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Friday, August 12, 2011

Normal Physiological labor....something medical professionals don't see

I have come to the realization the many medical professionals in the birth field very rarely see a birth without some sort of medical intervention. An even more difficult thing to swallow, is that they view a woman laboring with a sense of horror. They have a great distaste for the noises made and the movements of swaying or rocking that help a woman cope are seen as strange. When a woman is laboring they see all they happens as a sign of distress, not effective coping.

I don't think this is true of all medical professionals, but if a normal birth is no longer the norm, then how can they know or understand what is truly normal and not a cause for alarm or rejection.

Many of the clients I have worked with have run into this in some shape or form. The question is, how do we educate on what is normal when it isn't seen anymore. Then even more problematic, how do we create a culture that can accept what is normal.

Many nursing students go through their clinics having never seen a labor without interventions. Many doctors go through their rotations without feeling the pressure to somehow "do" something with the lady that is moaning or making noises.

When I went through my own orientation in Labor and Delivery, I was not taught what a normal labor looks like. I was not taught how to assess where a woman is at in labor by her movements or actions. I was not taught that noises are normal or acceptable. I was not taught how to help facilitate a normal labor for a woman who may need more monitoring. I was not taught that a woman who is a little spacey during labor is ok. I was not taught that a woman who is laboring without medication needs less light and distractions. I was not taught that a woman may need more help to make decisions. I was not taught that it's ok to be out of it during labor. I was not taught that grunting is a sign of pushing. I was not taught that a normal labor does not have to be distressing.

An interesting thing happened with the last woman I was laboring with. The heart rate started to have late decelerations...those are the ones you don't want. She had been trying to rest, but was a little too far on her back, so the nurse wanted to move her on her left side. This was the side that she hated the most because she felt so uncomfortable. So I asked the nurse if my client could go on her hands and knees. She adamantly refused. She said she had to be on her side because the heart rate needed to be fixed. I agreed that the heart rate looked bad but that being on her hands and knees would accomplish the same thing. The nurse looked at me like I had no idea what I was talking about.

It dawned on me that nurses are not taught correctly why they intervene the way they do. They never see natural births, so most women are on their backs and can't go on their stomachs, thus turning them on their sides is the easiest way to get the uterus off the aorta(which is what happens when you are on your back, causing a problem with the blood pressure and thus oxygenation). They are taught, therefore, just to turn them on their sides and things will get better. What they need to be taught is the basic principles...get the pressure off the aorta any way possible. For a natural birth, this can be accomplished in numerous ways, not just by laying them on their sides. Thus two purposes can be fulfilled: comfort and safety.

Nurses need so much more experience in dealing with normal physiological birth than they receive in order to safely and effectively help a woman labor....any suggestions on how to help do this?:)


Rain Clair said...

Likewise most CPMs and lay midwives have never had to deal with emergencies or been taught how to deal with them correctly. CPMs and lay midwives need so much more experience dealing with and recognizing red flags and dangerous complications in order to help woman labor safely and effectively. Any suggestions on how to do that? I wish very much we could take what both types of midwives are good at in combine it into one. However, I will tell you it would take a lot less time to teach a CNM or an RN what CPMs know and are good at then it will be to teach CPMs everything that CNMs and RNs know. How about we do away with CPMs and LMs and push for home birth and natural birth training for CNMs and RNs. Let's make it easier and more appealing to CNMs to attend home births. Let's working on changing the whole system so qualified nurses who can handle an emergency also know how to handle a "normal" birth. I say get rid of CPMs all together and give nurses who want more training in the care of normal physiological birth that opportunity. However, if birth is so "normal" and in need of no intervention at all, then why would a women need someone to help them labor safely and effectively at all? If I had to choose between a midwife who knows only how to deal with a normal "birth" but no idea how to deal with emergencies or a nurse who knows how to deal when things get "unnormal", I'm choosing the nurse. Statistically speaking most births would turn out fine if the women labored all alone with no help at all. I'm much more concerned about having someone there to help me when thing don't seem to be going fine at all. My friends can hang around and encourage me when I'm having a normal birth. I don't need to pay a midwife to do that! I want someone around just in case things to go wrong. Just because that woman found laying on that side uncomfortable doesn't mean it wasn't safe or effective for the nurse to ask her to do it. You seem be implying this nurse was some how putting this woman in grave danger. Yes perhaps it was more uncomfortable for the laboring woman but it's a lot safer then letting a woman labor at home with her waters broken for days which seems to be becoming a common scenario lately with home birth midwives who have so much of the experience you seem to think is more important. You want nurses to learn more about normal birth and I want CPMs to start being trained to admit when things aren't normal anymore.

Rachel said...

You know, I have not dealt with the homebirth world personally, but more from an outsiders perspective. I am sure what you are saying is true and many of them do need more training. That is something that should be addressed. Actually, what I would like to see is a better back up system so that CPM's can refer safely those who need more help.

That said, many medical professionals mistake something that is normal for something that is not and use needless interventions for this.

