Saturday, October 25, 2008

Health Care With No Legs to Stand On: The Questions Behind the Question

Below is an essay written by my good friend, the midwife, naturopath, voice of reason, mother, herbalist, and all around wise woman Alison Bastien. When I saw the picture below I was horrified at the new depth of depersonalization happening in obstetric care but Alison managed to frame my knee jerk response in a far more useful way.

There is a lot of information available these days. Access to the

Internet has made hundreds of journals, books, and opinions available to us

wherever we live. What fascinates me, though, is all of the information I

obtain by what is not being said. It is sort of like those brain teaser pictures,

depicting a white vase but actually, when you focus on the blackness, you

realize you are looking at two ladies in profile. It's not even that it “wasn't”

a picture of a white vase, really, it's more like there's more than meets the eye.

Modern health care paradigms feel like this to me. It's not just what they

“say” is good practice, it's the assumption behind it, the ladies in profile that

become revealed when we stop admiring the vase.

For example: As a midwife and as an interpreter I attended some of the emergency

obstetrical trainings for doctors and midwives in my state in central Mexico.

They are presented by an international medical association composed of

doctors and nurse-midwives who travel all over the Americas giving excellent, and

succinct workshops on the latest updates in lifesaving techniques for the

most common obstetrical emergencies. They simultaneously train the

attendees to become trainers themselves, to share the knowledge in their

medical communities and with their peers.

One of the workshops was on Shoulder Dystocia, a very scary situation

in which a babies shoulders may become stuck, or wedged behind the

pubic bones of the mother on delivery, so you have the babies head outside

her body, and the body unable to rotate and slip out. If not resolved, this

emergency could result in brain damage, or even death by asphyxia to the

baby. Timing is then essential to recognizing and resolving the situation.

The instructors, using their Power Point presentations to emphasize the

steps, and their large model torso of a woman with a removable belly-

cover and the model baby to be stuck inside her, take us through the

options and the steps to resolving the problem:

  • 1. Call for help
  • 2. Consider an episiotomy (cutting the perenium to “get more room”)
  • 3. the “McRoberts”maneuver, flexing the womans legs up by her ears, to “open the pelvic outlet”
  • 4. Suprapubic pressure (someone pushes really hard on the outside, while someone else is putting traction on the baby)
  • 5. Internal maneuvers (is this starting to sound like a war room strategy yet?)
  • A) the “Ruben“ maneuver, inserting ones fingers behind the anterior shoulder of the baby and trying to push it towards the baby's chest, so it can turn and scoot out.
  • B) the“Woods-Corkscrew” maneuver, whereby one presses ones hands on the posterior shoulder of the baby and presses the opposite direction.

These maneuvers are simple and useful, provided one can even slide their fingers in along the stuck baby

in the first place. Though the textbook then mentions as a footnote, the “roll on

fours” (or “Gaskin” maneuver) in the workshop the teacher moved straight on to

worst case scenario measures, such as breaking the baby´s clavicle to get it out,

pushing the baby back in and doing a cesarean, or breaking the woman's pubic bone

(no easy task!)

“Excuse me..” A nurse midwife from the midwest also attending the

workshops waves her hand up, “What about the Gaskin Manuever?”

I was wondering the same thing. The Gaskin Manuever was popularizad

by midwife, Ina May Gaskin, as result of her observations of other

empirical midwives in the highlands of Guatemala in the 1970s. This

consisted of turning the birthing woman over onto a hands and knees position

which , it was found, spontaneously or with minimal interventions, rotated the babies

100 percent of the time with no negative outcomes to mother or babies.

Personally, and for my nurse midwife friend, it was always our first choice for its

much lesser risk of trauma to both mother and baby. In this position, there is no

pressure on the coccyx and the baby's own weight presses the on the pubic bone. It

gives us automatically a little more room in case we still need to use any gentle traction

or maneuvering.

The instructor cleared his throat. “Well, the Gaskin maneuver? It almost always

works. That's why it's last on the list. If all else fails, that one will almost assuredly

rotate the baby and get it out. “

“That's crazy!” The nurse-midwife blurted out, “ Why would you waste all

that valuable time and effort and risk all the tissue trauma on all those other things

first if you yourself just acknowledged this is usually better?”

There followed much loud murmuring and muttering by the several dozen

Obstetricians and gynecologists in the room.

The presenter of the workshop shrugged his apology: “I know it's counter-intuitive, but like these docs are saying, we've got women with

intravenous tubes in their arms, fetal monitoring belts on, and they are mostly

lying prone on the hospital beds. It's a lot more tricky to get them into the

all-fours position with all those wires and tubes. Most of the women have epidural

anesthesia as well, with tubes in their spinal column and no feeling down below.”

The doctors are all nodding in agreement as I translate.

“Really, it's a mess trying to get someone to turn onto all fours on a

slippery metal hospital gurney, especially if their legs are already tied up

in the stirrups.”

My midwife friend seethed, conceding the point.

The Question behind the Question was: “ So why are we still putting women

on their backs on a slippery hospital gurney with tubes and wires all over them and

their legs up in the air in stirrups in the first place, if it hinders them in getting their

babies out?

