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Tuesday
Nov022010

When I'm Asked a Question

A lot of my life is answering questions. I love talking about birth and babies. I think I spend more time online talking with women about the various aspects of their mother-lives than any other activity on the computer.

So when women ask me specific questions, I take the task seriously; a woman's trust must be respected and honored.

Most questions are easy enough to work through. 

- I'm not sure if I have thrush.

- Can you help me with my birthplan?

- My baby won't take a pacifier.

Like that.

But, sometimes I get questions that are either out of my league or not of very great interest to me. While I think I do a decent job researching many topics, I am not a professional. Statistics all blur together and I've found for every study completed, you can find three more that dispute it. So it takes a focused and motivated person to weed through the mass of numbers and take the piles of words and make some kind of sense out of them.

My motivation varies. I am passionate about fat in pregnancy, gestational diabetes and insulin resistance. I love writing about midwifery and writing. It brings me joy to share my photography. But, even within those parameters, not everything excites me enough to exert the energy (or spend the time) writing about.

Today, on the heels of my post declaring I will write a blog post for each day in November (NaBloPoMo), I got this question in the comments.

"Can you write a blog (post) about high blood pressure/preeclampsia? I feel like the issue is getting very fogged by doctors lately, and I'd like to know more about when induction and c-section are appropriate."

Meg! I really am honored that you want my opinion... that in itself is a wonderful compliment. But... I do have to say, this isn't one of those topics that resonates with me. And, if I did attempt to tackle the topic, it would easily take 6-8 weeks to finish. This kind of involved subject really tests my mettle!

So, instead of a term paper on the subject, I have an idea. How about you ask me pointed questions about BP/PE/PIH... what exactly confuses you -or that you see others being confused about. That way, I'll be able to not talk about that you already know about and/or what has been written about extensively already.

And, too... know I am a midwife. I am trained to know normal and to know what isn't normal... and refer out. I suspect a lot of the topic will be out of my scope of practice and I am really sure I would not be able to determine when induction or a cesarean is indicated. Mostly because each woman is so individual, but also because I do not make those decisions. I work with women as they learn about their options, offering information and support for their process. I do not ever make the ultimate decision about an induction or a cesarean. Not to lightly pass off the duty to a doctor, but those decisions are between a woman, her partner/s and her OB. Her midwife can be a great consultant, but (speaking for myself) I will never have all the knowledge an OB does regarding the complicated issues surrounding preeclampsia.

So, hone your questions and I will do my best to answer what I can. Readers, you can help, too!

Monday
Aug232010

Taking a Fat Woman's Blood Pressure

(A short word about the term "fat." As I use it, it is not a negative, but merely a discriptive adjective. Using euphemisms like "plump," "fluffy," and "full-figured" are much more insulting to me than the word fat. Many of us who've dealt with fat prejudice for way too much time have come to "reclaim" the word fat so it doesn't have the biting sting it once did, especially when hurled as an epithet. If you are terribly uncomfortable with the word, first, look inside and see why... and second, feel free to substitute the euphemism of your choice.)

 

It happened again. 

I went to the doctor for a follow-up appointment and was called into the ante-cubicle-room, sat down and was asked what my "complaint" was. It's always such a funny question to me because it says exactly what I'm there for on the screen in front of her. But, I suppose if the complaint has changed from "ankle pain" to "hair falling out," that would be something to note.

"I'm going to take your blood pressure" as she grabs the cuff, a small one (for my big arm) and heads for my forearm (at least she didn't consider putting it on my upper arm!). "It's not going to fit," I say, yet she continues her forward movement. "It's not going to fit," I repeat -and watch her wrap it around. I didn’t let her get to the Velcro, pulled my arm out and said, more sternly this time, "It's. Not. Going. To. Fit." She huffs a little and has to (oh my god! the difficulty of the chore!) unscrew the small cuff and then, (tell me it isn't so!) has to pick up the large cuff and (argh!) screw it on the cuff thingie.

Knowing my arm (it's really flappy floppy - I really should tattoo the American flag on it or something), even the large cuff dorks out, electronically squeezing the hell out of my flesh, reading, "Good god! What is that under there! I have to do it again." And again. And again. I don't even go there anymore.

Instead, I have the Fake Nurse (the Tech who thinks she owns the hospital) just put the darn thing on my lower arm.

But, can I tell you how many medical people have no idea that that can even be done? A lot of 'em.

I've taken to watching them, amusingly (when I'm bored), try to figure it out. Where does the tubing go? Oh! up where it's supposed to be like the upper arm cuffing (antecubital), right? "It's not reading there, either." sigh (With a manual cuff, I expect a "Hmmm I don't hear anything," but [and I'm not kidding] there are techs that will make up a number instead of admitting they don't know the answer.) No, this is the wrong way to put a cuff on the lower arm.

The Correct Way to put a blood pressure cuff on the lower arm:

Holding the cuff, let the tubing fall towards the floor, the place where the tubing goes into the cuff closest to the floor as well. Then, as you wrap the cuff around the lower arm, the tubing goes over your inner wrist; the tubing can rest in your hand (don't grab it, though!). This can be done with both electric and manual sphygmomanometers (the technical name for the cuff contraption).

