#34 OB Myths with Lisa Miller, CNM, JD

One thing I’ve loved about season two of the podcast is that we have been able to learn from some amazing guest speakers, and today, we have Lisa Miller. For some of you, you’re going to be fangirling just like I am. For others, you’re going to meet someone, one of the greats as we call her. So, Lisa, if you can go ahead and just introduce yourself. We’re going to talk about myths in OB and she’s going to change our mind about a couple of them. So, go ahead, Lisa.

I love you. You guys probably already know the correct answers. You’re the ones that dispel a lot of myths.

We’ll see.

I started as a labor and delivery nurse in 1979 at Apprentice Women’s Hospital in Chicago. Then shortly after that, I became a transport coordinator for one of the first maternal transport systems in the country that used multidisciplinary approaches. Then I went to midwifery school. I got out of midwifery school. I got a certificate only, so I was a diploma grad, certificate midwife, got out in the end of ’82 right before Christmas, and started working at Cook County Hospital where I worked for many years and then was in the Chicago land area. During the time I worked as a nurse midwife, I went back and got my BSN through a completion program. Then I decided to go to law school, because I wasn’t smart enough to get a PhD, but I was smart enough to be a lawyer because all you got to do to be a lawyer is read a lot and be willing to argue and be willing to get yelled at.

When I was a labor and delivery nurse, I’m like, “Oh, I can do all of those things.” So, I got the JD instead and then started teaching and have developed a bunch of practices, blah, blah, blah, blah, blah. Anyway, now I teach fetal monitoring, some risk management and normal labor. I do a little course that I’m now going to recommend folks to you and your website because I do a little topic called Physiologic Logic. That’s what you guys are all about. Yeah, that’s my little title. Feel free to steal it.

I love it. I love it. Well, we’ll credit you for sure, Physiologic Logic.

I might have stolen it from someone.

Well, you’re the first.

Well, that is fascinating. I never knew any of that. When did you start teaching? What year?

Well, really, my first teaching gig, believe it or not, my first presentation was in 1979. Shout out to Nancy Jo Reedy, who’s a midwife. I think Nancy might be retired now, but she’s a longtime midwife in Chicago, the first one at Northwestern. She worked with a perinatologist there and she’s the reason I went to midwifery school, but Nancy saw something in me and I literally had been out of school six months and there was going to be a big perinatal conference for all the outreach hospitals. She said, “You’re going to present.” I’m like, “What?” She goes, “You’re interested in fetal monitoring. A report had come out.”

So now we see the NICHD, but this was a book. It was probably a 70-page book that came out probably in ’78 or something, said, “You’re going to talk about fetal monitoring and whether it has any place in OB,” because remember, we were just starting. Well, you’re too young to remember.

Oh, wow.

But when I started, there were only three fetal monitors. So, a year later, I did this presentation, and the other day, I found my index cards from it. I had all the notes.

Oh, my goodness.

This is when you made slides. Somebody took a picture and then they developed them into slides and you had those carousels. So, that’s how old I am. We did not have pumps. We had glass bottles, and our big tech thing was the mini-drip. So, instead of a regular size tube, it was a little tiny tube and you counted the little mini-drops to get the rate. All of this stuff, we didn’t have anything fancy.

How fascinating for you to see OB progress over the last 50 years and how so? I mean, so much has changed over my 12 years or something. I mean, epidurals wore off when I started and now they’re on a pump. Even that little practice change, let alone everything you’ve seen, I can’t even imagine.

Well, yes, I agree, but I’m not sure all of it is progress. I think there’s a lot we may have lost.

Like what?

Hands-on, the ability to do a physical assessment. I talked about Leopold’s maneuvers. People don’t know what I’m talking about. So, using your hands, people are like, “If there’s a problem, I’ll put a pulse ox on.” I said, “Well, why don’t you just take a pulse with your fingers on her wrist? Why don’t you just touch the patient?” I think we’ve lost some skills and I don’t know that we’re the better for it. I think we’ve gained a lot. I’m not going to lie. Yes, there are a lot of great improvements, but there are things we had before that maybe we need to bring back. I don’t need a checklist to tell me the signs and symptoms of shock, because I learned that in 1979 and it’s stayed with me.

