Spring break is here at last! The beloved boy and I are off to London for the week to visit his family. Just think: no clinicals, no school, no presentations or deadlines hanging over my head, nothing to do but study during the day and hang out with my British friends by night. How luxurious, and what a much needed break! Have a great week, and I’ll see all of you on the flip side.
Via The Lactivist and Women’s Health News, there is a new documentary in the works entitled Pregnant in America which explores the medicalization of birth and the creation of the birth industry—the American birth machine—for profit and corporate gain, often at the expense of the health (and sometimes lives) of women and babies in this country. From the website itself:
Pregnant in America is the controversial story of life’s greatest miracle in the hands of the nation’s most powerful interests
Looks quite fascinating, and I can’t wait to see this film. Not that any of this is news, since it’s already something that midwives have been aware of and fighting against for years, but perhaps this documentary will help raise more widespread awareness of this issue. To view the trailer, visit the links above.
People ask me a lot of questions, and unfortunately I rarely get a chance to post very many of them here. However, I thought this was a particularly good one, and might be useful to other readers as well, so here we go:
Funny that you should ask about this, because we actually had our lecture on thyroid conditions during pregnancy today. My earlier report was on different thryoid conditions which are often seen during primary care of women (not necessarily during pregnancy), although today’s lecture focused only on pregnancy. My first suggestion would be to go to an endocrinologist as soon as possible. There are many different causes of hyperthyroidism, the most common cause being Grave’s Disease, which is an autoimmune disorder caused by thyroid stimulating antibodies. However, there are many other different causes of hyperthyroidism, running the gamut from pituitary tumors (very rare) to iodine-induced hyperthyroidism. This is why you’ll really need an endocrinologist to help figure all of this out; it’s complicated stuff, with many different etiologies.
Another thing to think about is when your symptoms first began. Was it before your pregnancy, during your pregnancy, or has it been only during the postpartum period? If only during the postpartum period, there might be another cause for the hyperthyroidism: postpartum thyroid dysfunction (also called lymphocytic thyroiditis or postpartum thyroiditis), which occurs in about 5-10% of all pregnancies. With this disorder, usually hyperthyroidism develops first, about 2-3 months postpartum, and will continue for up to 4 months postpartum, followed by a hypothyroid phase lasting 1-3 months. In 70-90% of all cases, this will usually resolve spontaneously without treatment, usually within 6 months. However, 10-30% of women with postpartum thyroiditis may have permanent hypothyroidism, so again, it would be a good idea to have an endocrinologist following this in order to determine the true cause of your hyperthyroidism, and whether it will resolve or not.
Treatments for hyperthyroidism usually include either PTU (Propylthiouricil) or Methimazole (Tapazole), both of which interfere with the synthesis of thyroid hormones by preventing iodine uptake. Both of these medications can be used during pregnancy AND are safe for breastfeeding. Atenolol (a beta blocker) was also listed in our lecture as one of the drugs used to help control the severe hypermetabolic symptoms of hyperthyroidism, such as tachycardia (fast pulse), tremors, palpitations and heat intolerance. Beta blockers are actually the treatment of choice for thyroiditis, and are safe to use during pregnancy. There is no contraindications to using beta blockers while breastfeeding. I just visited the website forum of Dr. Thomas Hale, one of the leading experts on pharmacology during breastfeeding, and looked up Atenolol. In this post, as you can see, one woman was concerned about the possibility of a baby having hypoglycemia after breastfeeding from a mother who was taking atenolol, but it seems that while atenolol might cause hypoglycemia in adults, he didn’t think it was present in breastmilk in suffiicient quantities to cause hypoglycemia in an infant:
The thread on antihypertensives makes it very clear that beta blockers are fine during breastfeeding, so I think you would be okay taking atenolol and nursing at the same time. Medications in Mother’s Milk might be a really good resource for you.
Other treatment options for hyperthyroidism, if that is indeed what you have (as opposed to postpartum thyroiditis), include radioactive iodine treatment or surgery (partial thyroidectomy), but again, these are options best discussed with your endocriniologist.
I’m including a few resources here in case you want to look any of this stuff up yourself. These were some of the references from my presentation. Hope this helps!
