Current Research and Paradigm Shifts

I will never be free from medical ethics and consumer advocacy.  I am thankful for that.  Not only have I learned so much about my body and the complications of the medical field, but I have also learned that much of this knowledge can be applied in other fields.  I am hopeful that my research will help further an inevitable paradigm shift in my field that has yet to be “named.”  I can’t be more specific about it at this time.

I can be specific about my reading list:

  • Groopman’s How Doctors Think is at the top of the list (but currently MIA from my library, argh!)
  • Gawande’s The Checklist Manifesto and Complications: A Surgeon’s Notes on an Imperfect Science
  • Gadamer’s The Enigma of Health
  • Medical Error, Rosenthal & Sutcliffe (eds.)
  • Medicine Looks at the Humanities, Newel & Gabrielson (eds.)

I suppose this will keep me busy over the long winter break!

Not sure how I feel about Maryland

I just read a press release from Maryland’s Department of Health and Mental Hygiene. First, how strange is that term . . . mental hygiene . . . MENTAL hygiene?

Anyway, on the one hand I am glad that steps are in place to give women access to home birth. And if physicians and CNMs will actually attend these home births, then it’s possible that insurance will cover these births. Hooray!

However, I don’t believe that a physician or CNM is necessary for a great outcome at home. A trained midwife, CPM or otherwise, should be just as capable of handing low and lower risk births at home.

Furthermore, many women who fall outside of the definition of low risk will have better birth experiences outside the confines of a hospital. Typically, physicians and CNMs are not able to provide homebirth services to these women and their babies. I don’t recommend limiting their ability to find qualified providers who will attend them at home. I hope this board will use better mental hygiene and reconsider their ban on lay midwifery.

Empowered Birth Week

I’ve been so overwhelmed with the start of a new academic year, raising four young daughters, and trying to reserve some time for fun . . . that I have neglected other important aspects of who I am.  I am this blog!  And I am an empowered birther!  Are you?

Even if you had pain meds . . . or an induction . . . or a cesarean . . . you might have had an empowered birth.  Who decides what constitutes an empowered birth.  YOU DO, and don’t you forget it.  It’s not for medicalists or luddites to determine though many are happy to throw in an oar.  You have to be ok with your birth experiences, and if you’re not, I encourage you to figure out why and try to resolve that.

Did I have an empowering birth experience?  I suppose the answer depends on the moment you ask me about it.  Sometimes I think that if I had gone a different direction in terms of care providers that I’d have had a birth experience perhaps more resemblant of the one I so deeply desired.  Sometimes I think that my pain-in-the-ass, scare-tactic OB was an angel.  He was the best birth coach ever, as far as I’m concerned, especially considering that I had NO idea where my ass was nor how to push from that imaginary ass.

And it’s ok to struggle with being ‘ok’ with your birth experiences whether they are au natural or full-service medicalized.  It’s ok to question (or not) the validity of your birth choices (or the choices made on your behalf).  Wherever you are on the spectrum, I encourage you to think of yourself as an empowered woman.  You have the power to be fully present and accepting and/or participant in your health care decisions.  For me, being fully present and a participant are at the heart of being an empowered ‘patient.’

Birth Snapshot: The Epidural

Labortrials got an epidural?!  Oh me oh my.  Yes, friends, I consented (begged for, even) to the bleepin’ epidural.  How did this happen, and how do I feel about it now?  Well . . .

I arrived at the hospital worried that something was wrong.  The labor contractions came fast and painful, and I knew that less than 24 hours previously I was not dilated but a smidge.  I also felt as strange ‘pop’ down there and knew it wasn’t my water, so that in conjunction with the scary contractions (tetanic, perhaps) sent me packing to the hospital quickly.

The OB arrived, checked me, and found me to be 2cm dilated, but the baby was high.  According to the monitor, the baby was not handling the contractions well.  (She was having late decelerations.)  The OB restricted me to laboring on my side; the labor nurse told me I had to relax my body in order to dilate.  The contractions really were more than I could handle with the position restriction.  The OB checked me a few hours later, and I was still stuck at 2cm.  I knew that as soon as I could get an epidural that I needed to have it put in.  There was no way I was going to withstand the contractions, restrict my movement, and relax enough to dilate without pain management.

Interesting that this evening on my twitter feed, I saw @RobinPregnancy’s tweet about epidurals:

Did you ever have an #epidural that didn’t work quite as well as you’d hoped? http://ow.ly/6ejKI #pregnancy #About

I had an intrathecal with an epidural placed.  The idea was that the intrathecal could possibly get me through the next several centimeters of dilation more quickly and would wear off.  If and when I wanted the epidural, it would be ready and waiting for me.  The intrathecal improved my quality of life dramatically, and indeed I did progress quickly from 4cm to 8cm dilation.  Then I got stuck at 8cm and for a few hours, so I wanted the epidural.

However, the epidural was slow to work, and when it did, it didn’t provide enough relief.  My labor was not progressing very well, so I was concerned that if the epidural didn’t work and I needed a cesarean, that I’d feel the surgery.  I was terrified, actually.  This caused me to over-react.  The anesthesiologist gave me a bolus of something (yes, it’s horrible that I can’t recall this information), and when that didn’t seem to give me enough pain coverage, I received another bolus of something (nope, can’t remember what that was either).

