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Unknown
Welcome to Hello Uterverse, where perinatal peeps come for more evidence, more clarity, and fewer WTS for Jen and Heidi. Labor nurses, educators, and research obsessives here with you in podcast form. From deep dives to surprising rabbit holes, we're here to help you think differently about the work you do every day. Let's launch.
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Unknown
Hey, guys. Welcome back to hello, Uterverse Hello, Uterverse. We are going to do today's podcast based on another
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Unknown
readers listener follower question, because we feel like
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Unknown
we might answer at one place, like the newsletter, like the walrus newsletter. But there's always so much more to talk about.
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Unknown
Yeah, and that was in written form. Now you're getting it in live form? Yes, we're talking through it. So we have it's called the Nurse Hotline where you guys can actually submit questions to us. You can do it through the US on Instagram at hello or on our website. If you scroll to the bottom, there's a contact form and you can submit a question to the birth hotline and we will answer it.
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Unknown
We will go down that route. Yes we will, we will. And like Gen Z, we'll answer it maybe in a newsletter or here on the pod or both.
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Unknown
I mean, I personally love when we get these questions because it's one
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Unknown
am astounded at. Like the, you know, the things change, right? We have to be so aware and so comfortable.
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Unknown
And the way I would have answered this question 2 or 3 years ago and now is definitely I mean, it's not a lot different, but there's definitely more nuance to it. And I think that's something that that evidence gives us. Yeah. Okay. All right. So let's let's dive into the question here. So what we had sent into the birth nurse hotline is can we talk about early Arem which is artificial rupture of membranes.
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Unknown
And it feels so backwards to me. And yet apparently to reduce our C-section rate, we're going to start encouraging a round before four centimeters. They did a question mark and an exclamation point, so all punctuation was left intact. Yes. So this nurse is feeling very skeptical. And I mean with good reason, right? We're really taught. Abraham is like a later thing.
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Unknown
Yeah. Because we're like, you know, then you're kind of opening them to infection. You know, we worry about that. That is just kind of the baby. Right? It just seems more of like towards like an end game thing. Yes.
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Unknown
working where we work in the northwest
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Unknown
the bag doesn't actually have to break. Right. And in spontaneous labor, we're not saying you know nothing about the question has nothing to do with about, you know, whether they're, you know, an amniotic sac is left intact versus a in spontaneous labor. This question, just to be like super clear up front, is about in the course of induction of labor.
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Unknown
Yes, for medical reasons. That will be our caveat, because I know people are like and then they got on and they started saying they are saying some real wild stuff physiologic birth, spontaneous labor. You leave that alone, right? We don't leave it be. We don't want to intervene in normal. If they are normal, they're just cruisin. Normal is not a qualifier of anything except for just they're doing things that we don't want to use our.
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Unknown
Yeah, like we don't have to use our tools. Which Aram is a tool. Right?
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Unknown
Aram is a tool. Induction tool. Right. Those are medical interventions. So it does feel really, really backwards. But it's something that's coming up more and more because Acog
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Unknown
has a new ish I guess.
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Unknown
New ish
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Unknown
2023 2023 recommendation for early amniotic me as an adjunct to labor induction. So the first thing is, you know, they cite all of these different randomized trials and all of these things to go along with this. But I think just like even back it up is for our purposes today, like what is the definition of early Aram.
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Unknown
So what is that definition. Early Aram means that you it's rupture of membranes either just after like expulsion of the Foley balloon or just after cervical ripening and before you start pitocin. Okay. So it doesn't have to do anything with cervical dilation per se. It's just you do it after cervical ripening and you do it before using pitocin.
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Unknown
Okay. Is there a more like specified time frame for that or
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Unknown
I mean within the 1 to 2 hours after. Yeah. So 1 to 2 hours after cervical ripening. But yeah. So just after cervical ripening but before you start anything else is what they're, they're saying is early amniotic.
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Unknown
And so they, you know they've made this practice guideline and they're citing, you know, their main reason is that it can decrease time to delivery and decrease C-sections.
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Unknown
Okay.
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Unknown
so physiologically, I think we can kind of there's like a few probably principles at play. Yeah. We're shifting the environment from like a fluid mediated pressure system to just like just that head, just just pushing on that cervix. Yeah. All right. So that's gonna obviously be like more changing that. It's gonna help with our Ferguson reflex.
