Friedman's Curve is a Bunch of BS!

Read it and weep, one centimeter per hour devotees!! Muahahaha!!

This is an incredible piece of research. If read and implemented, I think it could save SO MANY women from the pitocin-epidural-cesarean cascade. There is also an excellent review of the article on Academic OBGYN. Check it out! If you want the full article, shoot me an email or comment and I will send you a PDF. The formatting gets messed up if I try to post it here.

Enjoy!

The Natural History of the Normal First Stage of Labor

Zhang, Jun PhD, MD; Troendle, James PhD; Mikolajczyk, Rafael MD, MSc; Sundaram,
Rajeshwari PhD; Beaver, Julie MS; Fraser, William MD, MS
Obstetrics & Gynecology
Issue: Volume 115(4), April 2010, pp 705-710
DOI: 10.1097/AOG.0b013e3181d55925

Abstract

OBJECTIVE: To examine labor patterns in a large population and to explore an
alternative approach for diagnosing abnormal labor progression.

METHODS: Data from the National Collaborative Perinatal Project were used. A
total of 26,838 parturients were selected who had a singleton term gestation,
spontaneous onset of labor, vertex presentation, and a normal perinatal outcome.
A repeated-measures analysis was used to construct average labor curves by
parity. An interval-censored regression was used to estimate duration of labor
stratified by cervical dilation at admission and centimeter by centimeter.

RESULTS: The median time needed to progress from one centimeter to the next
became shorter as labor advanced (eg, from 1.2 hours at 3-4 cm to 0.4 hours at
7-8 cm in nulliparas). Nulliparous women had the longest and most gradual labor
curve; multiparous women of different parities had very similar curves.
Nulliparas may start the active phase after 5 cm of cervical dilation and may
not necessarily have a clear active phase characterized by precipitous dilation.
The deceleration phase in the late active phase of labor may be an artifact in
many cases.

CONCLUSION: The active phase of labor may not start until 5 cm of cervical
dilation in multiparas and even later in nulliparas. A 2-hour threshold for
diagnosing labor arrest may be too short before 6 cm of dilation, whereas a
4-hour limit may be too long after 6 cm. Given that cervical dilation accelerates
as labor advances, a graduated approach based on levels of cervical dilation to
diagnose labor protraction and arrest is proposed.

Slightly drunk on a summer night

I must say: it is a really lovely feeling to ride my bike through the city slightly drunk on a warm summer night, after laughing a lot with good girl friends. This must be what youth is about.

Good Day, Sunshine

I don't have a lot to say today except that it was a good day. I woke up to sunshine streaming in through our bedroom window. Alex and I had a good snuggle while we listened to housemates making breakfast downstairs. When we figured it was about ready, we headed downstairs and were treated to yummy porridge in the breakfast nook with our homies.

I forced myself to do paperwork all morning, and studied, then in the afternoon I rode up to McPhereson's Produce Stand and splurged on summer fruit-two kinds of cherries, grapes, papaya...and ingredients for spring rolls. My giant new grocery delivery basket on my bike works like a champ-three bags of groceries, no problem! I spent the afternoon making spring rolls until my fingers got pruny from pulling the rice wraps out of the water. Alex and I had a backyard picnic, watched the clouds, and I started a new book (The Bicycle Diaries, by David Byrne).

When we got bored we headed down to Full Tilt Ice Cream for some delish cream and pinball. I got Thai Iced Tea vegan ice cream, and Alex got the classic Ube flavor. We detoured on our way home to watch a spectacular sunset over the sound, mountains, and city skyline from Jose P. Rizal park. We were among several other pairs of lovebirds, and one lonely looking Latino man watching the sunset from his tiny, old red car. As we were sitting there we saw three Airlift Northwest flights dropping folks off at the helipad behind Harborview. It was strange to be having such an incredibly peaceful and content moment with my lover, and know that at the very same moment there were nurses and doctors in Resus Rooms 1, 2, and 3 trying to save people's lives. I was grateful to be on my side of the moment.

