at Legacy, also PDX(review to follow!). So, I am in a domestic holding pattern, but looking forward to having lots to write about!

The tie that binds....thoughts on suturing.

WARNING: not for the faint of heart!!
The first two times that I ever sutured was when I was working as a body piercer. Around that time(mid to late 90's), different body modifications were coming into vogue, like branding(verrrry stinky), scarification, surface-to-surface piercing(variation on a theme), lobe enlargement by 'scalpeling', and something called 'pearling'(more on that in a minute). One of my co-workers was this very dreamy, but certifiably crazy man (lets call him Bob, for the sake of privacy). He had these huge brown eyes with thick dark lashes that could melt your heart. He also had a bum-lobe, from too much stretching too quickly. His lobe was stretched to several inches in diameter at this point, and one day it started to get sort of stinky and green. It was necrosing. Bob was they type to take matters into his own hands, and over a full pot of coffee each, we cooked up the scheme to cut out the necrosed tissue and suture it back together. It really was a brilliant plan. And so as soon as the shop closed at 11pm, I did my first suture job, without anesthetic. In all honestly it was two interrupted stitches. But the ear healed beautifully, and the necrosed, excised piece lived in a jar somewhere for a long time. Ew, huh?
My next suture job was a lot closer to a vagina. This is where the pearling comes in. Pearling entails making an incision in the skin, working the dermal layers open, and placing a sterilized pearl or surgical stainless steel ball in the pocket that you've created. It is really very simple. People were putting them everywhere from their temples to their backs, and the more adventuresome types were putting them under the skin on their penises and in their labia. The only set I did were in a friends labia, and allowed me my second suture job. Another piercer at the shop did one side, and I did the other. Mine looked prettier, but his held better. A good lesson. I think I did about four interrupted stitches that time.
Fast forward many years and I finally received some training in suture technique. I of course read everything I could get my hands on, and practiced once or twice on chicken breast, but the first formal training I had was with Aly Kuntz, Suture Goddess, at Casa De Nacimiento. We practiced on beef tongue, and we learned instrument tying(I confess, I am no good at it! I hand tie), and a really neat little mattress stitch that I love. You start at the apex, throw a few deep, and then starting at the bottom stitch vertically alternating sides so that as the suture is tightened, it pulls the edges together. Tie off at the apex. I love how tidy this turns out.
The first suture job that I ever did after a birth was on one of my final supervised primaries, and my preceptor was amazed at how steady my hands were. I like to suture.
I not only like to suture, but I want to be very good at it, and like to take whatever classes and opportunities to practice come my way. I took a 4th degree tear workshop at the ALSO course. This model was more complex, using a candy bar, sausage casing, flank steak and a condom. I absolutely would not attempt to repair a 4th degree tear at home(I sure hope to never see one at home, duh), but I learned a ton. I like suturing with doctors. They are so good at it. They are not afraid, and they get tons of practice. Whenever I transport, I ALWAYS hang over the doc's shoulder and watch, because I learn something every time(and they're so FAST!!!). I make a point of discussing it with them if I get the chance. I wish I had a doctor friend that would let me bring a beef tongue over, drink beers at the kitchen table, and suture. This is my idea of a good time. Truly.
As much as I love the aforementioned mattress stitch, I have never used it on a person. Only beef tongue. I have seen many doc's use it, and I always think that I'm going to, but I either don't need that many stitches, or, as in the case of my last suture job, it was too ragged and complicated. The trend for midwives in my area(the ones that I have grilled about it at least) is to put in as few stitches as is necessary to pull the tissue back together. The bare minimum. The doc's put in so many. But talk to a doc who has gone to a third world country to repair bad suture jobs, and you wonder which is the right way. It stands to reason that more stitches will cause more tissue trauma and swelling, and more itching and discomfort, but there is already going to be swelling, discomfort, and itching. I don't know what the answer is, but for now I do as few as I can get away with. Any thoughts? I would love to hear them.

Predictions

I quit making them.

Response to UC blog post by Pamela Powell

Please read the blog post on UC birth resources by Pamela Hines-Powell:

