REPLAY: EBB 267 - Debunking Myths about Fundal Massage with Barbie Christianson, RN

0:00Barbie Christianson: Hi, everyone. On today's podcast, we're going to talk with Barbie Christianson, a nurse, community educator, and advocate to debunk myths about fundal massage after birth, also known as uterine massage. Welcome to the Evidence-Based Birth Podcast. My name is Rebecca Dekker, and I'm a nurse with my PhD and the founder of Evidence-Based Birth. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See evbirth.com slash disclaimer for more details. Hi, everyone. My name is Rebecca Decker, pronouns she, her, and I will be your host for today's episode.

0:44Barbie Christianson: I wanted to let you know that we will be talking about uterine massage, which can be a traumatic experience for some, and we will also be talking about obstetric violence. If there are any other detailed content or trigger warnings, we'll post them in the description or show notes that go along with this episode. And now I'd like to introduce our honored guest. Barbie Christensen, pronouns they, she, is a nurse, community educator, and advocate, as well as a parent of four young children. Their mission is to communally dismantle oppressive structures, specifically in a reproductive perinatal healthcare, while contributing to the expansion of existing Black and or Indigenous-led community-based care structures.

1:25Barbie Christianson: Barbie's special focus is on addressing and eliminating obstetric violence using trauma-informed perinatal advocacy, care, and education. Today, I'm so excited that Barbie is here to help us debunk some myths about fundal massage after birth, also known as uterine massage. And we'll be talking mainly about fundal massage when it's used in a preventative fashion, not when it's used in a medical emergency. We will also address the misinformation on social media about this procedure, talk about what the evidence actually says about preventive fundal massage. We'll also talk about informed consent and how nurses and providers can bring a trauma-informed approach when the procedure is actually medically necessary, which, spoiler alert, is not that often.

2:12Barbie Christianson: So we are so thrilled that Barbie is here. Welcome, Barbie, to the Evidence-Based Birth Podcast.

2:18Rebecca Dekker: Oh, thank you so much. I love your spoiler alert. Yes.

2:22Barbie Christianson: Yes. But we are here to give everybody all the details about this.

2:28Rebecca Dekker: I love that. And thank you so much for the introduction. It is truly a privilege to be here with you all today or whenever you're watching or listening or reading this as I usually do.

2:39Barbie Christianson: So before we get into the weeds with uterine massage or fundal massage, can you let us know a little bit about your background, what brought you to birth work, and more specifically, how you ended up as a nurse who focuses on obstetric violence and using trauma-informed care?

2:57Rebecca Dekker: Thank you. Yes. I actually used to work in special education for many years, and then I fell down the rabbit hole when I became pregnant with our oldest. I think a lot of birth workers do either come into birth work through their own or, you know, appear somebody's experience, right? Some kind of personal attachment sometimes. So I went to school to be a labor and delivery nurse while parenting and thank you for all the support that got me there and the privileges and the resources. And I was fortunate enough to also go to doula training. I'll admit it wasn't with an organization that I support any longer necessarily.

3:38Rebecca Dekker: And I am so thankful for all the doulas who are really still in that work and thankful for what they provide and we support them more certified or not right so after becoming a doula during nursing school realizing that wasn't going to be sustainable kind of in any way I was already on the nursing path I continued in that journey although I did still provide a lot of birth work support and when I went right into labor and delivery as a new grad, you know, I felt very well prepared with a lot of the evidence-based care and some personal experiences and kind of knowing that there was a strong need for advocacy as well, knowing that I would bring a lot of privilege and responsibility into that.

4:20So I don't want to say I went in with, you know, eyes closed or anything. However, I, you know,

4:28Rebecca Dekker: I didn't really know. Within my first weeks, I, you know, came face-to-face with obstetric violence in a whole new way. A lot of barriers to reporting, you know, just a very traumatic throughout the whole process, right? Especially as a newer nurse without even knowing the term obstetric violence at the time, you know, that came later through birth monopoly, learned that the term came from South American activists and victims ourselves, like it's a victim developed term, right? And I think that's really important when we use the term obstetric violence to really orient that.

4:59Barbie Christianson: And I worked in labor and delivery at bedside at several facilities.

5:04Rebecca Dekker: either as a staff nurse or per diem until I made the decision to support my family in a different way. And I went into maternal child, adolescent health, public health nursing, working with families and individuals in like a perinatal and early childhood period. And it was really there that I actually learned about trauma-informed care and ACEs, you know, adverse childhood experiences. And then I felt like this whole new wave or this world opened up and this whole connection piece about how much trauma we're causing in the birth setting, right? With obstetric violence generationally and how it's literally attachment trauma, feeding trauma, human rights violations abound, right?

5:47Rebecca Dekker: So it really became, and that was one of the reasons I was grateful to go into public health is not only were we there to address a lot of the complicated, the post obstetric complications and really refer and try to resource people. But I had hoped to work on more on the prevention side as well. Like this is preventable, right? We can, we can stop abusing people. It is possible. And using whatever resources in the unit we were able to do, we did our best. Unfortunately, you know, after several years, the pandemic priorities within the department, the organization change, resources weren't really available or allocated to address obstetric violence at all.

6:29Rebecca Dekker: Despite us, many of us advocating that the ramifications of it are going to be worse during the pandemic, of course, which continues, right? We are still in it. Things are still happening, although we don't have the same visitor. I used some air quotes there, restrictions that we saw during the height of the pandemic or the initial period, I should say. And so I did end up going back to bedside for a bit. And now I find myself back in the community health setting as well as educating. And that is really where I have found a lot of my passion and skills align is in educating and collaborating, organizing around, you know, exactly those myths, Because so much of obstetric violence is rooted in the myth of white supremacy, the myth of that capitalism and healthcare works, all of these things, right?