Our little chicks are spending their first night outside tonight. Up to now they've either been in our dining room under a heating lamp or in the garage under a heating lamp. They've had brief adventures in the chicken tractor during the warm part of the days, but tonight is the first night that they're on their own out there for the duration. It reminds me of kids having their first "camp out" in a tent in the back yard. Alex and I have been simultaneously worrying over them and glad they're out there growing up. They're teenagers now, after all. Last we checked, they were in a chick cuddle puddle in their nesting box in the chicken tractor. They seemed quite content, but we brought them some extra food and bedding just in case. I hope they do OK out in the big world tonight!

Purple Scrub Safari

So....I woke up this morning with a clear idea of how my day would go. I had a study group in Madison Valley from 9-12, then a group photo for at my clinical site at 1pm, then miscellaneous finals week tasks to do until dinner time. I rolled out the door and got to Madison Valley just fine. We got all the new study guides for the final done! But then, things took a turn. I had an adventure. Well, a misadventure.

I used the new bike maps feature on Google Maps to plan my route from Madison Valley to Children's. It routed me through Broadmoore, which I thought was a little odd, but probably quiet and peaceful and safe, so away I rode (directly up hill-Madison Valley is not called a "valley" for no reason) towards Braodmoore. For non-Seattlites, Broadmoore is a gated, private neighborhood of mansions inhabited by the bougousie, plunked down in the middle of a major public park, the Arboretum. Only in Seattle, dudes, only in Seattle. I was admitted to Broadmoore once, to attend the board meeting of a non-profit I was involved in. I wasn't involved in that non-profit for long. It turns out Broadmoore does not allow bicyclists to roam it's golden streets, and so I had to continue past the guarded gates and take the main road, Lake Washington Blvd, through the arboretum. It's a nice route, flat and tree lined, except that it's also a major traffic route. Two lines of twisty, winding, narrow pavement, traversed by many an SUV-and me in front, holding up the show. There is no shoulder. But, to be honest I have no qualms about holding up traffic whatsoever. If they want bicyclists not to hold up traffic, maybe they should build some decent bike paths, eh?

Now we get to the misadventure part. Following Google's directions, I took Foster Island Rd out to the waterfront trail. It turned out not to be so much "water front" as "water covered." It was ok, if just slightly muddy for the first quarter mile or so. Then it got a little more muddy, but still passable if I walked my bike. Then suddenly, in a single step, I was knee deep in swamp mud. The kind of swamp mud that sucks your shoes off. Swamp mud also smells like shite, a familiar and comforting smell to a girl who spent many happy hours playing in the swamps of south Georgia, but definitely still a shite smell. Did I mention I was wearing my purple scrubs to pose for a group photo in a hospital? Last I checked, most hospitals do not welcome with open arms students covered to their knees in foul smelling mud, nor does it make for a lovely, professional photo. I was half laughing, and half cussing as I extracted myself-with both shoes, miraculously-from the mud. "Ha!" I thought to myself. "Nice try. I'm made of tougher stuff than that!" I decided to get through the rest of this god-forsaken trail, then pause at the sylvan water's edge and wash the shit off my scrubs and running shoes and hope they dried out a little bit on the rest of the ride to the hospital, which I now had about 20 minutes to make. A brilliant plan, no? I made it through the rest of the mud, and finally returned to the maintained, wood chipped part of the trail. Along the way, I noticed not one, but two pairs of abandoned running shoes on the trail! I was clearly not alone in my woes. Now that I was through the mud it was time to implement my wash-dry-look decent plan. I leaned my bike against the railing, stuck my left foot in the water, shook it around, and was relatively pleased with the mud removal accomplished. Next, I stuck in my right foot. Next, while balancing on my left foot, I fell into the water up to my thighs. Damn. It. It was a long, cold, wet ride home. I really turned heads, let me tell you.

So, here are the bummer things about that bike ride:

1) Google bike maps can kiss my patooty

2) I failed (FAILED!) to deliver the cards I had for students to sign for the nursing staff who have so kindly allowed us to breathe down their necks, step on their heels, and ask really dumb questions all quarter. I will get them to them somehow, but dadgumit!

3) Someone will have to photo shop my head onto Jennifer Anniston's body, and then make it look like Jennifer Anniston is wearing purple scrubs, and then insert that into the group photo.

Here, though, are the great things about that bike ride:

1) If you have to fall on your butt, it's really much nicer to do that in mud and water than going 30 MPH on pavement, which is what I was doing only a few minutes before I fell in the water. I think fate was looking out for me, in a dysfunctional kind of way.

