Tag Archives: Vermont Midwife

Continuing Education – IV Administration

Most midwives will tell you that midwifery, and obstetrics in general,  is a profession where education is ongoing and constant.  No two courses of prenatal care are the same.  No two births are the same.  A midwife could have the most sophisticated education offered, and still be humbled often.  It’s guaranteed.  As a consumer of home birth, I would be concerned if I encountered a midwife who seemed to have all the answers.  Even the very best high-volume OBs I know are not afraid to say – I’ve never seen that before.  Because it’s the truth.

 

Licensed Vermont home birth midwives are required to attend 20 hours of continuing education every two years to reapply for licensure.  There are a small handful of organizations who sanction Continuing Education Units (CEUs) that are recognized – a couple of these entities are MEAC and ACNM.

October seems to be the month where CEU clinics are often held.  Vermont midwives in solo practice often find it difficult to peel away from our client loads and 24/7 on-call status  to attend workshops out of commuting area to an anticipated home birth.

 

I had a blessed window of time off-call this fall and attended two continuing education workshops – one in Montpelier, VT and the other in Keene, NH.  They represented 14 hours of total class time and 8 hours or total drive time.  This is no small feat considering I am seven months pregnant with my fifth child.

 

The first workshop was “Peripheral IV Insertion and Care” – a didactic and experiential course.  It was facilitated by an RN who trains tertiary hospital staff the same skills.  She was amazing.  I completed a few workshops in IV insertion while attending midwifery school, but it is a skill that is best maintained by doing 20 a day.  Obviously, as home birth midwives, we are not doing them often, if at all in clinical practice.

Photo Oct 01, 2 46 19 PM

Midwife Heather placing an IV catheter in midwife Hannah’s arm with nursing supervision. Both of us very pregnant.  Still smiling!

Why and when would we offer an IV to clients?  A few scenarios:

1) If a client is experiencing a very severe hemorrhage and the regular course of medications that are routinely given via IM injection are not effective, we would call for emergent ambulance transport to the nearest facility.  If we anticipated a wait time of significance for the ambulance, we would consider inserting an IV with fluids that would help stabilize a woman while in transit.  Some ambulance services in very rural areas do not have Paramedics who are trained to insert IVs while enroute to hospital.  In home birth practice, I have never seen IV insertion for this scenario.  But it is an important skill to have solidly onhand in the once-in-a-career event that calls for it.

2) Some Vermont midwives offer IV fluids to normally laboring women who are seeming a little dehydrated.  Rather than transport for dehydration, the issue may be resolved by IV administration during labor at home.  Other Vermont midwives feel that if a woman requires an IV for any reason, she should be transported to a hospital.  I see no fault with either thinking, but my training in IV administration did highlight the gravity of the procedure and the risks that accompany it.  It also made me feel like any of us who have IVs in the hospital must closely monitor the procedure for extreme cleanliness and proper insertion and I walked away from my training wondering if I had ever experienced or witnessed an appropriate IV insertion in the hospital or if I or those I was with were being placed at risk by the nursing staff.

3) Lastly, a Vermont home birth midwife might offer a woman who tests positive for Group B Strep  (GBS+) at the end of pregnancy IV antibiotics in labor.  This is the CDC recommendation and the community standard of care in the hospital setting.  The culture of home birth has been one where most women decline IV antibiotics prophylaxis, but there is additional risk to the newborn of sepsis in this scenario.  I had one septic baby last year, presumably due to GBS, who was born perfectly but showed signs of sepsis in the first couple of hours.  He went on to a NICU at a large facility and was in perfect health after a 7 day course of IV antibiotics.  Although the parents suggest they have no regrets, I got another grey hair from the case and have been offering GBS+ women IV antibiotics in labor.  So far there have been no takers.

As midwives are not inserting multiple IVs a day – it is not a skill that is even taught in nursing school – it is really important to continuously hone the skill.  The Vermont Midwives Association has brought the instructor back in for those wanting more practice.