7:20Rebecca Dekker: So here I am in this moment in time with, again, the privilege to be here and speak on these things and really debunk some of the myths around simple things like routine utero massage as prevention rather than intervention, which has its own risks as we're going to talk about.

7:40Barbie Christianson: Yeah. And something you said really stuck with me, you know, the fact that you had pursued doula training before you finished nursing school. And then you went straight into labor and delivery nursing. And within the first couple of weeks, you witnessed obstetric violence, but you didn't have the terminology or words or tools on how to deal with it. Like, what did you call it? Like what, if you had to describe it to someone before you knew what the, what the term was, what were you witnessing? How were you feeling about it? Well, when I spoke to what, number one, I, you know, reported it internally.

8:14Rebecca Dekker: There's internal, like incident reporting systems that almost every facility is going to have. Some of the facilities will use programs like Quantros or, you know, whatever, various other things. So within that, I very, like in the moment, I called it assault and I was instructed because again, I was, you know, on orientation, I was instructed and essentially coerced in the moment to remove the word assault from my written report. I did do that and I did remove the word. So I described that particular incident of obstetric violence for what it was. I described like the actual physical action, what happened to the skin integrity, what the concerns were, the documentation fraud regarding what had happened.

8:58Rebecca Dekker: So I just very objectively said that.

9:00Barbie Christianson: However, in all my verbal

9:02Rebecca Dekker: reports to director of the Women's Health Services, which was called at that facility, to the CNO, to the CMO, to California Department of Public Health, to the Glendale Police Department, to later on to Ventura County Public Health. I always called it assault. Okay. And because that's what it is. I later learned probably about maybe a year later through the know your rights course, actually, with Birth Monopoly, that in some places, legally, you could call it medical battery. And then I was gaslit at different facilities, particularly that one, you know, when I was brand new and saw this particularly horrific thing.

9:43Rebecca Dekker: Not to call it assault because, quote, that sounds so violent. And my response was, well, yes, it was extremely violent like he you know did did did whatever he hurt her essentially and the manager kind of shuddered and said well you know don't worry he won't be he said he's he knows he's not supposed to do it again or whatever and that was pretty much like their way of handling it right this assault so that's what I always called it before I knew the term obstetric violence

10:14Barbie Christianson: I know at birth monopoly they have a great poster that you can purchase that shows the upside down pyramid of obstetric violence. And, you know, there's things ranging from outright assault to, you know, coercion and pressure. And one of the things we're going to talk about today is something that is one of those routine procedures that when it's done without consent and without medical necessity, it could be considered on that spectrum of obstetric violence, and that's bundle massage or uterine massage. So I was wondering if you could start off by like sharing with our listeners, what is this procedure?

10:52Rebecca Dekker: Yeah, absolutely. I want to start by kind of orienting to the fact that most nurses, well, the provider, whether that's a midwife or the obstetrician or family nurse practitioner, whoever it is attending the birth is usually going to provide that first fundal assessment or even fundal massage if that's what they're doing as well.

11:11Barbie Christianson: Yeah. Can we describe maybe the difference between a fundal assessment and fundal massage? So I have my knitted uterus here with a... Wonderful. Baby inside. So where is the fundus on this?

11:22Rebecca Dekker: Yeah. So that uterus, oh, that's a nice big uterus.

11:26Barbie Christianson: I'm holding it in front. So yeah, it is, I guess. So the fundus is going to be the top of the uterus.

11:32Rebecca Dekker: And that is essentially, that's what we're kind of feeling when you're pregnant, as your uterus grows, maybe you're going in for regular prenatal care or just any prenatal care. They're kind of measuring like where the top of your belly is, you're actually feeling the top of that fundus right where Rebecca's that light blue section, right?

11:51Barbie Christianson: Yeah. If you're watching on YouTube, you can see our visuals.

11:54Rebecca Dekker: Oh, thank you. And so that really just kind of requires, depending on where it's located, you know, a little bit of searching around. So that's kind of what we talk, you know, people either through if it's taking a while or we stop and say, how are you doing? You know, After we've kind of, again, informed consent, start there. So explaining what it is, maybe I should start there. I would like, if it's okay with you, to check your uterus after birth. Sometimes your uterus is very smart. It's going to most likely do what it's supposed to do. However, sometimes, especially depending on the risk factor, I might go into those.

12:32Rebecca Dekker: Maybe they were there for a very long induction. They were on high-dose continuous cytosin infusion, which is going to put them at more risk for postpartum hemorrhage. So I'm going to explain why I want to do this intervention. I'm going to start there.

12:45Barbie Christianson: Yeah. And you're not actually going to massage or rub the uterus. You're just going to assess it. It means you're going to use your hands to find that top of the uterus from the outside. And I'm going to go ahead and take the baby out of here because it's going to be after the baby is born, it starts to shrink down and contract. So quickly.

13:06Rebecca Dekker: So quickly. Within two weeks almost, you can hardly even feel it after birth, depending on where it kind of was at and what your uterus is doing. So what I would typically talk to patients, depending on their risk factors, is how often I want to be assessing their uterus. So how often do I want to be checking it? And why do I want to check it? So that's where I'm going to start. Unfortunately, a lot of facilities will have requirements like you have to check a fundus every so many hours. And I say, unfortunately, because although that is important to do assessments that sometimes interferes with other things, right?

13:40Rebecca Dekker: Like, like sleep, you know, just living and whatever you're trying to do after having a whole human come out of you. So it's not really individualized to patients. But ideally, I'm going to provide them some kind of guidelines about why I want to provide this information about what I am expected to do. And also, you know, why this may be important for them. and then I'm going to explain that what I would like to do is take my hand, well two hands, one hand and place at the bottom like near the pubic bone and just kind of hold some support. This is a little different depending if you've had a vaginal or a cesarean delivery, just that difference in support there.