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Unknown
Right. Right. So there's going to be that direct cervical pressure. Amniotic fluid is full of
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Unknown
hormones. Prostaglandins. Landon's right. And so, you know, it has all of those, you know, effects as well. Right? But what was really interesting, obviously I have my own like my own biases. So when we think of that evidence based funnel I'm like, okay, I know I have biases of like, do not don't touch people, don't do early Aram in my mind I'm thinking infection.
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Unknown
I'm thinking mal position, I'm thinking more pain. All of these things. So for me, I'd be like, no. But I really forced myself to go back to that like top of funnel. Okay. And relook at the research. Okay? Okay. How do you call that? Yeah. Okay. ECoG. Where'd you get this stuff? Where are you going?
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Unknown
So there's also I mean, I think something to talk about is like publication bias.
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Unknown
So we do tend to have more heavily. Wait, things that are published in, like medical journals versus nursing journals. I've done some peer reviews lately of nursing works, and I know the evidence based. So if they're asking you to do a peer review, it's because they think you have some knowledge of this topic to be a peer reviewer for these journals.
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Unknown
And so I got one, and I and I know the literature pretty well. And then I looked at their reference list and out of say, 20, I don't remember how many it was, but say 20. References. It was like 17 from medical journals and like 2 or 3 and didn't even cite like the guideline from a one guess in a nursing work.
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Unknown
So we do have this publication bias, which an Acog certainly does too. Like their guidelines are going to be pulling from these more medical journals. But they pretty much cite this one that showed that it could speed up labor,
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Unknown
is that across the board, though? I mean, there was an analysis that was out in like 2020 by Battersby, I think is the last name at all.
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Unknown
And they did look at some subgroups. And so some of the groups, you know, overall, if you just applied it to a whole population of people giving birth, there is going to be a benefit. But that means some people, some groups, some subgroups, depending on their characteristics, are going to have a lot of benefit or most of the benefit.
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Unknown
Some no benefit in some groups are going to actually be harmed in like it's going to be increase their C-section rate. And that's what they found. There's like specifically like this is one of those classic like more research is needed. One subgroup that they found was null, who are also obese, were actually had worse outcomes with early Aram.
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Unknown
well, I think what we know a lot about like worsening outcomes and obesity, this
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Unknown
is not my area of expertise, but what I've seen like in my deep dives, maybe I'll put toss in is that it's mostly like, you know they've encountered anti weight bias.
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Unknown
So for so long and now you're in the hospital giving birth which is like one of those most like bodily focused activities. And you're in this like small gown. You're like everyone's poking and prodding at you. And something that could be if you've had poor experiences prior and now you and now you're just everyone's hyper focused on you and your body and the body inside of your body, your little fetus.
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Unknown
Like, I just think that the cortisol is got to be running. Oh for sure. And cortisol and and oxytocin are not friends. They are not friends. They do not work well together.
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Unknown
Yeah. So I mean, yeah that's going to play a huge thing if, if the person doesn't feel safe. Safe. And they've had bad experiences before, you know.
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Unknown
And then I mean that can translate to really like pretty much anybody really does anybody. So then you you like go further. It's like, well did we study the diabetics in early Aram. Did we study people with preeclampsia? Did we study people with, you know, help all of the different things? What about people who are underweight? What about people with, you know, twins?
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Unknown
What about at what gestational age is it the most beneficial? Like the 40 and 41 weeks are beneficial, but the 39 and below are not beneficial. Like I think we just before we just say this is what we're doing for everybody. Again, we have to filter through that funnel and say, we got to go back to that funnel, go back to their funnel, and then use our experience to say, okay, is this research?
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Unknown
Right. So there's this guideline that guidelines made up of research did we actually is what the guidelines saying. The research say actually what the research says. Oh that's controversial.
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Unknown
Oh. Drama drama drama drama. Right. We don't do that. Like if A1 or Acog or Occam or SM or whoever comes out with a guideline, we just are like they read the research, they're telling us what it says.
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Unknown
But I do think if you've got some time or something doesn't quite sound like you don't have that questioning attitude, question the answers and look at what the research really says. And when we did that, for the to answer this question, we found like, oh one there is evidence for early
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Unknown
Aram. Yeah,
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Unknown
which surprised me to be quite honest. But then you go one step below that, you're like, oh, for some people, but not others. So it still takes that middle part of the funnel.
