reprise

I've met more than my fair share of people wanting to adopt who also fail to see a baby as a separate and distinct human being with needs and rights and who still perceive the adoption system as existing in order to provide them with a child rather than to provide children with loving, stable, homes. While our laws relating to adoption are pretty brutal from the viewpoint of potential adoptive parents (all adoptions in my state are "open" to some degree, and many potential adoptive parents who make it through the screening processes will become "unqualified" before a child becomes available for them to adopt), if the purpose of adoption is to truly serve the best interests of the child (and not the best interests of the relinquishing or adoptive parents) then I think we must continue to set the bar very high and acknowledge that the most expedient solutions are not always the best ones in the longterm.

Our adoption system here is totally different to that in the US and was changed some years ago to reflect the fact that many of the situations under which young women previously relinquished their children for adoption were temporary. Now, when the reasons for relinquishing a child are temporary in nature (poverty, youth, inexperience) the focus is on providing the mother with sufficient support to enable her to ultimately care for her child herself. In practical terms, this means that it takes about 2 years for an adoption to become final here and that a very small amount of newborns are available for adoption (IIRC, it was less than 20 in the whole state last year). Although it's still not a perfect system, it's a lot better than the one we had previously in which young women were often coerced into relinquishing their babies on the basis of their situation at the time of the child's birth.

it was little thanks to the attending midwives. I am angry beyond measure at the way my daughter was treated by her attending midwives last night and I know that I *should* be grateful that grandbaby was safely delivered and all of that. I'm way too tired right now to compose a formal complaint, but for the sake of all the other teen mums who come after my daughter, I intend to ensure that no midwife who ever works that hospital again has the opportunity to tell a labouring woman that she's just being a "sook" and it's not *really hurting* because she's only been in labour for an hour and a half and has hours to go yet. From spontaneous ROM to birth was just under 5 hours. From first contraction to birth was 3 hours. The ambos had TOLD the midwives that her membranes had ruptured and that her contractions were 4 and a half minutes apart during the ambulance ride to the hospital. I hope that the experience my daughter had was exceptional and that most midwives do not assume that because someone is 18 and it's their first baby that they are just "being a sook" and that they can't possibly be in *real* pain because their membranes only ruptured 90 minutes ago. Thank goodness for the anaesthetist on duty actually listening and hitting the room within 5 minutes of the call (in spite of the midwives telling her "not to hurry). Thank goodness also that she actually listened to my daughter and not the midwives and managed to calculate the appropriate dose so finely that it took the edge of a rather tumultuous labour without in any way compromising her ability to push. Baby was born 50 minutes after the epidural was given. Normally, it takes 30 minutes for the anaesthesia people to even hit the ward, let alone set up the epidural. I guess she must have seen enough babies who are the exception the the rule to know that you can't count on the one centimetre per hour rule and you especially can't count on it in women who hit the door and 5 cm and were 8 cm 45 minutes later. We get to debrief. We're part of a longterm project specifically aimed at teenaged mums and producing better outcomes for them and their babies. I am utterly appalled at the assumptions which were implicit in the way my daughter was treated. Ironically, the post-natal nurses are telling her that she *cannot* come home until at least tomorrow morning and until they've have seen her bath the baby at least once. *The doctors won't let you* is what she was told when she said she wanted out of there at lunchtime today. I reminded her that the hospital policies and the preferences of the staff are not law and promised her that if she still feels tomorrow morning that the staff are treating her like crap because she's only 18 that I will help her sign out AMA and take her to a facility which doesn't assume that "young and pregnant" equals "stupid and pregnant".

The overall statistics can be found on google and are quite frightening. HOWEVER, when you disaggregate the figures and take into account hospital policies, the numbers show a different story. What do you regard as "pain medication". A single shot of narcotics? Are you counting an epidural given for a scheduled caesarian or an emergency c-section as "pain medication"? What about locals given for episiotomies or for stitching tears? The effects of various medications on breast-feeding have been endlessly researched and while some of the results are still disputed, there's a huge body of evidence out there related to the half-life and direct impact of drugs given to labouring women and neo-natal outcomes. What's even more interesting from a pure research point of view - and the terms in which you phrased your question lead me to believe that you weren't asking about these - is the impact on breast-feeding (via their impact on the mother) of drugs and procedures which do not have a direct in utero effect.