14:19Rebecca Dekker: And then I take my other hand, you know, kind of talking to you as if you're the patient a little bit or the client and I find the top of your uterus. Hopefully this is going to be gentle. If you've already had them, I'm going to definitely ask you how they've been for you before also. And then this is where it does get a little tricky because people are expecting that uterine massage. And then I'm offering a uterine assessment, which is different. All I'm doing is reaching my hand down into the abdomen, kind of far enough to feel where is the uterus is it in the middle because that's important like in the middle

14:58Barbie Christianson: of your body and like in the center yeah is it midline i should say like is it midline is what we as nurses would use we're charting like midline and the reason this is important if it's

15:09Rebecca Dekker: not midline or if it is and then later it's not we want to know like why is maybe your bladder is full that is a really simple thing that we can help you do empty your bladder and as soon as the bladder is empty, the uterus, you know, tilts back from usually the right back to the middle. And that's really important because the bladder can interfere with, you know, what you talked about, the uterus like shrinking back, we call it involution back into, you know, the cavity. So that's really all I'm doing. I'm looking for the top. And I'm, I'm always a little bit sad for people when they, oh, that was so easy.

15:46Rebecca Dekker: Oh my gosh, that didn't hurt at all. You're so gentle. And it's not that I'm gentle. It's that I'm all I'm doing is assessing. All I'm doing is finding where is your uterus? And also, what does it feel like? Is it nice and firm? We do want, ideally, it to feel firm. If it's not feeling firm, that could be a sign that it's not contracting the way it's supposed to. Sometimes people are surprised they may feel contractions or cramps after birth, especially if we haven't, you know, like supported people in

16:15Barbie Christianson: like learning that I didn't know. What is that? The after, people call them after pains, but that's essentially your uterus is contracting after the birth to try and prevent where the placenta peeled off from bleeding excessively. Correct?

16:33Rebecca Dekker: Exactly. Exactly. So those contractions, they're going to firm up the uterus. They're going to keep it nice and firm. If it's not doing that, the uterus will feel different. It'll start to feel a little soft. I've heard some nurses describe it as like a deflated dodgeball, something like that. Other terms that people may have heard, you know, sometimes we're not explaining it well, but maybe they're talking, this has happened to you, I'm sorry, and they're talking about a boggy uterus, you know, maybe

16:59Barbie Christianson: boggy, B-O-G-G-Y.

17:01Rebecca Dekker: Yep, boggy. But what that feels like, you know, as I'm assessing, if I can't find it and it doesn't feel nice and firm, then I am going to switch to, you know, asking about an intervention or I might pause and kind of assess further what's happening when I'm assessing to like, you know, is the person painful? So this is like a whole person assessment, right? Like even with that slight little assessment and maybe a little bit of pressure just from assessing where it's at and how firm it's feeling, am I seeing any like active bleeding with that? Right. Again, I'm not trying to press like very hard or massage, but even with that light pressure, am I seeing bleeding?

17:38Rebecca Dekker: So this is a whole person assessment. This isn't just like, like a little, let's just find the uterus and, you know, chart it's midline, it's firm, it's, you know, plus one, or let's look at the previous nurses charting or, you know, whatever it is. So that's what I'm asking people or talking to them about when I'm coming in and talking about a fundal assessment with them.

18:00Barbie Christianson: And how is that different from a fundal massage or uterine massage?

18:05Rebecca Dekker: Yeah, I am so grateful for the knowledge that has been protected, you know, about uterine massage. It is a very helpful intervention when there is active bleeding. So if there is active bleeding.

18:23Barbie Christianson: Like you're at risk for hemorrhaging.

18:26Rebecca Dekker: Yes. Like we are, many people probably be more familiar with the advice. Like if you are, you know, bleeding through a pad in an hour, or you are passing large clots with your bleeding, or if you were just seeing, you know, obviously streams of blood coming out, that would be concerning. This is not the like trickles or those like gushes that we may feel with some position changes, things like that, right. Or even small clots in tissue. This is active, like heavy bleeding. So we are concerned now, right? We want to ask you to intervene because we know that if we intervene early with postpartum hemorrhage and postpartum hemorrhage, you know, has very strict definitions depending on even like, you know, we have the California or the CMQCC.

19:12Rebecca Dekker: I love their guidelines. So if you've had a vaginal delivery or a cesarean, it does change, but a lot of places are moving toward quantitative blood loss. So we're measuring everything. We're really looking at how much blood is lost during the actual delivery. And then based on that and based on some other risk factors, we're monitoring your blood loss for a certain amount of time after. If you're kind of in that risk category and we see that active bleeding, again, that and, and this is where there's kind of a breakdown in that flow, at least in practice as I see, you know, we are very fear-based in nursing sometimes and we'll start intervening when it's not necessary and that carries its own risk.

19:55Rebecca Dekker: So if there is not active bleeding, you know, and we are not hemorrhaging, they're really, and the uterus is doing what it's supposed to be doing and we've assessed it, there really isn't any need to move into a higher level of intervention, right? Especially without informed consent. Like just, you know, oh, I'm right here. I'm just going to massage anyway to make myself feel better. You know, I've heard some, you know, even very experienced nurses and goodness, I trust their gut feelings, but you know, just say, wow, there's just not enough bleeding for me. Like, let me just push and massage anyway and see what happens.

20:29Rebecca Dekker: Like I've been taught that in some facilities before, right? As a new nurse, it was really hard to differentiate. Is this a gap in like evidence-based care? Is this actually what I'm supposed to be doing? so was really grateful for evidence-based birth resources thanks as a new nurse also again that intervention is very helpful when we have that active bleeding what it does is it is stimulating the uterus hopefully that's that's the goal and it's gonna work if it's uterine at me and the uterus is able to respond it really is helpful so what that's gonna to feel like is us taking our hand. And I'm going to ask you, hey, I don't really feel like your uterus is as firm as it should be.