Smeltzer, S., Bare, B. (2000) Metaboloic and Endocrine Function; Assessment and Management of Patient with Endocrine Disorders. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing, Lippincott, Williams and Wilkins: New York.
Reid, J., & Wheeler, S. (2005) Hyperthyroidism: Diagnosis and Treatment. American Family Physician, 72(4): 623-630.
American Association of Clinical Endocrinologists. (2002). Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism. Endocrine Practice, 8(6):458-469.
I’ve been under a lot of pressure lately to become much much MUCH faster at my clinic visits. My clinicals are at a very high volume clinic where the midwives (two to three, depending on the schedule) can often see about 35 patients in a day. This means that each midwife, on the days that there are three, has to see at least 10 patients during their 8 hour shift, and on the days where there are only two midwives….well, you sort of hope that a few of the patients won’t show up for their appointment (and in fact, there are often many who don’t come, for various reasons…either they went into labor and delivered already, or something else came up). Prenatal revisits are supposed to take about 15 minutes, and initial prenatal visits are supposed to take about 30 minutes. Add to this the fact that my preceptors are having to supervise me, and follow-up on all of my fundal heights, and be present in the room during all of my pelvics and bimanual exams…and, well…it gets a bit overwhelming at times.
I’ve been trying really hard to go faster, but try as I might, I am still really, REALLY slow. Really slow. A new visit will take me about an hour, and a revisit will take me about half an hour—sometimes 20-25 minutes, on a good day—and yes, I’m timing myself (my preceptors insist on it). Part of the problem is that I’m still very new at this, and there are still many, many visits where I’m presented with a problem or a complaint that I have never encountered before. Sometimes I do have an idea of what to do for the patient, but because I’ve never had to do this before, I always want to run it by my preceptors first to make sure that I have the right plan, or the right dose, or the right medication, which takes time. This happened the other day with a woman who was vomiting 10-12 times a day from her terrible morning sickness. She was eating and drinking okay, able to keep a little bit of it down, and she didn’t look dehydrated (good skin turgor, mucus membranes moist, no ketones in her urine), so I wanted to prescribe rectal compazine for her, to help get the vomiting under control, and then Vitamin B6, but I wasn’t sure if this was the right thing to do. Turns out, my preceptor totally agreed with me, and added some oral Reglan to the mix, but this required a 10 minute consult to work out. Other times, I have no idea what to do for the patient, in which case I need to talk with my preceptors anyway, just to sort of figure out how to wrap my head around the problem. Part of it, as well, is that because I’m new to all of this, I’m also a bit paranoid: I want to be as thorough as possible and I want to do this well, so I always try to cover as much information as possible in each visit and to teach as much as possible in each visit, to make sure that I’m not missing anything, and frankly, 15 minutes is just not enough time to cram in all of the teaching and talking which needs to be had during a revisit. And of course, I’m slow because I really enjoy listening to women, and I have a hard time interrupting them, or rushing them in order to get to the point of the visit. If they ask question after question, I answer question after question. If they have a slew of complaints—their round ligaments hurt, and they have sciatica, and what is this funny rash on their arms, and they keep getting leg cramps—I let them tell me all about it. I try to ask about their mental health: how are they feeling about the baby now? Still ambivalent? Getting excited about the impending birth? Worried about pain management? Maybe I shouldn’t be asking them any questinos, because it usually opens up a can of worms, and I think this is where I lose a lot of time…but I feel like this is important stuff. One of my preceptors told me the other day that I let them talk too much….I think they were saying this jokingly, but honestly, I thought one of the biggest parts of our job was listening to women??
