Monday, June 21, 2010

Doulas, what do you give your clients?

Another doula practice question! I'm working on a packet of info for future doula clients. I haven't done this before but it seems like a nice resource to give. I'd like them to have local breastfeeding resources (e.g. support groups), general parenting resources (e.g. organized playgroups, places to get low-cost services/baby needs), and a few info sheets from me - on things like writing the birth plan, thinking about your options in labor, etc. What else is helpful? Doulas, what do you give your clients (if anything)? If you've used a doula, what information did you get, or would have liked to get?

Reply turned post, on birth plans

At Your Cervix has a post up on birth plans from the nurse's point of view:

I have noticed that the longer the birth plan, the greater attempt at control, the more likely that the woman will not get the birth she desires. The increased chance of pitocin, epidural and eventual c-section.

Keep it short and sweet. Many things can be excluded from your birth plan/list. ...

Don't go into great detail about freedom of movement in labor, lights down low, no students, plans to breastfeed, no supplements, etc, etc, etc. Many of those things you can control in labor. Get up and move in labor. Turn the lights down. Use the tub/shower.

I encourage you to go over there and read the whole thing, as well as the comments - all pretty interesting.

My reply, which got kind of overlong and so is getting its own revised and expanded post:

Interesting comments!

My (evolving) philosophy on birth plans is that they should be about what you can control, not what you can't. It's not a movie script.

Some birth plans will say "I want to be allowed to push in a variety of positions, and to squat for delivery." Well, you can't control whether you will deliver squatting. Maybe when it comes times to give birth, you're going to be too tired or baby only tolerates you being on your side or you're more comfortable on your hands and knees.

You also can't control whether you'll be "allowed" to push in different positions - or rather, the only way you can control that is by 1) choosing a provider who is open to that and/or 2) actually GETTING in different positions to push, whether or not your provider likes it. Putting on your birth plan doesn't make it so.

And, like you said, there are some things that are under your control without needing to specify them - you can turn the lights low and fill up the bath on your own. If you're concerned that you'll be too intensely in labor to think of things independently, then make sure your support people are ready to be proactive! And if you're not sure if they will be, hire a doula! ;-)

In the end, I think the best way to use a birth plan is for things you know people are fine with you doing, but that are not totally routine so that they might need a reminder. In your sample birth plan you talked about intermittent auscultation, no IV, no separation, no offering pain meds. In advance, you made sure that everyone was on board, and this was just a reminder that these were your preferences.

I will say, I think for some people, it doesn't hurt to put "no students" on there too if that's very important to them. I know as a nurse you might feel confident about recognizing and turning away students, but not all patients do. I talked to a mom recently who had people flood the room for her first birth as baby was about to crown and she was frightened. She thought something was wrong with the baby. When she asked the nurse later, the nurse said it was a group of students. This mom was surprised to hear that she could have declined to have students in the room. I think based on her previous experience, she might be more emphatic about that this time around - if so it would probably help to state it up front.

Saturday, June 19, 2010

Why do babies get supplemented in the hospital? A story from my first week on nights

While I have told myself I was going to try to pick up the posting rate in June, this week was my first doing night shifts (11 pm - 7 am) on lactation support at the hospital where I've been training to be an LC. I feel pretty comfortable there at this point, but it feels so strange to have my own electronic charting ID and not have to wait for anyone else to log me in - before, we were being supervised by the LCs and so I would chart on their accounts under their supervision.

Obviously, I've been a little anxious about whether the night nurses would be welcoming, whether people would be willing to call me - basically whether I'd have any work at all! While all the staff I've talked to so far have been nothing but happy and excited to have lactation support available, the first night was really quiet. I saw a few people in the first couple of hours, then sat around, and then things picked up from 5 am - 7 am when people started to wake up and call for assistance. I told myself that the census was low, and staff were still getting used to me being there, but I wondered if every night would be so quiet. The big hope was that having someone overnight on lactation would help prevent a lot of the bottles and supplementation that happens at night. Was I going to be able to do that?

The following night answered that question for me. I basically never sat down except to chart. I spent at least an hour with in three different rooms. And my big victory was helping keep a hypoglycemic baby from being unnecessarily supplemented. The cut-off for hypoglycemia in the newborns here is 45. The nurse caught me in the nursery and said she had tested twice, baby was just below the cut-off and heading in the "wrong direction". To the nurse, formula seemed like a medical necessity at this point. She asked if maybe I could do it at the breast. When I came into the room, though, mom was crying - she didn't want to supplement. I offered to handle the situation from there and the nurse said that was fine - she left us to it. The mom told me the baby had been hungry and about to feed, right before the nurse had come in and taken him for the blood sugar testing. I said "Well, if he's hungry, he can nurse and if he nurses well, he won't need any formula."