http://www.pamamidwife.com/

I was trained through apprenticeship, and have lately been thinking long and hard about the pro's and con's of not having gone to midwifery school. However, hearing the responses to this post from school trained midwives, I was able to add to the 'pro' column that I was exposed very early on in my training to UC as a positive and empowering experience for women and families. My first exposure came through a friend who had a falling out with her midwife mid-pregnancy and decided to have an unattended homebirth with her second child. I was newly interested in midwifery, and I was in awe of this woman. She successfully birthed her baby with her partner, son, and a friend a few days after my 20th birthday. It so normalized UC for me, that I have very rarely thought of UC as an extreme option. My second and more formal exposure to UC came through a midwife that ran a study group that I attended for years. She had some of her babies UC and helps UC families as a back-up and source of PN care and advice. I considered a UC for the birth of my second child, but decided against it mainly for the reason that my husband wanted a midwife. It didn't seem fair to put him in a position of responsibility that he didn't want himself. I was also just looking for an out to having to choose a midwife from my many wonderful colleagues. In the end, I was so happy to have my midwife, for many reasons that are both mundane and deeply personal.
As a new midwife, I have gone through phases about my feelings about UC. I have always assumed that when the opportunity presented itself, that I would help. I am always curious about the WHY of it for a family. (Interestingly enough, I might now be 'suspicious' of a mom who wants a UC because she didn't get along with her midwife!!) I am concerned about the liability involved in helping families who may refuse your best professional opinion when the chips are down. I am not naive enough to think this doesn't happen when you've been hired as the Midwife! I do not believe that my presence at the majority of births is what makes birth safe, and therefore do not believe that UC'ers need to have a perfect or deep understanding of all that our work entails-you don't have to be a midwife- to have a safe birth! I do believe that I have enough tricks up my sleeves to avert an unnecessary transport. As with everything, my feelings about UC are constantly evolving, and I expect will continue to do so. I thoroughly appreciated Pamela's advice to TALK to UC'ers. It is through women's stories, tempered with an understanding of the physiology of birth and a good measure of critical thinking, that we receive our best education.
I find myself more and more sitting in the corner at births. It is becoming less and less about me all of the time, and I am constantly exploring my ego-involvement in my work. The topic of UC is a catalyst for me to think more deeply about this, as well as a challenge to my true beliefs about the perfection of the birth process!
Many thanks to Pamela for her post.

Editorial, JOGNN

http://www3.interscience.wiley.com/cgi-bin/fulltext/121645508/PDFSTART?CRETRY=1&SRETRY=0

Transitions..., or, The End of An Era.

I just taught the last in a six week Beg. Midwifery Study Group (more of a class really). We finished up with normal PP and watched Birth Day with Naoli Vinaver, I cried as usual. I always cry during birth movies. Sometimes I think it's the sound track, and sometimes I think that it's because I can't cry when I'm working so I save it up for when I'm watching birth videos. As with most things, the truth probably lies in the middle. It was a wonderful group, eight amazing women who may or may not become midwives, but will all be bearers of the torch of truth. An equally important job. They are now going to take the reins and form a real study group. One where thay actually do self motivated learning at home and then get together to hash out the details. I have agreed to come every other week to guide them and make sure that they are hitting all of the relevant points. I am thrilled to see them taking charge of information gathering and book learning.

Still only one of four February babies, so I am enjoying the little spots of sunshine and having time with my kids. I am reading "Green Thoughts" by Elanore Preyeni, and recomend it to the horticulturally inclined. Now is the time when my daydrems of digging in sun-warmed earth start creeping in to my daily life to an alarming degree (alternating with a day drem that involves a beach in Mexico and an ice cold beer...). Arlo is about to loose a tooth, and Emma is talking like crazy, and both of my kids are inspiring warm feelings in me. Every once in a while I realize how much I like my kids, and how lucky I am that I do. Even when Arlo is teaching Emma to scream "baby butt" at the top of her lungs. Good thing I think Baby Butts are cute.

What a girl wants, what a girl needs....

I am constantly spinning my wheels about business models that work for homebirth practices. I am intrigued by the idea of partnerships, and am constantly soliciting advice from those who have been there and done that, or are still happily partnered. I am curious about the idea of superimposing a birth center model onto a homebirth practice. This could just be several midwives that have a revolving call schedule (3 mos on, 1 mo off), or two midwives that alternate weeks on/weeks off for prenatal care. What about an office space? One midwife recently suggested to me that a co-op office space to house several practices might work. It is interesting to think about. For those of you that have an office, how do your clients feel about it? Do you feel like it changes your clientele? I was trained in a solo practice, and worked as a second midwife in what was, essentially, a solo-practice(we both did everything). It's what I know. But it doesn't allow for time off call, and it feels lonelier somehow. I have always worked in clinical settings, and really enjoy the camaraderie that comes from sharing my work with others who get it, so I think that's part of the draw to a group practice.Please send me any ideas/experiences!

February has turned out to have a mellower feel than I thought it would going into the month. One mama went to the hospital early with pre-eclampsia(she had an amazing birth! beautiful, really), so I'm just waiting on three primips who are all doing their primip thing. In the mean time, I hope to get my website up and running, and finish up my Beginning Midwifery Study Group. I am turning 31 on the 14th, which feels pretty anti-climatic. But if everybody stays pregnant, I may even get a date with my hubby!

The Next Generation

I just finished the teaching the fifth class in a six week introductory study group for aspiring midwives. We have covered a lot of territory, much of it personal. At each class, I have been graced with the details of these amazing women's lives; some of it mundane, and some of it deeply personal, all of it important. Next week we will finish with a class on Post-partum Care, and then we will decide if we should continue, if they want to be more of a 'real' study group, or if we all want to take a break. As an apprenticeship trained midwife, I am so thrilled to be able to continue the thread of passing on knowledge. I have the fondest memories of all of the study groups that I ever attended, and of all of the midwives that graced me with stories and information. The oral tradition is a powerful one. I am part of the newest generation of midwives, but I can already see the seeds of the one to follow being planted behind me. My rally cry: MORE MIDWIVES!!!