21:11Rebecca Dekker: You are, you know, having some trickling when I'm even pressing lightly. I'm a little concerned. Sometimes, you know, the uterus just needs a little help to be stimulated. We're already, you know, maybe we're not running. Well, I'm sure we'll talk about that, you know, active high dose bolus of Pitocin or synthetic oxytocin after, because that is medically stimulating the uterus, right? But again, say we see that active bleeding, I'm going to ask, can I massage your uterus a little bit and see if I can stimulate it to start contracting and really kind of stop this bleeding on its own. And then I'm assessing, you know, as that intervention is happening, like what's happening when I'm massaging?

21:50Rebecca Dekker: Are larger clots coming out? Is the bleeding increasing? Did a large clot come out and now it's slowing down? So again, the massage is also being assessed, but it is not a fundal assessment. It is a different, you know, it is an actual intervention.

22:07Barbie Christianson: So Barbie, what I've heard you say is there's fundal assessment where you're just kind of assessing the situation and what is the uterus doing right now, which is a light pressure to find the top of the uterus. Then there is preventive massage, which is when somebody, a nurse or provider starts more forceful rubbing from the outside of the abdomen to try and stimulate the uterus to prevent postpartum hemorrhage. And then there is fundal massage when there is active bleeding, which is what the World Health Organization recommends as one of the first steps for a postpartum hemorrhage. So you kind of have the fundal assessment, you got preventive fundal massage or uterine massage, and you have the uterine massage when there is a active bleeding going on that needs to be stopped.

22:54Barbie Christianson: Is that correct?

22:55Rebecca Dekker: Yes. And I would almost reframe that preventative funnel massage to routine. Okay.

23:01Barbie Christianson: So we'll call it routine. And I did want to share with our listeners, you know, in preparation for this, I pulled up our article at evidence-based birth on the third stage and active versus expectant management. And I just kind of wanted to let, you know, give everybody a brief picture, if that's okay, of the evidence on the routine massage. And we cover this in the section of the article on Pitocin during the third stage of labor, and there's a section called, Are There Benefits to Uterine Massage? So we'll link to this article in the show notes. And there was a Cochrane review with two randomized trials where people were randomly assigned to either receive fundal massage or no massage after they birthed the placenta.

23:45Barbie Christianson: And in the first trial, they found really no difference in postpartum hemorrhage, so it was not effective at preventing postpartum hemorrhage. A second and much more larger trial had 2 ,000 birthing people in it, and they were assigned to receive synthetic oxytocin or pitocin, uterine massage, or both. So there were three groups. And the group that received uterine massage alone had the most cases of heavy bleeding in 30 minutes. When synthetic oxytocin was used, meaning you're given pitocin after the birth, they found that the massage did not provide any additional benefit. And about one-third of people reported that the procedure was painful.

24:28Barbie Christianson: And then there is another study that was published after that Cochrane review, and they randomly assigned about 1 ,200 people to either get Pitocin shot after the birth, plus 30 minutes of continuous uterine massage. And then some people just got the shot of Pitocin. So actually there were about 1 ,200 people in each group. This was a really big study. And they found that doing the uterine massage did not reduce blood loss when you added that to Pitocin. So that the shot of Pitocin was all that was needed in that case. So all of this research on massage does not support using it routinely without a medical need.

25:13Barbie Christianson: Yep. So, but you're seeing, how often would you say in the hospitals you've practiced, is it used routinely like after the birth? Is it common or is it rare or is it almost all the time? I would say almost every preceptor I've ever had during any orientation has always, at one point, during an opportunity to do a whole recovery or anything, has included

25:43Rebecca Dekker: routine fundal or preventative air quote fundal massage instead of assessment.

25:49Barbie Christianson: So everywhere you've worked, the preceptors, meaning the people training the new nurses, are telling people to do this routinely.

25:56Rebecca Dekker: Yes, which is how they're trained, right? it's, you know.

25:58Barbie Christianson: Okay. Yeah.

26:00Rebecca Dekker: It's a cascade effect. And we're very here. Yeah.

26:04Barbie Christianson: That's why we're here. And can you tell, you know, in the studies, they mentioned pain, like in your experience of what you described trying to do it with informed consent and people are often surprised if it's their second or third baby. They're like, wow, that didn't hurt. Cause you were just gently pressing to do the assessment. Like how forceful can it be when a nurse or provider is doing this preventatively?

26:28Rebecca Dekker: I mean, everybody, you know, of course is different. I've seen people or I've seen nurses do what I would consider very aggressive fundal massage when, you know, fundal assessment was indicated and the person, you know, breathed through it and didn't seem to be much affected by it was expecting it or knew how to manage or it just didn't really bother them. I'm whatever it was. They coped with it somehow. And then I have seen people crawl away on the bed.

27:01Barbie Christianson: Like trying to get away from the nurse.

27:03Rebecca Dekker: Yes. Like unconsciously, consciously both, right. Like trying to stop it, you know, just not managing well. They're trying to escape. Yeah. You know, here they are sometimes often, you know, chest feeding or skin to skin or trying to bump their baby or having a moment away. A sock on him is like free human for a second. Yeah. And then they're going to spend it in pain.

27:28Barbie Christianson: And I can say here at EBB, we get lots of messages and comments from people who are sometimes even traumatized by the massage because it was so forceful and painful and done without their consent. Absolutely.

27:41Rebecca Dekker: And that, or, you know, I think it's also hard sometimes to learn later that something wasn't necessary. And then to know that even if it wasn't necessarily painful, maybe it interrupted something. Maybe you just,

27:51Barbie Christianson: you know i mean it was interrupting what you were doing like recovering again or to be woken out of sleep to have that being done to you that too and so i always love you know to make a plan

28:03Rebecca Dekker: realistically i i hope you know especially in california at least they have ratios right like we have some of the best ratios especially for conflict care and postpartum still too many in my opinion especially if you're going to support lactation at all or you know anyway that's a whole nother rabbit hole. But on that note, pain also can interfere with lactogenesis and lactation, as well as recovery and healing, bonding, all the things, attachment.