I am utterly and totally offended by medical staff who are at least supposed to have read the cover sheet on my file which quite clearly states my lack of religious belief injecting their personal metaphysical belief systems into my personal tragedies or triumps. If you want to pray for our family in the break room, then that is between you and the higher power in which you believe, but if you come back and tell us you have done so then all we are going to hear is your disrespect for OUR beliefs.

I truly believe that the reason some people call the emergency services is because they don't want their family member dying in front of their eyes or that they don't want to be alone in the presence of death (and let's be honest, death is not always the gentle "slipping away" portrayed on TV - often it's messy and noisy). I'm not sure that they fully realise the implications of initiating emergency care, but I certainly understand their immediate desire to have someone else (anybody else) deal with the situation at hand.

One thing which was quite common 10 years ago was selective adherence to advance directives - so while only palliative care would be given for the underlying, terminal condition, doctors would actively treat any opportunistic infections or other complications likely to cause death as they arose (and they would present such treatment as being to make people more comfortable while either not mentioning or minimising the fact that it was also life-prolonging). I'm not sure how common such a practise is now. My partner had an advance directive in place and I held a medical power of attorney, but the doctors still tended to ignore both when they wanted to. A neighbour of ours was on a ventilator last week and the doctors seemed to be working hard to try to convince the family to spare him the ordeal of a tracheotomy (he has emphysema and a host of other respiratory problems and has been "pulling through" for a year at the cost of appalling reductions in his quality of life each time). On that very issue, I made the rather difficult decision to allow my 13 year old to visit him in ICU last week and I don't regret that decision. I was concerned that she would find the experience distressing, but in fact it gave her a much greater understanding of just how sick he is (he's also experiencing multiple organ failure and had passed less than an ounce of urine in the previous 24 hours, so he was blown up like a balloon) and how interventions tend to cascade. We spent a couple of hours after the visit discussing why he was sedated and why his not weeing was such an issue and the fact that decisions made about his treatment do not affect whether or not this man will soon die but to a large extent they do determine how.

During the time I worked in the HIV/AIDS field, I found it quite puzzling that often it was the families of those who'd been suffering a terminal illness for a considerable period of time who were most reluctant to discontinue futile treatment. Intuitively, I would have expected the families of those who'd suffered unexpected, catastrophic events to be the ones who had the most trouble "letting go", and yet time and time again they seemed to cope far better (perhaps because they were buffered by shock) than families who'd had a long time to prepare themselves for the inevitable. Has anyone else noticed somethign similar?

It's unclear from your post whether you were actually fired or whether you were employed subject to satisfactory performance during a probationary period and your employer elected not to continue your employment after that time. You also don't mention whether you were employed within the public or the private system - this may affect the willingness of your co-workers to provide references on your behalf. You need to be aware that omitting this period of employment from future applications could have negative consequences and that what seems like a small omission at the moment could become a "big lie" down the track. Most employers take non-disclosure of relevant information pretty seriously - especially in occupations which involve a legal duty of care - so you might want to contact the professional body which represents nurses in your state for advice on how best to proceed from here.

I don't think that Larry meant staff couldn't use that number to lodge complaints. I read his post as saying even if you don't know the "right" number to complain to at least you can use that one as a starting point and they should be able to refer you to the most appropriate body. Here, calls made to the number which is posted on every wall in the facility (or which should be) are logged in a manner from which it might be possible to identify the original complainant and staff are encouraged to use an alternative number to report matters which do not require immediate intervention. Ideally, your state will have a toll-free number which is printed on the back of your license which you can call to report your concerns. In truth, if the incident you are reporting involved only a handful of people then it's likely those who are present will be able to work out who lodged the original complaint, but if you're reporting a systemic problem within your facility which could have been observed by anyone then I'd definitely go the "professionals" hotline rather than the "general" one.

