Mother-Baby Friendly Hospital Changes

I am LOVING the changes that were implemented in the past year as we grow to becoming more Mother-Baby Friendly!

ALL babies go skin to skin from birth with mom at vaginal births, unless mom refuses to do it.  Families are educated on this as a standard of care (prior to the birth), and I'd say that 95-99% of them agree with it and love it.  I also educate families before the birth that baby stays skin to skin with mom for AT LEAST the first hour, or until after the first successful breastfeeding.  Whichever one is longer.  I go on to explain the benefits of the uninterrupted time of skin to skin from birth, and how it benefits both mom and baby.  Dads do get a little upset because they either: want to hold their new baby too, or they want to know the baby's weight.

I also explain that knowing the baby's weight isn't the utmost important thing in this "Golden Hour", and point out that the rest of the family can wait to see/hold the baby until after that first hour -- because you as the new parents will NEVER get that first hour back again.

As for c-section births -- we are trying to get baby skin to skin with mom within the first five minutes of the birth.  However, it's a different story in the OR.  If mom is vomiting, shivering, or her arms are too weak (as is often the case with some of the spinal/epidural blocks), it's a safety issue over the skin to skin issue.  In that case, we offer skin to skin with dad/significant other in the OR.  Some dads/SO's love it, while others are just totally turned off by it.  So, if mom/dad doesn't do skin to skin in the OR, I make sure that baby is skin to skin with mom in the PACU as soon as she gets there.  (Medical stability of mom comes first, so sometimes it's delayed.)  Breastfeeding attempts are made in the PACU as well.  Not always as successful as with a vaginal birth, because of mom having to remain relatively flat after a spinal (risk of spinal headache if her HOB is elevated too soon).

Another change that we have implemented is that if your baby is going to the NICU, it is no longer an option to NOT choose to breastfeed/pump.  You simply must start pumping for the colostrum for your baby's health and well-being.  The NICU providers are insisting that all NICU babies get that colostrum/breastmilk for the health benefits.  So far, moms are ok with this.  This is where it gets sticky for me --- I don't feel that it should be forced on those who are adamant about not breastfeeding/pumping.  But at the same time, I understand the health rationale for colostrum (at the very least), especially for the premature infants.  Formula will never, ever take the place of the nutrients found only in mom's breastmilk.  I do know that our NICU staff are excellent at providing the education to the parents about why colostrum/breastmilk is so important for their premature baby.

Anyway, we are on our way to truly becoming Mother-Baby Friendly!!  YEAH!!!!

Skin to skin in the OR

I recently had a patient who underwent a primary c/s for a medical reason, and guess what I did?  Less than 10 minutes after the baby was born, once the NICU doc left the room, the baby went skin to skin with mom and stayed that way for the rest of the length of surgery!

One of the most amazing sights to behold.  Mom absolutely LOVED it.

C-section rates by state - The Unnecesarean

I highly encourage you to go to The Unnecesarean's new site with C-section rates. She did an awesome job! Unfortunately, it's going to take more than just publicizing the horrendous c/s rates to get things to change. But, it's a start.

Babies and births

I have had such a super duper busy week! I started back in my classes (go advanced courses! WOOHOO!!) and had a mega busy week at work as well.

Holy schmoly, the number of Friday the 13th babies was just insane! I was in on four different (all vaginal) births that day as either the primary nurse or as a second nurse for the birth. Can I just say -- holla! -- to all those new babies born on an "unlucky" day. Happy sweet birthday to each and every one of you!

Let's see, what else happened this week........ stat c/s (always get the heart pumping), a set of twins, took care of a mom having triplets (who was just the sweetest thing!) -- I can't wait to see these triplets when they're born. Participated in a neonatal code (I hate them, they always make my hands shake).

Just lots of and lots of "stuff" going on in L&D this past week. I would like to place my order for a nice, relaxed week this week, pretty please? I somehow doubt that will happen.

Refusal of a c-section

I see this many, many times -- dysfunctional labor with a posterior/asynclitic positioned baby. Labor drags on and on. Sometimes, the provider is relaxed enough to not jump the gun on calling a c-section for FTP, and "allows" the labor to continue.

Eventually, the woman gets to 10cm. Baby is still posterior/asynclitic. Urge to push commences, and the pushing stage begins. She pushes, pushes and pushes, and the baby barely budges.

Will the baby fit?

