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which be done by using fibres of silk, saturated with a thin solution. A more recent article on atrial fibrillation is available. DANA E. KING generic ambien cost without insurance M.D., LORI M. DICKERSON, PHARM.D., and JONATHAN L. SACK, M.D. Family physicians should be familiar with the acute management of atrial fibrillation and the initiation of chronic therapy for this common arrhythmia. Initial management should include hemodynamic stabilization, rate control, restoration of sinus rhythm, and initiation of antithrombotic therapy. Part II of this two-part article focuses on the prevention of thromboembolic complications using anticoagulation. Heparin is routinely administered before medical or electrical cardioversion. Warfarin is used in patients with persistent atrial fibrillation who are at higher risk for thromboembolic complications because of advanced age, history of coronary artery disease or stroke, or presence of left-sided heart failure. Aspirin is preferred in patients at low risk for thromboembolic complications and patients with a high risk for falls, a history of noncompliance, active bleeding, or poorly controlled hypertension. The recommendations provided in this article are consistent with guidelines published by the American Heart Association and the Agency for Healthcare Research and Quality. Although comorbid conditions such as hypertension and vascular disease are factors, the predominant cause of strokes in patients with atrial fibrillation is embolization of a clot from the left atrium. When evaluated using transesophageal echocardiography, up to 30 percent of patients with atrial fibrillation and embolic stroke are found to have atrial thrombi within 72 hours of the stroke.3,4 Risk factors for stroke in patients with atrial fibrillation include a history of transient ischemic attack or stroke, age greater than 65 years, a history of hypertension, the presence of a prosthetic heart valve , rheumatic heart disease, left ventricular systolic dysfunction, or diabetes. Heparin is the preferred agent for initial anticoagulation because it provides almost immediate effects and can be discontinued rapidly if bleeding complications arise.5 The drug should be given as a continuous intravenous infusion, with the dose titrated to achieve an activated partial thromboplastin time of 1.5 to 2.5 times the baseline value. In patients with atrial fibrillation that has persisted for more than 48 hours, heparin can be used to reduce the risk of thrombus formation and embolization until the warfarin level is therapeutic or cardioversion is performed. Prevention of deep venous thrombosis and pulmonary embolism are potential added benefits of initial anticoagulation with heparin. Warfarin therapy is monitored using the International Normalized Ratio . Therefore, it is important to consider risk versus benefit before warfarin is prescribed. Risk factors for major bleeding include poorly controlled hypertension, propensity for falling, dietary factors, interactions with concomitant medications, and difficulty controlling the degree of anticoagulation because of patient noncompliance.9,10 To ensure efficacy and minimize harm, the INR should be kept between 2.0 and 3.0. Other antiplatelet agents, such as ticlopidine , have not been studied in the prevention of embolic strokes in patients with atrial fibrillation. Hence, they are not recommended for use in these patients. Information from references 2, 9, and 10. Information from references 2, 9, and 10. INR = International Normalized Ratio. Information from references 2, 9, and 10. INR = International Normalized Ratio. Information from references 2, 9, and 10. If cardioversion is unsuccessful and patients remain in atrial fibrillation, warfarin or aspirin may be considered for long-term prevention of stroke. If atrial fibrillation recurs or patients are at high risk for recurrent atrial fibrillation, warfarin may be continued indefinitely, or aspirin therapy may be considered. Factors that increase the risk of recurrent atrial fibrillation include an enlarged left atrium and left ventricular dysfunction. Factors that significantly increase the risk for stroke include previous stroke, previous transient ischemic attack or systemic embolus, hypertension, poor left ventricular systolic function, age greater than 75 years, prosthetic heart valve, and history of rheumatic mitral valve disease. With persistent atrial fibrillation, patients older than 65 years and those with diabetes are also at increased risk. The lowest risk for stroke is in patients with atrial fibrillation who are less than 65 years of age and have no history of cardiovascular disease, diabetes, or hypertension. Heparin therapy should be considered in hospitalized patients with atrial fibrillation persisting beyond 48 hours and in patients undergoing medical or electrical cardioversion. Antithrombotic therapy using warfarin should be given for 3 weeks before cardioversion and 4 weeks after successful cardioversion. Patients with persistent or recurrent atrial fibrillation after attempted cardioversion should be given chronic warfarin or aspirin therapy for stroke prevention. Information from references 2, 9, and 10. Heparin therapy should be considered in hospitalized patients with atrial fibrillation persisting beyond 48 hours and in patients undergoing medical or electrical cardioversion. Antithrombotic therapy using warfarin should be given for 3 weeks before cardioversion and 4 weeks after successful cardioversion. Patients with persistent or recurrent atrial fibrillation after attempted cardioversion should be given chronic warfarin or aspirin therapy for stroke prevention. Information from references 2, 9, and 10. To see the full article, log in or purchase access. The authors indicate that they do not have any conflicts of interest. Sources of funding: none reported. All comments are moderated and will be removed if they violate our Terms of Use. 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by Erik Lee

