Lamaze/ICEA Conference part 2

Saturday did not start well for me. I slept maybe 2 hours the night before, due to a combination of congestion and two little children who decided to wake up and either cry (Zari) or party (Dio) most of the night. I wondered how I would make it through the day...

But I didn't have much choice. My presentation--based on my article Attitudes Towards Home Birth in the US (PDF)--was in the morning. I arrived early and ran through my presentation to make sure I wouldn't go over time. I used prezi rather than PowerPoint, as I think it's a much more dynamic and visually interesting platform.

Safe or Selfish? Attitudes about home birth in the US on Prezi

I had a fun time giving the presentation. We had lots of discussion and comments both during and after my talk. Even though I was dead tired, I didn't feel it while I was speaking. We had to cut the discussion short to make it to the big celebratory luncheon. I sat with April, a lovely CPM from Dayton, Ohio, who works closely with Dr. Guy of Miami Valley Hospital in Dayton and Dr. Can't-Remember-His-Name in Cincinnati. These OBs are known for supporting women who want VBACs, vaginal breech births, vaginal twins & triplets, etc. She and I talked about her training (master's level degree from the Midwives College of Utah) and her reservations about the loopholes in the CPM certification process.

Later in the day, I found out that Geradine Simkins, president of MANA, and Dr. Raymond De Vries were both in my audience! I had never met them face-to-face before and so didn't know who they were at the time. I talked with Geradine afterwards for a while. She urged me to consider doing research with the home birth statistics MANA has been compiling over the past decade or so. She was especially curious about my suggestion that NARM upgrade the CPM certification into a 4-year university degree. We weren't able to talk much because of our busy schedules, so I'll have to continue our conversation via email or phone.

I did double duty in the afternoon breakout sessions. First, I listened to Christine Morton's presentation about the historical evolution of doulas and how the profession is intimately connected with the development of childbirth education. Really fascinating! I've "known" Christine online for a while--she's a sociologist at Stanford University and doula--but never saw her in person before the conference. I never had time to talk with her face-to-face, unfortunately. But here's a virtual wave hi, if you're reading!

I then ran to another session about MoreOB, an evidence-based program being adopted throughout Canada. The presenters were an obstetrician, Dr. Karen Bailey, and two nurses/childbirth educators, Liz DeMaere and Sharon Dalrymple. With MoreOB, what childbirth educators teach in the classroom is exactly what happens once the laboring woman arrives in the hospital. This is definitely not the case in most parts of the US, as attendees emphasized over and over again throughout the conference.

The speakers gave a case study about how MoreOB works in their hospital regarding fetal monitoring. The hospital staff has a clear set of guidelines for when to use intermittent auscultation (IA) and when to use continuous electronic fetal monitoring (cEFM). Basically, unless a woman has certain clearly-delineated risk factors, she will only be monitored with IA. If a nurse, midwife, or physician wants to use cEFM, they have to document which specific medical condition warrants using cEFM. If it does not meet the established criteria, they won't be allowed to use cEFM. And they'll receive a talking-to from the charge nurse!

I entered when Dr. Bailey was talking about the before and after experiences in her hospital. She works in a small rural hospital in High River, Alberta that cares for only low-risk laboring women. Before adopting MoreOB, every woman would automatically be hooked up to the fetal monitors and confined to bed. After MoreOB was put into place, no one goes on the monitors--no 20-minute admission strips, even--unless there's a very specific reason for it. At her hospital, that means almost everyone receives IA and is encouraged to stay out of bed. Dr. Bailey explained it like this: "I'm an old cowgirl. And every cowboy or cowgirl worth their salt knows that you can't just slip your feet into a good-fitting pair of cowboy boots. You have to wiggle and jump and shimmy your way into your boots!" (This said as she's hopping around the room on one foot demonstrating the gymnastics required to put on cowboy boots). She was adamant about keeping women walking and moving and out of bed. She joked about how they used to always know where to find the laboring women--in bed. But now, they never know where to find them. "Where's patient X? Not in her room? Not in the shower? Where could she be? Oh....probably the staircase!"

We then moved into three small groups, each tackling a common scenario in US hospitals: augmentation, induction, and restriction of food/drink. We were instructed to discuss how to implement evidence-based, consistent policies, similar to what their hospital has done, for these various scenarios. I joined the induction group, which Dr. Bailey was part of. Our group, I sensed, felt extremely hampered and frustrated with how little they felt they could do to change the rampant rates of both elective and quasi-medical inductions (i.e., for a "big baby" or being "overdue" at 40 weeks and 1 day). Where Dr. Bailey works, they only do elective inductions for really extreme circumstances--such as a grand multip with a history of 30-minute labors who lives two hours away from the hospital and a really big snowstorm is moving in (close to a direct quote from Dr. Bailey). They don't start offering inductions for post-dates until 41 weeks 3 days. So if a physician wants to book a patient for an induction, and the induction doesn't meet certain evidence-based criteria, the charge nurse will tell the doctor--and I quote Dr. Bailey--"Bullshit."

The last session on Saturday was a general session by Dr. Warren P. Newton. He teaches at the UNC School of Medicine and works with UNC's department of Family Medicine. He spoke about developing a systems approach to health care. While the quality of individual physician-patient (or midwife-client) interactions is key, we also need to ensure that everyone has equal access to such care. He explained the implementation of the Family Centered Medical Home into the UNC Family Medicine Center and demonstrated very impressive results: much less waiting time for appointments, better health outcomes, etc. I'm still fuzzy on what exactly a FCMH is and how it different from standard medical care systems, but it was very intriguing.

The last part of his presentation explained how he applies these approaches to maternal-child care. His staff includes family physicians, nurse-midwives, nurse practitioners, and acupuncturists. They have really impressive numbers with their maternity patients. They do about 350 births/year and have a primary cesarean rate twice as low as the overall primary c/s rate at UNC. Their practice's epidural rate is 25%, compared to 82% for the rest of the hospital's maternity patients. (He noted that not allowing the anesthesiologists into the woman's room soon after admission to "talk about her pain relief options" and "assess her airway in case she needs an emergency cesarean under general anesthesia" had a significant impact on lowering the epidural rate.) He's also been involved in backing up the only freestanding birth center currently in North Carolina, the Women's Birth and Wellness Center, which does about 400 births per year. He demonstrated a strong belief in the normality of the childbearing process and of women's inherent ability to give birth, especially when given the time and space to do so.

By time 5:15 pm rolled around, I was beat. I could hardly stand upright and was feeling quite unwell. I wanted to stay longer and talk, but I needed to get back to the kids, eat dinner, and go to bed. My sister and I split a Tylenol PM; the sleep aid is benadryl, so it was perfect for our congested noses. (Thanks to April for finding someone with medications on hand!) It did the trick, and I was able to have a good night's sleep (which meant I only woke up 3 times to pee, and Dio only woke up once at 2am.) My apologies to anyone who thought I seemed disinterested or distracted on Saturday...it was just the fatigue!