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Postpartum Hemorrhage Management for the out of hospital midwife

Atul Gawande’s beautiful book The Checklist Manifesto easily applies to all of us out of hospital midwives. Check that link out–it’s the audio format because I know you are driving several hours per day between carpool and pick-ups and drop-offs and client visits and the grocery store and the gym. And back to the grocery store for whatever you forgot on the first trip.

Why does this book matter to us?  Why do these ideas matter to us? I can hear your midwife brains roaring about how we intuit our way through our practice–even obstetric emergencies–and we do it better and more efficiently than an entire team of OBs, neonatologists, and resuscitation teams designed just for, well, obstetric emergencies and resuscitation. You’re right, we carry a lot of the capacity of the combined powers of these teams in our personhood. We do so out of necessity. Because we are fortunate to spend most of our time in observation, but we are trained for the times where we must act and resolve obstetric emergencies in the out of hospital setting. ALSO is a training course originally designed for family practice docs to learn to manage obstetric emergencies through the use of team work and checklists in the form of mnemonics. I took this course way back and was the only midwife present with about 200 residents and practicing physicians. It was a terrifying 3 days and I learned the management of obstetric emergencies in hospitals–then adapted what I had learned to the out of hospital setting for use in my own practice. To say it has served me well over the years is an extreme understatement. So I was thrilled to see that I could re-up my certification this year at the end of a recent midwifery conference. I am happy to say the course is now extraordinarily well adapted to my learning style and actual practice. I highly recommend it or attending Expect the Unexpected, BEST, or one of the other specific courses designed for managing obstetric emergencies.

When it comes to emergencies, there have been many studies (many! Pubmed search “safety checklist and get reading!) that we should pay attention to. Studies show that outlining steps, having someone in charge of reading the steps, and making sure they are followed really matters when it comes to outcomes.

Who is your team?  In the space of an out of hospital obstetric emergency, every adult human in the room and building is a part of your team.

I’ll be posting additional sheets like this one—they are from our practice and not universally perfect.  Take it and make it your own, let it inspire you to have clear easy to read information for every kind of emergency you drill for.  Use it, adapt it, make it work for you.

This sheet is a simple tool to help you navigate through a postpartum hemorrhage–a common maternal morbidity in high resource countries that is trending upward. By acting promptly, hitting each step, and using your best skills along the way you greatly improve the chances that you will stop it long before it causes the need for a transfer. And for that rare mom that will require the entire run of our storehouse and hospital support to boot, by completing these tasks and documenting them you can help ensure a smooth transfer of services.

Please note this is designed for states where midwives have access to legend drugs and carry them as a regular tool in their birth kit. It does not address the use of herbs or other measures employed in states where medications are not available for use or low resource settings. I would love to hear what you are doing in those places–let us know in the comments below!

Click Here for the PDF

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Inuit or I Knew It

This is a post about the profession of midwifery. It is a bit of a window into our world—all are welcome to read and give feedback, leave your comments below! Somebody give me a little CPR—this is my first post with one space after each “.” It feels cramped! It’s a new world, blogosphere!

Midwives are often viewed as mystical. We are touted as having been “called” to this work, perceived or harassed as wise women, seers, or my errgmmm lease fave of all time, “hippies” which I think implies just really earthy and soul-driven. I can’t speak for all midwives–I am fresh off of a conference of a few hundred of us and can speak only so far as to say that there is a huge variety of the kind of people and types of practices in our field today. Leadership is in some places very state focused and in others very nationally or globally or village focused. I could go on and on but here’s the best way of explaining it. When you meet an Engineer in Washington, or Tennessee, or Australia, or Uganda, or China you’re hiring someone with the basic kind of education that each of their counterparts has. Their experience, bias, and framework will be individualized for the geography, setting, and environment they work in as well as the one they grew up in. Same goes for educators, lawyers, and yes, even us midwives. And for the record, most educators, engineers, civil servants, and even lawyers I know felt drawn to their profession, so I don’t think that sets us apart in any meaningful way. We’re just people trying to get paid to do what we love.