Anyway, I’m slow. I’ve been working with my preceptors to try to find ways to make me faster, such as always approaching the visit the same way, and trying to save time by efficiency and hyper-organization. For example, on a revisit, this is what I do (or try to do), every single time, so that it becomes an efficient routine for me (that’s the theory, anyway): I open the chart, read the problems list page, read the labs page, look up her record in the computer, see if there are any new labs which need to be added to her chart, then I scan through her history and physical quickly, read her last ambulatory care note (if I have time), then call her in and talk to her. First I ask her how she’s feeling, then (when she’s finished talking, which can take awhile, see above), I tell her how many weeks pregnant she is, I tell her the results of her last lab test or sonogram, and then I talk to her about what routine lab tests we need to do today, and why we’re doing them, and what they’re for (GCT, quad screen, CBC and RPR etc.). I ask her if the baby is moving, if she’s had any vaginal bleeding, loss of fluid or contrations, is she taking her prenatal vitamins and iron, and then, up she goes onto the examining table. I measure her fundus, do my Leopold’s, we listen to the baby’s heart beat, and then I get my preceptor and have them come in to double check my findings. If she needs a pelvic or a wet mount or a clean catch, we do that too, and then I have to go look at it under the microscope (always time consuming)…and then prescribe the correct medication for her yeast infection or vaginitis, and order her chest x-ray or urine culture and sensitivity or glucose challenge test. Then, I try to reinforce her teaching, ask her about her diet, go over the tests we’re doing today, as applicable, tell her when her next appointment will be (2 weeks, 4 weeks), and send her on her way. Just typing all of this out has taken me nearly 10 minutes. Sheesh!
It really doesn’t seem possible to me, and yet I know it IS possible, because I see my preceptors doing it all the time. They work under incredible time constraints, and yet, somehow, I feel like they always manage to put the patient at ease, get to the point of the visit, provide excellent and appropriate care, and still make her feel like she was heard. How in the world do you do that??? It defies me!
Anyway, I am twice as slow as where my preceptors think I should be right now, so daily, in the clinic, I always feel like I’m not meeting expectations, or not performing to the level that I am expected to perform at. And, as you might have noticed, I tend to be a high achiever. It really bothers me when I feel like I’m not up to snuff, and has been wreaking a fair amount of havock on my self-confidence lately. I just keep thinking about the fact that pretty soon I’ll be doing this on my own, and how can I, if I can’t even do a 15 minute revisit? How will I survive as a real midwife in the world?
And here’s the other problem: when I go slow, at the pace I need to go at in order to absorb all of the information correctly, and process it, and figure out my plan, and take my time, I do very well. I’m thorough, I generally don’t miss anything, and my preceptors compliment me and tell me that I’m doing well (aside from the speed issue, which they’re always telling me needs to get better). A few times, now, we’ve been timing my visits, and I’m only allowed 5 minutes to go thorugh the chart prior to having the patient come in, and wouldn’t you know it…when I’m really worrying about my timing, and constantly glancing at my watch, and thinking in my head “faster, faster, faster!!!”, I make mistakes, I miss things, I don’t do a good job at anything, and I feel like a failure, all at the same time. And yet, when I go slow, I feel like I’m not meeting expectations, and not progressing, and not at the level I’m supposed to be at….and I feel like a failure, too. It’s just this glorious sense of just not quite being as good as I’m supposed to be at all of this, and it really kind of sucks.
But sometimes I wonder…am I actually not up to snuff, or are my preceptors’ expectations a little unrealistic? Is it possible that maybe I am actually at the pace and level that I should be, at this point in my education? I go back and forth about this a lot.
Of course, there are settings where no midwife is expected to do a 15 minute revisit. Homebirth midiwives and private practice midwives can take a lot longer…maybe even as long as they want. But I don’t think these are the settings I will be practicing in as a new grad. The market for midwives isn’t great right now, and I know I’ll pretty much take any job that is offered to me, and I’m fairly certain that this will be in a hospital setting, where I will be practicing (you guessed it!) in a clinic. Honestly, though, this is the job I want, because I’m certainly not ready for homebirth or private practice right now, and I need the experience and structure. But sadly, in these kind of settings, 15 minute revisits are pretty much the norm. And I really do want to be good at this. I want to be like my preceptors, fast AND good at the same time. And I DO think I’ll get there eventually….but maybe not during my Integration. Just give me a little more time, please.
Seems like I spend a lot of time telling women in labor to breathe, but I really need to take a moment to remind myself of this as well. And breathe again. “Overwhelmed” doesn’t even begin to cut it these days. Burnt-out seems closer to the truth sometimes. My schedule is relentless, and now that I am 8 weeks into my Integration, the pace is really beginning to take its toll. One of the worst things about my program is the way that our Integration coincides with our Complications class, which is, to put it very mildly, an extremely difficult class taught by a professor that is detail-orientated to the point of almost being obsessive. Luckily, my program has seen the problem in this, and I am part of the LAST class which will ever have to Integrate and take this class at the same time; future students will Integrate during the summer semester, after all of their classwork is done. Which is great news for them, but unfortunately, this doesn’t help me so much right now in the thick of things.
