Belly Tales

So, I’ve been a bit incommunicado thanks to the intensity of my clinical schedule, and the fact that last week was our first exam, and I was busy spending every spare minute studying for it (I’m very pleased to report that I did well on my exam, despite my deepest concerns regarding my sincere lack of study-time). In the meantime, lots of news has been breaking out all over the place, and I’ve been letting it slide. But no longer! Here’s what’s new in the world of women’s health and midwifery news:

First, Merck has recently stated that they’re going to stop lobbying for state legislatures to adopt universal HPV vaccine requirements, in part because of all of the sudden bad press and objections to their lobbying efforts and their fear that continued lobbying would undermine use of the vaccine. Meanwhile, questions continue to arise regarding Merck’s financial invovlement with Texas Governor Rick Perry’s campaign. The CDC has also recently emphasized that no additional warning labels will be placed on Gardasil and that so far, all of the side effects reported with use of the vaccine (mostly inflammation reactions at the injection site and fainting) are low risk.

Since we’re on the subject of vaccines, it appears that research is now targeting Chlamydia for a new vaccine.

A post by Miriam Zoila Perez, the latest NAPW guest blogger, is up on Feministing regarding Radical Doulas.

The Mommy Blawg has a great break-down of all of the latest midwifery legislation being proposed in various states, particularly legislation working to legalize that status of direct-entry midwives (CPMs).

And finally, via Women’s Health News, Tenessee Representative Stacey Campfield has recently proposed legislation requiring a death certificate for each terminated pregnancy in the state of TN, while simultaneously not requiring death certificates for each spontaneous abortion (miscarriage) that occurs in the state of TN. In most states, death certificates aren’t issued until the baby reaches certain gestational age and/or weight requirements, such as 20 weeks, or 500 gms. Since most elected terminations occur during the first trimester, and most spontaneous miscarriages also occur during the first trimester, does it not seem a bit hypocritical to issue death certificates for one and not the other? Naturally, the Tennessee Guerilla Women have plenty to say on the subject. And while Campfield continues to look foolish by trying to deflect attention away from the nitty-gritty details of his bill, NARAL Pro-Choice America has joined the fray by setting up an online form for the women of Tennessee to contact their state representatives.

The strangest vaginal exam I’ve ever had so far happened two nights ago, on my first night-shift clinical rotation, when a woman in early labor came to triage. She was full term, she’d had some light spotting, hadn’t felt the baby move as much as normal in the past 24 hours, and was contracting about every 5-10 minutes. I took her history and started my physical exam. We were most concerned about the lack of movement, since this is often an indicator of fetal distress, and the tracing didn’t look that hot. I palpated her abdomen and I had a difficult time figuring out where the baby’s head was, but I assumed it was vertex (head down) because we were auscultating the fetal heart below the woman’s belly button, which is usually a good sign that the head is down. I’m a student and my Leopold’s maneuvers aren’t expert by any means, so I figured it was due to my poor Leopold’s that I wasn’t able to tell for certain where the head was.

We moved on to the vaginal exam. My preceptor checked first per usual, and smiled at me as she pulled her hand out and said “this is going to be a great vaginal exam for you.” I began my exam cautiously, figuring the woman was 2-3 centimeters dilated, and wondering what my preceptor was talking about. I felt the cervix right away, and indeed, she was 2 centimeters dilated and about 80% effaced….but where was the head? I didn’t feel the head anywhere. My preceptor told me to put my fingers inside the cervix and feel the bag of waters….and OMG, what is that???! Not a head at all! Some kind of strange, small, hard little thing bobbing up against the intact bag of waters, clear as day. I almost gasped in surprise (but managed not too, thank goodness!). What in the world is that? My preceptor mouthed the word “foot” to me, and suddenly it all clicked in to place. It was indeed a foot, I could feel the outline clearly, I could tell where the heel was and where the toes were….I was basically tickling the baby’s foot, and she was in a footling breech position. An ultrasound scan quickly confirmed what we’d felt, and the head, rather than being in the fundus (or over the symphysis pubis), was actually way off to one side, almost transverse more than anything else. The woman said the head had been down at her last check-up a few days ago, so I wonder….did the baby flip all of a sudden, and is that why the woman thought the baby wasn’t moving as much as normal, because all of a sudden she wasn’t feeling the usual movements in the usual places?