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Unknown
Yeah. And I think that makes sense. And that's true for, I think a lot of things that it's not a one size fits all sort of thing for, for anything.
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Unknown
It's like, okay, we have this research. But then also who is that research done on how do we apply it. And then also you have to look at the other things that are going on with the patient too. Right, right. You know
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Unknown
so yeah. So that's where it's going to take this experience of us actually looking at it and not just being like, hey, Acog says we're going to rupture your membranes.
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Unknown
And that's what's happening. And if they push back a question, right, that can make us really uncomfortable. But we say, like, hey, there's this recommendation. It's based on this research. Here's how I think it applies to you. Do you want to do that or not? Somebody might be like, heck yeah, I'm a perfect candidate. And you think this will make me have a shorter labor?
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Unknown
Absolutely. And some people be like, I don't know that that applies to me or that just doesn't line up with my values. Yeah. And maybe there's like, I, you know, my sister had rupture of membranes and it didn't go well after that. Or, you know, they might have some. I mean, how often have you had a patient that's like, oh yeah.
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Unknown
Once my mom's water broke, the baby came 15 minutes earlier. You're like,
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Unknown
I'm going to need a table in here, but I need a table in here before we do this, right? Yeah. So that personal piece or that personal history stuff, that doesn't I mean, we're not going to study or maybe we don't even know why it happened, but we all hear those stories all the time.
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Unknown
We've had those experiences. So that's where like that evidence based funnel, I think really is applied in a good way. Thinking through this question that they sent us, I was like, yeah, it was a good little exercise in humility for me, I think. So, yeah. It was interesting. Like one other thing that interests me
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Unknown
when we were talking about Arum and like looking into it was
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Unknown
about whether or not they should Aram like before or after an epidural.
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Unknown
Oh yes. Yes, yes. Yeah. And historically we were always like let's get you comfortable, get them the epidural first, you know, because you want you don't want to do something painful. Right, right.
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Unknown
But then we found especially if, if the recommendation or the consideration is going to be for an early Aram. Yeah. How much movement does that baby still need to make and do to get through the pelvis?
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Unknown
Where? Yeah, Abraham at seven centimeters or whatever. They're they're they're rocking and rolling. Right. They're active. They're cruising. They're engaged. All of these things. But like. Yeah. So that anyways that that paper said it actually do the Aram first and then get them and then get them that and try to delay it for at least what like 30 to 60 minutes.
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Unknown
Yeah. Which
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Unknown
I actually did that a couple weeks ago. How did that work. It actually really great. So the plan was kind of, you know, she knew that she wanted an epidural. And then the plan was like the next thing was like, yeah, we want to break your water. And she was like, yep, that's what I want to have done.
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Unknown
But yeah, let's get my epidural first. And I was like, well, actually, you know, and so we had this like whole discussion about it. And I was like, here's like how I think this could look. And then you tell me, like how you feel about it. Because other thing too is like what the patient wants, right? Their voice is clinical data.
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Unknown
It really like it's very important. And so I was like, here's what I think this could look like for you. You
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Unknown
also mentioned to me that you really want to like you want to bounce on the ball. Once you get the epidural, you can't be bouncing on the ball. No more ball, right? So I'm like,
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Unknown
if we do the around first, you kind of bounce on the ball.
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Unknown
I get the room and everything kind of set up for you to get your epidural and then,
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Unknown
you know, kind of see how you're doing and then get your epidural like after that, you know, around that our marked depending on like how you're feeling and stuff, you know, and she's like, oh I like that. Because one thing that she was sort of freaked out with, with the epidural, even though she really, really wanted it was like not being able to move.
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Unknown
Yeah. You know, well, and our patients are not dumb. No they're not, they're smart. And so it's like, I love that you were able to just offer her some new information and you. And like, I know you, you're like, fine. Either way that she had decided to go or her and her partner decided to go, but also how comforting it would be to me as a patient to be like, wow, my nurse is like pretty smart or like, I like that they're able to talk me through sort of this, like physiology or the mechanics of this in a way that makes sense to me, because, I mean, that was drilled into us in nursing
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Unknown
school, like, oh, patient education. Right. And we're not to be clear, like we're not doing informed consent or anything like that. What nurses do do is do patient education. So yes, we're allowed to teach folks about the pelvis labor. What is rupture of membranes, what happens during all of these things. And so to give her that information, I'm sure she was just like, oh, oh I'm in good hands.
