A note from a nurse

I received an email from a maternity nurse in Maine and I thought I'd share it anonymously because she has valid points about the issues her profession faces. My responses are in bold after her comments.



"I became a nurse out of an interest in women’s health and feminism. Initially I thought I would work for a Planned Parenthood type of organization, helping to provide safe, confidential STI testing, pregnancy prophylaxis or abortion care. I wasn’t too interested in labor until I witnessed my first delivery. It was in a tiny rural Maine hospital. The woman came in and delivered precipitously, laboring on the toilet and in hands and knees position sideways on the bed. I was in awe of her beauty and her likeness to a wild animal in those moments before and during birth. I knew then and there that I had found what I was meant to do. It is my job not only to administer medications and follow physician and midwife orders, but to tune into and meet a laboring woman’s needs as well as her and baby‘s needs in the postpartum period.

I found that the discussion of registered nurses in your book did not do the profession justice or give it depth. When nurses are mentioned outside the realm of becoming nurse-midwives, the remarks are cursory or indicative of laziness. On page 232 you account a nurse-midwife’s disdain for the Leboyer baths. Though you do go on to say that later studies showed no evidence-based benefits from the practice, I am not sure whether you intended this quote to demonstrated how difficult something like the bath is to prepare and administer properly or if you wanted nurses to seem stubborn, lazy, and unwilling to adapt as the text implies." In terms of a nurse's disdain for Leboyer baths, I actually understand their annoyance. It was a ridiculous practice of yet another fad. Such fads must weigh heavily on the staffs, and have implications for childbirth in general.

"On page 102 you describe nurses undermining a woman’s wishes for natural labor by asking her “’Do you want your epidural now?’” in the hopes of having an easier-to-manage, more stationary patient. While I do not doubt that this happens, I can tell you that I try my best to respect a woman’s wishes for pain management in labor. If she comes in stating she wants a drug-free labor, I make sure she knows that resources are available if she changes her mind and that it is up to her to bring up the subject of pain medications if she wants them. Things become complicated when an obstetrician or a partner say to a woman repeatedly “You can have an epidural if you want.” It is also tricky when a woman who is initially adamantly against labor anesthesia begins to ask for these medications when she hits active labor. What is a nurse to do? Should I try and hold her off until delivery, after which she may or may not thank me and her partner for not letting her get the drugs she was requesting? Or should I immediately contact the obstetrician or midwife with her requests and give her what she says she wants now. Either way I face a conflict in respecting patient rights and autonomy, not just for mother but for baby. If she is asking for IV medication and delivery occurs within four hours, the baby may be drowsy and have a difficult time breathing because the narcotic medications typically given pass through the placenta and decrease both mother and baby‘s respiratory rates." This is, perhaps, the most salient issue of modern childbirth. The only right answer is having uninterrupted supportive care and to have the woman be comfortable in her surroundings and with people she knows are there for her. For typical hospital births, unless a woman hires a doula, or has a mother or friend there who really understands the stages of labor, she will typically be alone for long stretches with a partner who is equally anxious, and perhaps feeding her own anxiety. Of course women ask for pain relief in these circumstances, often changing their own minds. But I think what they are really asking for is someone to hold their hand or truly be there with them to encourage progress. In large urban maternity units, constant handholding is a staffing impossibility. The epidural is not. So I feel your dilemma. It is not nurses who are the problem. They are just dealing WITH the problem, just as mothers are. The system is the issue and we should all find ways as a nation to spend more money on supportive care and less on narcotics because, as you know, it will be cheaper in the long run with better outcomes and happier mothers and babies.

"Due to your extensive research and your own childbearing experience, I am sure none of the following information is news to you. However, I urge you to read the next paragraphs from a nursing perspective, imagining the responsibilities that registered nurses carry throughout the labor, delivery, recovery and postpartum period. The fact of the matter remains that emergencies do happen. Women with low-risk pregnancies can and sometimes do seize in labor or the postpartum period, a potentially fatal condition for both mother and baby. Postpartum hemorrhages after routine, low-intervention deliveries sometimes bring women to near-death experiences." I had one c-section and I witnessed several others during the course of research for my book.