We change her position frequently to help facilitate rotation and descent.

Pushing continues.

There may or may not be some pitocin infusing. Most women have an epidural long before this point.

The doc comes in, tries a vacuum. It doesn't work. Doc recommends a c-section. The woman and her husband refuse the c-section. They would rather keep pushing and changing positions. (Thank goodness for a good nurse when this situation happens!)

Lo and behold, but what happens?

Most of the time, vaginal birth just isn't in the cards. Proceed to a c-section. Not always so........believe it or not, I've had some births that follow this exact same scenario, and after a failed use of a vacuum, the woman is able to push her baby out spontaneously.

Tearful cries of joy abound!!! The baby is here!! No shoulder dystocia, great apgars!! Baby lies skin to skin with mom, and nurses like a champ.

All in a day's work.

Can I clarify something?

I have read several comments lately that seem to feel that I come across as judgmental or non-supportive, or negative about whether a woman births with or without pain medication/epidurals.

Let me just clarify: I support a woman's choice in how she intends to manage the pain of her labor. Natural childbirth is my passion, of course. And I am constantly in awe of women who have a natural childbirth.

HOWEVER - that does not mean that I do not support or berate or even belittle women who choose to have pain medication or an epidural (or both). I had pain medication with my first two babies. Wouldn't that make me a hypocrite for judging women who want pain medication while in labor?

If you want an epidural, I will make sure you get one (as long as the baby is not ready to be born imminently - although, I have gotten women epidurals placed that late.) I will educate you on when is the best time to get an epidural, how it is placed, the possible side effects, and what you will feel once it is working.

If you want IV pain medication, I will tell you what it is, what you can expect from it, and how the baby will respond to it. And yes, I will be the mean nurse and withhold it if your baby is going to be born imminently. (Reason: respiratory depression in the neonate, need for Narcan and resuscitation, possible NICU admission if the baby fails to be properly resuscitated or has extended apneic episodes.) I will also tell you why I cannot give you pain medication so close to the birth. I will also help encourage you in going that last little bit of labor and pushing if I cannot give you pain medication to help your labor pains.

Truly, I do empathize with your pain! I remember begging for more drugs with my 2nd child, when I was 7 cm and moving fast.

I think that each and every woman is a powerful being, capable of such strength and amazement at being able to give birth. Does that mean that I am judging or leaving out the women that give birth by c-section? Do I think they are any "less" of a powerful woman? HELL NO!

I really hope that I have cleared the air.

YES - I am a supporter of natural childbirth.

YES - I will give you IV medications or get an epidural placed if that is what you want or need.

YES - I will support your birth choices.

NO - I do not advocate or support elective inductions for no medical reason.

NO - I do not advocate or support elective primary c-sections for no medical reason.

YES - I support VBAC, if it's the right thing for you.

YES - I support a repeat c-section, if it's the right thing for you.

YES - I will be your advocate.

YES - I will help to ensure that you and your baby have the best possible outcome.

YES - I believe that birth experiences are very important for some (many?) women.

Forgive my lack of posting

Sorry for the lack of posting. I just haven't had anything recently to strike my writing fancy!

I had a nursing student with me for one of my shifts this week, and she was a joy to work with! Very enthusiastic, asking lots of questions, and seemed to be very genuinely interested in nursing.

I've been invited to speak at a local ICAN chapter. So, I guess that is something new to report! I'll be speaking at the April meeting, so I have a little bit of time to formulate what topic I'll discuss.

Placental abruption, from the nurse's point of view

It was change of shift, and I was just starting out my shift on L&D. *Annie and her husband *Frank (*names changed*) had also just arrived on L&D. Annie had noticed some vaginal bleeding, and she and her husband were concerned about this, so they decided to come in to be evaluated.

Annie had a known history of a partial, but stable, placental abruption. I walk in the room to find two nurses valiantly trying to establish an IV site and maintain fetal heart tones.

**thump...thump...thump**

The fetal heart monitor is kicking out a too slow rate ~ about 80-90 beats per minute. Oxygen is on and one of the nurses turns Annie on to her side.

**thump.........thump..............thump**

Even slower.

I jump in and deftly insert an 18 g IV site, pulling various tubes of blood off of the line, then hook up IV fluids.

**thump..................thump............................thump**

Slower and slower.

We race Annie back to the OR. Her poor husband Frank, bless him, understood the implications of what was happening.