I know the relationship between pulse and blood pressure, but now we’ve got to have maternal early warning signs. When I read that, I thought it was going to be something new. Then I read it and I’m like, “Well, these are the signs and symptoms of shock. Doesn’t everybody know that?” That was a real wake up call for me to realize how significant, in some cases, the lack of knowledge was, the core knowledge of physiology.

Well, and the nurses that know that knowledge and were trained in that knowledge are, one, either retired or retiring. I tell the nurses that I do work with that have been on the floor for 30, 35 years, I’m like, “You got to teach us. You have to teach our new grads.” We need you to teach, but one thing I’m seeing is that they’re tired and they don’t want to teach. They’re done. I’m like, “How do I suck all that knowledge out of your brain because you have it in there?” So that’s definitely a challenge. That’s one thing I’m trying to do here, I think all three of us.

Yeah. Well, I would say that as much as those resources on our units, my goodness, some of the best things that I’ve learned as a nurse came from those nurses and yet it shouldn’t fall on them either. This is my little soapbox moment. There should be better training.

You hit the nail on the head. I understand that nursing schools have a lot of constraints, budgets. Who’s able to teach? I mean, some people aren’t even getting live time in labor and delivery. It’s all simulation based, which I get. But then when we hire a new grad or even somebody coming from another hospital, why isn’t there a detailed preceptorship? Now, some places have it. Some places have these nurse internships or nurse residencies, and those are great. I mean, I remember my orientation. This is going to be like I walked uphill in the snow to school both ways. You get old and you think of all these things. Oh, they were better, but some things were better.

I had a 90-day orientation, and it included classes on normal labor, oxytocin use, how the uterus works, high risk conditions, diabetes. I would work with a preceptor, but then I’d go hear lectures sometimes from an MFM and I’d have to go. Part of my orientation was going to these lectures, learning about hypertension in pregnancy. I remember the first book I bought was by Gant, and it was I think $50, which in 1979 was a lot of money. I bought that book, because I wanted to learn more about preeclampsia and all these other things. So, we were encouraged to read. We were given classes, and this was a professional expectation that we were at the start of our career and that we would gather knowledge and do research and learn these things and take some responsibility for becoming a better professional.

Well, we definitely agree with all of that.

We’ve talked about it on various formats as well of what’s the theme of this season. It’s continued to learn and educate yourself and seek out your own learning. You have to hold yourself to the standard of excellence. We’re not getting it, but we have to be accountable to get it. That’s why all of us exist.

No, I agree. I agree.

Well, thank you for that insight into your career and past, but today, we want to talk a little bit… I think maybe we’ll try to hit three if we can, some myths. So, if you have been following along on Instagram, I asked you guys to throw in some myths in a box. The reason why it was because Lisa was going to help us see if they’re true or not. So, I sent them to her and she picked her favorites. So, the first one is, is it true that we should pit through doubling or coupling contractions? We’ve all heard it, pit through it. Lisa?

All right. Well, I want your guys votes. What do you say, Justine, Sarah? What’s your response? Yay or nay?

Nay. Nay.

Okay. Nay. Nay carries the day. Nay is correct. There’s absolutely no evidence to support this anywhere. This is a myth. I can’t believe it’s still there because it’s a myth that was around back when we first started using… You need to know how old I am, 79. We weren’t using intravenous oxytocin. We had just started. We were still using buccal pit. Some young nurses out there don’t know what I mean, buccal pit. B-U-C-C, not C-K, oral, sublingual. So, no, there’s no evidence to support that. In fact, when you have coupling and tripling, my recommendation is number one, evaluate overall relaxation time. Make sure resting tone is normal. Now, people get relaxation time and resting tone mixed up. They’re not the same thing.

Relaxation time is the time between contractions when you measure resting tone, which is the tonus of the uterus at rest. So, in a 10-minute window, you want to have at least about 50% relaxation time. This is in first stage labor, primarily active phase of first stage. So, an average data from, say, [inaudible 00:12:41], who talked about fetal acid base, is you want to average about 60 seconds. So, when you have coupling and tripling, you have to evaluate that relaxation time. Then you have to look for why the muscle is not contracting regularly. So, you have your own differential diagnosis in your mind. Some of the things, poor blood flow to the uterus. How do I evaluate that? Let me check her blood pressure.