She was committed to having a vaginal delivery, so we referred her to the physicians on the floor, who offered her an external cephalic version in the operating room. As they were trying to turn the baby, though, the heart rate decelerated, and she ended up giving birth by cesarean. To be honest, the tracing, even in triage, never looked fabulous…there were never any accelerations, and the variability was occassionally flat, and as it turns out, there was a cord wrapped very tightly around the baby’s head. So everything happens for a reason, and I do think that sometimes babies have a mind of their own when it comes to how they want to be born. This little one wanted to come out foot-first!

One of the greatest concerns with a breech delivery is that the cervix will not be open enough to allow the large head to pass through, even though the smaller body might have already been delivered, and then you end up in the dangerous situation of a body fully born with a head entrapped by the cervix. While vaginal deliveries may be possible for other breech presentations, like a frank breech or complete breech, because at least the breech (i.e. the rump) is hard enough and unyielding enough to press against a cervix and help it fully dilate, with a tiny little foot presenting, the chances of the cervix opening fully are very small. Because of this, footling breech presentations are the most dangerous type of breech presentation to deliver vaginally, and I’m really glad this woman came in when she did and was able to give birth via cesarean, expecially once it became clear that a version was impossible and that the baby wasn’t doing that well with her tight nuchal cord. So, here’s to cesareans done for a good reason; they really can be lifesaving when they’re truly indicated. And as for me…I will never forget this vaginal exam for the rest of my life!

One of the midwives at the clinical site where I am working has a sign on her locker that says: Support Midwives, Make Love.

In that vein, here are eleven tips which were given to us by our guest lecturer on Sexual Health last year:

For a Better Sexual Life:

Suggestions that Work!

1. Connect before you caress—do things alone together that make you feel closer. At least weekly, spend anuninterrupted hour doing something that is fun or mutually satisfying (i.e. take a walk, have brunch, see a romantic movie).

2. Don’t forget romancing outside the bedroom—court each other.

3. Plan time together (when children arrive, or life intrudes, spontaneity leaves). Make a “date to make love”.

4. Create privacy (lock the door, turn off the TV and phones).

5. Sex is adult play—be sensual–let your skin and senses wake up to touch and caress. Use oils or power so that your hands can glide.

6. Dont expect mind reading—let your partner know what you would like: the kind of touch, the movements, the pace you enjoy.

7. Think about enhancing the variety of your sexual activities. Occasionally, try something “new” or slightly “forbidden”.

8. Stay positive and constructive—criticism never made anyone a better lover.

9. Keep your sense of humor—things often go wrong. Humor is the best lubricant.

10. Forgive easily—don’t let the little things ruin sexual intimacy.

11. Make your partenr feel valued—give a gift of yourself every day—a word of praise or a compliment, a hug or caress outside the bedroom, a flower, a card or special food, a few minutes of your full attention, your special helpfulness.

A loving connection is the most important goal.

—Drs. Marian E. Dunn and Sandra Leiblum

Via Gothamist, New York City mayor Mike Bloomber has recently pledged $2 million dollars to city-run hospitals for the promotion of breastfeeding, with the goal of getting more women to breastfeed for six months or longer.

“We don’t yet have any hospitals in New York City that meet national ‘baby-friendly’ standards,” Bloomberg’s health commissioner, Dr. Thomas Frieden, said at a parenting conference last week.”That means getting formula out of the nursery. It means putting the baby on the breast immediately after birth. It means that every person who interacts with that mother and child is supportive and encouraging of breast-feeding.”

Well, three cheers for that! I can tell you, a boost like this is sorely needed, particularly in public hospitals, since research has shown that the rate of breastfeeding increases with income, education and age, and public hospitals most often take care of the women who have the least. I hope a fair portion of this money is spent not only advertising and promotion among the general public, but on education for hospital staff. Women need so much help and support in order to be able to breastfeed, especially during those early crucial days in the hospital, when both mother and baby are still learning how; the attitude and encouragement of the hospital staff, from the doctors and pediatricians on down to the PCAs and nurses’ assistants, is absolutely crucial.