2) I quite enjoy wallowing in mud. I think it's romantic. The most romantic thing I've ever done in my life was picking raspberries in a cold drizzle, ankle deep in muck, at the foot of the Cascades with Alex.

3) That was, sadly, the most adventure I've had since my 5k/Polar Bear Plunge in January! I really need to get out more!

The Midwife

I'm reading a really great book-in fact, since I checked it out yesterday I've read 160 pages of it, Care in Illness exam be damned! It's called The Midwife. You'll never guess what it's about...

OK, OK, you guessed! It's the autobiography of a young midwife, Jennifer Worth, working in the East End of London in the 1950's. In the first pages, the midwife nonchalantly describes getting a call out (at the convent where she was living while in training), rolling out the door at 2am, and...clipping her birth kit to the back of her bike! How cool is that!! I can't tell you how much this sparked my imagination, and actually reminded me of my first births with the midwives while I was a student at SMS. I was so excited to hear my cell phone ring in the quiet stillness of the night. I concientously changed my cell ringtone to something I thought would be a gentle awakening in the wee hours. This midwife (Jennifer's) description of what it was like to prepare for and attend a birth reminded me exactly of what I imagined it would be like before I knew what it was like. Reading her description of getting the call, checking her kit, and riding to the birth in the company of the other night workers. The quiet, quick, straightforward birth, everyone down to earth with their expectations for hard work and pain, but not fearful, and open to the inherent wonder of birth.

Reading from her perspective actually made me wonder why birth is so damn complicated. Is it the me? The women? The culture? Of course all of these births Jennifer is describing are at home, so that helps greatly. I have been to plenty of home births that mainly involved women standing around in the kitchen, eating, making food for the family, laughing, massaging and generally loving up the mom, entertaining other kids, and being glad that a new little one was on the way. Creating a good, relaxed, loving and normal vibe in other words. But, I've been to lots of births where people got really, really excited when the mom had a (as in one, single) contraction, lit candles, and turned on the yoga music seemingly expecting a wholly spiritual, mainly pleasant event, to take no longer than 6-12 hours (whether it's a first birth or not). I can't help but think that a return to a more realistic view of birth could be helpful: not sheer terror, agony and suffering. Not orgasmic and ethereal. Real, hard work, that takes time, patience, love and care. The spiritual element I think comes from the community of people that come together to support the mom, and her finding her inner resources to do this hard work. I just saw a nice film in fact, about the need to return to realistic images and expectations of birth. It's called Laboring Under an Illusion. But, I digress.

Jennifer describes some antiquated practices, like shaving and enemas, but she seems to giggle at herself and the rediculousness of the practices in hindsight. (Side note: sometimes I do wonder- if we still used enemas routinely in the hospital, might we use less pitocin? They do get things moving, and not just the poo. But of course, the best solution is neither enemas nor pit, but patience.) She describes testing for proteinuria by holding the top half of a vial of urine over a flame and watching for the protein to cook, thus turning white (like an egg), which is kind of ingenious. Glucosuria was tested for by adding something called Fehling's solution to the urine and comparing the color to a chart. So much more complicated than our fancy dipsticks these days! Fetal heart tones were assessed exclusively with a fetoscope (pinard horn), not with a handheld doppler and certainly not with one of the gawd awful continuous electronic fetal monitors.

Mothers were routinely kept in bed for 10-14 days after birth. This is now known to predispose women to deep vein thrombosis, a blood clot that can break off a vessel and become lodged in the lungs, or rarely, the brain. However, Jennifer also points out that in the days and places where women had 5-10 or more other children and extremely difficult living situations, 'lying in' did ensure that they got a little bit of much needed rest to recover, eat, and breastfeed. I, along with many, many other student midwives, have been taught the phrase, "A week in the bed, a week on the bed, and a week around the bed," as our advice (given with all of our full medical authority) to new moms. No electronic commuting, working from home, full schedule of childbirth and postpartum yoga classes. Certainly no going back to work that requires standing all day, lifting, etc. and provides little or no break time for pumping. Just a few weeks where the priority is to feed mom, feed baby, snuggle and get to know each other, and sleep when the baby sleeps. But by all means, get up to use the bathroom, take a walk, flex your legs and keep that blood pumping.