The problem with this schedule is twofold. First, I am working a full-time midwifery schedule, approximately 42 hours a week, which means 2 clinic shifts and 2 labor and delivery shifts, which is probably highly acceptable and do-able if this is all that you’re doing, but on top of this, I am also up to my neck in schoolwork, which means that I never truly get a day off. My three days off during the week are spent trying to desperatley catch up on my classwork, which I am chronically behind in, and trying to sleep and maintain my fragile hold over my health at this moment in time. One of those days off is actually a school day, anyway, where I am in class for most of the day, so it’s not really a day off anyway.
The other problem with this is that none of this comes easily to me. It’s a really difficult schedule and a really difficult job, and the hours are really long, and if I were a midwife who had been doing this for years, sure, I’d have long, hard days, but there would be a routine-ness to them which would make it a lot easier to get through, and a knowledge and confidence which would also make it a lot easier. As it is right now, my brain is struggling all the time just trying to make sense of everything that’s going on at the clinic and on L&D: chart review, identification of problems and abnormalties, appropriate management of said problems, plus just trying to actually spend time with the patient, hold her hand (if at all possible) through at least one contraction (not always possible, because I’m doing the job of a real midwife, which means that if a patient comes into triage, I have to leave the laboring patient to triage the new one). When I come home at the end of the day, my brain hurts, and I am always so totally exhausted and worn out, physically and mentally, that sitting in front of my computer and trying to tackle my homework is absolutely impossible. I need my days off just to recover from my shifts, but alas, my days off are not really days off. My days off are spent trying to make headway on my homework. For example, next week I have a huge presentation on alloimmunization in pregnancy due, which is not exactly the easiest subject in the world to parse. This week I have a case study to do; we have a new case study to do every other week. Oh, and don’t forget our upcoming exam, or the huge, terrifying, awe-inspiring Comprehensive Exams which are just around the corner. And when I do spend time willfully blowing off my homework in order to rest and recover and try to replenish myself (physically and mentally and spiritually and emotionally), or spend time with my beloved boy (which is part of the replenishment), I feel inordinately guilty about it, because I know I have a mountain of homework waiting for me, which really needs to be tackled. Writing this post is willfully blowing off my homework.
And then of course, there’s the terror that runs through me when I think about the fact that essentially, I only have 6 weeks to go until all of this is over. That’s it! Just six more weeks of being a student, more or less. Just six more weeks before I qualify, and suddenly none of this will be under someone else’s license, with someone else watching my work and backing me up and making sure I don’t miss anything really important. Just six more weeks, and suddenly the full weight of responsibility will be mine, and mine alone (although, I do think that most jobs will offer an orientation to a new grad, which means there will be at least some cushion built in initially….assuming I can find a job). Argh.
Which is not to say that I’m not enjoying my final days as a student, because I am, on some level. But on some level, this really feels like boot camp, and it often seems like enjoyment is not what this is all about. Survival might be the better word. But hey, I seem to be surviving. Somehow (and really, I am continually surprising myself this semester), I actually seem to be holding up okay. At least, my grades are good so far, and all of the feedback I’ve been receiving from my clincial site has been positive and constructive. My preceptors think I’m doing great. They think I’m exactly where I should be, progressing at the level I should be progressing at, and have no doubt that I will pass with flying colors. They’re convinced that I’m going to be a fantastic midwife someday. From where I am in the trenches at the moment, though, I am not as convinced of this as they are.
I usually try to keep the details of the daily grind off of this blog, because really, who cares about the minor gripes and inner politics and daily ho-hum which is a part of any graduate school experience? And yet, when I speak to other graduate students, or to midwives fondly (or not so fondly) recalling their student days, it seems like there is a pretty consistent phenomenon which occurs towards the end of the program, and for the purposes of posterity, so that someday I can look back on this and remember exactly what it was like, I’m going to try to record all of this here. I think the phenomenon is something akin to: I am SO SICK OF ALL OF THIS, I JUST WANT IT TO BE OVER REALLY REALLY SOON. And yeah, that’s pretty much where I’m at. Feeling simultanelously very very ready to graduate, and simultaneously terrified of it.
