not many students going into obstetrics
docs "desperate for preceptors"
mana exam qualifies you for NARM and WA midwifery exam
prof is slender blonde in her 40's maybe 50, Zieman
political efforts to squash midwifery are prevalent
she recommends peds classes to all who want to do midwifery
this class oriented toward general practice
what will you do if woman comes in with vaginal bleeding?
CATHERINE ZIEMAN
grew up in upstate NY, Peaksgill
father was English teacher
theater was 1st career, then phys therapy or DO idea, then chiro
secret homeopathy club at chiropractic school
speaker at club from CA let her in on naturopathy
chiros in OR can delivery babies
didn't like chiro school
cat needed homeopathic remedy, found NCNM last minute (thurs, school starts next mon)
Jarred Zeff was dean, she hustles transcripts from NY, Delphi U cry to get transcripts
got in
she's a talker
midwifery is about community
small group, great environ in PDX, not same east of rockies
prof now to go down list, all on roster to intro self
lots of poignant stories
how we found naturopathy and why we ended up here at NCNM
break then comments about current state of medicine
interventions in birth-->not always useful
let mother listen to her body, give her some privacy
if insecure give reassurance
better imprinting with more natural birth
now inducement, epidural given routinely
at what moment does a doc consider a birth overdue? when it is convenient for them
elective C-section before 39 weeks is risky
women prefer C-section at 36-37 weeks
fat storage on back for nursing goes on after 36 weeks, women want to avoid that
there are midwives out there who are untrained
may not recognize dangerous situations: eclampsia, fetal distress
fetal monitors-->no change in infant mortality, but did increase C-sections a lot
no better predictions via monitor
must be good from pain in childbirth: natural endorphin release-->ecstasy
baby gets same endorphin release: intense to be born
babies look peaceful who've come through canal, not like c-section babies
also oxytocin cascade
released dt: sex, orgasm, chocolate, friendships, women cooking together
makes us bond, warm feelings
causes release of colostrum, breast milk
suppression of hormonal cascade-->no hormonal help bonding with baby
less emotion
human pelvis not optimal for birthing
wrong shape, we gave something up becoming bipeds
pelvic floor not best
sheep do it easier
HOMEBIRTH
having a baby is natural, not medical unless problem
"you didn't bring this whole team of people in to watch you have sex, why do you need bells and whistles and machines that go beep to give birth?"
woman can squat, move around
need to feel safe to have baby unmedicated
more relaxed-->easier birth
mothers remember the wonder of birth
HOSPITAL BIRTH
cortisol/stress suppresses oxytocin
pitocin-->harder contractions, more painful
need fetal monitor-->can't get up and walk around
constrict blood to placenta more
pain-->want epidural more often-->must be on IV
epidural may cause fever, can't tell if infx then give abx even tho mb se of epidural
epidural slows labor-->pitocin drip needed
epidural-->more malpresentation because pelvic floor is flaccid
epidural bigger when HMOs take over healthcare: cut labor and delivery nurses
1-3 nurses for whole floor, drug 'em up, put 'em on monitors
less endorphins
tv story about old ER show, given epidural between twins, birth as emergency drama
epidural rate up (98% at local hospital) because docs trained to do them
hospital staff with buttons that say "no pain", women are afraid and don't want pain
before they gave morphine derivatives but that suppresses baby's breathing
end up with blue depressed babies
before that gave scopalamine, made women crazy, not remember, tied them down & extract baby
women remember the pain and drama of birth
STAGES OF LABOR
latent phase is early labor, 0-4 cm dilation, do loving things
active labor 4-5 cm, more intense contractions, blood, cervix
transition 7-10 cm, most intense part of labor, shortest phase usually, reassurance needed
HISTORY
1750's docs became involved in childbirth
not good handwashing-->more infx
started shaving women, etc to prevent infx