So, we put the baby to breast - and this baby was, indeed, very hungry and nursing fairly well. Still, I was anxious - I did not want to screw this up, I was going to get all the colostrum into that baby that I could. The nurse had brought a couple of dental syringes for the formula. I took one and popped the stopper out, and asked mom if we could hand express into it from the other side and supplement the baby with expressed colostrum. Mom said OK very readily and wow, she had plenty! I was boggled to think this baby could have ended up with formula with so much colostrum available. The mom's sister was spending the night to help her out and happily assisted with hand expression (with mom's agreement, of course) - it was so nice to see such good family support! Who says other family members can't participate in breastfeeding?

Between nursing and supplementing, by the end of the nursing session I was having to take him off and wake him up repeatedly, and he would fall asleep as soon as he got back to the breast. This kid was full. (But I was not going to let him go to sleep without getting every last drop he could!) Finally, I put him skin-to-skin with mom (also good for blood sugar!) and called the nurse to tell her "went great, no formula needed!" And you know what? The nurse was totally fine with that. She gave the baby a full hour before rechecking his sugars and - yay! - baby was back above the cut-off - "heading in the right direction". The nurse was actually very gracious and helpful about all of this, and I realized after talking with one of the other LCs that it's not a "breastfeeding is bad" mentality at all on the nurses' part - this nurse just wanted to fix the blood sugar, and the formula could be the fix, or my help with breastfeeding could be the fix. Of course, since I'm not always there, it would be nice if this experience helps her have more confidence in the future with putting baby to breast as the first line of treatment. But one step at a time!

After all this drama about avoiding what probably would have been just several milliliters of formula, you may be wondering, what's wrong with just a little supplementation? Just to get the baby's blood sugar up - then they could go on breastfeeding, no problem. And I think it's a fair question. It doesn't seem like a single bottle would do that much harm. And yet we know that babies who are supplemented - even a single bottle - in the early days tend to have shorter durations of both exclusive and any breastfeeding. And is that so surprising? After all, we say to mom "You need to supplement with formula because your baby's blood sugar is low", what is the message we are sending? "Your milk has not been feeding your baby adequately, and it will not feed your baby adequately; we cannot trust that it is there in sufficient amounts and/or that your baby can get enough of it." Any wonder that these moms go on to mistrust their ability to nurse their babies? Additionally, even just a little formula affects baby's gut flora for weeks, changing the balance of beneficial flora that exclusive breastfeeding establishes (for more information on all of this, see this article by Marsha Walker, particularly the section "Some Cautionary Words About Supplementing with Formula").

Does all this mean we should not give formula when medically necessary? Of course not! But as you can see, medical necessity in this situation was somewhat blurry. With no breastfeeding support, it's possible that this baby would have needed to be supplemented with formula. But in the end, it turned out not to be necessary at all. Babies get those bottles of formula not necessarily through malice, but because of staffing issues, longstanding habit, and lack of education and lack of trust in breastfeeding. They get formula without the understanding of the risks of "just a little bit".

What can you do to avoid unnecessary supplementation in the hospital? A few things:

1) Prepare yourself for breastfeeding - read, take a class, attend La Leche League meetings - boost both your knowledge and your confidence.

2) Choose a certified baby-friendly birthplace - this won't eliminate the possibility of unnecessary supplements, but it will greatly decrease them!

3) Make sure breastfeeding is going well - let the staff know you are committed to breastfeeding, ask for a lactation consult, and solicit outside help from La Leche League or a lactation professional if you need to. Yes, those people can come visit you in the hospital!

4) Surround yourself with family and friend support. Maybe the sister-in-law who keeps asking whether the baby is "too hungry" is not the person to spend the night with you!

5) Be ready to advocate for yourself if needed, and have all that knowledge, preparation, and support ready. I saw another mom a few months ago who confronted the same night-time pressure to supplement for hypoglycemia. She insisted that she get a chance to breastfeed first and, lo and behold, that baby's sugar came up too. Self-advocacy is not always easy (and unfortunately not always successful), but it is very important!