Once the cuff is on, the electric cuff can have its button pushed to get it going, no muss no fuss. With the manual cuff, the technician/provider needs to use a stethoscope to listen for the heart/pulse beats.

(An Aside) Sphygmomanometer Tutorial

When we take the blood pressure manually, once the cuff is on securely, we pump it up beyond what we think will be the highest/top/systolic/when the heart squeezes number. I was taught to pump it up to 200mm Hg in fat folks... WAY too tight and high for the fat women I've had in my practice... a nasty assumption that fat women will have high blood pressure. (I have notoriously low blood pressure, so low that, on more than one occasion, the tech thought the cuff was broken!) When I am the pumper-upper, I usually go up to about 170-180mm Hg, then begin the release of pressure.

When we release the pressure, it needs to be done slowly because we’re listening for the thumping of the pulse in the stethoscope (please don’t talk to the person doing your BP; we’re counting.) We’re listening for two things: 1. when the pulse begins (the systolic/upper number) and 2. when the pulse ends (diastolic/lower number). So, say I pump the cuff up to 170mm Hg then release the pressure (with the twisty button) and hear the first thump when the gauge is at 128. The thumping continues, but when the gauge says 72, all of a sudden, the pulse disappears. The person’s BP is 128/74… the 74 being the last number we heard a heartbeat. While we’re doing the blood pressure, we memorize the numbers (repeating them over and over and over) until we write it (the BP number) down. Note the above numbers are all even. It’s not amusing to hear people use odd numbers with manual cuffs because there are no odd number choices. What they are trying to say is: I don’t know what the hell I’m doing. If that happens, ask for someone else to take it.

For typical blood pressure cuff placement, the stethoscope goes right below the cuff at the bend inside of the elbow (antecubital). When putting the cuff on the lower arm, the stethoscope listens inside the wrist (ulnar).

(Aside over)

 In order to get an accurate blood pressure, there are a few “rules.” If any of them are amiss and you are told your BP is high, think about the steps, tell the nurse/aid/doc you want to wait 5 minutes and re-take it again. Then begin the steps.

When they return to do your blood pressure,

  1. MAKE SURE THEY ARE USING THE RIGHT SIZED CUFF!!

This should give you a much more accurate reading.

If a practitioner takes your BP, doesn’t like the number and re-pumps the cuff on the same arm without removing it for awhile, they are doing it incorrectly. That dorky/stupid machine automatically will do the same thing if it doesn’t get a good reading. Ask for a few minutes to rest, without talking, etc., then have them put the cuff on the other arm. If they whine or balk, tough caca; this is your health, in your records. You have a right to have your BP done correctly.

Elevated Blood Pressure Readings During Pregnancy

When the blood pressure is elevated during pregnancy (130/90 is the dividing line, but is arbitrary depending on the person’s baseline… another discussion for another day.), the above steps can be extremely important to do.

For some women, getting their blood pressure done is the most stressful part of their prenatal visits, especially if they are in that borderline or high BP place. If your blood pressure is always higher at the doctor’s or midwife’s office than it is when you take it somewhere else, this is called “White Coat Syndrome” –it has a name it’s so common. The breathing and visualization can help ensure you’re getting an accurate reading. Everyone can practice lowering their blood pressures at will, doing the above steps, with or without having the real BP taken, but these practice sessions can be really important for those with White Coat Syndrome so a diagnosis of hypertension/Pregnancy Induced Hypertenion/Pre-eclampsia is not assumed.

But, what if you’ve done all the steps and it’s still high? The standard of care is to have mom lie on her left side for about 15 minutes before re-taking it, usually with mom still on her left side. This has long been the standard in medicine as well as midwifery. However, I’ve seen a few studies that de-bunk the myth of using the left lateral position’s blood pressure reading as accurate. Perinatologists I’ve spoken to agreed; the practice of putting a mother on her left side, for readings is a false sense of security because the true reading needs to be done with a mom sitting. The issue of left-side bedrest is another issue I’m not going to get into here. This is already too long!

One more short story. In 1993, I fell at a birth center where I was working and went to the ER. The tech, a young guy, took the small cuff and put it on my upper arm. I told him, over and over, it wouldn’t fit, but he kept pumping it up anyway, the cuff’s Velcro noisily unfastened each time. He was getting pissed, so put it on again, roughly, even though I told him to get a large cuff and proceeded to use medical tape (not kidding) to wrap around the cuff to hold it on. He must have used a roll! When he pumped it up, sure as shit, the tape ripped, the cuff fell off –and I started crying. Why I cried because he was the asshole is beyond me, but I wasn’t as “evolved” about fat as I am now. I told him to get his supervisor and when the Nurse came over and saw what he’d done, she was the sweetest and kindest woman, grabbing the large cuff that wasn’t even 2 feet away, talked to me like I was a human and not a blob of flesh and told me she would absolutely correct his behavior as well as explain to him about human dignity for everyone, our prejudices be damned. I hugged her before she walked away.

After that, I realized I had to take the reigns with regards to my fat care; not leave it in the hands of those who should know better. They don’t. But, hey, we can educate them, can’t we!