Tuesday, May 31, 2011

Thursday, May 26, 2011

What do orangutans, dolphins, cats, and horses have to do with delayed cord clamping?

I'm often reading through blogs in a time and/or place that I can't watch videos - particularly long ones - and when I put them aside for later viewing, they tend to pile up. I finally sat down to watch Dr. Nicholas Fogelson, who writes at Academic OB/GYN, do a Grand Rounds talk on delayed cord clamping. I wish every OB, midwife, and pediatrician would watch this! I still hear from doula clients that they are told the OB doesn't want to wait to clamp, or will only wait [45 seconds, 60 seconds, etc.] out of concern for polycythemia, jaundice, or some other pediatric concern. I think this talk effectively addresses those concerns, and very nicely lays out the evidence that we do not benefit babies, and instead create potential harm, when we - as standard practice - routinely phlebotomize babies of 40% of their blood volume (as Dr. Fogelson so succinctly puts it).

One thing he did not discuss - although he did touch on the topic - was the connection between breastfeeding, delayed cord clamping, and the "need" for supplemental iron in breastfed infants. While there is very good information and research out there to debunk the idea that breastmilk is "low" in iron and that all breastfed babies need routine iron supplementation, there is a small percentage of babies who become anemic and require supplementation. But when we look at one of the studies he cited, Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial, you can see that early clamping had a greater detrimental effect on the iron levels of 6-month-old babies who were exclusively breastfed; the breastfed babies who had delayed clamping had iron levels closer to those of the infants getting iron-fortified formula or milk. It makes sense to ask that if a breastfed infant DOES end up needing supplemental iron (based on a check of hemoglobin levels), could we have caused its anemia by early cord clamping, given that we have interfered with the normal system of providing a baby's iron in its first months of life?

Enough talk from me! I put off watching this in part because it's about 40 minutes long, but they were a very fast 40 minutes (and you can just listen, with an occasional glance at the slides, if you need to do something else while you're at it).

Here's Part 1, the following segments should pop up as you finish. If you have trouble finding them, you can take a look at Dr. Fogelson's original post; I recommend also reading the comments for discussion of various related topics including the practicalities of delayed cord clamping for preterm infants. (Oh, and all those animals in the title of this post? You'll have to watch to find out!)

When you're done watching, please share this video! I think Dr. Fogelson does a very good job making the argument that delayed cord clamping should not be a nice "add-on" that someone gets if they put it on their birth plan, or be seen as a hindrance instead of a help to neonatal resuscitation; it should be the standard of care in all but rare cases. But it cannot become the standard of care unless more people are aware of the evidence!

Wednesday, May 25, 2011

Guest Post: Mollie's path to pregnancy/birth (Part 3: Pregnancy and Birth)

In Part 2, Mollie talked about learning how important her place of birth was and how she interviewed care providers. In the final installment read all about the part where she gets knocked up!

Part 3: Pregnancy and birth

I calculate my date of conception as August 7. This becomes important, as I learned very quickly to lie to the hospital’s ultrasound tech about the date of my last menstrual period (thanks to FAM, I knew I had ovulated on the 19th day, not the 14th day, and five days is a long time when one risks out of the birthing center at seven days overdue). As it turns out, it was a very good idea to pick out my midwife and go to their orientation night before I was even pregnant, because when I called at five weeks pregnant with a due date of April 30, they said they were already full. They said I would have to come in for the orientation before even getting on the wait list, so when I said I had already been to it, they begrudgingly took me on as a patient (again, this was the receptionist being a little snotty about my proactive approach).

There were a few times when the researchy side of me was an issue when it came to the pregnancy. First, when I went to my gynecologist’s office to confirm the pregnancy (I wasn’t going to see my midwife until about 9-10 weeks), they found a subchorionic hematoma but never told me. A few weeks later I picked up my chart to bring over to my midwife office, and of course I read through it (what sort of researcher would I be if I hadn’t?). I saw the note about the hematoma, and of course FREAKED OUT! (By the way, don’t Google subchorionic hematoma. Better yet, don’t Google anything. You’ll end up convinced that you’re about to bleed to death, guaranteed. In this case, TheBump.com forums, though I don’t recommend message boards in general, were actually more helpful and offered a quicker response than my doctor.) Another time, during my 20 week ultrasound, I asked the doctor if he could tell where the placenta was attached (I had just finished reading about placenta prevea and cord prolapse, so it was on my mind). Instead of just telling me, or politely asking me if I had reason to suspect an issue, he snapped at me with “WHY!?” I replied with a bewildered, “Um, because I read a lot and I know what can happen if it’s too low”, at which point he gruffly checked and said, “It’s fine.”