What I meant to imply is that the woman did not have to labor on her side to be safe. In fact, being on her hands and knees may have been an even better position. Having worked in hospitals as an RN, and certified in fetal heart rate tracings and NRP, I feel like I am able to discern some of these things that perhaps others. That said, my point with this story was that woman can be safe and comfortable. And that this particular woman did not need to be in more pain to help her baby, yet her nurse did not understand this.

Rachel said...

"How about we do away with CPMs and LMs and push for home birth and natural birth training for CNMs and RNs. Let's make it easier and more appealing to CNMs to attend home births. Let's working on changing the whole system so qualified nurses who can handle an emergency also know how to handle a "normal" birth. I say get rid of CPMs all together and give nurses who want more training in the care of normal physiological birth that opportunity. "

I agree with this absolutely. I am a Labor and delivery nurse that has trained myself in natural births and I am calling for the same thing you are. I can tell you though, that RN's are not given that opportunity...that was something I had to push for myself. And I never meant this post to be a push for cpm's or really is a call for educating medical professionals in normal birth. Which I can attest we(as I am one of them) don't get it.

Anonymous said...

CPM's ARE trained to recognize abnormalities specifically because of their understanding of normal birth. You have to know what's normal before you can recognize what isn't. No, they are not surgeons, and cannot perform highly invasive procedures, but they are trained and qualified to handle minor complications non-invasively and to transfer acre when the need for intervention is beyond their scope of expertise.

Which brings me to my second point: Who said that because birth is "norml" that it needs no intervention at all? Sometimes it does. That's one of the reasons that so many women choose homebirth midwives. To have a knowledgable birth attendant who can assist them in monitoring their labor for signs of a problem, and if one arises and medical attnetion is needed, they can access it. This is different from being in a medical environment with a staff who is unfamiliar with the variations in normal labors, and will see the same problem s amidwife will see, except that they'l see them even when they don't exist because they've never been taught otherwise.

You make it sound as though it's a competition between midwives and nurses. It's not. Nurses work in medicine. Medicine is pathology. Midwifery is not pathology. And normal laboring women are not pathological. As long as midives are properly trained to recognize a pathological labor and TRANSFER care to a nursing staff, then there is no compeition. And I don't know where you met your midwives, but all of the ones that I know are very , very well trained in doing just that.

Anonymous said...

And Rachel, I'm so glad to hear you say that as a nurse, you took the initiative to educate yourself about normal birth so as to be supportive. YOU, unlike many nurses, are therefore able to recognize that a hands and knees position may have actually had benefits for this mother. That doesn't imply that being on her side was "a danger", as the first commenter read into it. But as care providers trained in normal birth understand, a woman's body signals her as to the most efficient position to birth in. There is a difference between normal labor pain and "this isn't what I need to be doing" pain. When a baby is malpositioned, it will create more pain for the mother, and she can often instinctively find the position to help reposition the baby by finding the position that relieves some of the pain. This is known to work by birth professionals all over the world. Turst a woman when she says "I don't want to be in this position" because her body might be telling her something that a textbook can't. Kudos to you for learning more about it.

Brittany Cromar, CD(CBI) said...

Interesting discussion. I think we need BOTH more standardized education for direct-entry midwives and more experience with minimally-disturbed birth for hospital providers. As I understand the NARM exam to become a CPM is pretty easy and they are not required to do very many births before they can get that certification. State licensure requirements vary drastically--from just getting the CPM credential to what we have in my state, which requires graduation from an approved, MEAC-accredited midwifery education program and additional births. You just can't lump all CPMs into the same category, because there is so much variation in their training! I have thought about becoming a midwife, and I don't think you necessarily need to have training as a *nurse* to be a good midwife, I think it is very possible to learn everything you need to know from a very good direct-entry program. However, unless there are some really big changes to CPM training in this country between now and when I am ready to start that path (if ever), I will choose to pursue a CNM degree, because nurse-midwifery training is more respected and standardized, and I feel it would be more likely to prepare me better for the serious responsibility of midwifery, not because of the nurse training itself, but because the midwifery training once you are a nurse is typically better.

I also believe we need good standards as to which women are too high risk for homebirth, but in order women who prefer homebirth but don't qualify because of risks to feel comfortable going to the hospital, we need more natural-friendly hospital care, and options for vaginal delivery of twins, breech babies, and VBAC in the hospital for those who are good candidates and want to birth vaginally--women shouldn't be forced to choose between a high-risk homebirth and a cesarean.

Birth is a Journey: Does it have to be life changing?

  • One woman might have to climb on an overfilled boat, risking her life and nearly dying as she escapes over the ocean to come to this land. This experience could certainly be life altering. It may very well color the rest of her life, positively or negatively. (I overcame this amazing struggle and here I am triumphant! OR Holy crap, that was SO hard I don’t know if I can go on! By the way, neither response is “right”. No one would judge the woman with the 2nd response.)
  • One woman may buy an airplane ticket, sit on a comfortable 747 and fly to America with a nice smooth flight and landing. She is happy to be in America. Those welcoming her are glad she is here safe and sound. She may only travel by plane 2-4 times in her life, so it is pretty memorable. But the journey itself probably wouldn’t be life changing; it would simply be a journey.
  • One woman may learn to fly an ultra-light plane to lead a flock of geese into America teaching them to migrate. This experience could certainly be empowering and life altering.