Everyone is rushing around in the OR, working to get Annie transferred to the OR table, catheter placed, instruments at the ready. Annie looks around, about ready to burst into tears. I'm on the phone with the NICU, telling them we have a STAT c/s for an abruption, hearts are down.

I walk over to Annie, get down close to her ear, gently touch her arm and hand, and whisper to her:

"My name is ____. I know it's very scary right now, but we're doing many different things at one time to help get your baby out. You're going to feel the catheter go into your bladder in just a second here - it's going to burn and hurt for a minute. Cold gel on your belly as we listen to your baby's heartbeat - listen to that! It's up again at 120 beats per minute. That's very good!"

Annie nods her head, tears welling in her eyes. "His name is Matthew."

"The baby?" I ask her.

"Yes, his name is Matthew."

"Annie, we're going to work very quickly now to get Matthew out, and we will take very good care of him and you. You're going to go to sleep in a just a few seconds here, but I will be with you and Matthew the whole time."

"Save my baby," she says, as we tightly grip each others hands.

Cold antiseptic solution is splashed on her belly as Annie is quickly put under general anesthesia.

**incision!**

**membranes ruptured - bloody fluid!**

**baby!**

An immediate lusty cry is heard as baby Matthew is born.

Audible sighs of relief can be heard throughout the room as Matthew is dried off and assessed by the NICU team.

Frank, now a proud new papa, is escorted into the OR to greet his new son.

**smiles**

A very positive outcome for a situation that could have been much more dire.

Times like these make me feel very honored to be present at the amazing miracle of birth.

Happy birthday Matthew!

Various links today

Sometimes it's just a day for links!

Cultural Beliefs, Honoring the Placenta

The Placenta in Lore and Legend

Vernix - an analysis of it's microbial properties

A blog post about Vernix

Caput - what is it?

Umbilical Cord Abnormalities (March of Dimes)

Options for pain-free birthing

Tokophobia

Primary Elective C-Section

Going to the operating room & more

I had a birth the other week, where the mom was completely dilated, with an epidural. When I assumed her care, she had been laboring down in an upright position for about an hour. This was her first baby, so I knew it was more than likely going to be a long pushing stage. I would wager that for first time moms with an epidural, it takes on average 2 hours to push. Sometimes more, sometimes less. But usually right about 2 hours.

I always make sure to change positions while pushing every 15-30 minutes. Sitting upright, semi-fowlers, squatting (if she can bear weight), far left side, far right side, heck, hands and knees if she can really bear weight with her epidural in place.

I was starting out pushing with this mom. She was making slow progress, albeit, it was progress. I was very hopeful and encouraging.

In walks her doctor, who through facial expressions, verbal and non-verbal cues, was very negative on her progress. He reeked of negativity & of wanting to just do a c-section and be done.

He put a vacuum on prematurely. Pulled and tugged. Well, duh, no progress with it, because she was only pushing for an hour! I begged for more time to push with her. He tentatively agreed. I got her in a far left lateral position and worked with her.

I barely make any headway, and the doc bursts in again, examines her, tells her it's done, time for a c-section. "You're exhausted. You can't do this anymore. I could 'let' you push for another hour or two, and you 'might' have your baby vaginally, but I doubt it."

Argh. ARGH! ARGH!!!!!!!!!!!

#1: Your negativity reeks from your pores. It does not belong in the birthing room.

#2: Vacuum after only one hour of pushing. Are you fucking insane? (NO fetal distress, EVER!)

#3: Your continued negativity. Oh yeah, I did mention that. Hmmph.

#4: Baby was a posterior lie. I could have worked with her and gotten that baby to turn.

#5: Why the rush???? Oh yes, that's right. You wanted to get home for dinner.

#6: The baby was sooooooo huge. A whopping 7 1/2 lbs. Never would have fit through her pelvis. Sure, yeah, right. Keep it up. I have some swampland to sell you too.

#7: Now a "scarred" uterus. Hopes for a VBAC in the future? Not if she goes back to see you again.


It hurts me to see women sliced and diced like this. This (above) happens far, far, too often. I am sometimes disgusted by the system that I work within.

The good moment of the night (yes, there was good too!) is that I had another birth that went off without a hitch. Baby skin to skin, nursing shortly after birth. There is beauty in this world. I need so much to focus on the beauty, and not so much on the ugliness.