Around 12 weeks, we started looking for Doulas. Again, this is probably earlier than most normal people would start booking their help, but my experience with nearly getting shut out of my preferred midwife office had me spooked that we wouldn’t get “the good one” unless I started looking early. I asked for recommendations from friends, but mostly looked through the DONA website. You can search by location, and while there are a TON of doulas listen in the New York City area, I looked up a handful, gauged their experience (we decided we didn’t want a newbie), and emailed then. We met with a few, and chose one who best fit our personalities (plus, she had a really nice website).

The rest of the pregnancy was pretty straightforward – I threw up, I gained weight, I did my prenatal tests, and everything was fine. I never had any real surprises. My husband and I took the Childbirth Ed class, Newborn Care class, and Breastfeeding class, and did our best not to be the know-it-alls in the class. Planning like this is second nature to me, so often I would forget just how prepared we were. But there was one moment in class that really solidified it for me, and made me grateful for all my research. In Childbirth class one week, we discussed routine interventions, procedures, and regulations like Electronic Fetal Monitoring and restricted food and drink. The next week, during our “check-in”, one of the couples seemed so upset as they began to talk about their week. Mom was about 36 weeks along, and had just gone on the tour of the hospital. They had found out that the hospital required all laboring moms to stay in bed, on their backs, for their entire labor and delivery; IVs were mandatory, and all food and drink was prohibited; continuous Electronic Fetal Monitoring was required for all moms. They were devastated. They asked their OB if he had any flexibility regarding these rules, and he said no – the hospital’s rules were his rules. No one in class knew what to say to them; nearly all the coping strategies we had learned in class required SOME sort of movement.

I was discussing her situation with my husband that night. “Not to sound judgmental,” I said, “but how did she NOT know those were the rules until 36 weeks?” “Well,” he said to me, “you have to remember – you know more about this than anyone I’ve ever met. You’ve known this stuff for months. Other people don’t know that they don’t know.”

While there were times when I feel like I knew too much for my own good, there was one moment when all my studying felt worth it. Just before 4:00am on April 11, 2011, I was walking the halls of the Birthing Center at St. Luke’s Roosevelt Hospital, in labor, with my doula. At the height of one contraction, I finally let the words “I can’t do it” escape my lips. I cried, fearing that if it got any worse, I wouldn’t make it. After the contraction was over, my doula said to me, “Now I know you’ve done your homework. You know what ‘I can’t do it’ means.” And I did. I knew it meant Transition; I knew it meant it was almost over.

By the end of pregnancy, I had prepared everything as best I could. I had midwives whom I trusted, I had chosen a hospital that would allow me to have the kind of birth I wanted, and I had a doula who would guide me through it. It was a great comfort to know they respected my birth wishes, especially because at the very moment of my son’s birth, I was finally NOT in complete control of everything. None of my research could have prepared me for that moment, but at least I knew we were in good hands.

Baby Rowan was born April 11, 2011 at 3:54am.

Just a reminder that you can read the story of Rowan's birth on Mollie's blog, Tough Love Knitters. (You can also follow Rowan's current life and adventures at Little Red Rowan.) And check out Mollie feeding Rowan while he models her newest knitted creation. Congratulations Mollie! I can't wait to meet your adorable baby ASAP!

Monday, May 23, 2011

Home birth on the rise in the U.S.

When I heard Eugene Declercq speak at the CIMS forum, I jotted down some notes on his data, but it was one of those "scribble it on the back of the conference program because you forgot to bring a notepad" situations, and he talked about so much interesting stuff I didn't have room or time to write it all down. One thing I was intrigued by was his statement that 1% of all births to white women are now happening at home. That seemed high to me, but he co-authored a new article out in the journal Birth, and it has that statistic plus a lot more info.