Our profession overall is shifting–with many of us dedicated to maintaining an apprenticeship based model, self-regulated in practice, and outside the mainstream health systems. There is a newer model blooming, responsive to the pressures of technology and societal norms in education, standards of practice, and accountability. It is designing itself to function as an innate and integrated part of the healthcare system in the US as midwifery does in so many places globally. Those of us working on this model are engaged in legislative efforts, systems change, policy-building, education reform, and standardization. These midwives will be seen as educated (many with a Master’s degree in science), working in professional settings like community-based clinics, birth centers, and hospitals. They might wear scrubs every day or some will wear the clothes they’ve always worn because they believe that scrubs can create a sense of power differential and are committed to health care in partnership in all ways—starting with the perception of power. Some of those in street clothes will exude power and some in scrubs will create an art of shared-decision making. Most midwives will fall somewhere along the spectrum of this vast continuum and move up and down it over the course of their day, year, and career. I’m not here to tell you what’s right or wrong for you as a midwife or which midwife a consumer should absolutely pick. My opinion is that there is a mother for every midwife and I suspect we will always have a midwife for every mother.

I’m an evolving human being and my sense of where I am and where I want to be in my career has evolved as well. If you’ve hired me or worked with me or read anything I’ve written you can probably figure out where I fall in. You can always ask me if you want to, I’m open about my views on all this evolution in our profession.

But wait, what’s all this got to do with intuition?  I want to recap a great discussion I had many years ago which taught me one of the most valuable lessons of my professional and personal life. I admit to being one of these people who pops light bulbs in my vicinity on the regular (literally). Need a watch killed?  I’m your girl. Unsure about dating a certain someone?  Gimme 5 or 6 minutes tops and I’ll have them read. I don’t know why I do these things…I’m not always right and my willingness to participate in the world by thinking and feeling my way through has gotten me into some trouble but overall, over time it has served me just fine. For a long time people called me “intuitive”. I could “sense” things about people, or the course of events. But here’s what a very seasoned midwife laid out for me. I promise you know her and you think she’s a hippy.  She might be!  And she’s a smart, savvy, well-studied, educated and engaged learner also. She pays attention. I called her to review a difficult case I had. As I recalled the care and birth of this mother I said, “I knew that xyz was coming”. She asked me, “Jodilyn, how did you know that?”  ” I just knew it–I sensed it–I…”  “Intuited it?” She asked me in a rather forceful manner. “I suppose so. Yes, I guess that is what one would call it. I intuited it.”

She proceeded to walk me back through incident, and had me identify, step by step what I saw, smelled, heard, noticed, thought of, and did. As I did so I built a profound stack of scientific evidence that, when put together, would undeniably lead to this outcome. According to every text book ever written since the beginning of obstetric text books. “So you see,” she chirped pleasantly, “you didn’t intuit anything. That’s crap. It’s an undersale of your knowledge and abilities. You have three dozen pieces of proof for your diagnosis and you don’t need anybody’s permission to know that you were right.” Three dozen pieces of proof. She was right. I did. I knew my stuff and I knew where this mom was headed and that she needed intervention. I took the right steps and got her into the care she needed in time and just as I saw coming, she had extreme need of high level intervention. But at the time, I couldn’t explain to the doctors how I knew what I knew. Forget them, I couldn’t explain it to the family, or even to myself.