Let me compare it to a pulse. Let me make sure everything is flowing nicely. Positioning, is she on a sideline? Sometimes people go, “Oh, well, she’s sitting up, so it must be a good position.” But some of these beds have those puffer pillows, lumbar supports. When you do that and you arch the mom’s back, so she is sitting up, but she’s arched, you are pressing that eight or nine-pound baby against the inferior vena cava. So, are you really getting good blood flow to the uterus even though she’s not “on her back”? So, evaluate blood flow to the uterus, look for signs and symptoms of infection. An infected uterus will not work well. So, you got to take care of that. Then the other thing you want to think about is going back to relaxation time, relaxation time with normal resting tone has two important purposes.

Number one and this is the one most nurses do know, it’s to avoid deterioration of fetal acid base, because during a contraction, those spiral arterials are closed off and blood flow in the interval space comes to a relative standstill. Now, this is for a short period of time and that’s normal during labor. Fetuses are built to take that. There’s no problem there. But if the contractions are too many or too close together, that can cause problems not just with fetal acid base, where the fetal oxygenation cycle is not working correctly with enough time in between to recover from those breaks, but what else are the arterials doing? They’re providing oxygenated blood to the muscle. That’s what the uterus is. So, think about this.

Any of you that work out or lift weights or anything else, if you tax a muscle to exhaustion, what happens? It fails. So, if you don’t have adequate relaxation time with normal resting tone, that uterus, that muscle’s not going to contract effectively. So, these are all the things you have to look at when you’re thinking about how to deal with coupling or tripling. If you do have some uterine muscle lactic acid buildup and if you’re interested in this, just go to PubMed and do a search for amniotic fluid lactate. This is a measurement that other countries are using. Primarily Sweden as the research come out of Sweden, but they did research all over the world.

What they showed is when you have a high buildup of lactic acid in the amniotic fluid, that reflects a uterus that has gotten to the point where it’s unable to recover. You can give all the pit in the world that uterus is not going to contract effectively. So, high amniotic fluid lactate has been associated with both dystocia and postpartum changes. You tax a muscle to the extreme. How well is it going to contract once the baby’s out? We have all these initiatives and God bless, I’m glad we do, but we have a lot of initiatives to deal with maternal sepsis and maternal hemorrhage because maternal morbidity and mortality is huge in this country. Really, we should be ashamed. We’re rescuing people.

Here’s all these initiatives for how to rescue people, but I don’t see anybody talking about the use of physiology of the uterus, understanding uterine blood flow, understanding uterine muscle function to prevent the risk of sepsis and prevent bleeding. Hello. So, sometimes I feel a little bit like Sisyphus where I’m pushing a rack up a hill trying to get people to listen. I bet you guys feel that same way too, because this is just lack of knowledge. This is not bad intent of anybody. People have great intent.

Nobody goes to work wants to hurt people, but it’s lack of information on core physiology that could help us so much. Until there’s a terrible outcome, hospitals aren’t usually doing a lot of work. Now, some of them are. Some of them I think are bringing folks in and trying to get better education, not just for the nurses, but for the docs, midwives, residents, but it’s not universal and it’s certainly not standardized.

So going back to this amniotic fluid lactate, can the uterus get there naturally to lead to dystocia or other complications, or is that mostly because of oxytocin or Pitocin use?

Well, I think it could get there on its own if for some reason you had a situation where somebody had poor blood flow or blood flow uterus was affected, vascular disease, some of the higher risk conditions, that type of thing, anything that’s going to affect it. But definitely, I would have to say that in my opinion, the majority of it is going to be related to misuse of oxytocin, whether that’s via induction or augmentation. I go in and this is fairly common, but I had a group where 80% of the group couldn’t define tachysystole. They defined it in the multiple choice question as greater than 6 contractions in 10 minutes, and it’s greater than 5 contractions in 10 minutes. Again, averaged over 30, but that’s a big difference.