Some excerpts that were particularly interesting to me:

Large differences occurred in the percentage of home births by maternal race and ethnicity, and these differences widened over time... In 2008, 1.02 percent of births to non-Hispanic white women were home births, representing a 28 percent increase from 2004, when 0.80 percent of births to non-Hispanic white women were home births. In contrast, the percentage of home births declined slightly for non-Hispanic black women from 0.30 percent in 2004 to 0.28 percent in 2008. In 2008, the percentage of home births was 0.20 for Hispanic women and 0.38 for American Indian women, statistically unchanged from the 2004 figures. In 2008, the percentage of home births was 0.27 for Asian or Pacific Islander women, up from 0.24 percent in 2004. Approximately 94 percent of the increase in the overall percentage of home births from 2004 to 2008 was because of the increase for non-Hispanic white women. In 2008, 83 percent of home births were to non-Hispanic white women, compared with 54 percent of hospital births. [emphasis mine]

In 2008, Montana had the highest percentage of home births (2.18%), followed by Vermont (1.96%) and Oregon (1.91%). Three other states (Alaska, Pennsylvania, and Wisconsin) had a percentage of home births of 1.50 percent or above. An additional 10 states had 1.00 to 1.49 percent of home births. In contrast, 18 states had less than 0.50 percent of home births.

Interestingly, the recent increase in home births in the United States began before the release of a series of documentaries and newspaper articles about home birth... Such a development is not without precedent. In the United Kingdom, a government-endorsed movement called Changing Childbirth has been credited with leading to a growth in home births that has continued until the present. However, the home birth rate in the United Kingdom had already been increasing for five consecutive years before Changing Childbirth came into being... Women choosing home birth may be a harbinger, as much as a result, of increased activism related to childbirth...

These make me think about the highly culturally specific nature of the homebirth movement in the U.S. White women (in states with small minority populations) are accessing, promoting, and creating change around homebirth, and I would say I see a culture of normalcy arising around out-of-hospital birth in a certain segment of the population. (Overheard outside a prenatal yoga class: "Well, you don't have to pack a bag since you'll be staying at home, but what are YOU packing to bring to the birth center?") There is clearly a lot of privilege at work here...there are so very very few voices speaking to the non-educated-middle-class-white-woman demographic. I often think some of the Hispanic women I work with in CenteringPregnancy would be interested in having their babies in a setting other than the hospital - out-of-hospital birth with midwives being the standard in many countries they/their families come from - but there is simply no way for them to even know that homebirth is possible in the U.S., much less sort through the complicated process of finding and accessing it, insurance-wise. (And I can't pitch homebirth to them in my role, unfortunately!)

It comes back to my frustration that the people with privilege seek out the nurturing, mother-friendly, midwifery care; and the people who need that care the most, so frequently get a prenatal care through a health department or community health center, every visit with a different provider and then labor and delivery with another set of strangers, usually the general OB service at the hospital. I see basically zero outreach to low-income/minority communities from the birth community, and walking my delicate line between working in the system right now, I am guilty of that too. How do we fix this??

Wednesday, May 18, 2011

Guest Post: Mollie's path to pregnancy/birth (Part 2: Preparation)

In Part 1, our intrepid heroine learned the secrets of her reproductive cycle and was blown away by a showing of "The Business of Being Born". Check out the next installment on...

Mollie's path to pregnancy/birth: Part 2: Preparation

So now my world had been turned upside down and I was looking for answers. Where did I go? The internet of course!!! I began following the Public Heath Doula’s blog, as well as anyone SHE followed. Soon I had a nice little list of Natural Birthing bloggers: Birth Faith, Our Bodies Our Blog, Science and Sensibility, The Unnecesarean, the Midwife Next Door, Enjoy Birth, and many others. And I read and I read and I read. I couldn’t get enough of it. Sometimes they were a little out there and scary, with a “if you give birth in a hospital you WILL end up with a cesarean”, but most of the time they were informative, and over time I learned about Doulas, episiotomy rates, c-section rates (and the vast discrepancy among hospitals in New York City, which range from 16% to 48%!), and most importantly, the questions to ask your care provider BEFORE you agree to work with them:

Questions to ask
A few more question
And a few more

Around this same time I also attended a talk given by the head of Parent Family Education from St. Luke Roosevelt Hospital. My company often holds mini lectures on topics like getting your kid into private school or how to reduce your stress at work. This one was called “Preparing for Pregnancy and Childbirth”, and thank goodness it had listed as one of the talking points “preconception” (I learned later that the instructor did not know she was expected to talk about preconception, but obliged because there were a few of us non-pregnants who showed up). The talk was basically a quick and dirty intro childbirth ed course, with an emphasis on “This is a really big deal, so after this, you should sign up for a real course.” But the most important thing that came up was this: pick your birth location BEFORE you pick your provider.