How many bossy midwives does it take to change a lightbulb?

“Bossy midwives.”  I found that phrase in a London Times story on British hospitals (sadly unavailable online now).  The phrase has stuck with me for years.  I remember telling a friend about it and hearing that some women get so disgusted with “bossy midwives” they forego all medical assistance and give birth on their own at home.  Astounding.  I remember sitting back in sheer admiration at the audacity of the unassisted childbirth movement.

When we had our first child, my wife and I decided to work with Certified Nurse Midwives.  For years I didn’t think of it as an encounter with “bossy” midwives, but “seriously whiny” midwives.  Our first midwife rushed down hospital hallways between two clients, one of whom was screaming a lung through the ceiling during birth.  By contrast, my wife must have seemed as calm as a piece of furniture.  I certainly felt like some kind of fixture, and at times I felt our midwife treated my wife like a fixture too.  After hours of urging the fixture in a strained and whiny voice to push out our little lightbulb, she gave up.  The OB came on the scene and decided a suction cup might work.  Our little lightbulb twisted right out, but we vowed we’d never go back to that situation.  We were quite lucky our bulb didn’t get surgically extracted.  I didn’t think of the whiny behavior as “bossy” until years later when a doula mentioned the “manipulative” practices of Certified Nurse Midwives at her local hospital.  Manipulative, bossy – okay, those seem like branches on the same vine.

I can understand how a Certified Nurse Midwife could become “bossy”:  CNMs work in hospitals, which have to be among the most “directive” places on earth, as one birth care provider put it to me.  It takes serious bossiness to get anybody to take off all their clothes, put on that flimsy gown that never quite closes in the back, and then make them walk down the hallway on cold tile floors to a room where the real business begins.  Hospitals are bossy places; the attitude is bound to wear off on anyone who works there. 

Not all midwives have “CNM” after their names, however.

Dottie, a midwife-doula in Colorado Springs, told me, “We specify up front that whatever we do will only be by the client’s consent.”  She told me at times she felt she had to say “I need you to do this…” when legally required, but didn’t think midwives normally did anything that could be considered “bossy.”

I called Laura Shanley, the founder of zolpidem 10 mg imprint, to hear what she had to say about bossy midwives.  I expected an unassisted childbirth advocate to say something like, well, they’re midwives, of course they’re bossy, that’s just the way they are.  Instead, she expressed a positive attitude toward midwives and strong support of their work.  “I think the main reason midwives might seem bossy is the fear of losing their license,” she said.  She listed a number of ludicrous laws hampering midwives:  in our State of Colorado, midwives are required to transfer care to the hospital if labor hasn’t significantly progressed twelve hours after the water breaks (in Oregon, the law allows seventy-two hours);  the placenta has to be delivered within one hour of the baby.  Midwives in every state work under ridiculous legal limits, and jail time can be a very real consequence for using their own professional judgment.

According to Colorado law, our second child developed in an almost-anemic uterus.  My wife’s iron levels were hovering right above the legal limit for a homebirth, and fortunately never dipped below it.  Our homebirth midwife got a bit bossy about food, urging my wife to eat more and take supplements to bring her iron levels up.  That birth went far more quickly – the midwife arrived ten minutes too late.  She got to show the placenta and cord blood stem cell kit who was in control, but that was her only outlet for whatever bossiness she might have felt.  Lightbulb #2 floated serenely in our bathtub at home after a far safer, far faster, far better birth experience than Lightbulb # 1’s birth had been.