After that incident, I began to peel apart my “sense of things” and force myself into a tedious exercise. Doulas are usually massively equipped with this “sense of things” skill–you walk into a room with a laboring mother, her partner, family, providers, nurse. The music is on and people are having side conversations. The room smells like a lot of bodily fluid and a lot of sterilization chemicals. In an instant that doula sizes up the room, the tone, the interactions, the body language, the mother’s noises and movements, who is holding stress in what parts of their bodies, the tension, the love, the energy, the gaps in energy, who is driving the intention in the space. Then, she matches all of that up against what she knows are the mother’s wishes, hopes, worries, fears, and dreams. And she meets every single person in that room exactly where they are with hardly a word. She seamlessly integrates and harnesses the parts and pieces needed for the family that is relying on her. It isn’t long before everyone–provider, nurse, family–everyone is in love with her. They all feel seen and understood by this woman. And that was how I trained my brain for years and years and hundreds and hundreds of births before midwifery.

My mentor set me on the path to train my brain to quantify all of the dozens if not hundreds of data points along the way that were my teachers and to let myself be informed primarily in bullet points instead of feels. At first this process gave me tremendous headaches. It was a slowing down that took discipline and discomfort. I had to stop seeing myself in one way, and open up to myself in this whole new dimension–smart, savvy, educated, knowledgeable, prepared, and capable.

I remember the first time I took a mom to a physician because of the same condition as the one that started me on this path moving from Intuit to I knew It. The physician asked me, what are you seeing that leads you to believe this?  I said here’s what I know and why I know it. I believe you are here to help this mom but I know what she needs and that’s why I’m calling. And I gave her my list of evidence. And she agreed. And mom and baby were healthy and fine because I identified a simple physiological disruption long before it ever got a chance to manifest as a diagnosable pathology.

Now I’m old (which I enjoy!) and I’ve embraced not needing anyone’s permission to know that what I see–labs, signs, symptoms, constellations of symptoms, are of great import and can make a real difference in the health of a family I am working with. I happily consult colleagues, teachers, and mentors and work with them to hear fresh ideas, consider possibilities, and to build a care plan.

But I needed the intervention of a surprising midwife to find my way. It taught me to stay waaaayyyy open to what all midwives have to offer, to trust that even if it’s not how I practice, or we don’t share cultural, social, or especially here in the south, religious ground, we share the work of mothers, babies, pregnant people, families, and ourselves. How do you Intuit? How do you Knew It?  How do you seek the knowledge and wisdom of others to help inform you as you grow and learn?  How can you leave space for others to practice in a way that is genuine to them and continue to be yourself? What pieces would you want us all to pay attention to?

 

Dysglycemia in Pregnancy

Scroll down or click here for the slide show and link to the pdf.

Many women come into pregnancy primed for Gestational Diabetes.  This is a disease process which exists on a continuum and with support, guidance, and effort, pregnancy  can be a leverage into optimal health.  This is a very exciting option compared to the standard expectation that one will move from at-risk all the way into a full blown disease which requires multiple finger pokes a day, medication to control, and affects nearly every organ system in both mom and baby as well as their long term health outcomes.  Additionally, nutrition and exercise interventions during pregnancy reduce the likelihood of cesarean section (and you know how I feel about avoiding the primary cesarean and VBACs).

Do not be fooled by common recommendations which allow for a great deal of carbs per meal.  The single most important dietary intervention is the elimination of sugars and carbs with the exception of fresh fruit which is loaded in fiber that provides benefits which far exceed the effects of fructose.  Choose low glycemic load fruits. Increase levels of lean protein and low glycemic load vegetables for filling alternatives to sugars.  Look for glycemic load which represents glucose in a normal serving (the index represents portions much greater than one person can eat). Expect the first 3 days to be the hardest as you teach your body that it can get energy from sources other than sugar-heavy foods.  Cravings will be very strong but can be helped by keeping nourished throughout the day.

During pregnancy it is especially important to provide families with support for these changes until they can take them on as their own.  Failure due to “non-compliance” is usually blamed on the patient but is actually the failure of the provider to work on education and support that is meaningful to the individual and their family in a personalized way.  It is a huge investment of time with dividends in multitudes:  short and long term health for the pregnancy, mother, baby, and family.  If the provider cannot spend the kind of time needed, and does not have a health coach on staff who can–switch providers.