I’m going to say that last part again.

Pick your birth location BEFORE you pick your provider.

“Um, are you on crack?”, you must be thinking. “That makes no sense.” It sounded strange to me at first too, but the more I learned, the more I realized that the difference between hospitals – even hospitals within a few miles of each other – could drastically change the type of birth I would have. For example: St. Luke’s Roosevelt Hospital has an in-hospital Birthing Center, where many of the standard Labor and Delivery rules do not apply (e.g. there are no restrictions on eating or drinking, and continuous electronic fetal monitoring is not required). Approximately six miles away, Elmhurst Hospital requires every laboring woman to be confined to bed, on her back, with continuous EFM regardless of her risk assessment. The rules of the hospital would DRASTICALLY change not only my overall experience, but the specific ways I could cope with pain (if I’m not allowed out of bed except to go to the bathroom, I’m certainly not going to be allowed to walk the halls or labor on a ball).

“Well, my provider would never force me to stay in bed, and she can just meet me at the good hospital.” She could, if she has privileges there. I happen to love my gynecologist, but because of recent insurance changes, she only has privileges at Jamaica Hospital – not only inconvenient for me, but Jamaica Hospital has a 41% cesarean rate (as of 2008), compared to Roosevelt’s 28% (Read the stats here). You may decide that you want to do a home birth, but I highly doubt your OB/GYN is going to be your provider. Also, if your provider has privileges at multiple hospitals, he may have you meet him at the hospital where his current mom is laboring, not necessarily the one closest to you or the one with the amenities or rules best-suited for your desired labor experience. Now, this point may be moot if you only have one hospital or birthing center in your area, but if you live in a metropolitan area with many choices, it makes sense to get to know the hospitals first, and then ask the hospital or your insurance company for a list of practitioners with privileges at your favorite.

Ok, so I had my reproductive system down, I knew I had some options for hospitals, and I knew more about episiotomies than any child-less person should know. Over the three “preconception” months, we went on three hospital tours – Roosevelt, Lenox Hill, and The Brooklyn Birthing Center. I liked Roosevelt the best, so I asked them to send me a list of practitioners who had privileges in the Birthing Center. I narrowed down the ones covered by my insurance company (oh, side note: I called my insurance company and it was the opposite of helpful – the guy on the phone told me that midwives were illegal in the state of New York so they don’t cover them . . . oh Aetna customer service . . .), and set up consultation appointments. Now, I had no issues going on hospital tours while not yet pregnant, since they didn’t ask (I have heard rumors that some hospitals won’t let you come unless you’re pregnant, hoping to weed out trainee doulas and paparazzi I guess, but in that case, I imagine you can just lie). I got a little bit more push-back from the receptionists at the doctor’s offices (“Wait, you’re not even pregnant?!”) though thankfully, not from the doctors themselves; they knew exactly why I was meeting them so early, and even seemed to appreciate it. One midwife office (the ones I ended up choosing) actually had an orientation night, where they sat for an hour or so and talked about their practice and their birth philosophy, and where anyone could come and ask questions. I ranked my favorites, and now I was ready for baby-making!!!

Saturday, May 14, 2011

Weekend at the movies: TED Talk on "Love, Breathe, Just Doula!"

Really enjoyed this humorous and engaging Doula/Birth 101 by Ginny Phang, a doula in Singapore.

The only thing I disagreed with her on was she was maybe implying that first-time mothers can get a 3-4 hour labor by preparing and educating themselves...I think that preparation and relaxation can certainly help shorten labor, but I wouldn't want a mom who had worked hard to prepare for birth expect a 3-4 hour labor or feel like she had done something "wrong" because a first labor took longer. But she also talks about not knowing how long labor will take, being prepared for anything, and writing a comprehensive birth plan with Plans B, C, and D. It was a fun and inspiring little video, and I think will help people understand what a doula does and why it's important. (Also, catch the gasps when she talks about planning to breastfeed for a month, then mentions how long she actually breastfed her son!)