28:28Barbie Christianson: And I will say it's very rare

28:30Rebecca Dekker: that I was ever not able to make a plan to protect rest, to protect autonomy. And also, a fundal assessment, you know, we're taught to do in a very specific way. It can also, I think, I love that you've mentioned that it can kind of be traumatic because it can also be triggering. We're sometimes taught that the only way to do a proper fundal assessment is to put somebody in the lithotomy position again, right? Which, depending on what happened in their birth or before, who knows? There's so many resources out there now, thank goodness, and more coming on trauma-informed birth care. We can mention one of them, the Trauma-Informed Birth Nurse Program.

29:09Rebecca Dekker: I think they even offer CEUs and hospital programming now, too, or reimbursement, I mean. but circling back, I have very rarely, again, been able to make that plan. And then also a funnel assessment can be done and checked in not just the lithotomy position.

29:27Barbie Christianson: And when we say lithotomy, you mean like legs up in stirrups on your back?

29:32Rebecca Dekker: Yeah. On your back or, you know, at least legs up on the bed and, you know, knees apart, like, yeah. Cause we're checking for bleeding too sometimes. And, you know, yes, there are going to be times where that may be how I ask you to assess everything. Maybe there is a little, maybe you have some more risk factors. Maybe we've already seen some concerning things. Maybe you told me you should saw a big clock or maybe in that position while you're chest feeding your baby and having your snack. And I'm slipping my hand, you know, under both of you, not to interrupt your skin to skin and doing a light, right?

30:06Rebecca Dekker: Cause you can assess like that. I really can. Like I can find your uterus. I can tell if it's kind of where it's supposed to be, especially if I felt it before but even without and then if I can't find it then I'm going to ask you or if there's like actively I'm going to ask you like is it okay if we do this or this and always present the options and you know if you don't want to do it right now like can you please let me know when you're ready if you know they do want to do it but not right then whatever we make a plan and ultimately it's their decision.

30:35Barbie Christianson: So I know you spend a lot of time on social media and So you're kind of in touch with what people are saying, maybe what labor and delivery nurses are talking about on TikTok and Instagram. And can you talk a little bit about some of the misinformation that you've seen on these reels and TikTok videos?

30:53Rebecca Dekker: Yeah, I would love to. And I do want to also note that I love, hate social media, I think as many of us do. And I have also, over the last few years, curated my experience very carefully there. to protect my own boundaries, mostly. And I will say that I've sort of bubbled myself in that I don't engage any longer in social media accounts that do promote many of those myths, I would say. So I, you know, really appreciate a lot of the work that Lore, you know, with just broken so many barriers. I mean, I, as a nurse in all my experiences and as a dual and as a birthing person myself, I have seen things on her account that I would never see in my profession because of systemic barriers and things that nurses and residents wouldn't see because of that.

31:57Rebecca Dekker: So social media, again, can be an amazing tool. So it's a little hard for me to answer that question because at this point I usually stick to the places where the building is happening. I hope.

32:11Barbie Christianson: Although the ones that I was thinking of in particular that, and if you could talk about are when the nurses say things like it's a necessary evil and you just need to suck it up and let the nurse do their job. Yeah. Yeah. Even if it hurts, it's in your best interest.

32:27Rebecca Dekker: Yeah, we're just trying to take care of you, right? And again, going back to Floor, she recently had a post on just that, you know, that really abusive, dangerous care can be very sweet and nice and packaged very, very nicely for us to accept and normalize, you know. And I think, you know, particularly as a form of gender-based violence, we're almost groomed throughout our lives into accepting this, whether that's through, you know, the like freeze, fight, flight, fawn response, however that is. We as nurses can be and are complicit in that. Oh, I know this isn't any fun, sweetie. We're just like rubbing, rubbing, rubbing, right?

33:15Rebecca Dekker: I am mainly like, sometimes I'm just standing there, especially always in the first week of orientation at a facility. I'm like, why? Just get through orientation. Because even in those moments, yes, we can try to interrupt that. And also, realistically, you're on a 90-day probation at facilities. And if you want to make change at a facility, especially as a staff nurse, and you want a union to protect you, you got to get through that 90 days. So it's really hard, I think, sometimes as nurses to balance that period.

33:49Barbie Christianson: And that brings me to like, if you find yourself in that situation as the patient, and you're not actively bleeding, you're not hemorrhaging, and the nurse just starts rubbing forcefully on your belly, what are some words that you could use to advocate for yourself or that the family could use? Yeah. I had to take a little breath right there and release some tension, I think, because that question alone brings up a lot for many people speaking up and stopping an intervention carries its own risks, honestly.

34:28Rebecca Dekker: So I want to note that before I even start, but simply saying, stop, stop what you're doing. And then anybody who is in the room providing support, just repeating literally what the person just said. And I have done that as a nurse myself. And sadly, and gratefully, unfortunately, however you want to say that, you know, providers, other nurses will often listen to the nurse or the other person, the partner, even a mother, right? The actual client. And I chose that word client because sometimes I wonder if even that language change could help us, at least in the inpatient setting, you know, patient, like in labor and delivery care.

35:13Rebecca Dekker: it has a certain connotation. These are our clients. We work with them. I'm in the hospital, but I'm providing the service to you. You are my client. I am your service provider. I'm providing nurse service to you. So people can, again, repeat what is being said, or, you know, they can ask like, why do you need to do this?

35:36Barbie Christianson: Am I actively bleeding right now? Am I hemorrhaging? Yes.