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Unknown
Yeah. This hot blond bee knows exactly what she's doing.
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Unknown
So it worked out for her. Yeah it was great. She, she was really happy. She got her time on the ball. Got to like move around a little bit and then you know kind of like I think she liked to that. Then she was like kind of able to, like, clean herself up, you know, because they hate they hate that, right?
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Unknown
I mean, who doesn't feel like sitting in? I know it feels like you're peeing yourself. It really does. It's so it's the weirdest feeling sensation. Or you think your water broke what you did. Just be yourself. Which was. Which was you.
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Unknown
Hey, you could be a labor nurse, but you are definitely still a prime up. Yeah, well, I mean, it's like, I think, you know, you just go into a different mindset when you're when you're the patient, you know, it's kind of like, you know, then like when you get into your mom brain and you're worried about your kid, it's like your nurse brain just sort of shuts, shuts off and you're, you know, do you
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Unknown
remember Pam that worked with us?
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Unknown
Okay. This is how bad she effed with me as a prime up. So I came out of the bathroom and I was like Pam I lost my mucus plug. And she goes we'll go get it. I don't know what I was thinking I did and I brought it back out to the nurse's station on a napkin, and she made me show it to everyone.
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Unknown
And now I'm like, she was messing with me. I'm sure they were all like, she couldn't really do it. I know what what purpose did you think? I don't know, because your brain does not work at the end of pregnancy. It doesn't work at the end of pregnancy. So it's like, how could I have been a labor nurse at that point?
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Unknown
I had been a labor nurse for seven years. Like such a dumb dumb. But I'm so. I am a little bit gullible. Like when people tell me or something I do. My default is to go. Oh, okay. You know, you are like, you are very trusting. I'm a little bit more trusting about. Yeah. And so. But man. Yeah.
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Unknown
Oh that's hilarious. I do have a soft spot for prime ups because I'm like, yeah, you know, especially when they come in and they feel really bad, like, oh, I'm sorry I came in. If it's nothing and you're like, no, you, I mean, you have to come in. You don't know, you have to come in because it maybe something or maybe nothing.
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Unknown
Yeah. You don't know. Yeah, yeah. When I tell
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Unknown
I was also triage for paying my pants and I had been a whole labor nurse. They're always like, oh, that actually makes them feel a lot better. Yeah. But yeah. Back to the. You're paying back to your patient. Back to your patient. Wait. I'm going to divert back from your mucus plug.
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Unknown
R.I.P. Reston plug. Reston plug. Yeah. So anyways, it just I think it's it's so important to present all those options to patients because it's like their it's their story. It's their journey, it's their thing. And then, you know, that we're reading through that research, we're working through that funnel and then able to present these things to them and like, help them to choose what's going to be like the next right thing for them.
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Unknown
Well, and to be not just like, yes, we're going to get you the epidural, we're going to bring your water. But like, you know, if we do it in this order, like how much more like active, I guess in their participation of their own birth. Like, because I think we can either be constantly inviting or disinvited people in and out of their own experience.
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Unknown
And as a labor nurse, we want to always be like actively, you know, it's not it's not comfortable. I think for most people to be we get that birth in a hospital is like a relatively newish thing. We want people who need to be in the hospital or want to be in the hospital to be there, but, I mean, it's no secret.
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Unknown
Like it's not like a like a normal natural environment for people to be birthing in. Right? We did birth at home forever and ever and ever until, like what, like 100 and something odd years ago. Yeah. And then even then, not even everybody just. And still not everybody and still not everybody. Especially in Oregon. We're like, what, five, 6% home birth or birth centers?
00:20:33:19 - 00:20:59:21
Unknown
Yeah. So pretty high here. But yeah. So once they're in the hospital I get that there's you know, there's always going to be these like power structures that were navigating. But one of the ways that we can start to level that and to be constantly inviting them in is offering them evidence base, offering them information, but then being explicitly clear, like the funnel stops with you.
00:20:59:23 - 00:21:19:23
Unknown
You're you're choosing and, yeah, I just love that story. I love, like, how empowered and like that she by all by all reports. Yeah. Enjoyed her birth. Yeah. She did found that an empowering experience. She's off to mom. Yeah. In a in a better state than maybe having not had that experience. Good I hope so.
00:21:20:00 - 00:21:23:14
Unknown
Yeah. She did. Yeah. Yeah she did. She was she was very grateful.