First of all I need to declare an interest here. I am not a nurse. I am a licensed health educator and a state approved community visitor (which basically means I have a badge which allows me to walk into certain facilities - public or private - which are licensed and regulated by the government at any time of the day or night without warning and cannot be refused entry). In the time I have been a community visitor I have learned to spot the difference between a facility which just happens to be short-handed on a temporary basis (which happens in every facility from time to time) and one in which tolerance of departure from basic licensing standards has become the norm and is excused and justified at the highest levels. While I'm aware that the legal issues involved are slightly different in the US than here, my understanding is that the duty of care issues are not and that "junior" staff can be held legally responsible for not taking their concerns to the highest possible level (which in my nation is the state and federal ministers for health). Unless I have totally misunderstood US laws, your legal duty to the patient totally trumps any other consideration every single time and in the event that something goes very wrong and you say that the DON or the facility administrator or somebody else told you that they would handle it and didn't it is YOU who will be called to account for not going over their heads. Document everything. 34:1. You've got to be kidding. We demand better ratios here for assisted living facilities and those are mostly old people who want to maintain their independence but want the assurance of onsite medical care being available in an emergency. High school classes aren't allowed to be that large here (and they're full of young, healthy people), and much as I think that you have some odd standards and benchmarks for medical care over in the US, I very much doubt that they include that kind of ratio under either state or federal laws. While I appreciate Cherybaby's comment, any DON who doesn't know that ratio is unsafe and who isn't actively protesting against it on a daily basis probably isn't going to be of much assistance.

As the mother of one of those young mums to be who everybody and their dog (including myself) thought should have terminated the pregnancy, I'd just like to tell those of you who are able to suspend your judgements long enough to offer help what a difference your support makes. This time last year my daughter was an inpatient in a psychiatric ward as a result of her depression and its attendant suicidal and homicidal ideation. Today, she is a (mostly) confident, self-assured young woman who while apprehensive about what the future holds is pretty sure it holds in store positive things. What her psychiatric care team could not accomplish, her midwives have. To sit here this morning and listen to this young women who was so afraid of life 12 months ago explain to her sister why she isn't scared of the pain of giving birth was a simply amazing experience - the support which you offer young women like my daughter has consequences which extend far beyond their pregnancy, labour, and delivery, and I hope that one day my daughter will pick up the phone or a pen and let every one of those midwives know that they made a difference which - literally - changed her life.

Like most women in Australia, my daughter doesn't have an ob. Unless something goes wrong there won't be a doctor involved in her delivery at all, and if something does go wrong it will be handled by one of the obs who is on duty at the time (high risk women do see the hospital obs regularly throughout their pregnancy, but low risk women see them only twice and those visits are more of a formality than anything else). The midwives have pretty much confirmed that individual doctors have their own preferences and that it's pretty much a crap shoot whether you'll get a doctor who prefers forceps or one who prefers vacuum.

I do know that none of the hospital doctors do rotational forceps (the midwives seem to regard the couple of private obs who still have the knack of doing these as fossils). I also know that the policy is to do a routine episiotomy for all forceps deliveries (which seems to be at odds with some studies I've read which suggest that women are more likely to experience severe tears during a forceps delivery if an episiotomy has been performed). The episiotomy rate is pretty high at this hospital (around 60% for first time mums), although the epidural rate is quite low (70%, which is pretty good (although a little artificial as it's nor a tertiary level unit and some patients get transferred with bub in utero if major complications are anticipated). Standard practise seems to be to suture 2nd degree and above, although the midwives maintain that there are plenty of 2nd degree tears which would heal just fine (or even better) without sutures. The particular midwife who will be attending my daughter would intimidate even the most arrogant consultant and I suspect that no unnecessary intervention slips past her, so DD is reasonably confident that if her midwife says "honey, we need to get some help here" it's not simply a CYA decision.