Should the ACNM become just the ACM?

A long and thought-provoking interview with a CPM/CNM on the American College of Nurse-Midwives' proposal to become the American College of Midwives:

Erin: You have spoken out publicly against the proposed name change of the ACNM. Yet you have worked as both a CPM and CNM, and have previously spoken out for unification of the profession. Why would you be opposed to this move?

Hilary: I would only support this name change if the ACNM concurrently commits the organization to working in partnership with MANA, NARM and MEAC to create one unified midwifery profession in the US. Without this commitment, calling CNMs “midwives” will increase their potential for working in opposition to direct-entry midwives who are striving on the political front to have CPMs included in national health reform initiatives, and of their being at odds with legislative efforts in states where the CPM has not yet been recognized. If the ACNM is going to rename itself the American College of Midwives, is it going to wield this moniker for the betterment of ALL midwives, or is the organization going to promote only its own brand of midwifery? As a corollary, is it going to change the title of all its members to CM – Certified Midwife?


Erin: You’ve mentioned a merging of nurse-midwifery with direct-entry midwifery. How would one midwifery credential better serve childbearing women? Wouldn’t it mean less choice for them?

Hilary: It would only mean less choice if we allow the current model of nurse-midwifery to subsume direct entry.

A true merger takes the best of both worlds, and in the process gives the participants a greater societal voice. As long as we continue to put our focus on creating hierarchies within the midwifery community, rather than really listening to each other and learning how to work together, we will not be successful in building midwifery as an independent and powerful profession. If we choose instead to have one unified profession, where all midwives are educated to work in all settings, where the goal is to increase the profession until all women throughout the US can have access to a midwife, then we are creating more, not less, choice.

Read the whole thing here.

Guest Post: Mollie's path to pregnancy/birth (Part 1: Preconception)

You may remember that a few weeks ago I posted about my friend Mollie's birth story, in which she had a lovely and exciting (in the good way) delivery in a birth center, attended by a midwife, with the support of her husband and doula. I also promised a guest post by Mollie. So now you know the end of the story, I'm delighted to bring you a three-part series that she's written about how she came to learn about her options for birth, decide what she wanted, and find her care providers and place of birth.

Of note, Mollie and I met a surprisingly large number of years ago (surprising to me at least! I don't feel that old!) living on the same dormitory hall, at a college known for having its students do a lot of independent, self-guided research. As you can see, Mollie learned these lessons very well!

Mollie's path to pregnancy/birth: Part 1: Preconception

The path to becoming a mother is different for everyone, as is the path to getting pregnant. My path was in many ways straightforward – get married, get settled, get pregnant, have baby. I did manage, however, to insert a step in the process which, for anyone who knows me well enough, was absolutely essential: I researched the crap out of it. I left no pregnancy book unread, no birthing blog un-lurked, and no midwife in a 10-mile radius without at least a hit on her website. I needed to know it all, and I needed to know it all before there was even a fetus to worry about.

It all started about 15 months or so before the baby was conceived. I was on The Pill and was interested in a non-hormonal form of birth control. I chatted with some friends and with my GYN, and ultimately picked up “Taking Charge of Your Fertility,” a fantastic how-to guide for the Fertility Awareness Method of both birth control and conception. I devoured this book! I couldn’t believe how much I realized I had never known about my own reproductive system. “Why didn’t they ever teach me this in health class?” I kept yelling! I couldn’t get enough of it. I charted my cycle for over a year before ever attempting to get pregnant, and I learned more about my hormones and my body in that year than in my previous 15 years as a reproductively mature female.

Now it was time to research conception, because who could POSSIBLY do that without adequately researching it!? [har har]. So I picked up a few books (and thank you New York Public Library, for allowing me my fill of research without having to purchase a single book). “Your Pregnancy: a 90-Day Preconception Guide” was pretty informative – a lot about nutrition and vitamins, exercise, and understanding genetic diseases. I went back to “Taking Charge of your Fertility” and reread the conception chapters. I also picked up “What to Expect Before You’re Expecting” . . . oy. If you thought the “When You’re Expecting” book was bad, the “Before You’re Expecting” may just give you an aneurism. Unless you’re not quite sure on the mechanics of sex leading to babies, don’t waste your time with this one.