"In addition to these and other emergencies, routine care duties are continuously increasing. During labor, external fetal monitoring and a highly-litigious society require that nurses document progress every 15 minutes during continuous monitoring (per protocols when a patient has an epidural, or a high-risk medication infusing such as pitocin or magnesium sulfate). Women with a positive GBS status generally have physician orders for antibiotics to be infused every 4 hours during labor. The bladder is drained every 3-4 hours by catheter if a woman has an epidural. If a fetus has a prolonged deceleration in its heart rate, it is the nurse’s job to turn her (usually many times), place an oxygen mask on her face, give her IV fluids if she has venous access, stop a pitocin infusion, call the midwife or physician to the bedside, administer terbulatine by physician order to relax the uterus, perhaps transfer her to the operating room for an emergency cesarean and, not least of all, explain everything that is happening to the patient and her family. It is not uncommon for a laboring woman to have almost all of these things simultaneously: epidural, pitocin, magnesium, GBS, and/or signs of chorioamnionitis (a condition that, if delivery is not immediately imminent, will buy a laboring woman a ticket to the OR). Having worked in a high-risk, high-interventional labor and delivery setting, I pride myself on patient interaction, understanding that labor can go in several different directions, many of which even the most educated family would not be able to imagine for themselves." As you so clearly state, much of this is done first and foremost to protect the hospital and the doctors and alot of these interventions can actually create more dangerous situations for mothers and babies. I understand postpartum hemorrhage is dangerous, but being forced to lay in bed during labor so you can be "monitored" is not a healthy way to enable labor to progress. So again, I believe the system is messed up, and if nurses didn't have so many machines to pay attention to, there would be no need for so many machines.

"Infant abductions cause scandal and add security interventions that must be completed almost immediately after birth along with standard neonatal resuscitation for the normal newborn (tactile stimulation and bulb suction), assignment of Apgar scores with the required assessment, and administration of erythromycin and vitamin K per the parents‘ request. A healthy mother and baby pair are generally allowed two hours of one-to-one nursing care before staffing regulations allow that pair to be transferred to a postpartum unit or, in the case of an LDRP set-up, that nurse is assigned other new families to care for. The nurse-patient ratio on a unit may be as high as five or six couplets, meaning a nurse is really caring for 10 to 12 patients at a time. All this inhibits a nurse’s ability to provide timely, individualized care to a family in the 2 or 3 precious days before they go home." If an infant was never separated from its mother, there would be no avenue for abductions, unless someone actually ripped the babe from arms, which seems preposterous and likely that the mother would tackle the intruder. As for postpartum care, I agree. It's a shame for all concerned, including the harried staff. Postpartum care should last longer than two days in a hospital. I believe having a checkup even two weeks out at home could prevent or help diagnose postpartum depression and breastfeeding issues, which have greater costs for society.

"I have seen how women who end up with emergency c-sections and their families can be traumatized by the experience and I want to be clear that I work very hard to help my patients process what is happening to them. I am making no statement here about whether the interventions themselves are right or wrong - I have often struggled with those questions - but let me be clear that as a nurse I do everything I can to help support my patient and her family emotionally throughout the birth process and afterwards." That is wonderful to hear. I bet nurses themselves can be traumatized by what they see tough. You have a very hard job. I couldn't do it. I remember clearly what a postpartum nurse said to me about 6 hours after my c-section, when she asked why I was crying. "I wouldn't want that to happen to me either," she said. Needless to say, it did not make me feel better.

"Maternity nurses are not merely overworked minions of obstetricians and pediatricians, we are patient care advocates who take an interest in our patients’ wellbeing and childbirth experiences. I don’t know a single nurse working in labor and delivery, mother/baby care or lactation who does it just for the paycheck. The nurses I know are passionate about patient care, are constantly asked to adapt to changing practices and are strained by ethical dilemmas. Obstetrical nurses work in a complex ethically, legally and politically driven environment, having to balance all of these factors as providers and patient advocates. I hope that I have impressed upon you the multiple stressors nurses face when providing patient care, along with this nurse’s desire to meet every need of her patient: mother, baby, partner, family." Excellent points.

And she lived to tell the tale

There is a great post on Unnecessarean that aggregates lots of stories about Ines Ramírez Pérez of Rio de Talea, Mexico, who became the first woman known to have survived a self-inflicted cesarean section. I wrote about her case in my book, but you can read a bunch of fascinating news accounts about it here.

I got a nice email today from a woman in Missoula, Montana, who had read my book. She said there is a big controversy in her town between the only hospital that has an OB ward and a longtime certified nurse midwife who opened a tiny independent birth center... and lo and behold, the same week that she opened her birth center for business, she was personally banned from the property of the hospital.

I think more attention (and appropriate outcry) might force the hospital to really reevaluate the issue or at least make some concessions.