For a long time, breastfeeding education and attention has been given short shrift, but thank goodness things are starting to change—from much-publicized public nurse-ins in places like Toys R’ Us to the Massachusets ban of hospital distribution of diaper bags loaded with formula coupons and advertising. The hospital where I am currently doing my clinicals (a public new york city hospital) has recently created a new policy where formula is never placed in a baby’s bassinet when the baby is brought out to the mother, even if the mother is breast and bottle feeding. If the mother wants formula, she has to specifically ask for it. Small steps like that, but the hopefully the overall impact is much greater.

Mothering magazine recently ran a competition to create an internationally recognizable symbol for breastfeeding. The winning symbol, created by graphic designer Matt Daigle, can be seen at the top of this post. This symbol has been made part of the public domain, so it can be downloaded and displayed anywhere, by anyone. The intention is not to segregate breastfeeding mothers, or to designate specific places for breastfeeding, but to simply indicate that breastfeeding is welcome and acceptable on the premises. Hopefully we’ll start to see this symbol cropping up all over the place, in restuarants and malls and airports and libraries, movie theaters and convention centers, maybe even on subways and buses….starting with our public hospitals (I’m going to print out a couple of these and bring them to clinicals tomorrow).

Dear American Association of Birth Centers:

I have a lot of respect for you. I feel that you’re a very informed and informative organization, providing countless resources for both families seeking a birth center experience, and for midwives, doctors, nurses and other care providers and community advocates who are interested in opening up birth centers around our country. Your response to ACOG’s misguided new policy on out-of-hospital birth was particularly brilliant: well researched, well stated, and just spot-on. And trust me, I wholly agree with your mission statement: we need more birth centers in this country! The work you do is crucial and very much needed and appreciated.

However, I just recently discovered that you’re planning on having your annual meeting in Anchorage Alaska this year. Midwives, nurses, doulas, doctors and other birth workers tend to be very busy people. We tend to be stretched in many different directions at once, and we tend to have our fingers in several pots at the same time. We’re dedicated, but we’re not rich. We get time off, every now and then, but not heaps of it, especially for those who’re living the on-call lifestyle. We’re presented with many conference opportunities throughout the year, and because our finances, budgets and work schedules are often prohibitive in the number of days off we can obtain, and our ability to attend a conference is often a luxury and not a mandate, our conference choices must be made very carefully.

There are already several large and popular conferences hosted on an annual basis on midwifery and birth related topics, such as the ACNM National Convention, Contraceptive Technology, MANA conferences and Midwifery Today conferences. There are probably many of us who are very interested in promoting and enhancing access to birth centers in this country, and who are interested in attending your conference, but why Alaska?? While I am sure that Anchorage is a beautiful and vibrant city with much to offer to attendees, and Alaska is just as much a part of the birth center debate as the lower fifty states, the simple truth of the matter is this: hopping to Chicago for a long weekend is probably much more do-able and affordable for many people, while Alaska is much less so. Very few of the busy and active workers, the ones who would benefit the most from your conference, and the ones who you probably most want to attend, are going to be able to make it—at least, not in the numbers that you are probably hoping for, and not in the numbers that we need in order to really begin to make positive change in this country regarding the promotion of birth centers.

By hosting your conference and annual meeting in a remote location, you are ensuring that birth centers remain remote from the national debate on birth in this country. In fact, as birth centers continue to close and become marginalized in this current unfavorable climate, hosting a conference in Alaska seems to sadly epitiomize where birth centers stand in this debate. I strongly urge you to consider a more central and easily accessible location for your conference next year, so that your urgent work and mission can receive the attendance and attention it deserves.

Sincerely,

The Student

Amanda from Pandagon and Jessica from Feministing, both of whom were lucky enough to attend the National Advocates for Pregnant Women Summit a few weeks ago, decided to continue to explore many of the issues and topics covered at the summit through weekly guest bloggers hosted on Feministing. The first two are up already:

Jill Morrison on Laws that Punish Pregnant Women and Priscilla Huang on Killing the Immigrant Body.

Both are fascinating and highly recommended reads. Can’t wait to see who the new guest blogger will be.

Texas governer Rick Perry has recently signed an Executive Order requiring all girls between the ages of 11 and 12 to be vaccinated with Gardasil, Merck’s new HPV vaccine, which is currently the only vaccine on the market that treats HPV (other HPV vaccines from other companies are in the pipeline and soon to be approved by the FDA). In response to this, Texas legislators have recently proposed a new bill to remove Gardasil from the vaccination list required by TX law for entry into public school.