So that's my first dispatch from nights! I'm currently in recovery from the crazy schedule-shifting and ready to get back to regular sleep patterns for a few days. Any nurses out there have tips on shifting back and forth? I'm used to doula work where you can't plan it - you just power through and then sleep it off over the next couple of days. Tips for actually planning your night shifts would be greatly appreciated!

Tuesday, June 15, 2010

My final LC class exam

Our LC class met for the last time the day before graduation. It was sad as such a big percentage of people were getting ready to leave. We'll be taking the exam in July spread out across the country.

While said real exam is coming up frighteningly quickly, we had to do a bit of a pro forma exam at the end of class to make it all official. We wrote it out by hand (ouch! I haven't done much sustained fast handwriting since middle school, and after just a page and a half my hand started to cramp) and then the professor asked us to type it up. I was looking it over today, and I thought I would post my answers here as a little piece of reflection on my LC training this past year:

Question #1: What is the most important things you learned as an LC candidate?

That you can't learn everything you need to know to be a great LC in one year - or maybe not even two or three - and that you don't need to become a great LC before you sit the exam. You have to keep asking questions and learning, and believing that you don't know everything!

Question #2: What are 3 very specific things you'll do as an LC based on your answer to #1?

1) Not to be afraid to admit when I have reached the end of my skills and need help
2) Have more experienced LCs on speed dial
3) Continue educating myself and observing with different people when possible

Question #3: Make up an exam question based on this learning
(Note: We were supposed to try to format the answers just like the LC exam: two wrong answers, one "distractor" that is almost right, and one correct answer. We all complained we could have written a much better question given more time! I'll reproduce my original response faithfully here anyway.)

You have been working with a mother and baby for several weeks attempting to improve the baby's sucking skills, but there has been little change despite using all the techniques you have learned. Your next step should be:
a) Counsel the mother that there is likely nothing that can be done to improve her baby's suck
b) Plan to attend a training on sucking skills
c) Refer the mother to another LC or other specialist with more advanced knowledge
d) Suggest to the mother that she switch to bottle feeding expressed milk and give her baby time to mature before attempting breastfeeding again

This really does reflect a very important piece that I learned this year. I had visions of emerging from training ready to independently help the premature baby with cleft lip and oral aversion whose mother has a low milk supply. And they would be successful, too! At times I got impatient with training: how was I going to learn all this advanced stuff if we didn't move faster? Now I appreciate better that few, if any, LCs are ready to tackle the most advanced stuff when they become certified - at least not independently. More than one LC whom I respect has told me that she became as skilled as she is by admitting when she didn't know what to do next, finding someone who did, and learning from them as they helped that mom.

Back when I did tae kwon do, everyone emphasized that getting your black belt wasn't the end of your training: it was like starting all over again. Well, I start working nights at the hospital this week doing lactation support, and I'm ready to start all over again! This is going to be (I hope) a whole new learning experience.

Monday, June 14, 2010

Choosing and getting into MPH programs: Part 2: What is a Master's in Public Health, anyway?

This is Part 2 in my series about choosing and getting into (and funded by!) MPH programs. Read Part 1 here.

I thought that before really launching into this discussion, I should discuss a little bit more about the field of public health and why you would even get an MPH.

"So, what is an MPH? Do you like, work in a hospital then?"

On behalf of all MPH students everywhere, let me ask everyone, everywhere, one huge favor: don't ask us "What do you do with that? Like, work in a hospital?" As my fellow MPH-er put it recently, hospitals are not public health; they are where you go when public health has failed. (Of course I'm only confusing those people more now by going to work in a hospital - but that's with my clinical lactation consultant training, not with my MPH.)

I think this question does nicely illustrate how most people seem to equate "health" with "medicine", without stopping to think about the huge array of social and environmental factors that impact health and disease. On the other hand, if you are one of the people who does stop to think about that, you may be ready for a career in public health!

So what IS public health? The American Schools of Public Health have decided to answer this with a "This is Public Health" sticker campaign Their website and video will give you a pretty good overview. But just as a summary:

- Public health deals with populations, rather than individuals

- So public health professionals tend to work on programs, policies, administration, and research - not with personally delivering services to individuals

- Public health focuses much more on prevention than on treatment

To get an idea of what kinds of jobs people get with an MPH, you can take a look at Johns Hopkins' archived list of job postings (note that some require more than an MPH), or look at the American School of Public Health's careers page (and explore their website in general.)