If your mental model has an extra contraction in there and that’s what you’re looking at, you are probably unwittingly, unintentionally providing more contractions than necessary. The other thing that I see that relates to this is the idea that people don’t understand there’s a difference between what happens in early labor and then what happens later. So, people are inducing women and saying, “Well, we need a contraction that’s really strong every two minutes.” That’s a second stage labor pattern. You do get to somebody who’s one or two centimeters. Not only are you going to have problems with fetal acid base, but you are then much more likely to have problems with uterine acid base as well.

So, these are some of the things I teach that I was taught in 1979. What does normal labor look like? What happens? How do the contractions start? There’s a lot of research that was done in the sum of it, very invasive. It certainly wouldn’t pass review today. Nobody would be allowed to do some of these things, but this was before IRBs and this work came from all over the world on how the uterus works. But I find very little evidence of knowledge of these core principles in many institutions where I teach.

Because with our physiologic birth class, we’ll have hospitals reach out or nurses reach out and they want their hospitals to be trained in it. The hospital’s response is, “Well, what’s the evidence on the class?” I’m like, “Well, the pelvis has existed like this forever and the uterine muscle…” They want a study saying, this particular class leads to X, Y, Z, which might be in the queue, but only for the sake of appeasing hospitals, to me, open an anatomy physiology book. I’m not making this stuff up. I’m summarizing the knowledge and literature of what is there already. It’s so hard for me to answer that question.

What’s the evidence for the muscular skeletal system? Where is the evidence?

Would you like me to go back to prove to you that there is muscle in there or the uterus is a muscle and bone and fascia and ligaments and all of the that? It’s such a silly question, but I think we’ve gotten so focused as Western medical system on the evidence. Well, is there a clinical research study? Is there this and that? What’s the proof? When the entire point of the physiologic birth class came from CMQCC’S recommendations where they did a multidisciplinary toolkit on how to increase vaginal birth.

I’m literally just answering their question and saying, “Okay, you want us to train in physiology with a wellness approach, avoiding medical interventions that are otherwise unnecessary? Got you. Done.” I’m sure you see this too in all the work that you’ve done. It’s just that research piece from we’re so focused on the study that shows that we have a uterus versus this is widely known if you’ve done the work.

Right, exactly. But I get ridiculous questions all the time. What’s the evidence for the oxygen pathway? Really? You want to research for how the oxygen molecule gets from the environment to the fetus? How are we going to do that study? Yeah, let me put a pillow over your face and measure what happens compared to somebody who doesn’t have a pillow over their face. I mean, this is insanity. Yeah, this is physiology. You don’t need evidence for physiology because they did this already. It’s in every textbook.

It’s been done. Yeah.

Anatomy and physiology, it is.

Yeah. That should just be our new tagline, everyone. You don’t need evidence for physiology.

There you go. Yes. I’m going to start saying that.

Yes. Okay. Well, that was fascinating. I already have two pages of notes on what you talked about. So, if you’re listening, you may need to pause this and make sure you’re listening with paper in front of you, because we have another myth for you to bust. This one, I would like, Lisa, for you to address nurses on how they’re supposed to talk to providers about it, because I think that’s the issue. I think nurses know the myth, but it’s convincing providers that it’s not appropriate. But the myth is that fetal scalp stim helps during a deceleration.

Okay. I can’t believe this one is still out there, but I will say this in a lot of my classes, I ask this question and I’m getting 80 to 90% of the multidisciplinary groups I teach recognizing it as false. So, that’s good news. There’s just a few holdouts and they’ve just been taught incorrectly. So, there is evidence for it’s not a treatment, it’s a test. If you did a lit search on scalp blood sampling and scalp stimulation, you would find that scalp stimulation is a test that was studied to replace the invasive scalp blood sampling that I actually did when I was at county. That was problematic for a number of reasons. So, it’s a test. It’s not a treatment. Now, think of the physiology.