 

 

Chiropractic in Pregnancy

chiro pregnancyI am a Big Fan of Chiropractic care.  My four children have received periodic adjustments throughout their lives for persistent runny noses, the rare ear infection and rough-housing or football bang ups.  A few of them have never been to a medical doctor.  A good adjustment can preventatively keep the spinal fluids moving freely, the nervous system operating efficiently and contribute to overall immunity and good health without the use of drugs or surgery.

Chiropractic care is associated with greater health and well being and has not been contraindicated in pregnancy.  I recommend chiropractic care to my clients who are experiencing common pregnancy-related back pain as the rib cage expands, the pelvis loosens due to the pregnancy hormone relaxin and breasts and belly expand placing pressure on the pelvis and spine.  I also refer women to chiropractic care for the following special situations:

* Breech fetal position near due date.

* Dysfunctional prodromal labor patterns.

Using an adjustment called the Webster Technique – balancing the pregnant pelvis, Chiropractor Katie Pinkus of  Pinkus Family Chiropractic has repeated success turning persistent breeches near term, allowing us to continue on with our home birth plans.  Breech babies may not legally be born at home with licensed midwives in Vermont.  Therefore when we uncover a breech during routine prenatal care, we work really hard to invite baby to turn vertex (head down) as we approach the due date.  Normalizing the stressed pelvis invites the baby to adopt their natural head-down position in the womb.  Results are always confirmed via ultrasound the day following the chiropractic adjustment and fetal position monitored closely heading into labor.  This simple non-invasive balancing technique has saved countless women across the country from invasive medical practices and surgical births.  I hope to someday encounter an OB/GYN in my community who will advise women of this important low-risk option.

Additionally, I have had a few women who have had “false” or prodromal labor for days at a time.  This can lead to exhaustion, frustration and sometimes medical intervention.  In such scenarios upon routine vaginal exams, I sometimes feel that baby’s head may not be presenting well on the cervix or not applied to the cervix at all, causing an exhausting, irregular contraction pattern.  A chiropractic adjustment and counseling on specific stretching patterns of contracted or constricted supporting muscles can eliminate the dysfunctional pattern, allowing the baby to adopt a more optimal position for descent and negotiation of the pelvis.  Sometimes this simple technique can kick labor into the gear it needs to bring a baby forth.

I’m grateful for the chiropractors in my community who are trained and interested in serving women in the childbearing year.  They have been an important resource for my practice.

Newborn Vitamin K Injections at Vermont midwife attended Births Necessary?

 

Vit K Injection

 

Below is a link to a recent USA Today article on a situation at Children’s Hospital at Vanderbilt University in Nashville.  Since February, four babies have been admitted for brain hemorrhages or bleeding in the intestinal tract.  All babies survived.  The article states that all of the parents in the cases had declined routine Vitamin K shots.  This is a scary article that causes me to revisit and ponder more the issue of Hemorrhagic Disease of the Newborn (HDN) and rationale for administering Vitamin K.

Although this story is in Tennessee, a licensed Vermont midwife is licensed to carry and administer Vitamin K shots for newborns.  I imagine that most states with regulated and legalized midwifery and home birth are similar.  The stark contrast in the midwifery profession related to the hospital/medical profession, is that midwives provide Informed Consent – meaning midwives offer education and information on the risks/benefits to diagnostics, interventions or prophylaxis before cookie-cutter administration of care.  Parents make their informed decision, perhaps further discussion is had, the chart noted on the clinical course taken and everyone moves on.  Parental rights trump all.  I really hate to see parents and midwives attacked in the national media by the medical community for not forcing drugs upon a newborn two hours old – who is still regulating his fragile temperature, glucose regulation and respiration systems.  Some studies examining the risks of Vitamin K are inconclusive, meaning that no health care professional can guarantee a parent that no risk will come to their newborn by flooding their system with adult levels of Vitamin K within 2 hours of birth.  Read this article – how do you feel?  If you are like me, you may feel like  a terrible parent or midwife for not accepting this injection or coercing clients into it.  Approximately 50% of my clients to date elect intramuscular  injection of Vitamin K at birth.  I’d say that sounds like I am doing my most important job of Informed Consent.