For those diagnosed already with Gestational Diabetes, take a look at lifestyle changes which have been shown to improve outcomes even over medication.  Work with your midwife or doctor to increase lifestyle changes and decrease medication.  If you are at the end of your pregnancy or a new parent–it’s not too late to start.  Breastfeeding longer than six months can also help regulate your insulin resistance and improve outcomes for you.

Click Here to download the PDF of this infographic.  Please submit your questions, comments or ideas for additional content.

 

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The Blog

You’ve reached the blog of Jodilyn Owen, Licensed Midwife and Certified Professional Midwife.

Planning or considering a homebirth?  Get the book today!

You can learn all about midwifery care, professional topics, and options that come up during pregnancy and birth here.  Enjoy and be sure to send me your questions or comments or contact me if you’d like to talk further.

 

NRP 7th Edition Out of Hospital Chart

CLICK her for a PDF.  OK to reuse if you cite the source (at bottom of chart)!  Use your own judgment in the care of every newborn.  Adapt for that baby’s needs.  If you need help, call EMS and get it.  This is not a replacement for your NRP program nor does it qualify you to give NRP.  It is a TOOL for people who have taken the NRP course and received their card, primarily directed to students to help you gain an overview.  And finally, this reflects my preference for practice but your preceptor will have their own expectations.

NRP EM AM WB

GBS Prevention

Read the long article

See the Infographics up-close

This post examines the role of preventative health care in the inhibition of Group B Streptococcus (GBS) infection.  It uses the term “mother” for simplicity’s sake although babies have all kinds of parents who identify in all kinds of ways and all are welcome here.

Let’s break down the long article:

Infections resulting from GBS  can be life-threatening to a newborn.  All pregnant moms are offered a test which detects this bacteria around 36 weeks of pregnancy.  If found, it can be treated through the use of IV antibiotics during labor, which significantly reduces the rate of infection and resulting meningitis and/or sepsis in newborns. While this article does not focus on the treatment of women who test positive, it does promote prevention, which improves the overall health of both mom and baby through the use of probiotics taken orally throughout the pregnancy.  These come in tiny capsules or a liquid packed with powerful lactobaccili (among other gut-friendly bacterium) that usually cost between five and twenty dollars per bottle or package).  It’s a small price to pay for so many amazing benefits.  As a midwife, I often pay for them for clients because of the massive health benefits of these supplements to every mom and baby, including avoiding a host of obstetric complications that would increase risks to mom and baby and often require transfers out of my care.  Great midwifery promotes the intrinsic health of mother and baby through programs like this which lend greatly to positive birth outcomes.

Let’s explore just some of the many benefits:

The Mother

Take a look at what the microbiota is if you aren’t already familiar with it.  The use of probiotics promotes this system that does a bit of everything good in the body including prevent the over-colonization of “bad” bacteria like GBS.  It also happens to prevent diabetes and keep your mood even.  It exists in the mouth, gut, and vagina of the mom and the placenta (and some studies found evidence in the fetal gut as well).

Over the course of pregnancy, the levels of good bacteria in the microbiota change.  By the time you give birth, you have an over-growth of lactobacilli which ensures that your baby will get exposure to this important “good” bacteria during vaginal birth.  When the system is supported right it will also prevent yeast infections, and keep the bacteria that cause UTIs and GBS in check.

The Baby

Impaired levels of probiotics have been correlated to preterm birth.   They are correlated because “bad” bacteria like GBS and candida (yeast) cause cellular damage to the cervix.  It loses its integrity and is not able to hold in the pregnancy as long as it should.  There are dramatic consequences for being born too early—the March of Dimes was founded because of babies born too early or too small.

When mothers take probiotics, they are found in the placenta and fetal gut and stay with the baby after birth to help regulate the baby’s microbiota.  That’s profound!!  You can help your baby synthesize vitamins and amino acids, regulate immune function, have smoother transitions between emotional states, and get a balanced healthy start just by taking probiotics during pregnancy.  After pregnancy, breast milk takes over the important function of populating the baby’s microbiota with everything it needs.