So, when it came time to push, and thank God I got to that point, I couldn’t feel a darned thing.  I could sense when a contraction was beginning, but that was about it.  I had some sensation in my toes.  I had no idea where my vagina was or how to push.  That was terrible.  My OB was a tremendous labor coach, so he talked me through every contraction . . . every push.

Ideal?  I suppose that depends on how you look at it.  The purist in me says “technically, you had a vaginal birth, but you missed the whole darned thing.”  The practical-ist in me says “honey, if you hadn’t gotten that epidural, who knows if you’d have dilated quick enough for the OB, or if the epidural is what helped calm the baby’s response to the labor contractions (stressed mom can lead to stressed baby), or if you would have outlasted the pain.”  No one made me get an epidural.  I told them on entry that I wasn’t interested, and they left me alone.  I asked for the epidural – it was my request; my choice.

People can be sooooooo judgmental about the use (or refusal) of epidurals.  Read this woman’s story over at Unnecessarean.  Don’t miss the comments which are QUITE polarized.  Given what I’ve been through, you may laugh at my comments.  Would I recommend an epidural to my closest friends and family members?  Yes, with caveats.  Would I recommend my closest friends and family members NOT accept an epidural?  Yes, with caveats.  Would I recommend epidurals for VBACs?  Yes, with caveats.  Is the epidural the beginning of the end in terms of natural childbirth?  Yes and no.  Does the epidural cause a cascade of interventions?  Yes and no.

Yes.

and

No.

Yes, it’s not that simple . . .

Recurrent Miscarriage: My happy endings

I am somewhat pleased and sad to know that my post about Pregnancy Hormones and Miscarriage is consistently one of my top posts.  I wish I could hold everyone who comes by looking for answers.  I remember being there.  It’s still a healing wound that opens up from time to time.  I still grieve that I’ll never know those souls I lost.  Or do/will I?

Nutshell background:

After an uneventful first pregnancy that produced my 6 year-old daughter in 2004, I suffered three consecutive first term losses.  Getting pregnant has never been my issue; staying pregnant was becoming a real problem for my body and my psyche.  The last straw, the one that nearly killed me, was the 10-week loss, and the OB standing over me as I woke from the curetage telling me my uterus was too thin to ever consider a vagina birth, and this same OB wanting to put me on Clomid to treat my losses.  This OB had also refused to test my progesterone levels, saying that even if they were low she’d not treat for low progesterone.

Here’s what I had to do:

  • Change providers – I’m in a small town, so no one is super specialized in this area, but I at least found a doc willing to work with me; he had also dealt with infertility personally
  • This OB did ultrasound to check for PCOS (which he thought he found in me) and HSG to check for uterine abnormalities
    • PCOS markers may include u/s, but that’s not the only determining factor, so I ruled that out myself
    • The HSG showed an abnormality, alright; the OB thought it was a double uterus
    • I decided it was time to find a specialist
  • I found a yahoo group that supports women with Mullerian Anomalies (double uterus is a type of MA)
    • This group has an anonymous consulting doc who looked at my HSG film and believed the anomaly to be either a septum or bicornuate uterus shape
    • This group had a fantastic resource – a database of recommended reproductive endocrinologists and repro surgeons
  • Because I have family in Denver and was planning on being in Denver the Summer of 2008 for a voice science research program, I chose a RE in Denver.  Tough stuff when you’re essentially ‘out of network,’ but thank God we ponied up and did it.
    • The RE looked at my film and didn’t think it was a MA; he was sure it was a fibroid
    • SHG confirmed his suspicions
    • Extensive blood work revealed . . . LOW FRIGGIN’ PROGESTERONE . . . actually, really really crappy luteal phase progesterone (I am still so angry with the OB who refused to test my progesterone; I still blame her for that loss.)
  • The RE also recommended a myomectomy to remove the fibroid
    • He wanted to do it laparascopically which means cutting through connective tissue and the fundus to reach the fibroid
    • I didn’t want the integrity of my uterus further compromised and requested a hysteroscopic myomectomy instead; he agreed
    • Folks, do your research so you can advocate for your needs!!  I can’t stress this point enough!!!!
  • Thank goodness we did the hyst myo because instead of a regular fibroid, he found adenomyosis which he attributed to the PREVIOUS CESAREAN!
    • Hyst myo turned out to be the best way to remove as much of the adenomyosis as possible
    • Otherwise my uterus looked normal, no thin LUS, cesarean scar wasn’t even visible
  • This RE had a drug protocol that worked to address my progesterone deficiency
  • 3 months later my local OB examined my uterus via ultrasound and said that I was healed and ready to TTC!
  • I also made sure that the RE confirmed that the integrity of my uterus was not compromised from the surgery; my OB was nervous about ‘letting me’ VBAC

My happy endings:

I naturally conceived twins in 2008.  Luckily, I was in Denver over Christmas, and the RE was involved with my early pregnancy care.  My HCG levels were abnormally high, and an early early ultrasound revealed twins.  I enjoyed an easy term pregnancy (39 weeks!) with di-di twins!  My twins are such a blessing – can’t believe they’re almost TWO!