Alright, so I had conception down. I had negotiated with the husband to start trying in September, so on June 1, 90 days out, I started my preconception routine: I was taking my prenatal vitamins (woo Folic Acid!), charting away, and trying to convince my husband that “no, I promise I won’t go crazy and tell you which days we have to have sex!” I made an appointment with my GYN to get checked out, talk through which medications were still fine to take, and discuss genetic testing.

At the same time I had the “Why didn’t I know this about my body” epiphany, I had the “Why didn’t I know this about childbirth” epiphany. The Public Heath Doula herself invited me on a little movie date one afternoon. “There’s this documentary about childbirth that’s supposed to be great!” she told me. Little did I know I would soon become one of those Natural Childbirth advocates who feel the need to educate the world about epidurals and yell at sitcoms which portray childbirth incorrectly. Because, you see, she took me to see “The Business of Being Born.” I’m not exaggerating when I say it changed my life, or at least my outlook on life. If you haven’t seen it, you need to. If you ignore everything else I write here, if you take away NOTHING . . . just see this film. It’s on Netflix instant-watch, and it’s only an hour or so long. I promise, it’s worth it. And get your partner to watch it too. I’m telling you, my husband was on the fence about this whole non-medicated thing (“If it makes the pain go away, why WOULDN’T you want it!?”) until I sat him down and made him watch this movie. He now excitedly educates his buddies about the side-effects of epidural analgesia and hospital policies on freedom of movement. (He still wasn’t sold on a home-birth, but he eased up on the opinion that I was effing crazy.)

Stay tuned for Part 2... Preparation!

Saturday, May 7, 2011

Weekend at the movies: Midwives Diner

What do you get when you go to the Midwives Diner? Well for starters, no IV and as much water as you want!

Tuesday, May 3, 2011

Living as a doula, making a living as a doula, and life without doula-ing

When I heard Penny Simkin speak at the Breastfeeding & Feminism conference, she talked about the rising fees that doulas are charging and the conflict between doulas who do it for a living and doulas who do it as sideline income or even without any real financial need/goals. I've almost never met a doula who can support themselves on doula work alone, but Penny Simkin was talking about how for an increasing number of doulas this is their goal. They love doula work and they want to charge fees that enable them to support themselves/their families on their doula career alone.

For a little while I had the idea that I could be one of those doulas...I gave that up pretty fast. I realized how long it would take to build a consistent referral base to bring in new clients and how even when you think you've got a good cycle going, things happen... many doulas I knew in NYC were really impacted by the economic downturn there, when fewer parents felt financially able/willing to spend on doulas (you all know I think that's one of the most important things to spend on, but those parents didn't ask me!) I also saw how most doulas needed other sources of income to fallback on: many offer a whole set of services like childbirth ed, placenta encapsulation, birth photography, etc. etc. I'm not a personality who is happy patching things together that way long-term, and it didn't seem like it made sense for my personal financial health either. I decided to go back to grad school and get me a Real Grown-Up Job (tm).

Fast-forward to my Real Grown-Up Job (tm) doing something I love - working as an LC - and I am now feeling the tug between my doula work and said Real Job. I attended my second out-of-hospital birth ever today - hooray! It went so well and was such a wonderful experience with a lovely family. It really reminded me of why I LOVE being a doula - why it is my favorite thing in the world to do. But it was hard to work it around the Real Job in ways that show it really wouldn't be sustainable in the long-term to take doula clients. When I'm in the midst of being on-call for clients - phone always on and with me, can't go out of town, can't make concrete plans, etc. - it doesn't seem like such a sacrifice. But then I go to a birth, all those little annoyances fall away, and it breaks my heart to think about stopping.

I have thought about doing a partner doula system, where clients hire me & another doula together with the understanding that one of us is always on-call and at birthing time she could get either one, depending on our schedules. But it has been frustratingly difficult for me to find back-up doulas, and I don't really think that bodes well for finding a full-time partner. There might be some more flexibility in going back to volunteer doula work, but I recognize that will need to be fairly rare; I found myself getting burned out on 30+ hour volunteer births where I wasn't willing to leave but wasn't feeling a return on my energy and experience.

I have one more doula client coming up (yep, still on call!) Both today's and the next one hired me before I went permanent at Real Job. After that, I know I'll be happy to get some time off from the on-call routine...and then what?