So, besides the fact that you cannot find a study anywhere where it is used as a treatment, you can only find studies where it is a substitute for scalp sampling, which by the way, was always performed during baseline rate between contractions. Okay? So you’re not doing it during a decel, you’re not doing it during a contraction. So, as the substitute, it’s also just simple physiology. When the fetal heart rate is in the 60s, that is not the essay node pacing anymore. Those are junctional or ventricular pacemakers, a different pacemaker. The kid’s giving you all the information you need. Now, if you go in and scrape up the scalp with your fingers or whatever, and by the way, one of the original scalp stim studies used in Allis clamp clicked to the second tooth. Look it up.

Can you imagine if somebody put an Allis clamp anywhere on me and clipped it to the second tooth? Would my heart rate go up? Yes, I would scream and I’d probably have a reflex like hitting motion. But in any case, when you go in and do that stimulation, if you see an increase in heart rate, you’re not helping the baby. It’s not that the baby’s okay. It’s not ruling out acidemia like the traditional use of the scale stem test. It is because you’re triggering a sympathetic discharge. You take somebody who’s under stress and then you apply another stressor. If they have any sympathetic discharge left, yeah, it’ll work. That doesn’t mean the kid’s okay and it doesn’t mean you’ve helped. Now you’re using up a sympathetic response that they may need as time goes on. Why would you do that?

If somebody’s already on a treadmill and experiencing symptoms in a cardiac stress test, do you make them go faster or do you stop the test? Come on. Come on. Here’s the good news. David Miller and I taught, it’s probably already over 10 years ago, maybe at an ACOG, at one of the ACOG national meetings. The good news, even back then, 80% and that was mostly, almost 100% physician attended, 80% knew this wasn’t true. So, we have holdouts that are still doing it. Now, to your question, how do you address it with the provider? Well, you can’t address it at the time it’s going on. You’re not going to do anything. You’re going to create a lot of cognitive dissonance. The person isn’t going to pay attention. So, you need to address it system-wide.

In other words, you need to go to your risk manager. You need to go to your nurse educator. You need to go to your chair of department, unless it is the chair of the department that’s doing it. But you need to do some peer education around appropriate use of scalp stimulation. There is an appropriate use for it, just as I said, to rule out fetal metabolic acidemia. All right. So, you’ve got to have that discussion and then you’ve got to make a departmental notice or change, whether that comes out in an M&M meeting or comes out as a verbal education versus something written. But the department, the whole OB department, nurses, midwives, physicians, just needs to be made aware and no shame or blame.

Again, nobody is doing this because they’re a bad person. They’re doing it because somebody trained them to do it. They sometimes see the heart rate go up, so they think it’s “working”. It is not the intended effect. Then somebody says, “Well, do you have any studies on this?” No, because nobody’s going to let you do a study. Can you imagine going to an IRB board? We want to do a study where we already have a fetal heart rate of 60, and we want to go in and do a stress test on the baby. Who that understands physiology would ever allow that? We want to see what happened. No. How would you consent somebody for that? We don’t know if this is bad, good, or neutral. How about we try it? Yeah, I don’t think so.

No. This is what people don’t get. Well, if there’s no study, let’s try common sense and knowledge of physiology. Let’s try that. I don’t need a study for that. Critical thinking, read the literature. I once got in a big argument and somebody said, “I had so…” I just said, “I defy you.” I actually said to somebody once, I said, “I absolutely defy you to find any literature or any study where scalp stimulation was used in any method other than simply to rule out acidemia. I defy you and I still defy you.” I’m still defying.

Yeah, good point.

There’s nothing you can say in the moment. Now here’s the good news. I don’t have any evidence that it’s dangerous. It’s just unnecessary. Physiologically, at least theoretically, I don’t really want to use up and trigger ongoing sympathetic discharge when you’re already giving me the information as a fetus to tell me, “Hey, I need some help.” I’d rather just help you. Not see how much help do you need? Let’s see if you can take this. You’re already under stress. Let me add another stressor. I mean, it just doesn’t make any sense.

Again, our hashtag or new line worked in that one too. Physiology doesn’t need evidence. There we go.

Just need understanding.

Yes. So, that’s good. I think this will be our last one for today. We might need a part two of this episode. Okay, so I had a couple people mention this one. When you have variables and nurses are saying or providers are saying, “It’s not a decel because it’s coming off of an accel.”