I became pregnant again in October 2010.  God has a sense of humor for sure.  I followed (more or less) the same treatment plan for low progesterone.  The first week of my pregnancy was stressful because I was having a hard time getting ahold of my OB and who had different ideas of how to treat low progesterone that conflicted with the RE’s protocol.  Can you believe this RE’s nurse was still supporting me through this stressful time . . . 2 years later?!  I was able to e-mail her and call her and they were willing to oversee my meds for the 1st trimester if I couldn’t get it worked out with my OB.  I had to ‘correct’ my OBs script a couple of times, and thankfully he was compliant.

Again, you have to advocate for what you need.  Right this minute.  Trust your intuition.  Know that infertility and pregnancy loss is more ‘art’ than ‘science’ at this point.  Know that there are widely disparate ‘camps’ when it comes to treating infertility and loss.

Currently, I am 37 weeks pregnant with my Happily Ever After baby.  May you find a way to yours!

Stakeholders for the Homebirth Summit

Stand and Deliver posted more information about the upcoming Homebirth Summit called by the ACNM.  Have a look at Rixa’s post and my previous post if you haven’t already (additional links on my previous post).

Geraldine Simkins, president of MANA, sent out a message with more information regarding this “work team.”  I’d like to further break down the point that addresses “stakeholders.”

The stakeholders are NOT ANY ORGANIZATION but rather are individuals who are defined as belonging in these nine stakeholder groups:

    • Consumers (from a variety of perspectives)
    • Consumer advocates (doulas, childbirth educators, childbirth and women’s healthcare activist)
    • Home Birth midwives (CPM, CNM, LM, Amish, traditional, whatever)
    • Obstetricians and OB family practice
    • Collaborating MCH providers (nursing: L&D, neonatal, pediatrics; CNMs who provide backup)
    • Health insurers and liability insurers
    • Health policy, legislators, legal, ethics
    • Research and education: Public Health, epidemiology
    • Health models, systems, administrators

In this way, the WHOLE SYSTEM is at the table. Otherwise, we will not be able to seriously come to consensus.

Here are my thoughts on each identified group of stakeholders:

  • Consumers from a variety of perspectives – why would they invite consumers who have no understanding of or appreciation for home birth to the table?  How would an anti-homebirth consumer help improve home birth?  How are these people being chosen?
  • Consumer advocates – are these all people who currently (or have a history of) support families who desire or choose home birth?  Doulas, CBEs, and activists are not necessarily supportive of or educated about home birth.  How are these people being chosen?
  • Homebirth midwives – ok good, hopefully they will select some midwives (with solid experience & reputations) who have chosen NOT to be certified.
  • OBs and FPOBs – aside from receiving transfers in a hospital setting, what experience do they have with homebirth?  It is possible that an FPOB would be more supportive of home birth, but puh-leez, how many OBs have actually attended home births???  Additionally, how forceful will a FP be in an arena over-represented by “first class” medical participants or will they be subverted by their more ‘highly esteemed’ colleagues?
  • Collaborating MCH providers – other than practitioners who willingly back up homebirth midwives and their families, what business do these other people have weighing in on homebirth?  I have yet to meet a nurse who thinks home birth is a good idea.  This is now the second category of stakeholders that I place within the larger category of ‘back up.’
  • Health insurers and liability insurers – at this point in time, I think it will be useful to have this group participate in the discussion.  They need to “face the music” and know that women and their families expect home birth to be a viable option.  Insurance is often a barrier for people who desire home birth.  Additionally, liability insurers have stuck their big fat toes into every crevice of maternal-fetal care, so they need to know what a huge obstacle they are providing for families searching for the best options that suit their needs.  (The fact that my OB couldn’t/wouldn’t deliver a breech baby because of his stinkin’ malpractice insurance drives me INSANE to this day!)  This group should listen and learn.
  • Health policy, legislators, legal, ethics – what in the HELL kind of catch all category is this?  I can’t make sense of it.  However, representatives from state-level governing/licensing boards, like Montana’s Alternative Health Care Board, should participate.
  • Research and education: Public Health, epidemiology – please add medical anthropology to this group!
  • Health models, systems, administrators – again, too vague for my comfort.  And it is premature to invite this group to the table.

Which of these stakeholder groups are rooted in public health and/or naturopathic (including midwifery) perspectives?

  • Consumers (??!!) – maybe, but again, it depends on the “variety of perspectives” invited . . .
  • Consumer advocates (??!!) – see above
  • Homebirth midwives

Which of these stakeholder groups are rooted in allopathic tradition?

  • OBs and FPOBs
  • Collaborating MCH providers
  • Health insurers, liability providers
  • Health policy, etc. (??!!)
  • Research and education – some of these folks might have training in non-allopathic perspectives
  • Health models, systems, etc.

So SIX groups (already with institutionalized POWER) interacting with THREE groups (with hardly any power when it comes to institutional change) with two-thirds of its representation from somewhat questionable backgrounds . . .

And people involved wonder why women (like me) are so concerned?