Can I just ask how many of the 37-38 weekers who end up in NICU were anticipated to need assistance prior to delivery? Many public hospitals here will not schedule inductions for prior to 38 weeks in the absence of a compelling medical reason (precisely because even "reliable" dating methods still have a margin of error which can make a crucial difference to outcome), so I was a little surprised by the extent to which "self-induction" methods were condoned without warnings during antenatal classes. Granted, many of those methods are probably of more psychological than physical benefit and are going to have no effect at all on a body which isn't ready to labor and deliver, but I do wonder whether treating preterm "self-induction" as something which is fairly routine might lead to women for whom the fairly innocuous methods fail might feeling over-confident about trying more risky methods of "bring on baby". Are the generally good outcomes for >34 weekers now so well publicised that people feel a false sense of security?

Oddly enough, this came up at antenatal classes (which were right before DD's antenatal appointment) yesterday and the midwife who was taking the classes made it very clear that which option is taken has as much to do with the preferences of individual doctors as it does to do with anything else. She also said that when it's anticipated that a forceps delivery is going to be difficult and that a caesarian will probably have to be done anyway they generally attempt the forceps delivery in theatre with the epidural and everything else already in place so that they can go straight to a caesarian section if necessary without any delay. At this particular hospital, apparently episiotomies are almost routine with forceps but relatively uncommon with vacuum deliveries (but this may reflect the practises of the different doctors).

Well, the week when my daughter needs to commit her birth plan to paper has finally arrived. The one question with which she's still having trouble is whether to rank an assisted lady partsl delivery higher than a caesarian if grandbaby needs some help entering this world and whether she'd prefer that assistance was by forceps or vacuum. To address a few points which are likely to arise. This is the hospital's birth plan which is drawn up for all women (including those whose labour and delivery is going to be totally medically managed) at 36 weeks. The birth plan pretty much ranks preferences from first to last for various unanticipated events which may occur during labour and my daughter understands that safety always takes priority over preference. The labour will be midwife managed unless an unanticipated event requiring the intervention of a doctor occurs. The "model" (for want of a better word) my daughter has chosen for her labour and delivery is one of minimal unnecessary medical intervention but with a high priority on minimising unnecessary physical distress (beyond the pain of "normal" labour) to herself and her baby. In other words, she's not going to persist in labouring without assistance beyond the point at which doing so is likely to result in more extreme interventions becoming necessary. Obviously, no-one can forsee the actual circumstances which will exist at the time an assisted delivery becomes desirable or necessary and the circumstances will determine whether there is more than one option available. My own deliveries were boringly normal, so I'm absolutely no help at all to my daughter each time she asks me "what do you think, Mum" about this issue. Can someone fill me in on what to consider in respect of the various options and, in particular, when a caesar might be more desirable (as opposed to more medically necessary) option than first attempting a delivery assisted by forceps or vacuum?

The only thing which really concerns me is the possibility of a drug reaction if ergometrine is used for third stage management. Reactions to other drugs are fairly consistent among the females in my family. In all likelihood (grandbaby is being delivered in a hospital based birth centre), there'll be no need for active third stage management, but in the event that there is such a need it would be nice to avoid the potential problem of her diastolic BP going through the roof as mine did (it was not mismanagement in my case - ergometrine was routinely used at that time and there was no particular reason to believe that I was at increased risk from it; to this day, my medical files are flagged to ensure that I'm never given it again ). I think that I'll probably mention it at the next antenatal appointment. That's the one where my daughter will be drawing up her birth plan and so third stage management will be under discussion anyway. For a while, most hospitals were using syntocinon routinely and only administering ergometrine for PPH, but from what I've read ergometrine is coming back into favour so it at least makes sense to find out about the standing orders at this particular facility.

Now that's scary. I'm somewhat tempted to ask what drug is used for third stage management at the hospital where my daughter will be delivering. When I had my son, the hospital routinely administered ergometrine - to which I had a dangerous reaction. I'm pretty sure most hospitals here use syntocinon now, but I should probably check.

I recall that when I was pregnant with my own children (my youngest is almost 13) I was asked many questions about my mother's obstetric history. Is it because there are so many tests available now to directly determine the well-being of mother and foetus that these questions are no longer asked or did family histories just turn out to be an inaccurate way of predicting the likelihood of specific events occuring during pregnancy, labour, and delivery?