The ASPH career page also has descriptions of various fields in public health, e.g. epidemiology, environmental health, biostatistics, maternal and child health, health education, etc. While small MPH programs will have just one or two general tracks, most schools of public health will have many departments encompassing various fields of public health. An MPH, even within the same school, can mean a very different set of skills and very different focus depending on what department you study in. I'll discuss this more in the next post on researching schools and programs.

I can't speak to all programs, particularly more technical ones, but I think I can safely say most MPH programs generally aim to equip you with a good understanding of how diseases and health conditions occur on a population level. Other focuses can be on how to administer public health programs (e.g. a vaccination campaign) and how to monitor and evaluate those programs (e.g., devise a plan to make sure that the vaccination campaign is reaching the populations it was targeting, and then assess whether it made a difference on vaccination rates in those populations, and whether the difference was big enough to justify spending all that time and money). They may also cover particular content areas (e.g. courses on epidemiology of infectious diseases, or an overview of HIV globally) or skills (e.g. advanced statistical modeling techniques).

A master's in public health is more practice-oriented than research oriented (versus a doctoral degree in public health) - generally considered a "professional degree" like, for example, a master's in social work. While some people in an MPH program may be there as a stepping-stone to a doctoral degree, most are there to go right back out into the workforce. So a master's program generally will have less emphasis on research and more on practice. This isn't to say that MPH grads don't go on to do research, but they also go on to do a huge range of other types of work.

A note about the nature of the MPH degree and exactly what the practice is that you do with it: One thing I struggle with personally is the pull between direct service delivery (which I looove doing) and the desire to make a bigger impact - which is why I tend to run out of steam with direct service delivery after a while. I start seeing how it all fits into a bigger picture and what needs to happen to prevent problems or deliver services more efficiently.

Yet while an MPH is very well suited to the big-picture work, as my classmates take positions in research fellowships, evaluation of programs, or doing technical assistance on grants, I find myself resisting taking anything that would put me in front of a computer all day, with several layers of people between me and the programs on the ground. Back and forth, back and forth! Right now I'm looking for something with more of a mix between the two, and those jobs do exist - but just remember, by its nature a public health job deals with populations, not individuals. If you thrive on the personal contact with the people you serve, you might want to consider a clinical degree instead or in addition. (I know I'm very glad to be working on my IBCLC right now.)

In the next post, I'll talk about how to sort through different MPH programs and think about which is the right fit for you.

Wednesday, June 9, 2010

Two great "how-to-breastfeed" videos

I love this breastfeeding video! I know approx. everyone on the birth blogs has posted it (I first saw it on Gloria Lemay's blog). But just in case you haven't seen it:

Things I love:

- Obviously, skin-to-skin and breastfeeding right after c-section - wouldn't that be a great instructional video for medical staff?

- Simple, calm, and clear discussion (with that cute Norwegian accent!)

- Showing that it takes a new baby a little while to latch, and what can be accomplished with patience

- Showing a good latch and how to get it, including a really nice illustration of how to compress/"sandwich" the breast - it is surprising how hard it is to get this concept across sometimes

- There's even a great demo of tongue-tie - and wow, was that baby ever a classic tongue-tie.

Along with Rixa, I would love to see the 45-minute version.

If you're looking for another good, short instructional video online, I like this one from Ameda:

(You can also find it posted on Ameda's website here.)

Things I love:

- Again, simple and clear

- Explanation of why a deep latch is important and showing exactly what's going on in a baby's mouth when it breastfeeds - so helpful!

- Suggestions for gently getting baby ready and alert to start breastfeeding

The LCs I have been working with sometimes show this video on the computer in the postpartum room. I think it would be even better if we had a smartphone or iPod touch so we could have it handheld right by mom's bedside (the computer is often across the room in an awkward corner). Think I can convince the hospital to buy us one??

With both of these videos, I will say I wish they were more diverse. The Norwegian one - OK, I get having a lot of white people. But I think Ameda could and should have done a better job of including moms and babies of color.

Wednesday, June 2, 2010

Choosing and getting into MPH programs: Part 1: Should you even get an MPH?

This is Part 1 in my series about choosing and getting into (and funded by!) MPH programs.

Let me start by saying something in general about master's programs. I have a fairly task-oriented view to master's programs, which is that they should serve a specific purpose in your life and you should feel fairly confident about what that purpose is.

