Before I begin with this post, I want to make clear about my "guiding principle" post...what my intention was with that post was the quote. That we are afraid to NOT do things that we're taught in birth unless it's proven to not be beneficial - and how backwards that is.
For the record, I agree wholeheartedly with Sara Wickham's article and my views closely parallel hers. Since neither I nor my assistant/student midwife routinely catch babies (the father, partner, mother or both do), we do not check for cords. If there was an issue of a super tight cord preventing the birth of a baby, I'd be looking for that. I'd also want to make sure that we weren't dealing with a shoulder dystocia prior to cutting the cord before the birth of the baby. Nothing is more frightening than cutting off a not-yet-born-baby's oxygen supply and then realizing that you're dealing with something other than just a tight cord. It is extremely rare (I have never seen it to date) for a baby needing a cord cut on the perineum - or needing the cord pulled over the head. Even with a tight cord, keeping baby close to mom's body and somersaulting it out can keep the cord intact nearly all the time. Of course, as with most things in life, there are exceptions.
Now, on to urinalysis dipsticks...
This seems to be one of the trickiest things for many midwives to consider letting go of. While I believe that many have a thought that it is beneficial, I often find myself wondering if we keep doing things because it's what everyone does, or because our clients expect it, or if we don't do these things, then what are they paying us for? It is important for all care providers to not get wrapped up in doing things simply for the sake of doing. After all, we're wanting to convey trust and a belief in the normalcy of pregnancy and birth, right? We're wanting to do things that are soundly evidence-based, right?
There have been many studies on the uselessness of routine urine dipsticks in asymptomatic low-risk women. While some of these studies have been published in US journals, it's Europe that has started putting its money where its mouth is. With socialized medicine comes a definite need to know if various treatments, tests, etc., are financially sound. In the US, the rate of malpractice litigation leaves little evidence-based practice to be found.
As an apprentice, we always used urine dipsticks. What I found ironic was how many times things popped up positive on the sticks, only to have it negated by my preceptor (almost 100% of the time this happened). Looking at the results of most urine dipsticks:
Protein - say "protein in the urine" and many people automatically think about pre-eclampsia, a scary disease/disorder with unkown etiology. What we know to be true is that proteinuria is a very late sign of pre-e - and not something that you're going to be finding accurately without any other symptoms. If a provider suspsects pre-e, the only way to accurately diagnose it is with a 24-hour urine collection (a single urine collection can have skewed results on actual proteinuria, based on fluid intake, etc) and a liver panel. Period. Urine dipsticks should not be relied upon for diagnosis or screening of pre-eclampsia.
Most women have trace protein in their urine for two reasons: concentrated urine (needing to drink more water) or extra strain on the kidneys (but not dangerous) requiring more protein in their diet. Many providers would argue that those two bits of information are enough - I beg to differ. Are you not talking to your clients regularly about water intake? Nutrition intake? Do you really need to police your client's urine to make sure they're doing what they tell you?
Glucose - in a non-pregnant woman, glucose in the urine points to further screening for diabetes. However, as we tend to do, we apply this same logic for pregnant women. This is erroneous and totally disregards the normal physiology of pregnancy.
A hormone secreted by the placenta (human placental lactogen) is responsible for suppressing insulin levels for the growing baby. Baby needs additional blood sugar in mom's body to help with growth. (In a woman who was borderline diabetic prior to pregnancy, this could throw her body into true Type II diabetes) In addition, from mid-pregnancy onwards, the increased filtration of the kidneys can often cause glucose to spill in the urine. Totally normal.
The only way to accurately diagnose blood sugar issues in pregnancy is with a glucometer. NOT with the Glucose Tolerance Test (again, using non-pregnant tests on a physiologically different being), not with urine dips.
Leukocytes - Leukocytes are white blood cells. While some people believe that pregnancy is a time of decreased immunity, we know that the white blood cell count is higher typically in pregnancy than not. Add to that a changing vaginal pH system, increased vaginal discharge and you have the perfect reason for nearly every single positive leukocyte reading on a dipstick. Many women - without other signs/symptoms of UTIs, will have leukocytes every time their urine is dipped. Leukocytes are benign and NOT a good indicator of infection.