35:40Rebecca Dekker: Like, and ask questions. Are you concerned? Like what's, why do you need to, you know, where? So that's maybe important for us to know. And again, like in all the time that we have during pregnant with pregnancy changes and all the things, and, you know, again, capitalism, all the things, how many people know what their uterus is supposed to be doing after birth? and I also want to reorient that so much of this is unnecessary if we change the way we care for people during labor and delivery we literally increase the risk for postpartum hemorrhage with our routine care bottom line yeah and I think if you if our listeners want

36:21Barbie Christianson: to learn more in our article on the third stage which is available at ebbirth.com slash third stage there's a table we created with all of the risk factors that for postpartum hemorrhage and And whether they're like major risk factors, mine or minor, and, you know, if they are something that could be done is done to you or if it's just something that you can't control. So I encourage our listeners to to check that out and educate themselves. You know, kind of on the opposite end of the spectrum, I think, you know, talking about speaking up when it's already happening and you did not anticipate it.

36:56Barbie Christianson: Can someone assess their own fundus and massage their own fundus? Oh my gosh.

37:02Rebecca Dekker: It's one of my favorite parts of recovery and postpartum care in the places that do what we call LDRP, where you go from delivery to recovery to postpartum with your same nurse. It's exciting when that can happen, if it was me. I love to ask people if I can show them where their uterus is and have they ever felt it and what should it feel like so like I often get talked to about talking too much because we always are chatting about like what we're doing and taking the time and I think that's a real barrier too is not having the time to have this discussion or not feeling like we're we have the time or we're going to be disciplined for taking the time even on the whole spectrum of that so I love teaching people how to find their own uterus.

37:47Rebecca Dekker: And usually how I would do that is just hand over hand if they're comfortable and finding it together. People in larger bodies also sometimes do require like a deeper fundal assessment. And that doesn't necessarily have to be painful either. And that's what I always, again, like I find it so sad whenever a patient or a client would say, wow, that was so different. And then I also want to note that sometimes that can be concerning for patients as well to have differences in care. They can create, you know, distress even like why would, why, you know, is this a, is this a bad nurse because they're not massaging my uterus like all the other ones did?

38:28Rebecca Dekker: Am I okay? Right. Or, oh my gosh, why did all the other nurses do that to me if this isn't necessary? So that's kind of a careful conversation to have as well. And sometimes clients have flat out asked me, well, why did the other nurse do that? And sometimes that's really hard to answer. Yeah.

38:47Barbie Christianson: It's hard to explain the evidence practice gap to somebody who just gave birth and doesn't know all of the nuances of how old patterns and behaviors persist, even when they've been proven not to be helpful.

39:04Rebecca Dekker: Right. And then, you know, I've sometimes also probably been complicit in myself and normalized it and tried to smooth it over. And oh, well, you know, maybe she was concerned about maybe she saw, you know, maybe at that moment, there was something happening. And maybe there was, you know, and then I go back on the chart and there probably wasn't.

39:25Barbie Christianson: So when you're feeling your own fundus, like I know in pregnant, like towards the end of pregnancy, it's up super high, like, you know, and then after you give birth, like in the first couple hours, where should the top of the uterus be when you're looking for it, like in relation to your belly button?

39:40Rebecca Dekker: Yeah. So, you know, if you like gave birth close to term or at term, you know, and had a, what we would call appropriate for gestational age baby, and it was a single pregnancy, right? Most people's uterus are going to be somewhere around their belly button.

39:58Barbie Christianson: Okay. After that, right after they give birth,

40:00Rebecca Dekker: you know, and maybe a little higher, almost every charting system. And this is just kind of interesting to see, you know, what's always similar and what can be different. We usually measure like plus three to minus minus two. That's our range. So, and then what we're, and it's a little subjective here because we're literally just measuring by fingertips.

40:18Barbie Christianson: And is zero your umbilicus, your belly button?

40:21Rebecca Dekker: Yes. Thank you for getting there faster than I did. So zero being the belly button and then plus three would be like about three fingers above your belly button. Okay. Minus one, you know, one finger below your belly button. And that can change depending on your position. If you're sitting up, it's going to be a little bit higher. If you are laying flat down, like it is going to be kind of at its lowest position. Okay. So that it might be. And this again, looks very different in home births and, you know, in community centered and like traditional midwifery care, that fundal assessment is, you know, when somebody's like wrapped up in bed and having their like whole body massage and like, they're feeling not just the fundus, like they're checking everything right.

41:03Rebecca Dekker: Like they're, it's very gentle and supportive. So I just want to note that, that this can look very different and you can do that yourself. You don't just have to find the top of your uterus and move on. Like you can actually kind of just feel it on your belly. Things are going to kind of feel different. You can feel the whole kind of top shape of the uterus, especially in the first few days after birth. And then it's going to like literally within one day start to shrink down. And so you should be seeing it, you know, move from wherever it is above the belly button or around the belly button, moving, moving down all the way back, like under the pubic bone eventually.

41:43Rebecca Dekker: And that's where you can't feel it. Yeah. About two weeks almost.

41:46Barbie Christianson: And if you are at home or say, you know, you had a birth center birth and you went home and then all of a sudden you're bleeding more, you can feel for your, your fundus yourself, see if it's where it's supposed to be, see if it feels soft or firm and it feels soft, you can rub on the outside of your belly, on the uterus to stimulate, correct?

42:05Rebecca Dekker: You absolutely can. I mean, it's your own body. Do it. If you did have a cesarean birth, I would caution you, hopefully they talk to you about splinting, like during a knee, like lifting or coughing, sneezing, things like that. That would be another time to kind of splint, you know, as you're...

42:22Barbie Christianson: Like hold, like support your lower abdomen while you're doing it?

42:25Rebecca Dekker: Lower abdomen, even like onto the incision gently. You can use a pillow or a little towel rolled up and then really start to look for your uterus. And you can just kind of, hopefully you've already felt it because that is kind of nice to be able to tell the difference, right? We also, again, we don't want to just see that it's firm. We all, I'm moving down. We also want to see that it's sort of in the middle.

42:46Barbie Christianson: If it's to the right, that's often maybe... Because you need to empty your bladder.