Sign of the times?

It's not just a select few that have noticed the rising rate of c-sections at work. Other nurses are finally noticing: L&D nurses, postpartum nurses, and nursery nurses. Just a few days ago, the nursery nurse that I was giving report to had said to me, "what's up with all of these sections? We had 19 sections (recovering) on postpartum the other day out of 34 patients total! How many of these were really necessary??"

Folks, that's more than 50% of the patients on postpartum who were recovering from c-sections. Is this a sign of the times? Possibly.

Our recent numbers for the month of July was a whopping 38% c-section rate for all births. Where we usually average 29-31% per month for c-sections, that is a huge jump!

How many VBACs did we have last month? One. Woo-hoo. (Well, WOOHOO!!! for the mom who did it, by a sarcastic woo-hoo for the total number.) Even ACOG is recommending less restrictive VBAC guidelines (July 21, 2010). Will we ever see a decline in the number of c-sections/unnecesareans? (By the way, best-word-ever!) We have such a long, long way to go before we see the c-section rate begin to decline instead of continuing to rise. Sad, but true. It's such a multi-faceted issue that there is no one way to fix it. We have:

• liability risk
• uterine rupture risk
• insurance company dictates
• maternal desires to have a c-section (primary or repeat)
• maternal desires to have a VBAC
• provider comfort level
• informed choice, or lack thereof
• hospital policies
• lack of access to alternatives to physician care (midwifery care)

We have so much work to do to improve/reduce the c-section rate. Don't get me wrong! There are times when having a c-section is a lifesaver. However, this is rarely the case of the majority of c-sections being performed in this decade.

Hurry up and wait

That was the name of the game. I was assigned to a preop c/section patient, who was scheduled for the day, but was bumped several times due to emergent c/sections. When I arrived, she was pretty much all prepped and ready to go, except for the few things we do within 30 minutes of the surgery (fluid bolus, sodium bicitrate, shave prep).

I'm telling you, to go from being able to prep a patient for a c/section in 5-10 minutes for a stat/urgent case (which I am exposed to more so by working the late night shift), to being able to have all of this time in the world to prep her........I was literally twiddling my thumbs BORED. I helped out with some transfers via wheelchairs and stretchers in the meanwhile. I even was able to take a dinner break! WOW! Something that rarely happens on my shift!

We finally get her back for her scheduled c/section, and the poor girl has a panic attack on the OR table. I think all of the waiting, then finally going to the OR really did a number on her mental status at that time. Baby was born, went off to the NICU (something we expected for this baby), and I recovered the mom in the PACU.

That day, it certainly felt like a "hurry up and wait" kind of shift.

Day shift?! What's up with that?!

Really!!

Getting up at 0500 before the sun is even thinking about coming out, and I'm having to get my butt up and ready for work. I am *so* not used to being up that early! I usually work just evening shifts (3-11), so getting up at the butt-crack-o-dawn is not my style.

Anyhow, I sucked it up, and moved my booty on in to the shower. Yeah, ok, stomach did a revolt ("you're up this early?? Waaaaa???" -- it said to me when I tried to feed it part of a bagel.) Ok, skip the rest of breakfast, head on in to L&D.

A nice brisk walk from the parking lot (several blocks away), and the sun still isn't even showing it's face. First stop: caffeine, and lots of it! Luckily, we have a coffee bar that is open at the crack of dawn in the hospital, so I picked up a big old cup of Joe.

Ahhhhh! Now that is more like it!

Change into scrubs, get shift report. I'm getting a c-section. Very nice - fantastic couple ::smiles:: I like being able to do everything from start to finish. Everything: admission, consents, IV start, patient teaching, prep for the OR, baby care in the OR, and PACU care of mom and babe. Everything went off fantastic and without a glitch. We even got to the OR a little early. Isn't that amazing? Something happening in a hospital a little ahead of schedule! I'm used to doing preps for c-sections in a more urgent situation (evening shift doesn't have schedule c-sections), so it was rather laid back for me to do one from start to finish.

Easy peasy.

Got lunch. (!! YEAH !!)

Came back, worked in triage for a bit for lunch relief for another nurse. I like triage some days. A nice variety of patients, symptoms, problems.

Go back for another scheduled c-section. Recover that mom.

Head home.

Repeat tomorrow. (Minus the c-sections. Could I have a vaginal birth please?)