So, this probably isn’t the post to read if you’re on the fence about going to school to become a midwife. Really, truly, it’s worth it. I know this deep down, and there have been so many amazing moments in the past 8 weeks that I can’t even begin to tell you about all of them, even if I actually had time to write about them. Some really, really amazing births. Some truly awesome prenatal sessions. Some days when I am so caught up in the middle of it, in the very thick of it, I think I am the luckiest women in the world doing the most amazing job ever, up to my elbows in vernix and amniotic fluid, teaching women about their bodies and contraception, helping them breathe through their contractions, catching babies. It really is a very special thing, this whole midwifery business, and those are the moments when I see the little glimmer that reminds me of why I wanted to do all of this in the first place. But the exhaustion is omnipresent, and on some days, the exhaustion outweighs the glimmer, by a long shot.
I guess on the bright side, when I am actually a midwife, and all I have to do is the work of a midwife, without all of the course-work on top of it, it will feel like a piece of cake by comparison. I. CANNOT. WAIT.
Someone asked me once how I can stand to be around birth all the time, with all its sights and smells and liquids and mess. I told this person that honestly, I very rarely notice it, and it doesn’t bother me, obviously, or else how could I continue to do this day in and day out? In fact, many of the sights and sounds and smells of labor are very encouraging, and when you see them happen, you know that things are going well. The unique, clean, slightly chlorinated smell of clear amniotic fluid, for example, when a woman’s water breaks (at least, it’s always smelled a little chlorinated to me, or maybe that’s just because amniotic fluid is a base, as is chlorine, and I’ve come to associate chlorine with a basic smell)…and how reassuring it is to smell that smell as opposed to the smell of meconium, or foul amniotic fluid that smells of infection. Or when a woman is pushing, how reassuring it is to see her push out a little bit of stool with every push—when you see that, you know that a woman is pushing effectively, and that before long, you’ll be seeing the baby’s head. When you’re watching a baby crowning, the last thing on your mind is the stool. Birth is messy, sure, but it’s so beautiful that you hardly notice the mess, if you even notice it at all.
Even so, some births are definitely messier than others, and I think I just had one of my all time messiest births last Friday. The woman was a multip giving birth to her second baby. She came to triage in active labor, already six centimeters, and things were moving right along for her. We got her into her room, and she spent another hour walking around while we monitored her baby intermittantly. After awhile, she sat down on the birth stool and began to push a little bit, but because she had had a partial third degree laceration with her last pregnancy, we moved her off of the stool and on to the bed, where the delivery could be more controlled and her perineum better protected this time around. She was fully dilated at 7:00 pm, and her bulging bag of waters spontaneously burst at 7:05 pm, and didn’t just burst, but BURST, with water spraying everywhere. We cleaned up as much of it as we could, but there was a lot of it, and more of it continued to flow out with every push. The baby moved down quickly after that and was crowning in no time at all, with the usual amount of stool involved, and we let the head crown slowly so that the perineum could stretch. The baby was born at 7:20 pm, a gorgeous, squalling 8 lb. girl, which we put on the mother’s abdomen while we went about the rest of the delivery, collecting cord blood after the cord had stopped pulsing, then delivering the placenta, and finally doing the repair (she only had a 2nd degree this time around, which is not great, but at least an improvement over the 3rd degree she’d had last time, and the head had been well controlled and the laceration had occurred in the same line as the original tear). While all of this was going on, the baby decided to demonstrate to all of us that all of her organs were working and all of her orifices were patent, and proceeded to pee all over the mother and then pass a healthy meconium as well. By the time we were done with the repair, the mother and her sodden hospital gown were covered in every possible human body fluid: amniotic fluid, blood, sweat, urine and meconium, and it wasn’t just on the mother, but all over the bed as well….even dripping off the bed and down into the cracks. It was a very impressive mess.
Thankfully, the mother was too overjoyed and caught up with her baby to even notice, and we were quickly able to clean up her perineum, take off her gown, give her a clean one, swab her down, change the chux, and get her and her husband comfortably settled in with their new baby. Even so, she definitely still needed a thorough shower, the baby needed a bath, and my own scrubs needed to be changed as well. No one ever said birth was clean, but have you ever seen a more beautiful mess?