Jennifer talks about delivering a-gasp!-breech baby. The technique sounds exactly like what I was taught in 2006! Things don't change that much, except of course that the midwife in this book was experienced and adept at breech birth, and this is not so much the case for most practitioners today.

Another interesting aspect of the book is Jennifer's description of midwifery training, and nursing training in general-the two being then and now more closely linked in England than in the US. She mentions the Nightingale School of Nursing, and a book Nightingale wrote about birth at the time, "Introductory Notes On Lying-In Institutions, Together With A Proposal For Organising An Institution For Training Midwives And Midwifery Nurses." I must read this! I just finished reading her "Notes on Nursing: What it is, and what it is not." I learned a lot from it and look forward to reading her thoughts on birth practices and midwifery. At any rate, it's fascinating to read Jennifer's description of becoming a nurse, and the strict hierarchy and occasional cruelty of the matrons she learned from and worked under. It sounded familiar.

Most intriguing is the fact that to learn midwifery after being a nurse for some time, Jennifer was sent to a convent in an urban slum. She lived with the nuns, whose entire practice was exclusively midwifery. I am trying to picture moving into a convent. Having my own stone room, a cot, a desk, a wash basin, a bike, and that's it. And all I would do, from dawn to dusk six days a week-midwifery. Antenatal clinic once a week in the church basement, births zoomed off to by bike, and twice daily postpartum visits to moms in the first week after birth, then once a day for another 1-2 weeks. I have to admit, it actually sounds kind of great. I would miss Alex of course, but I think I could love living with other midwives, and having my own stone room for a few months. It would be pretty amazing to have the opportunity to focus so closely on developing my skills.

Well, I should go. I am at Children's tomorrow morning, and I want to get up at the crack of dawn, so I can finally put my big rack and basket on my bike! I want to put my kit on it and roll away!

The book is The Midwife, by Jennifer Worth.

Holy Births and Howling Babies

Holy Births and Howling Babies

In my backyard there are nuns who live in a shaded brick building

next to the St. Stanislaus church and elementary school.

Together we rise before the sun is in the sky.

Behind the kitchen curtain, in the damp haze of morning,

I watch them walk in shades of blue robe.

They glide in white sneakers across the parking lot.

They are cool, calm, brisk.

Some day, I’ll go see them

I’ll ask for some lesson on prayer.

Because the thing is…I pray now.

Not Dear God Almighty!

Just slow, easy, quiet thoughts.

I pray when my patience is worn.

When my shoulders ache.

When my own voice becomes tiring to my ears.

I pray when my heart sits heavy with stories and faces of women.

A prayer for the 32 week babe.

A prayer for the lady with the skinny, squawking twins.

A prayer for a mother without a mother, or a lover, or a friend.

I pray when my cold hands run across a pregnant belly

And I feel a kick from the inside.

I pray for all my babies, Be good to your mama.

I pray for all my mothers, Be strong, be good to this baby.

I pray secretly and I pray slowly.

I pray for us, the midwives and the almost midwives.

I pray that we make the right decisions.

And I pray for those of us who make bad decisions.

Decisions we regret with outcomes we can’t change.

I pray that we learn from our mistakes.

That with age comes wisdom.

I pray deeply and I pray completely.

For all the hands and all the bellies.

I pray for holy births and howling babies.

-Dana Quealy, CNM, MSN

You are Already Enough

At the end of a long 12 hours at the hospital. Strangely, after a full day of urine dipsticks, gowning and un-gowning, call lights, pumps, shots, meds, and more pee, all I want to write about is how much I've learned from my clinical instructor, F. She has a pretty amazing depth of hands on, nitty gritty 'how to give that drug' 'how to assess this kiddo' 'how to chart that crazy thing that just went down' knowledge to share, and she shares generously. She's nice, too. She build us up my confidence and passion, instead of making me feel like incompetent jerk, going home every night wondering why on Earth I thought this was what I wanted to do. But the two biggest things I've learned from her are nothing to do with drugs, pumps, lines, or machines that go ping. The two things are 1) Our patients are human and 2) We are human too, and that is a good thing.