Go forth and tell the hospital why they are wrong and why it is women who lose, not their bottom line. Read her story.

The midwife, Jeanne Hebl, has a website.

Evolution and birth

Interesting connection between fat and newborns. I am on vacation catching up on my significant stack of unread New Yorkers and in the July 20th issue Elizabeth Kolbert has an interesting piece on the many books out there postulating on why we as a society are fat. In it, she discusses "The Evolution of Obesity" (Johns Hopkins), written by researchers at the American College of Obstetricians and Gynecologists. The authors argue that a person with a genetic knack for storing fat would have a competitive advantage in life because fat is energy rich and lightweight (surprisingly) and it helps our big brains run. "Human infants," Kolbert writes, "are unusually portly; among mammals, only hooded seals have a higher percentage of body fat at birth....Tellingly, humans, unlike most other animals, have no set season of fertility. Instead, ovulation is tied to a woman's fat stores: Those who are very thin simply fail to menstruate."

Breastfeeding Facts for Fathers

75 percent of women breastfeed if their partners support it. Check out "Breastfeeding Facts for Fathers,” a short booklet highlighting the crucial role men have in encouraging their partners to breastfeed.

Why do OBs like induction so much?

Thanks to a CIMS report for spotting the latest American College of Obstetricians and Gynecologists practice bulletin on induction, in which ACOG approves of inducing labor for "psychosocial" (non-medical) reasons and cervical ripening with the synthetic prostaglandin misoprostol (trade name Cytotec). By contrast, Canada and the UK do not approve of these risky methods.

Compared to women who go into labor on their own, women who have an elective induction are at increased risk for intrapartum fever, instrumental birth, cesarean section, and are more likely to use analgesia including epidurals. Babies are at risk for irregular heart rate patterns, shoulder dystocia, neonatal phototherapy to treat jaundice, neonatal resuscitation and admission to a neonatal intensive care unit. According to the white paper "Idealized Design of Perinatal Care" published by the Institute for Healthcare Improvement, "Based on a review of U.S. medical malpractice claims, [the labor-inducing drug] oxytocin is involved in more than 50 percent of the situations leading to birth trauma."

These complications of labor also impact mother-infant attachment and the initiation and continuation of breastfeeding.

ACOG approves of inducing labor at 39 weeks while a similar professional group in Canada states gestational age should be at least 41 completed weeks; UK guidelines state induction for non-medical reason can be considered at or after 40 weeks.

Misoprostol, an inexpensive synthetic prostaglandin, was developed and is marketed to prevent and treat gastric and duodenal ulcers. The use of misoprostol for cervical ripening and induction of labor (off-label use) is approved by ACOG, but not recommended by either Canada or the UK. Misoprostol is not approved by the manufacturer for use in pregnancy. Misoprostol is associated with excessive uterine contractions, fetal heart abnormality, hemorrhage, hysterectomy, and sometimes fetal death. Both Canada and the UK recommend its use be restricted to clinical trials.

Nearly one in four births in the U.S. is induced (many more receive oxytocin to speed things up) and according to the Agency for Healthcare Research and Quality (AHRQ), although it is not entirely clear what proportion of these inductions are elective (i.e. without a medical indication), the overall rate of induction of labor is rising faster than the rate of pregnancy complications that would lead to a medically-indicated induction. According to Childbirth Connection's report, "Evidence-Based Care: What it Is and What It Can Achieve," the most common gestational age at birth among single babies in the U.S. is now 39 weeks rather than 40 weeks.

A Walk to Beautiful

I watched a very powerful film the other night called "A Walk to Beautiful." The documentary, released in 2008, just came out on DVD. It's the heartbreaking story of the silent epidemic of obstetric fistula in Ethiopia. This film, besides telling the first-person stories of the five women it follows from their villages to the capital for treatment, also reveals a larger narrative about maternal mortality, reproductive rights, child marriage, malnourishment, and birthing practices in a third world country.

The film has traveled the festival circuit and met continual praise from critics, for good reason.

A fistula usually develops when a prolonged labor presses the unborn child so tightly in the birth canal that blood flow is cut off to the surrounding tissues, which then rot away. The result is a hole between either the rectum and vagina or between the bladder and vagina, which means the mother leaks feces or urine uncontrollably, leaving her a social pariah, typically abandoned by her husband or family.

The most common reason for fistulas shown in this film is the practice of girls being married off too young and becoming pregnant well before their bodies can fit a baby through the birth canal. Of course, lack of proper nutrition throughout their lives can also lead to them being smaller than they should be for a safe birth.