This isn't just some third world issue by any means. Just last week I was

at a prestigious Ivy League Nurse-Midwifery school. In this case, I was

being given a tour of the teaching facilities. My student guide led me to

the robot teaching models. Actually, we had used an only slightly less sophisticated

model in some of the CPR courses and in the emergency courses in Mexico.

In these versions, a life-like plastic dummy woman with the removable belly

and baby featured a mechanical system whereby everything was programmed into

a nearby laptop computer, to simulate a variety of complications of delivery.

The baby could exhibit asynclitism, malpresentations, as well as the dreaded

shoulder dystocia for the students to practice resolving the problems while

the robot baby and mother exhibit life-like responses in their vital signs

to reflect the “what ifs” of proper or improper management in techniques

and choices. The robot woman had a life sized labia and cervix which dilated

to 10 cm. so the students could also practice checking dilation and station.

I had seen these robots in the medical supply catalogs stacked up for free

perusing and purchasing in the nursing department locker room. I had read

up on all the cool simulator robots just the night before, in a fit of uncharacteristic

insomnia. The teaching mama and baby goes for about 18,000 dollars.

“So, pretty neat, huh?”

I nodded agreement with my enthusiastic student guide, who was at that

very moment demonstrating some hand maneuvers up our robots vagina and


“So, uh, do you guys ever learn about the Gaskin maneuver for shoulder

dystocia? “ I wondered. It wasn't a far fetched question — Ina May Gaskin

often toured the Ivy league medical schools and did grand rounds in

prestigious hospitals sharing her points of view and representing her own books

on the subject and the Midwives Alliance of North America.

“Oh, sure, “ The student paused, “You mean the hands and knees thing?

Yeah, they mention that, too.”

I repeated what the doctors had protested in the obstetrical emergency workshops,

about how impractical it was , given the I.V.s and the fetal monitors and


“Yeah , well, that's the thing…” The student shrugged, simulating a baby

getting swirled around by the corkscrew maneuver half inside the mother

as we talked. “We've got, like, a 90% epidural rate around here. “

That's the thing, I thought. It's pretty hard to practice getting a woman onto

her hands and knees when she has no arms or legs.

And that's the metaphor for many of our issues in health care. People

nod, say “Oh yeah, I've heard of that ...” but have no real models, no

access, no support with which to safely explore and practice the options.

Practitioners will be hard pressed to moving someone to their hands and knees

(ie: a grounded, self-motivated position in which internal changes may then

occur spontaneously) when that someone has no arms or legs!

We need to begin sharing our experiences and intuitions more boldly,

To ask the Questions behind the Question—in this case, if you can't do it because

the mother is on a narrow uncomfortable bed and has too many tubes in her,

then why do we have her on a narrow uncomfortable bed with so many tubes in

her? Is all that part of the problem or part of the solution?

Some people call this “thinking outside of the box” . But I think when

we identify ourselves as inside or outside of a box, that's actually part of the problem.

The question behind the question is: Where the heck did the box come from? At what

Point in our collective consciousness did we agree there even is a box? And then, whose

got a leg to stand on around here?

-Alison Bastien

May 08

Friday, October 17, 2008

Birthday Cake time again

So the Bunny wanted to go with a Swan Lake theme birthday again this year. The cake she wanted can be seen here as Swan 03. I took the advice and used Rice Krispie Treats for the neck and head. That worked great and I might just turn into one of those bizarre people who start sculpting with food.

Anyway, I thought that the initial amount of chocolate cake I had was a little skimpy so I made a batch of brownies hoping to use the gooey center as modeling clay. Well, Duncan Hines disappointed me with its unfudgyness but it still worked to fill in the gaps and give the bird a little more substance.

I also used Nutella as glue and mint flavored dental floss to hold it all together temporarily while the nutella set in te fridge.

Anyway, here are my in process shots. I have to say, although I didn't even think about doing a fancy base until it was quite late in the game, I'm pretty pleased with how it came out. Of course, it still has to survive in the fridge until tomorrow at about 2 so let's all just cross our fingers, shall we?

I do love cooking.

Hmm, does it look like that goose cookie jar is making eyes at my swan, or am I projecting?

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Wednesday, October 8, 2008

October's here!

So, Xoche has been needing to be groomed for a long time. Seriously, this dog has had her feral-looking moments but she's been neglected all summer except for a copuple of hose downs. But she isn't a particularly friendly dog when it's time to pull out all the matted, stinky, burry, stinky old undercoat. Not that I blame her, but if we want to keep our fingers on, she needs to wear this I tried to reassure her that it's very Lady and the Tramp but she wasn't impressed and tried to bite our hands off repeatedly anyway.

In the end we got a lot of fur out of her and she cleaned up nicely. She has actually been in a much better mood since then too, go figure.

In honor of living back in Squashville we've been doing some stuffed squash. I couldn't resist these cute sugar pumpkins and thught they'd make a nice meal. And they did, we polished them off. For real. Okay, I shared mine with Ali G and The Bunny gave a wee bit of hers to Xoche but basically? We're pigs.

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