You might be thinking "But Caren, you're a doula and a future midwife-you know you have to act in loving kindness, honoring the human experience." I do, it's true. I know it's important. I also have to tell you that it's a lot easier to do that when I have no real doubt that this will be a happy ending, an experience I will overall be glad I was present for and that I know is healthy and normal-not something that will break my heart and make me want to hide under a rock. Instead of being happy to engage in a joyful family process, I am scared to get pulled into the current of a terrifying, tragic, draining time in a family and child's life. Also, I was good at my job as a doula, and didn't have to think that hard about what I was doing at every moment. I was unlikely to kill anyone if I made a mistake. That made it easy to focus on the experience and the people. When I'm all thumbs and nervous as hell that I'll screw up bad enough to hurt someone, I get tunnel vision to what my hands are doing and which tasks need to be completed. So, although I have the values in place, F. has deepened my understanding of them and challenged me to live my values in more difficult times.

On the first point, that our patients are humans, you'll think "yeah, duh." But people in hospitals are dehumanized, for many reasons and in many ways. I think staff dehumanize patients in an effort to protect themselves from heartbreak and burnout (although I'm unconvinced that it's an effective strategy). For some professionals who do very high risk things (like surgery) it might take a certain amount of dehumanization to do their job without abject terror.

We are educated in a way that dehumanizes patients-we are shown gruesome pictures of terrible injuries and diseases, with only the diseased body part shown or the eyes blacked out. There is never a caption on these pictures that says, "This diabetic foot belongs to Mr. Jones, who is the proud grandfather of 3 boys and a girl, the husband of 65 years to Mrs. Jones, and an avid hobby train enthusiast." Mr. Jones is reduced to just a disembodied gangrenous foot. We memorize standard symptoms, pathologies, and treatments, and not how it feels to be a 17 year old girl who is incontinent, and has no hair on her head, but a full beard from her medicine.

Perhaps most importantly, we never see these patients-these people- in their "real" lives. When we see them they are afraid for their lives, surrounded by equipment, with lines and drains coming out of any or all orifices and out of unnatural holes we've made in their arms and chests. They are living under literal microscopes that tell us every detail of every body fluid and cavity, but also under figurative microscopes that are constantly observing how they parent, how they behave towards their parents, if they're 'compliant', if the parents' marriage is 'healthy', if they're 'in denial' or 'high needs.' For God's sake, do you know that your neighbor had an affair? Do you know how much they drink? Do you know they flipped out and yelled at their kid yesterday? No. You aren't given the opportunity. We have the opportunity to observe and pathologize and dehumanize at every moment of these kids' and families' existence. All of it adds up to make people into patients.

And yet, what we see in the hospital room is not them. It's not their real life. It's a little piece of something they're doing so that they can live their real life. For example, I was reading a blog today from Harvard's Center on Women's Mental Health that referred to pregnancy as a disruption to a woman's treatment for bipolar disorder. A year ago I wouldn't have thought twice about that statement. After this quarter with F. and the families on my unit I think, "No!" The treatment is a disruption of this woman's life course which includes pregnancy, not the other way around. The treatment is meant to enable her to have that life that she chooses, not to become her life. So, F. is teaching my to cut through the dehumanization and see a 2 month old and his parents for who they are, not for what the diagnosis is and what equipment he's hooked up to, and what the social work note says. She's teaching me to do the harder thing, to see my human patients, my fellow humans, our thus to see our shared human fallibility.

This brings us to the second point: we are humans, and that is a good thing. This is a hard one for me. Like most people, I pull back reflexively from things that hurt me to see or do. I do mean things to people sometimes. Shots, dressing changes, meds that make kids barf or cry. It's hard to be human when I'm doing sort of inhuman things, even when I know it's for the patient's health. F. pushes me to be uncomfortable and be in the moment with uncomfortable people. You may wonder what could be more uncomfortable than 40 hours of labor (which I happily and quite comfortably am present for), and I can tell you that acute illness of the kind seen at acute care hospitals is much, much more uncomfortable, undignified, and scary. Labor is normal, healthy pain with a joyful purpose, while diseases causes suffering with no purpose. But, just like women in labor, people in the hospital be they a kid with cancer or an adult with a broken pelvis need me to be human, be present, do everything possible to prevent suffering- but also not flee when I can't prevent it. F. said today, in response to a question about what we should know to say and do at the end of a patient's life, "It's ok. You are already enough. You are a human, just be human." So simple, so hard, and so true.