Governor Perry’s Executive Order has kicked up a lot of dust. While many people initially opposed universal HPV vaccination under the premise that it would encourage promiscuity in teenagers and women, concerns about the safety of the vaccine, as well as its long-term effects, have also been raised. From a legal standpoint, many people feel that requiring HPV vaccination for entry into school is an enfringement on their rights, particularly since the public health need for this vaccine is not as pressing, given that HPV is not an airborne or contact communicable disease that can be transmitted at school, but is actually an STD requiring genital to genital contact, and the rates of cervical cancer in this country are actually very low (annual pap smear screening for cervical cancer is one of our greatest public health success stories!). Questions have also been raised about the motivation behind this vaccine, given that Merck was a contributor to Perry’s campaign fund, and Merck alone stands to profit from routine vaccination of all girls in Texas, which the New York Times is estimating will cost at least 60 million.

Rachel over at Women’s Health News has posted three very thoughtful posts about this new law which encapsulate much of the current debate. The comments from her readers in particular are very telling:

1) On the Texas HPV Vaccine Law, 2) Backlash against Texas HPV Vaccine law continues, and 3) HPV Vaccine Concerns

For my own part, I would like to address some of the misinformation about the HPV vaccine that is floating around right now. From a reader on Rachel’s site who was arguing against universal vaccination: “…2) There are 15 types of HPV. The vaccine, created by Merck, which has received so much media attention, protects against 2 types of HPV. These two types are implicated in causing 70% of the cervical cancers that develop. 30% are caused by the 13 other types of HPV which this vaccine is no protection against.”

There are actually over 100 genotypes of HPV which have been discovered to date, of which approximately 30 strains are found in the genital mucosa. Of those 30 strains, 15 have been shown to be associated with cervical cancer, in particular types 16, 18, 31, 33 and 35. These types are considered the “high risk” strains and are usually subclinical/ non-detectable. Approximately 70% of cervical cancers result from infection with HPV genotypes 16 and 18. In contrast, HPV types 6 and 11 are considered “low risk”, and are responsible for 90% of all cases of genital warts (i.e. highly clinically detectable). HPV is spread through direct genital to genital contact, and can be transmitted even when using a condom, since a condom does not cover the entire genitalia.

Gardasil is a quadrivalent human papilomavirus L1 virus-like particle vaccine which offers protection against HPV genotypes 6, 11, 16 and 18. In other words, the two strains that are most often responsible for cervical cancer, and the two strains that are most often responsible for genital warts.

However, as many readers have pointed out, Gardasil only offers protection for 2 of the 15 genotypes associated with cervical cancer and only 2 of the genotypes that cause genital warts, and the research is not conclusive on how long Gardasil is able to offer protection, or whether booster vaccines will be needed at a later date. It is also important to note that all of the research on this topic has been funded and carried out by Merck. Most importantly, the pap smear has been a highly effective screening tool for cervical cancer since the 1960s, responsible for early detection and treatment of cervical dysplasia, and the number one reason why cervical cancer rates are so low in this country (although still disproprotionate: cervical cancer rates are highest for low income and uninsured women). Worldwide, cervical cancer is the second largest cause of female cancer mortality, with an estimated 493,00 new cases each year and 274,000 annual deaths. In other words, even if you do choose to be vaccinated with Gardasil, annual pap smears are still crucial.

It will be interesting to see how this plays out, both in the media and in the legislature. It will be interesting to see if other states follow Texas’ lead. The HPV vaccine is an extraordinary breakthrough, the first vaccine ever created that actually targets cancer, but as with any new vaccine or drug touted as a new miracle, I think a little caution in the beginning is well founded, since new research is still incoming and the long-term effects are unknown.

Source: ACOG (Sept., 2006) ACOG Committee Opinion #344: Human Papillomavirus Vaccination. Obstetrics & Gynecology, 108 (3), Part 1: 699-705.