42:51Rebecca Dekker: Often a bladder issue. And sometimes we have bladder issues if, you know, different things happen during birth. Epidurals can sometimes carry some bladder complications or urinary, you know. Yeah.

43:02Barbie Christianson: You retain the urine and so your bladder gets too full. Yeah. Yeah. And sometimes the uterus is tired.

43:10Rebecca Dekker: It needs to be stimulated because it was overworked or whatever it was. Yeah.

43:14Barbie Christianson: So some of the myths that people might hear include that it's a necessary evil. It's no fun, but you should do it for the safety of your baby. And you can't, the nurse has to, whereas like the truth is it does not help as a preventative or routine measure. It is evidence-based helpful intervention if you are hemorrhaging or it looks like you're

43:37Rebecca Dekker: on the path to hemorrhage and you can even do it yourself. You can't even do it yourself. I love that you said, you know, that nurses say they have to do this because some nurses really believe that. Yeah.

43:53Barbie Christianson: And hopefully they're listening to this podcast and learning because I don't want anybody to feel like, oh my God, I did that for 20 years. I'm a terrible person. It's no, it's like when you find out that something isn't helpful, you can, you can stop. It doesn't mean you're a bad person. It just means you had, you know, poor information at the time.

44:13Rebecca Dekker: Yeah. And I think that is also being trauma informed with ourselves as nurses and providers as well. Know better, do better. You have to do the better, right? Like you can't just learn that something you're doing is harmful and then, you know, not follow through with the responsibility to change it. Especially if it's your own practice. Absolutely.

44:35Barbie Christianson: I know we have some nurses who listen to this podcast, like at the nurse's station at night, you know, or when there's not a lot going on. So I was wondering for the nurses who are listening who do want to do better, can you give us, you know, you kind of said earlier what you would say to someone, but can you repeat it? Because your scripting was so beautiful. You already kind of gave us the assessment. Can you say again, talk to me as if I'm bleeding actively and it's urgent. Like, how would you explain in a trauma-informed way what you need to do so that you can help keep me safe, but I'm not traumatized by not knowing what you're doing?

45:11Rebecca Dekker: Oh my gosh. I love that question. I love scripting also. I've found so many things helpful. I want to refer to the feminist midwife who offers a lot of scripts and sort of just adapting those.

45:24Barbie Christianson: Right. And the feminist midwife is an email like sub stack that you can subscribe to. We'll link to that in the show notes because she releases a new script every week on different subjects related to obstetric and gynecology and reproductive health care.

45:38Rebecca Dekker: So what would you say

45:39Barbie Christianson: to me if I'm like actively bleeding and look like I'm going to hemorrhage?

45:45Rebecca Dekker: Yeah, I am hopefully going to have some help, number one, right? That is, I want to recognize that as a barrier also to really providing not only trauma-informed, but timely and effective interventions, right? So sometimes we hit that timely and effective, but cause trauma, right? By not taking the time or not having feeling like we have the time or the resources to give that. So ideally, I'm going to be having somebody else maybe be my runner, go grab some things. Because if you are actively leading, it's likely that we may need to do more than this one intervention.

46:22Barbie Christianson: So you need adequate staffing, first of all, just enough hands.

46:26Rebecca Dekker: Yeah. So I'm going to talk to you. I'm going to say, hey, you know, first, actively leading can also, I want to say, be a spectrum. Actively leading can be kind of like a heavy trickle to a lot of gushing, a lot of tissue coming out. It can feel very scary by itself. So the patient is going to be having the sensation of blood coming out of them. So we're going to talk about that too. We're going to say, Hey, I know, you know, this might feel scary. You are bleeding more than, you know, might be safe for you. This can cause some complications. It carries some risks if we don't stop it. The first thing I would like to do, if it's okay with you is put my hand on your uterus and see if I can stimulate it to contract.

47:06Rebecca Dekker: Sometimes just that alone is going to help slow down the bleeding and stop it. And also I'm going to call for help. Okay. So you're going to see some people come in with some things just in case we need them. Okay. So I'm going to orient to the situation. Here's where we are. I am concerned, right? Like I, I see you bleeding. Like if we're in a hospital, most likely we have informed consent to you, but you do have active management of third stage of labor. You likely have synthetic oxytocin running at some sort of bolus rate, an initially high rate for half an hour, a lower rate for, I've seen a range of things, right?

47:45Rebecca Dekker: So that is probably still going. I'm going to check, is that actually going? So I'm going to do some more assessment now. I'm going to say, hey, I'm going to look at a few things, interrupt me, speak up any time. So I say that. If it's appropriate, I also orient to the support people there. I say, hey, I need you to do this. You come over here, you be with them, you take the baby, whatever it is, you know, can you, can you do this for me? You know, we involve, we support if they're able to. or maybe I ask them, hey, do you want to step out while we get this? Because that's okay too. If it's whatever it is, again, so assessing the situation, being really fluid and grateful for those algorithms because we do have very clear guidelines and corresponding interventions to address postpartum hemorrhage and they are very effective and they start with uterine massage.

48:43Rebecca Dekker: So I'm going to start there and I'm going to continue to massage Will I talk to you? And I'm going to, again, that assessment. Okay. Hey, I'm, you know, I'm seeing a lot of blood come out. How are you? How are you feeling? Or maybe I saw a clock come out. Hey, I saw a large clock come out. Maybe that's going to help this. Are you okay if I keep going? I'm going to talk you through. Do you want to take some deep breaths with me? I'm going to make some eye contact.

49:06Barbie Christianson: So you're talking to them the whole time. Oh my gosh. I'm a big narrator. Like hands-on talking.

49:12Rebecca Dekker: Yeah. I read the room and they don't want it.

49:15Barbie Christianson: Yeah. Yeah. Yeah. And some people don't want to hear all the details. Yes. They just want to close their eyes. So the narration is really key though, I think, for people because literally knowing what's going on with our own body can be helpful in reducing the truth. And you're part of it. You're not being treated like a piece of meat or somebody who has no see.

