Friday, April 17, 2009

Obstetrics: causing a problem and then fixing it

Originally posted Jan 26, 2009, at the start of my maternity classes.

My maternity nursing classes have been interesting. I've never talked so much in class! I'm the only person in the class with any home birth experience, and I'm also the only male student (out of 3) with any recent birth experience. I think there's 37 women in the class. So I have a weird perspective on things.

For instance, we went over the different positions a woman may labor in - but the teacher said "I have to teach you this, but I also have to tell you you'll never see any of these. As soon as the water breaks, they're in bed until that baby is born." She asked if anyone has seen a woman laboring standing up - I raised my hand, and she said "Well, sure, you have. Your wife had home births, which was great because she could do whatever she wanted." :) She also asked if we felt more empowered giving birth at home. She's repeatedly said that lithotomy is the worst position from which to push a baby out.

She's also thinking of showing The Business of Being Born.

9 out of 10 complications we're being taught about are caused solely by the obstetric process - maternal fever from anesthetics, constricted placental bloodflow from Pitocin, urine retention from spinal blocks, babies with poor respiratory drive and suckling reflexes from opiate use. The most common problem is called supine hypotension syndrome - if a woman labors on her back, her uterus squishes the blood vessels supplying the lower body. This causes a reaction where her blood pressure and heart rate drops, which drops blood supply to the fetus. This shows up as heart decelerations on the monitor. Nursing response? Turn the woman on her side, slap some oxygen on her, start IV fluids to increase her blood volume. If that doesn't work, try the other side - if that doesn't work, prepare for a c-section. The cause? Laboring on her back - so she can be hooked up to an electronic fetal monitor. And the only reason she's on the EFM, as they've repeatedly told us in class: lawsuits.

There's not much emphasis on real pregnancy problems - placental abruption, placenta previa, eclampsia, etc. I have a feeling that OB nursing is all about complications of treatment, not complications of labor. A midwife or an obstetrician has to think about physiological complications, while an OB nurse has to think about treatment complications.

7 comments:

  1. Okay, now you've really won me over. I'll say it again - I heart you. :)

    Tell your wife from me that she has an awesome man!

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  2. I labored standing up, in a hospital, with my second...the only reason I did it in the hospital was that I lived far from the hospital and was alone except for my 3 year old.

    At the time, the province I live in did not recognize midwives. Now they do. Unfortunatly this means that all home births HAVE to have a midwife present...and there are no midwives in my area, so even though we want to have THIS baby at home, it isn't looking good.

    With my second, I walked for hours in early labor, and then waited until the contractions were very strong and close before checking in (the nurce who checked my dialation said "oh it's only 3 cm...4...5...6cm... we'd better get you into a room!"

    I was asked if I wanted a squating bar, as this was one of the older beds that did not have it built in. By the time it arrived I hopped up on the bed, and told them when the contraction started and that I would push.

    One of the nurces shook my hand after my 3 push standing delivery, saying it was the most beautiful delivery she had experienced.

    Compare this with my first, where they induced me, dispite my assurances that yes, I was having contractions, but no, I did not want to lay down, the nurce kept up-ing the dose of pitocin. In fact, it was my doula who suggested that I try a push, and I grunted, which apparently is a sign that baby was ready to come. She said to the nurce "I think it is time" and the nurce, with heavy skeptism, ordered me to lay down to have my "progress" checked. She found I was fully dialated, and the room filled with people and I was not allowed to stand up again. It was soo hard to push in that position, and I burst all the little blood vessles in my body except where my doula and the father had their hands on my back...it was a sight to see these pale hand prints on my red speckled back. I ended up needing stitches, was in the hospital for 4 days and it took weeks to be able to sit or walk without pain.

    With my second, I checked out 11 hours after checking in and drove myself home to my farm the next day.

    Thanks for the interesting reading!

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  3. Wow! Reading this was like seeing my current life reflected before my eyes in nursing school. I completely know what you were going through and felt. I too am the only homebirther in my class of 40, therefore, you can imagine the outcast looks I get also. My question...how do birth supporters like us support mothers in a hospital birthing world full of fear, ignorance, convenience, and rudeness? How do we make change? Is it possible not to fall into the ways of the masses and just stop carrying?

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  4. Birthkeeper: Thanks. :)

    Laila: I noticed with L&D nurses that there was a lot of, how should I say it, coercion? As in, you have to lay down, I have to check you now, things have to proceed the way I want them to proceed. We do this in all facets of nursing, actually, but what is appropriate when dealing with, say, drunks or unstable people, does not seem appropriate with a laboring mom. And I also hate the "oh, you grunted, that means things are happening the way I want them to happen now" attitude.

    Midwife in Training: I'm planning a more comprehensive post on what I thought of my OB class. I was somewhat able to support moms in the hospital, but to be honest I was more comfortable in the postpartum section, because I could actually intervene sensibly there. You can't exactly step over the doctor in L&D, but postpartum is managed more by nurses. I think it would be possible, with difficulty, to be an L&D nurse that stands up to convenience, poor non-evidence-based practice, and especially rudeness, but unfortunately I can't say I saw it on my rotation. I don't know how it would be to be a hospital CNM or OB, trying to let women have normal nonmedicalized births. I think you would have more leeway, but you'd also have to put up with hospital restrictions; and you'd constantly have to deal how the nurses treat of your clients while you're away.

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  5. I work at a LM run birthing center in the deep south. A local nursing instructor comes each semester with all her first years to visit us and watch "The Business of Being Born".The Lms and our one CNM sit down and do a Q and A, allowing for some great dialog and honest answers. Hoping that even that little bit of saturation into this birthing community makes the students think

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  6. I just had my third baby at home. My first two were delivered by CNMs in a hospital that was really a birthing center with an emergency room attached. This one was delivered by a CPM at my home, and by far my best experience, even though they were all natural, vaginal births. My midwife talked a lot about how the pelvis collapses when women lie on their backs, versus how much more room there is when their standing, squatting or in a number of other positions. For my second baby, at the hospital they did intermittent monitoring, but mostly let me labor however I wanted. Even after my water broke, I was walking around and moving a lot. I suspect the hospital's feelings about how labor should go have a lot to do with how laboring moms are treated, rather than just L&D nurses. Mine were wonderful, supportive and sweet. Except the one who told me not to scream. My friends at the hospital down the street were not so great. I imagine a lot of the process has to do with those kinds of scenarios.

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  7. Anonymous from February (sorry I didn't comment sooner!) - that's great that a nursing instructor brings her students to you. We did watch part of the Business of Being Born, though I don't know how much it sunk in. One of my fellow students said between that, what she saw in OB, and me talking about our home births, she would do it at home if she ever had kids.

    Anonymous in April - That's good that you had good experiences. I still think that we nurses tend to be bossy and have to manage the environment (hence telling you not to scream), which works in other areas of nursing/medicine but it doesn't seem appropriate for normal labors! And isn't it ironic that CPMs (who everyone thinks have 'less training' than CNMs or OBs) seem to know more about the mechanics of labor and birthing?

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