doc want more biz
women not well nourished
1840's pain management = chloroform and ether
get affairs in order before birth
1900's demand relief from pain
women's suffrage too
church punishment for sin
1910 twilight sleep scopalamine and morphine for upper class women available
Hannah Coulter books about midwife from Russia working in NY
book: the midwife and the midwife's advice
1900's hospital considered sanitary, safe, hygienic, age of enlightenment
med journals midwives described negatively, dirty, uneducated, etc
docs not have enough women to practice childbirth on: got midwives out of hospitals
Mary Breckenridge 1925 midwife svc and school, online, nurse midwife program
1930's NYC midwife training, deliver poor
1960's in south, granny midwives, African americans esp, phased out
1960's in Santa Cruz birth center formed, beginning of modern homebirth movement
1970s humor film Monty Python reveals nature of modern birth: machines, inhuman
1975 Ina Mae Gaskin commune, the farm, delivered babies along the way, spiritual midwifery
homebirth mecca
1977 Sherry Daniels midwife school on Tx/Mx border, El Paso
more popular
1990's hospitals try to become competitive w/ homebirth
more warm and fuzzy, shorter stays, painted pink, no delivery room
pre OSHA pre AIDS no use gloves
Lamaz technique taught in hospitals, more they teach machines and drugs and catheters
epidural bigger when HMOs take over healthcare: cut labor and delivery nurses
1-3 nurses for whole floor, drug 'em up, put 'em on monitors
NDs practice in many states
2005-6 school crisis, board threatens to cancel midwifery from school
thanks to Rita Bettenberg, she carried the torch, prevented NDs loosing birth training
counties in S Or where there are no OB docs
nobody goes into OB in med school now because malpractice is absurd
mostly become gyns
no docs doing births anymore
ND midwives don't carry malpractice in OR
best thing you do for malpractice: have them sign a release, I don't have malpractice insurance, I don't have a deep pocket
"we don't get sued, knock on wood"
the pts that come to us know it's not a guarantee
she is insured through niknik that excludes OB
if serving underserve pop can charge a lot less than hospital
SAFETY
25% of high risk preg women become high risk in labor
if just one risk factor, probly can manage
2 risk factors: maybe
3 risk factors: better send to hospital
she transports for trend, not for emergencies
sometimes she transports when not needed but it is rare
most babies born where they are supposed to be born
after they're born you learn why
most are not high risk
after transport, in OR or WA, midwife can stay with pt
often not allowed to catch the baby but can ask as doula
can help with interpretation of modern medical practices, act as advocate
qualifications needed
attend # of births
know how to resuscitate baby, set IV, recognize abn
know who to call
know hospital procedures to advocate in that arena
advantages of home birth
safe
no cascade of interventions, pitocin, epidural, other pain meds
familiar, less cortisol, better oxytocin
less infx
reasons to go to hospital
high risk: DM, HTN, preeclampsia, heart dz, aids, heroin addict
preterm labor, can't do supportive care after birth
problems/complications
c-section
wants full time nursing care x24 hours
needs insurance to pay
use of meds, forceps, saline rinse
naturopath can't administer anything when mom in hospital (vit K drop story)
risk screening
ros
CI for home: twins or more
anything but vertex presentation
yes exceptions
DM
HIV/AIDS controversial
bleeding disorder
placenta previa
PIH
itrauterine growth retard
vag bleed
anemia
thyroid dz
HTN
pancreatitis
fetal heart tone abn
resp dz, asthma
gall dz
neuro, paralysis
anatomical abn
teratogen exposure
hep
tobacco smoke-->friable placenta, abruption, low birth wt
bvac=vaginal birth after cesarian?????? what is this
typical hospital birth
pitocin
more at risk for uterine rupture
epidural
can't feel uterine rupture
bvac good option
more CI's for home birth
over 35, under 16 (nutrition not so good, low Ca, Fe, more pre-eclampasia, DM)
greater than certain size?
obesity
poor nutrit
serious psych probs (this one is key)