Refusal of Vitamin K Shots causing newborn hemorrhage? Or is something else going on?

I really hate feeling scared and coerced.  So before blaming devastated and traumatized parents for a simple decline, questions everyone should be asking are:

1.  Why are all of these deaths reported in the same community hospital?  Shouldn’t we be seeing even more deaths in states and hospitals where midwives and home births constitute up to 25% of babies born such as New Mexico?

2.  Did these children have any trauma during the births or weeks following delivery causing the internal bleeds?  What else besides Vitamin K injection declines do these four children have in common?

One of my favorite lines in this USA Today article is:

“Anna Morad, a pediatrician at Vanderbilt, said years ago no one questioned the protocol of giving the vitamin injection the day a baby is born. These parents also typically refuse a hepatitis B vaccine, which is given to the babies to protect them from possible exposure from the mother.”

3.  Are doctors and hospitals uncomfortable when parents “question” their practice?  Are doctors uncomfortable when a parent declines their recommendations?  Why?

4.  We are testing every mother for Hepatitis B prenatally, so short of being in one of the known high-risk ethnic groups, why are we forcing/coercing parents to inject newborns fragile immune system with a Hepatitis B vaccine that is aimed at preventing a disease that is transmissible by semen, body fluids or blood products?

5. Should there be ethical considerations when a doctor or hospital attaches their personal desires, beliefs and need to control onto parents who respectfully decline?

6.  Why ARE some physicians so attached to coercion control and scare tactics with parents who get themselves off the conveyor belt of the U.S. hospital delivery system?

7.  Perhaps most importantly, why are babies born naturally low in Vitamin K?  Common thought is a lack of intestinal bacteria immediately after birth.  Other considerations have to do with the placenta filtering it from the mother’s system.  Wouldn’t these low levels be considered the “norm” rather than adult levels considered the norm for newborns?  Are we effectively questioning God’s and nature’s perfect design for ALL babies and ALL womens’ ability to create and grow the perfect baby?

8.  Are there inherent risks to injecting all 1 or 2 hour newborns with adult levels of Vitamin K?

Since the article was published by USA Today, midwife internet boards around the country have been lighting up on the issue and healthy debate/discussion rampant.  I found another article that offers another perspective on the Vitamin K issue for newborns.

Vitamin K – An Alternative Perspective

I personally found the second article better cited and more balanced than the USA Today scary article.  The author did not interview one midwife or cite any opposing research.  It could almost be considered not real credible news.

Although I struggle to form a solid opinion or position on the issue, I’m discovering that’s not really my job.  My job as a midwife is to promote evidence-based care and informed consent. I’m doing that regardless of my personal opinion on the subject matter.  

Here is a link to a Stanford University protocol.

Stanford Guideline – Newborn Vitamin K

Legacy of Mormon Midwives – from a Vermont Mormon Midwife

Imagine wading through mud and snow in an ankle-length dress with petticoats, or dealing with a stuck wagon or a row boat through partially frozen water en route to a labor on the prairie.  I’d love to see a motion picture on the lives of pioneer midwives and their dealings so close with birth, life and death.  It makes modern-day Vermont home birth in a February blizzard with easy access to technology and medical services seem like patty-cake.

 

Mormon Midwife Pioneer

I live and practice as a Vermont mormon midwife in the most atheistic state in the nation.  Hence, I do not shout from the rooftops that I am a member of the Church of Jesus Christ of Latter-day Saints (Mormon) because my faith is intensely private to me. Faith has been a blessing for my family and is a consideration in all that I do.  Here is a fun article about the legacy and pioneer history of Mormon Midwives.

Rediscovering the Legacy of Mormon Midwives

By Jenne Erigero Alderks

Below is a book I’ve been hoping to buy and read.

Mormon Midwife Book

The Midwife: A Biography of Laurine Ekstrom Kingston

Lastly, another reading project I hope to someday undertake…

A Tribute to a Mormon Pioneer Midwife – Patty Bartlett Sessions