An anesthesiologist, an OB, and a midwife walked into a bar.  The anesthesiologist ordered a pitcher of stout and a double burger; the OB ordered a Reuben and a bottle of red wine; the midwife ordered their biggest plate of steak and fries with a margarita.  They all sat in a booth and shared war stories.

A long time passed, and the three realized something had gone wrong with their order.  They decided to find out what the problem was.  They found the busboy just behind the swinging double doors to the kitchen.  He was struggling to get their overloaded cart from the tiled kitchen to the carpeted dining area.  The wheels kept catching on the bump.

The anesthesiologist kneeled down and examined the tires.  “You just need to inject something here in the back,” he announced.  “Then everything will go better.”

The OB leaned down to look at the carpet.  “This part of the carpet is blocking the cart,” he announced.  “Give me a knife and I’ll just give it a little cut to help it along.”

The midwife leaned over to the busboy and whispered loudly in his ear, “You can do this!  Just PUSH!”

A male midwife in Colorado, Bill Dwelley, wasn’t happy to hear my question.  “Midwives get dumped on a lot as it is.  We provide more direct care, have better statistics… and now we’re going to get labeled as ‘bossy.’ Hmmm, I don’t know…” He was on his way out the door but gave me contact information for his colleague zolpidem 10 mg 50 stück

“Part of the skill of a really good midwife is the ability to differentiate when it’s time to give direction and when it’s time to sit on their hands,” she told me.  She didn’t think there was any connection between unassisted childbirth and a bossy midwife encounter.  “A very deep, unwavering faith in the birth process is what would allow unattended birth, not really disliking midwives.”

I almost missed our third little lightbulb’s birth.  The first two had each seen the light ten days after the medically predicted due date (that’s Method #23 for How To Make Your Midwife Legally Nervous in Colorado, as the law doesn’t allow for babies that go beyond two weeks).  We had planned for the same on this occasion.  Instead, ten days before the medically magic day, my wife felt contractions.  We brought them under control with an Epsom salts bath, and felt it would be at least several days.  Just in case, however, I took the two older girls shopping for foodstuffs.  We had allowed our supplies to run low to get ready for the mother of all birth preparation shopping trips.  When we arrived back home with a car bursting at the rivets, I spotted an extra vehicle in the driveway. 

Oh, the doula must have arrived, I thought, so things must be-. Wait, there’s TWO extra cars in the driveway!  Both doulas must have arr-. Wait, there’s THREE extra cars!  The midwife is here too!  We might be late!

 I left the two girls with the childcare doula and got to the bathtub in time for the last twenty minutes of the birth.  Again, the birth was far smoother and far safer than our hospital experience.  Thanks to helpful doulas being on the ball, the older girls watched their new baby sister being born during the last few minutes.  During the pregnancy, my wife had eaten one tablespoon of raw liver every day (not the midwife’s suggestion, by the way) and her iron levels were sky-high.  No need for bossiness there.  The midwife didn’t seem to feel she had missed out in any way.

“I grew up around doctors,” Laura Shanley had told me, “and just as there are doctors who have big egos, there are midwives who have big egos.  Some just like being the authority figure.”  

Rebecca Pugh had partially agreed.  “Some are more goal-oriented, which necessitates more bossy attitudes.”  Sometimes that varies with a midwife’s recent experiences as well.  “Midwives will be more urgent, more goal-oriented if there’s recently been a difficult situation.  A good midwife will set aside a previous traumatic birth and renew their faith in natural, normal birth,” Rebecca added.

As I sit here, typing away with Lightbulb #3 on my lap, I wonder if there’s any clever way to answer my initial question.  As with all people, midwives are complex; there may not be a trend strong enough to stereotype with a hoary old joke.

Ah – however, Lightbulb #3 has just made a sound that any parent recognizes.  As babies sometimes do, she has provided an answer to my long-pondered question.  Midwives don’t change lightbulbs, they only help you get the bulb out of the box without a 30% chance of having to use a scalpel. 

It’s the parents who change the lightbulb, and now I must be off to give my own a change.

Erik Lee is a writer, scientist, and father of three. He lives in Fort Collins, Colorado with his family.

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