I’ve been meaning to post this post for ages, but was never able to finish it during the school year last year. All of this comes from the research project that I worked on last year for 2 semesters as part of my research class, and even though I had to radically alter the goal and purpose of my research proposal in the end, along the way I had the opportunity to do some of the research I was really interested in doing in the first place, and it definitely needs to be shared. This is rather a long post, and it gets somewhat technical in places, but bear with me; a lot of the information here can help you fend off an unnecessary induction or cesarean, so it’s well worth reading. And with that, here we go:
Premature rupture of membranes (or prelabor rupture of membranes, aka PROM) occurs when a woman’s water breaks before she actually goes into active labor. It can happen to women at any point in their pregnancy, and when it happens to women who are still preterm, the danger to herself and her baby is much higher, as are the risks of infection (and many studies have demonstrated that in fact, preterm PROM, aka PPROM, is often caused by infection in the first place). However, the majority of PROM occurs in women who are at term gestation (37+ weeks)—90% of all cases, in fact (Zamzami, 2005), and it’s pretty common, too: PROM at term occurs in 8% of all births. (Hannah et. al., 1996)
In our hospitals today, there is sort of an unspoken rule—let’s call it the 24-Hour Rule. It goes something like this: if you haven’t delivered your baby within 24 hours of breaking your water, something is going to have to be done. In many cases, this something is induction, and in many cases, waiting a full 24 hours before inducing is something that never happens. Providers are often way too impatient and antsy for that, and will generally talk a woman into induction long before the 24 hours has passed. Many providers have the policy of immediately inducing a woman with PROM, either by using prostaglandin gels like cervadil followed by IV oxytocin (pitocin), or by just starting on the pit right away. The rationale for this type of management (often called active management) stems from research that was done in the 1960s (Shubeck, 1966; Rusell & Anderson, 1962) which found that the longer a woman was ruptured, the greater the chance of infection, chorioamnionitis (an acute infection of the chorion, which is part of the placenta), and maternal and/or fetal sepsis.
These early studies advocated immediate induction, and were the beginning of active management. The idea that the length of PROM is responsible for maternal infection is something which has sort of been hard-wired into modern obstetrical practice right now, and in my own experience, I have seen the 24-Hour Rule in effect many a time. Providers often use it to justify the need for an induction or augmentation, i.e. “we need to get your labor moving along, because you’ve been ruptured now for 8 hours…12 hours…18 hours…and you’re still not in active labor”, and as studies have shown, inductions and augmentations, especially for PROM, often lead to cesarean (Mozurkewich & Wolf, 1997; Grant et. al., 1992; Tan & Hannah, 2001). I have seen this deadline held over women’s heads before, and in my most humble opinion, it does absolutely NOTHING to help a woman relax, labor effectively, and have a vaginal delivery. (What’s that old Bradley joke about telling a man he better orgasm soon or else his penis will have to be cut apart to get to the sperm? No pressure, now!)
The thing is…the research from the ’60s, which forms the basis of the 24-Hour Rule, has more holes in it than swiss cheese. For one thing, these studies were retrospective, instead of prospective, which means that they relied on going back and looking at records after the births had already occurred, and never tried to control for any of the gazillion variables that might have affected these birth outcomes other than PROM. Similarly, these early studies were non-randomized, meaning that there might have been selection bias at play which could have muddied the findings. Additionally, both term and preterm pregnancies were mixed together when examining the effects of PROM, which seriously confounds results since preterm infants are much more susceptible to infection, and as I mentioned above, preterm PROM often occurs because of infection in the first place (McGregor & French, 1997). These studies had very imprecise definitions for infection, and the management protocols used were neither uniform or clearly discussed. And of course, NICUs and antibiotic therapy have improved so much in the past 40 years that many of the babies that died of infection in these early studies probably wouldn’t have died if they had been born today. So, as you can see, the studies from the 1960s had a lot of problems, and the fact that modern obstetrical practices are still based in part on the findings in these studies is an even BIGGER problem.
What have more recent studies shown? Well, many studies have shown that strict adherence to active management is often unnecessary, and in some cases, does more harm than good (seems to be a repeating theme when you start to look at obstetrical research—funny, that. And here is where it gets very technical. I’m putting the rest of this behind a cut, for those of you who are interested.) (Read on …)