49:36Rebecca Dekker: Yeah. Yeah. matter.

49:38Barbie Christianson: Yeah. Yeah. I can see that seems so much more trauma informed than, you know, somebody just starts doing stuff to you without explanation. And I like how even you said, oh, you know, is this okay? Like, you know, getting a quick confirmation and nobody's going to say no, like, let me plead to death. But I think this has been a really important conversation, Barbie, because uterine massage or fundal massage is one of those things that when it's used routinely without any medical need. It can be distressing and unnecessary, but it can also be life-saving when it is necessary. So yeah.

50:16Rebecca Dekker: Like things, right? And I have to, I don't, I didn't want to interrupt you, but I actually did have somebody say no once.

50:23Barbie Christianson: Oh, okay.

50:24Rebecca Dekker: Yeah. And, and I stopped. Yeah. And we popped. You could ask them to rub their own. Yeah. And they took a breath and they put their own hand on their belly. Okay. They took another deep breath and they said, okay, go. Huh? And that was it. And we like kept going and, you know, eventually needed by manual and we went to, yeah. So we, like we did beds and all the things, but, you know, and, but it wasn't like that pause that caused her to need more interventions at all. She just needed a moment.

51:01Barbie Christianson: Yeah. And that's important. Oh my gosh. So important.

51:05Rebecca Dekker: And she, you know, we, we were lucky enough in that situation, which almost has never happened actually to be able to debrief, not only with the patient, but kind of the team briefly. And she was coping so well.

51:19Barbie Christianson: She was what?

51:20Rebecca Dekker: She was coping so well, like postpartum, like breastfeeding and just saying like, Oh no, I felt great the whole time. And I was like, wow. Cause yeah, you know, I can feel that. And she was like, no, you guys had it. and I'm glad she felt that because we did have it. She had it. We had it together.

51:40Barbie Christianson: One more thing I didn't bring up while you were talking, and my sister, who's a family medicine doctor, Dr. Shannon, who reviews most of our articles, had pointed out to me the other day that she thinks one reason it's still so commonly used as a routine rather than medically necessary is because most providers and nurses are used to their patients having epidurals, and they can't feel anything anyways, right after the birth. And so, you know, people are not feeling the pain and they're not complaining. So there's no, like nurses don't recognize, well, maybe I should look into why this is so painful and is it necessary?

52:18Barbie Christianson: But when someone's unmedicated and has not had an epidural, the pain can be significantly worse.

52:25Rebecca Dekker: Yeah. Or as they move on into their like postpartum recovery, right? and everything kind of wears off and everything else hits.

52:33Barbie Christianson: Yeah.

52:35Rebecca Dekker: I want to note too that, you know, I think I mentioned this a couple of times. Again, we're very fear-based in nursing sometimes. And unfortunately, we do see a lot of hemorrhages. I mean, it's a leading cause of mortality. What is it? Like almost 80 % of postpartum hemorrhages are related to uterine tone. So, you know, we're very afraid, right?

52:54Barbie Christianson: Right. And even if it's only happening three or 4 % of the time, And for a single nurse over a year, that could be dozens of people that, you know, so it does make sense that you want to try and prevent it. But I'd encourage nurses and providers who are listening, go to evidencebasedbirth.com slash third stage. We have a lot of research there about active management and expectant management and the best ways to use both. And we have a podcast all about that too. So I'll link to that in the show notes. But Barbie, is there anything else you want to share with us today? any final words?

53:30Rebecca Dekker: I appreciate that you brought it back to, you know, the nurses listening who can hopefully, you know, change our practices or start to think about ways we can impact the unit culture around this, because it really is kind of a culture of obstetric care as a systemic thing. And also that we may have a lot of unaddressed trauma around this, around postpartum hemorrhages. Like, yes, it only happens so many times, but we are doing a lot of things, especially in like the more acute settings to increase the risk of hemorrhages. And we're not just seeing them in our own clients. We're usually the ones that are responding to other people's, right?

54:02Rebecca Dekker: And it's a very... It's a team thing.

54:05Barbie Christianson: It's not just you. There's a lot of adrenaline. You're calling all the other nurses to help.

54:10Rebecca Dekker: Right, right. So there can be a lot of trauma or PTSD or vicarious trauma for ourselves. And I think addressing that is also really important hand in hand with, you know, learning better practices and changing our practices. That's awesome.

54:25Barbie Christianson: And for me, this is very timely because we're recording this a few hours before Dr. Shannon is gonna give our pro members a one hour training all about the first steps for postpartum hemorrhage and safety and how you stop a hemorrhage. So I'm really excited that, you know, we're gonna keep educating birth workers on this topic and parents as well. I'd encourage you to listen to that podcast episode on the third stage and learn a little bit more about this topic. And there's lots of amazing resources at the California Maternal Care Quality Collaborative. Thank you. Let's get the letters a little bit mixed up.

55:04Barbie Christianson: Thanks. And you're a nurse in California, correct?

55:07Rebecca Dekker: You know, I recently relocated to Oregon and adapting.

55:12Barbie Christianson: Yeah. Adapting to different birth culture everywhere you go.

55:15Rebecca Dekker: So that's okay. Yeah. It is all different. And I think that's why these conversations are important too. These conversations are so important. So thank you so much.

55:25Barbie Christianson: Thank you listeners for joining us today as we talked with nurse Barbie Christensen all about funnel massage and uterine massage. Hopefully we were able to demystify this for you a little bit. And any nurses listening, we thank you for taking the time to educate yourself. And I love the scripts that Barbie shared with us. So thanks everyone. We'll see you next week. Bye. Thank you. Bye.

56:14Barbie Christianson: and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans, as well as scholarships for students and for people of color. To learn more, visit ebbirth.com slash membership.