1. Miller, Lisa A. CNM, JD

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With age comes a greater wisdom, an ease and comfort with oneself. - Cherie Lunghi


At the end of this year, 2017, I will have lived longer than either my mother or my father. My father died when I was 18 years old, and my mother succumbed to a form of cancer (that is now curable) when I was in my 30s; she was 59 years old. I am lucky to be healthy and am currently working on becoming more physically fit so that I may enjoy the future, should I be blessed with a longer life than my parents. And unlike many women I know, I can honestly say that each year gets better, not necessarily easier physically but certainly mentally and emotionally. I have also noticed that as I age, I care much less about what others think of me and I am much more thoughtful and honest with myself. Because I feel a greater ability to be open and honest about how I feel and think, it gives me an opportunity to believe that others should be open and honest as well. So today's column is about a few things I would like to get off my chest now that the time ahead of me is without a doubt less than the time behind me (barring any cool science fiction-type developments).


There are several things that I think are simply unreasonable and unnecessary happening in perinatal care, and I am going to give voice to my opinions, which are mine only, and which you are entitled to contest, reject, or simply ignore.


Number 1: I am very aware that breast-feeding is the preferred method of newborn and infant nutrition, and I am aware of all the wonderful evidence that supports this fact. But I am sick to death of women being made to feel awful or somehow less of a mother if, for whatever reason, they choose to bottle-feed their infant. Ditto for anyone making women feel bad about the choices they make for childbirth, such as whether or not they have an epidural or whether they choose a home birth. Good Lord, is it not time for us to simply embrace the spirit that is embodied in the word "midwife"? Midwife means "with woman," not "with woman as long as her choices reflect my own biases." Every woman should be given the appropriate information to make informed choices about breast-feeding, birth, and women's health. And once she makes those choices, she should not be judged or criticized or in any way made to feel somehow lesser as a woman and a mother.


Number 2: Can we please stop making more rules and protocols as knee-jerk reactions to unexpected outcomes? I know the intentions are always good, but the adage about the road to hell being paved with good intentions comes to mind. Some examples I have personally encountered include making every woman wear a pulse oximeter and have an ultrasound scan on admission and every shift to confirm that the maternal heart rate is not being picked up as the fetal heart rate. These rules were imposed after an unfortunate case of signal coincidence that resulted in a fetal demise. Or the rule that women receiving oxytocin in labor cannot be allowed to go to the bathroom because they might be off the fetal monitor for a brief period. Or a rule that low-risk patients must have electronic fetal monitoring for some arbitrary period of time before they can be "switched" to intermittent auscultation. How about subjecting every woman to an ultrasound scan on admission because someone missed a breech?I understand the desire all of us have after an unexpected outcome to ensure that it never happens again, but jumping to conclusions about practice changes without a thorough evaluation of the situation and the different alternatives that may (or may not) be appropriate for future prevention is simply going to result in more unnecessary interventions. Given that it is hard to be objective about incidents at your own institution, maybe it would be wise to enlist the aid of experts from outside your hospital or system who can provide an objective review and options that are not simply reactionary.


Number 3: It is not acceptable for nurses, physicians, and midwives not to understand the physiology of labor and birth. If you do not understand that the evaluation of uterine activity involves a myriad of factors, including all the components of the evaluation of uterine contractions as well as stages and phases of labor and the effect of uterine activity on fetal acid-base, you are not competent to practice and certainly should not be involved in protocol development, much less ordering or administration of oxytocin. All the algorithms and checklists in the world cannot help you if you fail to grasp basic physiology, because it is that knowledge that will allow you to understand the purpose of the rules as well as when to break them.


These are just 3 of my pet peeves; I could go on, but I have other things to do, such as get my 10 000 steps in before I go to sleep. You may or may not agree with my aforementioned opinions, and you may have other situations worth venting about, please feel free. The greatest thing about getting older is simply not giving a hoot (those of you who know me know that I would use a different word than hoot, but let's keep it professional here) about what others think of you. Please note that I am not trying to give offense to anyone; these are just some things that I really needed to share.


-Lisa A. Miller, CNM, JD




Perinatal Risk Management and Education Services


Portland, Oregon