Ketones - Ah, the lovely reading that many midwives use to see if their clients are getting enough to eat. Observation of a woman in labor (excessive vomiting, concentrated or diminished output of urine, etc) can tell you if she is spilling ketones. Ketones are created when the body is not receiving in enough nutrients to sustain the energy it is putting out. Women with extreme morning sickness will often spill ketones. Again, why do we need to dip women's urine to figure this out? If a woman is that sick, you will likely know that she is not electrolyte balanced - and work towards correcting the situation. Still, I'm not wholly agains ketone sticks, I just wonder why it's so vital to have to dip when you can assume based on other signs that this could be an issue.
Sometimes women with true blood sugar issues will spill ketones in their urine. Again, knowing what I do about 'gestational diabetes', I'm not a fan of needing to diagnose these things.
Nitrites - Bacteria create an enzyme process that results in nitrites. This is a good indication that some sort of urinary/kidney infection is going on. However, if you have someone with signs/symptoms of such, a clean catch with a laboratory identifying what sort of bacteria is present is far more helpful. If natural remedies do not show improvement, you have an identified bacteria to help with medication prescription....this saves your client one more step when they need to see a prescribing provider!
pH - Different people have different pH levels in their urine. Meat-eaters have more acidic urine than vegetarians. This is a pretty useless tool as a whole in a dipstick. Many providers like to keep their clients' urine pH a specific range, but I don't subscribe to that belief.
As a side note, many homebirth providers keep their equipment in their cars. Extreme ranges of temperature can cause MANY false readings on urine dipsticks. I feel that the small bits of information I may receive from urine dipsticks do not justify their use routinely in my practice.
So, that's where I stand on urine dipsticks. I haven't done them in a couple years and it feels positive to be taking a stand for evidence-based information. It never felt right to me, and I have heard from nurses and other midwives about the lack of useful information that comes from them. Instead of buying the party line, I'm wanting to bring it out more in the mainstream so more and more providers feel comfortable with letting go of something they may not believe in.
on the standard use of urinalysis dipsticks....
Monday, February 26, 2007at 10:45 AM
Labels: midwife practice
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6 comments:
I have to say that, honestly, I keep doing them because it is standard of care in my community and it is such a low level intervention that it doesn't seem worth the fight. Pick your battles and all that. I do, however, explain the politics of urinalysis sticks the first time a client uses one so that she knows where i am coming from.
Excellent observations, I agree with what you are saying. Perhaps with my next pregnancy I will decline the dip stick tests.
Thats great - thanks for explaining that one. I'd love to hear the whys on the other ones too.
"It is extremely rare (I have never seen it to date) for a baby needing a cord cut on the perineum - or needing the cord pulled over the head."
~~~I have had to cut the cord before birth numerous times; usually because of three or more loops of cord TIGHTLY around the neck, which could not be pulled over the baby's head.
"If a provider suspsects pre-e, the only way to accurately diagnose it is with a 24-hour urine collection (a single urine collection can have skewed results on actual proteinuria, based on fluid intake, etc) and a liver panel. Period. Urine dipsticks should not be relied upon for diagnosis or screening of pre-eclampsia."
~~~I don't know anyone who does diagnose pre-eclampsia based on a dipstick urine. But in the presence of hypertension and edema, if there is 1+ or more protein on dipstick, then further examination is needed. Prior to 28 weeks, there's no need for a dipstick.
"The only way to accurately diagnose blood sugar issues in pregnancy is with a glucometer. NOT with the Glucose Tolerance Test (again, using non-pregnant tests on a physiologically different being)"
~~~A normal fasting blood sugar says nothing. We normally do a fifty-gram GTT (only draw blood at one hour after ingestion) at between 24 and 28 weeks and if it is abnormal, do a 100-gram GTT, which takes three hours. If two values are abnormal, then the diagnosis of gestational diabetes is made. There is a view that a 2 hour postprandial blood test after ingesting 100 gms of glucose is enough. BTW, glucometers are regarded as accurate if they are within 10% of venous glucose results--and that's a wide range for "normal". If a woman with GDM is spilling sugar in her urine (and is not immediately after a meal) it can be significant.
Leukocytes--IF a woman has symptoms suggestive of a UTI, having either WBC or blood in the urine strengthens the diagnosis; otherwise, leukocytes in urine don't mean anything.
Ketones are indicative of dehydration, especially when a woman presents with hyperemesis.
The list of actions given below surprises me a little. Some have value, some are just "busywork"; some are needed in special circumstances. I don't make a blanket decision.
Weighing women prenatally
~~Not essential, but I like to have a baseline, and I do if there is edema.
Doing urine dips prenatally
~~~I don't make a big thing out of it, but if the woman is more than 28 weeks and can give a specimen, I'll test it. If I suspect pre-eclampsia, I want to test.