It makes me nervous when someone talks about having found a master's program in "EXACTLY what I want to do". This is often preceded by someone explaining to me that they love swimming, and they are really into crafts, and they have just been wanting to take this interest farther, and come to find out they have just heard about a master's in underwater basket weaving (MUBW)!! Isn't that PERFECT?

And then I get a little bit cringe-y. Because yes, while you can have a fun 2-ish years doing exactly what you want to do, you then need to get a job. Do I love doing breastfeeding work? Yes, I made it a huge focus of my MPH degree. Would I rather have gotten a master's in lactation studies instead of an MPH? Honestly, no. I might have a super fun 2 years thinking and talking about my exact interests, but then I have to find a job. The breastfeeding promotion programs out there are probably going to be looking for an RN, RD, MPH, or MSW. And while they may be happy to hire someone with a master's in lactation studies, they're the only ones: that degree isn't going to have a lot of portability if the only jobs I can find are in HIV prevention or monitoring a heart disease reduction program. Those jobs may not be exactly what I want, but life doesn't always give you exactly what you want; it's good to spend the time and money on something that is adaptable.

This may be a cynical view, but schools need money and a master's program is a way to get it. They don’t have to worry about your long-term marketability. Just because you CAN get a degree in something, doesn't mean you SHOULD.

And that applies not just to the MUBW degrees of the world, but also to these more generalized degrees. Just because you're interested in public health doesn't mean an MPH is right for you. You may be happier and better suited to come at the public health issues you're interested in from a clinical approach, a legal background, or a social work degree (and all of those are also programs which often offer dual degrees with an MPH, for what it's worth). One of those may offer better fallback options for your interests and skills than the MPH, if your dream jobs aren't opening up.

While having a fairly accurate idea of what kind of job you want to do is of course not a prerequisite (thank god for those of us who are indecisive) it can be very helpful. I was talking with a friend the other day who talked about working backwards from the jobs he wanted to the kinds of degrees that people in those jobs held. While the MUBW might seem attractive at first, you may discover that all the underwater basket-weavers have degrees in hydroengineering, or that they all came up through an apprentice system. Jobs in public health are likewise filled with people from a huge range of backgrounds, including biology, engineering, economics, midwifery, nursing, medicine, etc. The jobs you’re interested in may be in public health, but need another type of degree, either instead or in addition to a public health degree.

You can also work forward from the degree and see what kinds of jobs the people who get it tend to do. Keep in mind that by no means are you limited to those fields, but that if you hate the sound of all of them, they are probably not going to be great as your “fallback” jobs if what you really want doesn’t pan out at first.

If you aren’t really sure what you want to do, I’d sit down and ask yourself again why you want to go to graduate school right now. Again, grad school = means to an end. If you have unlimited time and money, get all the degrees you want! But otherwise, know why you’re going to grad school and what you’re planning to get out of it.

All this is less about an MPH in particular, and more about advanced degree programs in general, but I know a few too many people who have done Perfect Degree X and then been shaken by the realization that there are a) no jobs in that field, b) no jobs in that field that they like, c) no jobs they like that they are newly qualified for, d) that they had no idea what the jobs in that field actually were like in the first place, or e) all of the above. (You’ll find doctors completing their residencies who confront (b) and/or (d), which with hundreds of thousands of dollars in debt truly sucks.) So before anyone runs out to get an MPH, I had to do a disclaimer post: just because you can get in doesn’t mean you should do it! Don’t e-mail me in three years wondering why you wasted your time on an MPH when you should have gotten an MUBW! Think hard about it first. All this self-reflection will help you pick the right MPH program if that's what you end up deciding that you want to do.

Edited, June 2011: Many doulas and other birth worker-type people ask me if they should get an MPH. The attraction is pretty strong for us types! We see the system issues, and where the research needs to happen, we are often committed to working with underserved populations, we want to be in a place to make changes on a big scale. But I also see the tension for those same people (myself included) once they enter the field and realize just how far removed most public health is from direct service. If you thrive on personal interaction with the population you serve, there are positions for MPH grads that can fulfill those needs, but they are not in the majority. I find many of those direct-service-oriented people (again, myself included!) contemplating after they graduate whether they need both an MPH and a clinical degree to really get the right mix for themselves. Considering an MPH plus some kind of clinical degree (e.g. RN, CNM, MD, MSW/LCSW) may be a good option and there are many schools that offer dual degree programs. I say this, again, not to discourage anyone from getting an MPH but to really think about what is worth the investment of your time and money.


Next in the series, I promise to actually talk about masters in public health programs and how to get into them…