00:21:23:15 - 00:21:36:07
Unknown
you know, I had been with her all day and she was doing. So she was just awesome. They were a really cool couple. And she was like getting to the point where she was like, about to deliver. And it was change of shift.
00:21:36:07 - 00:21:51:21
Unknown
And it was like, when I hate that, I hate that, you know, I do want to go home. I know it's like you want to go home because you're exhausted, because you've been there for a long time. People are sometimes like, when are you getting home? Yeah, yeah, yeah, there's that too. Yeah.
00:21:51:21 - 00:21:54:13
Unknown
But anyways I just was like, oh, I don't want to leave her.
00:21:54:13 - 00:22:07:14
Unknown
She was so close to delivering, you know. And so then I ended up staying. Yeah. And she delivered like within like five minutes, like after, like my shift technically ended and,
00:22:07:14 - 00:22:14:21
Unknown
she had such a good delivery and she, like, was just, like, so honored that I had stayed and, like, thanked me so much.
00:22:14:21 - 00:22:36:21
Unknown
And so it was just like, it's such an honor to be a part of their birth experience. Yeah. I was like, it's so yeah, I was like, no, thank you. Right. I know I always that I don't think that will ever get old for me as a, as a nurse is like to be part of somebody. Yeah I know I think about that so much that, you know, anytime people come through those doors, their lives are changed forever, right?
00:22:36:22 - 00:22:48:17
Unknown
Whether it's it's good or bad, right. You know, and we're bear witness to that or to participate in that is like, it's just it's just so I mean, they ever get old for me. No no no no. Me either. I know you were kind of talking
00:22:48:19 - 00:23:00:09
Unknown
in an earlier episode about how, you know, our patients just really bond with us and, like, kind of looked at us for answers and, like, you know, it's just it is it is just, like, such a sacred duty.
00:23:00:10 - 00:23:35:09
Unknown
Experience and duty that. Yeah, yeah, I will forever just feel so honored to be part of shout out to witness whatever. A few weeks ago that was you. You did freaking awesome, man. You did awesome. Yeah, yeah. So love having little things like that. Yeah. And so I think that that's a way that, like, we really can see that this whole like, evidence based theory play out is like we took current research, up to date research, put it towards a, you know, in a modern example with this patient, our experiences.
00:23:35:09 - 00:24:04:04
Unknown
And then they made that ultimate decision. And now the loop is going to be continuing to evaluate, okay. Is this whole true for different groups of people different subgroups. Right. We don't want to clump everybody together because that can change like the effect size. Right. Make it look like there's a difference when there isn't. Or maybe there's even harm for some people, but also now, like your middle part of the funnel, you're like your nurse experience is like, oh, well worked for that one.
00:24:04:06 - 00:24:25:07
Unknown
Let's see how it works. You know, maybe this, you know, in this scenario of that scenario. Right. We're going to keep putting our own experiences with it. And then you know, as patients keep keep coming through those doors, we'll keep offering them their choices. Yeah. So well I hope that answers everyone's questions about early Aram, if there's something we didn't get to or makes sense.
00:24:25:07 - 00:24:30:07
Unknown
But yeah, it's it's one it's one tool in many. Is it like, the only way to speed up a birth?
00:24:30:07 - 00:24:45:09
Unknown
No it's not. Oh absolutely not, absolutely not. We have a whole litany. Tools, tricks. We've got the peanut ball. We've got us the providers. We've got the ways in which we use our don't use. But. Right. We have all of these things.
00:24:45:09 - 00:24:50:17
Unknown
But those, you know for today we're just talking about early Abraham. So thanks for
00:24:50:17 - 00:24:58:20
Unknown
Joining us again if you have questions you want your question to be answered on the birth nurse hotline. Drop us a DM.
00:24:58:23 - 00:25:05:14
Unknown
Fill out our contact form on our website. We would love to hear from you. Yes. Let us go down a rabbit hole.
00:25:05:14 - 00:25:11:03
Unknown
Please, please. All right. We'll see you soon. Down the next rabbit hole. Down there. Next. Bye bye.
00:25:11:03 - 00:25:13:16
Unknown
Thanks for listening to Hello Uterverse!
00:25:13:18 - 00:25:17:07
Unknown
For more evidence, clarity and community. Head to Uterverse.com
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Unknown
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Unknown
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