Presenting prenatal testing as 'mandatory' or things a woman 'should' do
~~~I think a woman DOES need basic antenatal care, because not infrequently one picks up other problems. However, I think the average middle-class woman today has far too much antenatal attention and it makes her apprehensive rather than reassured.
Treatment of "anemia" based solely on lab values
~~~I very rarely see anemia antenatally, to be honest.
Vaginal exams prenatally in the last month
~~~No need
Induction of labor if past due date
~~~Only if a monitor tracing is completely unreactive, or ultrasound shows the baby is not growing.
Treating all rises in blood pressure in the last six weeks of pregnancy as if it were not physiologically normal
~~~Unless accompanied by the other symptoms of pre-eclampsia, it isn't abnormal.
Vaginal exams upon arrival in labor
~~~Depends entirely on the quality of the labor.
Constant observation / direction in labor
~~~I've never worked in an environment where I could be with one mother at a time.
Speeding up labors that are deemed "slow"
~~~Again, that is a judgement call based on both the quality and length of labor. I had two days of strong contractions with my first baby, and never dilated even one cm. Primary dystocia.
Vaginal exams to "see if mom is ready to push"
~~~Only if she wants to push, or we need to get the baby out (fetal distress). Otherwise, she'll push when she needs to.
Oxygen to mom in presence of low fetal heart tones
~~~Usually doesn't help, but it can't hurt
Perineal massage during pushing
~~~No.
Direction and management of pushing stage
~~~Sometimes needed.
Checking for umbilical cords around the neck
~~~Only once the head is born.
Suctioning babies - with or without meconium
~~~With meconium, yes. I've experienced aspiration and consequent real complications without.
Breaking the delicate birth bubble (i.e., hats on baby, listening to heart rate even if baby is responsive and tone is good, rubbing baby or "drying baby off")
~~~Usually unnecessary
Management to get placenta out within a certain time frame after birth
~~~Definitely not, unless the woman is hemorrhaging.
Antigonos
Certified Nurse Midwife
BTW, regarding all your criticism of me--just how would you manage a labor and delivery in the home, without backup, of a woman with a perfectly normal pregnancy, and early labor, who suddenly developed a massive concealed abruption, DIC, Couvelaire uterus?
It happened to me--only one of the reasons I'm not in favor of home deliveries--but the woman survived, because of the Flying Squad (it was in the UK). She had to have a hysterectomy, however, and 37 units of blood to stabilize her. I expect the average direct entry midwife would run around in circles. Of course, it's entirely possible the patient would think this was all "karma".
I've been thinking a lot about this passage and the one prior to it. A lot, a lot, a lot... I'm a mom, not a midwife or nurse. Just a first time mom who was cheated out of her dream birth by a lazy MEDwife who didn't want to hang around all night while I had 45-second-long contractions instead of 60. I'm a mom who's done a lot of self blaming, research, crying, panicing and therapy do deal with the hell of a birth experience I had.
I would venture to say that I am now more in tune with my body than I have ever been all because I have learned the hard way and that listening to routine tests and procedures lead me straight down the road to a unwanted and (in hindsight) unnecessary c-section.
I think that the major problem that we as society is facing, in terms of reproduction, is the fact that very few women are willing to slow down and listen. Listen to what their bodies are craving, feeling, needing. For example, I truly believe that I craved peanut butter while I was pregnant because of the protein. I also truly believe that I should have trusted my gut when the nurses at the hospital told me that it was "hospital protocol" that every laboring woman MUST have an IV and wear a hospital gown when I showed up for my "induction" as instructed at 3am because of my faulty contraction pattern. Shame on my body for not knowing how to properly labor the baby it created!
I feel that until gestating, or women with the potential to gestate or have in the past, stop looking at pregnancy as something to be fixed, managed and handled by someone "more qualified", these routine disturbances to the normal progress of pregnancy will continue, unquestioned.
It truly disgusts me, and I know from the bottom of my soul, that change begins with me and the others who are completely unwilling to hand their care and the responsibility for their care over to somebody else, because in my opinion, NOBODY is more qualified than a woman carrying a baby to make decisions for herself and tune into what she needs. Even more importantly, though, the ability to tune into what she does not need.
Angela
Thought-provoking post. As you know, I admire your determination to look at these (and other) issues critically and holistically, something that those enmeshed in the medical paradigm rarely seem capable of doing. Whereas they put their energy solely into defending the status quo, you put your energy into looking for what truths can be had outside of it. Growth can only ever come from the latter.
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