So, my first week of clinicals ended last week, and I am only just now having an opportunity to sit down and write about it. Let me tell you a bit about my schedule: clinicals take up roughly 42 hours a week—2 labor and delivery shifts and 2 clinic shifts—plus one day a week in class, and every other spare moment devoted to either sleeping, eating or studying (well, and blogging…and watching the occassional episode of 24). Labor and delivery shifts start at 7:30 am for postpartum rounds and don’t finish until 9:00 pm. To get to the hospital on time, I need to leave my house around 6:30 am to account for the vagaries of the subway, which means waking up around 5:45 am (did I mention that this hospital has an absolute THOU SHALT NOT BE LATE policy? If I’m late once, we talk about it. If I’m late twice, I’m sent home. If I’m late three times, I need to find a new clinical site). It’s dark when I leave for the hospital, and dark when I come home. Not a very bright prospect for a certain student who really loves her sunlight. I thought I was going to be doing clinicals, but in fact, I think I’m in midwifery boot camp. I must have missed a memo somewhere along the way.

However, clinicals are going well. Much better than I had anticipated—in fact, most of the feedback has been very positive so far, and the preceptors I’ve encountered so far have been a lot of fun to work with. My second shift on labor and delivery involved working with one woman for most of the day. She was a multipara—first baby was 3500 gms, second baby was 4000 gms, and this one was feeling very large as well (we estimated 4000 gms), but she wasn’t diabetic, and she had a large, roomy pelvis, so we weren’t sweating (although we were watching closely, and we had a stool in the room just in case suprapubic pressure was needed in a hurry). She spent the first half of her labor out of bed and walking around (how about that! A hospital that actually has intermittent monitoring protocols that 1) work and 2) get utilized appropriately), but she wasn’t progressing quickly (about 1 cm every 2 hours), and certainly not as quickly as you would expect a multip to progress. We began to worry that if things didn’t continue to progress at a steady pace, the residents on the floor would begin to poke their heads into the room and want to start pitocin…and yes, I know! Progressing one centimeter in 2 hours is just fine, really, and not a problem if you’re at home or in a birthing center…but when you’re on labor and delivery, unfortunately there is a clock that is constantly ticking, and as a midwife on a hospital floor you have to take that into account. So we decided to rupture her membranes to see if that would help get things going. Not a benign measure, by any means, but preferable to pitocin. And sure enough, rupturing her membranes did the trick, and before we knew it, her labor was much more intense, and she was asking for an epidural, which she got.

Things slowed down a little bit after that, but she continued to make steady progress, and by 4:30 pm she was ready to push (we’d been laboring with her for the entire shift, since 8:30 am). We turned the epidural down so that she could better feel the contractions and the urge to push, and began the slow work of pushing that big baby down. Again, it took longer than we had anticipated, and she wasn’t the strongest pusher in the world, but finally, the baby began to crown. And crown. And crown. And we did, indeed, begin to sweat.

The woman had a very short perineum, and there was a little bit of scar tissue from what looked like a prior episiotomy, and her skin integrity was not that great. I gave perineal support as the head was coming out and we got the head over the perineum more or less intact. Once the head was out, my preceptor continued to apply perineal support while I worked on the shoulders. The head wasn’t rotating quickly…it definitley needed some gentle nudging to help it turn. We were concerned about a dystocia, but when I reached up I was able to feel the top of the anterior shoulder, so we knew for certain it wasn’t stuck. Nevertheless, this definitely wasn’t the type of baby that just slips out once the head is born. In fact, instead of holding the baby with both my hands gently supporting the head and neck, I actually had my hands on the shoulders, with one finger hooked under each armpit, and was gently tugging the baby out, bit by bit. I think I finally understand what is meant by “tight sholders” now. It’s not that they were stuck…but it wasn’t an easy fit.

When the baby finally came out, he looked HUGE! As it turns out, he weighed 4400 gms (not quite macrosomic)…but even so, a pretty hefty baby. Definitely took some muscle to lift him up onto his mother’s abdomen, where he proceeded to cry after about a minute of stimulation. Very adoreable baby; he looked like a 2 month old. Welcome to the world, fat and happy baby. There was terminal meconium, and when we had a chance to look at the perineum, there was a pretty nasty third degree laceration there, which baffled me since I was pretty sure the baby’s head had crowned without ripping. My preceptor told me that, given her short perineum, poor skin integrity, prior episiotomy, and just the sheer size of the kid, there was not much else we could have done to prevent it. Even so, I wonder if there was anything I could have done during the delivery of the posterior shoulder that could have prevented such a terrible tear.

In any case, the doctor came in to repair the sphincter, and we finished up the rest of the repair after that, and thus ended my 26th delivery. Tight shoulders. The largest baby I have caught to date.