I've used nitrous with all of my labours and love it. The fixed systems in all of the hospitals in which I've delivered allow for changing the ratio of the two gases to a maximum of 70% nitrous (the portable systems are set at 50/50). As others have pointed out, the delivery system is different to that used in dental procedures and isn't continuous. It can take a while to get the hang of using the mask properly so that you're receiving the maximum benefit at the peak of the contraction, and some women find it of little benefit. It worked well for me, and I liked the fact that it isn't persistent (pethidine just made me sick and spacey without doing anything to relieve the pain during my first labour and I was simply stuck with that feeling until it eventually wore off). Ob/gyns and midwives here seem to like it because it's excreted rapidly through normal respiration. The only time I've ever felt "out of it" while using nitrous was when my ob bumped it all the way up to 70% to remove a retained placenta with number two (the midwife had to hold the mask as once you feel light-headed it's pretty much impossible for you to keep holding the mask firmly). The rest of the time, the nitrous had left my system by the time a contraction had ended and even while it was in my system during the contraction I wasn't disconnected from reality and "out of it".

"Mum, I just feel yuck". "But I don't feel thirsty". Neither do I during summer but I know damned well if I don't drink enough fluids to maintain my BP I feel really, REALLY hideous. You drank nothing at all ovenight bar two sips. You know that you are both hypovoleamic and hypotensive. It's icecube time kiddo or it's drinking by the clock time. I hate drinking by the clock myself, but I know that it's something I absolutely have to do in hot weather and I'm not even pregnant. The midwives who have been looking after you to date have never been wrong - please don't treat them like fools when they tell you to drink more water. They're on "your side".

I had my first child in a maternity hospital some 24 years ago, and one thing I've noticed as the birth of my grandson approaches is how much better educated and prepared for the realities of labour and childbirth "average" (ie, those who are not paying kazillions of dollars to attend specialised birthing classes) first time mothers are today. Have those of you who work in labour and delivery found women better prepared now than ever before, or is it very dependent on the system within which you work? The vast majority of antenatal care and education here is now provided by midwives and it's extremely "holistic" in that addressing non-obstetric issues is seen as part of the package of producing better outcomes for mothers and babies (within the public health system, at least). The reasons why pregnancy changed from doctor managed to midwife managed here are largely economic (for public hospitals, it's cheaper staff-wise and for private practitioners it's more expensive to practise obstetrics and gyneocology than to practise alone), but I can't help thinking that the change has - overall - been for the better. How have things changed where you work?

I think that the different "standard" procedures may have something to do with it. Although the birth centre is part of the standard birthing unit (literally across an ten foot hallway), the L&D suites contain equipment which the birth centre rooms do not. In the normal course of events, a birth centre mother would only be transferred to L&D if that equipment was needed or if she requested an epidural. As the birthing unit as a whole is pretty much midwife managed, I can see that by the time an obstetrician has come to the unit and made an assessment, a woman has been prepared for theatre, and the anaesthetist has arrived, a general may be the fastest option available. It may also be that the birth centre and the birthing unit as a whole has had complaints from women who anticipated that if they needed a caesarian it would be done under epidural anaesthesia only to be disappointed in their birth experience when they were given a general and that the raising of the issue by birth centre staff is more of a CYA thing. Certainly the design of their birthplan as a whole seems to be aimed at getting women to consider the choices they would make in unanticipated circumstances (something which a lot of "do it yourself" birthplans often ignore completely). Birth plans are drawn up for all women who receive their antenatal care at either the midwives clinic or the birth centre (and from, from what I gather, also for those who attend the doctor's clinic due to medical reasons). The choices the women are free to make might be more apparent than real - especially in those who are high risk - but I have little doubt that the "forewarned and forearmed" policy probably leads to a higher level of overall "customer satisfaction" and women feeling that they have had more input into and control of the labour and delivery process.

This is really the situation which we are being asked to consider - mostly because if something has gone wrong enough for my daughter to be transferred to L&D for a caesarian there isn't likely to be a whole lot of time available for discussion and decision-making.