What Matters

  • Take probiotics throughout pregnancy to help keep your body hostile to “bad” bacteria and to strengthen the integrity of your tissue (muscles and skin included), especially uterine tissue like the cervix (and to boost your immune system, keep your mood even, etc., etc., and etc.!)
  • If you are planning a VBAC this winds up mattering a lot. Infections like candida and GBS can wear down the tissue that you are relying on to keep the scarred area strong and healthy.  Take a full dose of 4 probiotic capsules per day for your entire pregnancy.  I have supported an extremely high percentage of VBACing moms in my practice and this statement is NOT a judgment about your scar.  It is part of a recipe that will contribute to your overall success.  Check out this article for more ideas from the VBAC playbook or contact me to discuss further.
  • Have a vaginal, antibiotic free birth for maximum exposure to lactobacilli
  • Ask your provider ahead of time about swabbing your vaginal tract during labor prior to any antibiotics if you need them for any reason (including a planned or unplanned cesarean birth)
  • Regardless of how you deliver your baby, spend time skin to skin with her or him. Allow them to touch your breasts and arm pits with their hands.  You have lactobacilli on your skin that they will benefit from
  • Breastmilk feeds babies and promotes the growth of healthy bacteria in baby’s own microbiota, boosting their immune system and setting them up for good health
  • Babies born to a mom who had to take antibiotics or who were born by cesarean or who drink formula exclusively or as a supplement can all be given oral probiotics. They are available with a dropper or can be mixed into breast milk or formula and given through a bottle or made into a paste (just break open a capsule and add one drop of water at a time, mixing with your finger) and applied to mom’s nipples which is both soothing and healthy for the breast

Some disclaimers and information of note

  • The recommendations in this article are not designed to cheat a test but to actually improve the health of the mother, the integrity of the cervix, and the health of the placenta, fetus and newborn
  • Taking probiotics is not a guarantee of avoiding GBS or other complications related to imbalanced or missing gut flora. Talk with your provider about nutritional measures you can take to support your over-all health.  No amount of probiotics or exercise can undo the effects of a diet high in sugar and processed foods
  • Do get tested between 35 and 37 weeks for GBS. If you still test positive after a sustained period of time taking probiotics, eating a diet low in processed sugars and carbs, and rich in food that looks like it was alive, the colonization is highly likely to be one that needs antibiotic treatment. A pregnant woman who tests positive for group B strep bacteria and gets antibiotics during labor has only a 1 in 4,000 chance of delivering a baby with group B strep disease. If a pregnant woman who tests positive for group B strep bacteria does not get antibiotics at the time of labor, her baby has a 1 in 200 chance of developing group B strep disease.
  • If GBS is found in your Urine during pregnancy, antibiotics can eliminate or greatly reduce the high colonization. Take probiotics at the same time as you take antibiotics and for the rest of your pregnancy.  The CDC recommends that anyone with GBS in their urine at any point during their pregnancy receive antibiotics during labor
  • Please discuss this information with your provider and work together to find a solution that is right for you. If your provider does not have time to discuss this or other preventative measures with you, there are plenty that will and I highly recommend you shop for the one who will serve you best

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You can see the source for these infographics and get an up-close view by clicking here

Share your thoughts on preventative health care during pregnancy and your comments and questions below!

Additional Resources

Microbiota/Microbiome and Pregnancy/Birth/Breastfeeding

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4943946/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4464665/

https://www.amazon.com/Your-Babys-Microbiome-Critical-Breastfeeding/dp/1603586954

https://www.amazon.com/Microbiome-Effect-Affects-Future-Health/dp/178066270X/ref=sr_1_2?s=books&ie=UTF8&qid=1490123008&sr=1-2

Preterm Birth

http://www.marchofdimes.org/complications/premature-babies.aspx

Group B Strep Disease

https://www.groupbstrepinternational.org/