I had not heard this one before. This was news to me. This has got to be one of the wackiest ones that you sent me. So, I was thrilled because I’m like, “Oh, my God.” So here again, will you go back to physiology? Let’s just talk about the mechanism of a variable, which by the way is in pretty much every textbook on fetal monitoring with pictures. So, what happens? There’s three vessels in the cord, big fat vein, two small arteries. The vein is carrying the oxygenated blood to the fetus. The two arteries are carrying the deoxygenated blood back to the placenta. So, it’s a loop. So, when there is cord compression, what gets compressed first? The big fat vein. The big fat vein, as you recall, is carrying oxygenated blood to the fetus.

So, when it gets compressed, what’s going to happen to blood flow? I’m going to have a relative hypovolemia for a very short period of time, but it is enough because I won’t have as much blood coming to me as a fetus. It is enough to trigger the baroreceptors. Baroreceptors are stretch receptors. They will respond to this relative hypovolemia by saying, “Oops, not enough blood. I better call on the brainstem to give me a reflex response that will increase heart rate to make up for this lesser volume.” So, the increase right before a variable is directly related to umbilical venous compression and the relative hypovolemia it causes. Now, we don’t always see it. Why do we not always see it?

If the cord compression is fast enough, it is the arterial compression that will what we see. There won’t be enough time for us to see that hypovolemia response because once those arteries get compressed, now what happens? I have the opposite problem. I can’t get rid of the blood to the placenta. So, I’ve got a backflow, if you will, that’s going to increase my systemic vascular resistance, increase my blood pressure, and the baroreceptors are going to go, “Oh, my gosh. Your blood pressure’s too high. I got to drop that heart rate.” That’s why we see that rapid drop that is due to the compression of the two arteries.

So, again, any person, whether you’re nurse, a midwife, a physician, a resident who understands the actual physiology of a variable decel, which has been well studied, well documented in the literature, any textbook, you will understand that one, that’s not an accel before the decel. It’s not an accel like we think of an accel to rule out fetal metabolic acidemia. It is a response to the venous compression. Now, in the old days, we did call those things shoulders, but we don’t use that terminology anymore. But for you oldies out there like me, that’s what we used to call them, but they’re not accelerations. They’re increases in heart rate due to venous compression, which is part of the mechanism of a variable decel. It’s not rocket science, it’s just science.

I like that. Okay, so people are going to want more from you, Lisa.

For sure.

Where can the find you? Tell us where to find you. You do all the things. I will say, I’m going to link your book, what’s the title of the book?

Mosby’s Pocket Guide. I have a workbook if you’re studying for the NCC and you can go to my website. So, if you can put those links in, anyway.

Do you do just live classes now or are you still online? I know with COVID, you were online.

I did do online with COVID. Right now, I’m doing primarily live because I’m pretty booked up, but I am hoping to actually record a couple of things over the summer so that I can have some on demand recorded sessions. Also, I am really excited and I’ll have information on this by A1. I am really excited for my review course. I have developed an online review course for the EFM certification exam, but it would also be good for people who just want credits or people who just want a more basic overview of fetal monitoring. Again, primary focus is NCC EFM certification, but it’ll work for credentialing. It’ll work for orientation. It’ll work as a refresher. So, I’m super excited about that. So, information about that’ll be available at A1.

Great. That’s awesome. We will see you at A1 too, so that is so exciting.

I know. I can’t wait.

We’ll have to do lunch or something. We’ll plan a little thing.

Oh, for sure. We have to do something. For sure. Thank you so much for the opportunity. I super appreciate it. I really do.

Thanks for spending your time with us during this episode of Happy Hour with Bundle Birth Nurses. If you like what you heard, it helps us both if you subscribe, rate, leave a raving review, and share this episode with a friend. If you want more from us, head to bundlebirthnurses.com or follow us on Instagram or TikTok.

Now, it’s your turn to go and look at the physiology first as you’re looking for evidence on all the things that we do in our practice. Remember that physiology is the foundation of our practice, and we don’t actually need research studies for all of it. Go find Lisa Miller and take one of her classes as well. We’ll see you next time.