Preggie Pals
Choosing Your Health Care Provider: Midwives

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Please be advised, this transcription was performed from a company independent of New Mommy Media, LLC. As such, translation was required which may alter the accuracy of the transcription.

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MARLA HICKS: Recent studies show that midwifery care provides very good outcomes in terms of healthy moms and babies and is a good option for lower risk pregnancies. What are the different types of midwives that you can hire? What are the differences between midwives who work in a hospital versus ones who work in a birth centre or even at home? What should you be looking for when you’re interviewing a midwife? I’m Marla Hicks a licensed midwife, certified professional midwife and registered nurse and this is Preggie Pals episode 103.

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ANNIE LAIRD: Welcome to Preggie Pals broadcasting from the birth education centre of San Diego. Preggie Pals is your weekly online on the go support group for expecting parents and those hoping to become pregnant. I’m your host Annie Laird. Thanks to all of our loyal listeners who have joined the Preggie Pals club. Our members get special episodes, bonus content plus special giveaways and discounts. See our website for more information. Another way for you to stay connected is by downloading our Preggie Pals app. This is available free both on the Android and the iTunes market places. Samantha our producer is now going to give us some more information about our virtual panellists program. Samantha this is great for Parents that are people aren’t even pregnant, hoping to become pregnant but they’re not here in San Diego when we record.

SAMANTHA EKLUND: Right, definitely. We actually have one today. So if you don’t live in San Diego but you like to be a panellist on our show, you can still participate through our virtual panellist program. Just like us on Facebook and follow us on Twitter using the #preggiepalsvp. We’ll post questions throughout the week prior to our taping and then we’d love to hear from you and comment so we can incorporate your thoughts into our episode. You can also submit your questions directly to our experts. Learn more about our virtual panellist program through the community section on our website www.preggiepals.com.

ANNIE LAIRD: Great. Let’s go around the room. We have a panellist who is calling in today so Jade, why don’t you start off and introduce yourself.

JADE KING: Hi I’m Jade. I’m a mother to a son who will be two years old next Sunday and I’m also currently pregnant. I’m 36 weeks pregnant. I live in San Jose.

ANNIE LAIRD: Great.

KATHERINE BOTHWELL: My name is Katherine. I am currently unemployed but I work as a caretaker. I’m pregnant with my first baby. I’m 38 weeks. I was planning a home birth but I know now that I’ll be delivering in the hospital.

ANNIE LAIRD: Oh okay. With a midwife as well?

KATHERINE BOTHWELL: Yes.

ANNIE LAIRD: Yeah, great. Awesome!

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ANNIE LAIRD: Okay sometimes on Preggie Pals, we’ll review an app or look over a news article. This just happen this past week until this is just begging to be discussed here on the podcasts. Radio host rips a baseball player for paternity leave, suggests a C-section before the season start. So New York Mets second baseman Daniel Murphy, he missed the season’s first two games. The season opener and the game following the season opener all because his wife had a baby and then he, the American Baseball League they offer three days of paternity leave, so he took his three days of paternity leave whole whopping three days there. And so then this seems reasonable right, yeah according to some sports radio announcer so former NFL quarterback Boomer Esiason said the following “Quite frankly I would’ve said C-section before the season starts. I need to be at opening day. I’m sorry. This is what makes our money. This is how we’re going to live our life. This is how we’re going to give our child an opportunity to be a success in life.” That didn’t go so good for them. So the funniest part I think of the story is that Boomer Esiason apparently is affiliated somehow and I was talking about, you knew about this, with the March of Dimes. So if we know anything about…

MARLA HICKS: Was.

ANNIE LAIRD: So yes exactly so in anyway knows anything about the March of Dimes for the past I mean this is been for many, many years. March of Dimes is all about letting the baby pick their own birthday because that is when how the baby is the healthiest, got big good brain development, good lung development, baby is less likely to go in to the NICU so two days later then he gets on and says oh my good friends you know I talked to the March of Dimes you know and they told me all about this great things about not having an elective C-section then and so… What about our panellist, what do you guys generally what do you think about this whole article? Did you read about this?

JADE KING: I did. I did read about that you know I thought that my husband’s company was being unreasonable when they only give him five days. [Inaudible] you know I was like three days wow!

ANNIE LAIRD: Yeah.

JADE KING: And I mean what about the mom you know. What if she did get a C-section you know I mean what if her husband had talked her into that and you know with something that she was comfortable with? She’s not taking the consideration you know post-traumatic stress you know. It’s a really scary thing but if that’s something that she wanted more choice for her you know. But at least she had that choice. And you wouldn’t even really call for dad’s opinion for this chance to find out you know what they would’ve thought about that. You know coming from dad’s perspective.

ANNIE LAIRD: But it’s not uncommon here for celebrities you know were close to LA you know the whole phrase of too posh to push came from the posh spice you know came from what’s his name David Bekham’s wife.

SAMANTHA EKLUND: Right.

ANNIE LAIRD: She’s had four elective C-section. That’s just like they consider that kind of normal you know. You know whether that’s you not even though it’s not good for the babies. So…

SAMANTHA EKLUND: Right.

ANNIE LAIRD: Yeah.

SAMANTHA EKLUND: And it was amazing to me that in Baseball once you get down, for them it’s a job and I totally understand. But when you get down to the root of it, it’s a game.

ANNIE LAIRD: Yeah.

SAMANTHA EKLUND: It’s not critical to anyone’s life. So it’s amazing to me that it support is so valued over family.

ANNIE LAIRD: Yeah.

SAMANTHA EKLUND: And health.

ANNIE LAIRD: Yeah.

SAMANTHA EKLUND: It’s amazing. It’s baffling to me.

ANNIE LAIRD: Yeah.

KATHERINE BOTHWELL: I really like the part about what they say you know this is how he makes his living and how he’s going to pay for his kids to go to college unlike everybody else that works in the world who [overlapping] not paying for their kids to go to college.

ANNIE LAIRD: Yeah. God forbid he’s gone for 3 whole days.

KATHERINE BOTHWELL: Sheesh you know I actually read an article about how wet nursing has become pretty popular in Hollywood in places like that so…

ANNIE LAIRD: Oh wow.

KATHERINE BOTHWELL: They don’t have to…

ANNIE LAIRD: Have to get up in the middle of the night.

KATHERINE BOTHWELL: Yeah they just hire somebody to…

ANNIE LAIRD: Probably more than ten dollars an hour to…

KATHERINE BOTHWELL: Yeah.

ANNIE LAIRD: Wow.

KATHERINE BOTHWELL: I think I heard that the going rate was something like a thousand dollars a week so I was like you know what actually I’m going to be breastfeeding.

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ANNIE LAIRD: Today on Preggie Pals we are continuing our series about hiring your care providers. Joining us today as our expert is Marla Hicks. Marla is a licensed midwife, a certified professional midwife and a registered nurse holding a board certification in perinatal nursing, the high risk area of maternal newborn care. She has attended over twelve hundred home births as a senior midwife and has worked in labour and delivery, postpartum, newborn nursery, and community health settings. Marla welcome to the show and thanks for joining us.

MARLA HICKS: Thanks for having me Annie.

ANNIE LAIRD: So what is a midwife? I think sometimes you know as they say in the business of being born that a midwife that you know envision someone kind of from the old world with a woman comes in with a stick and are knitting needles and says okay bite down on this and you know that’s a…

KATHERINE BOTHWELL: I think that’s accurate.

ANNIE LAIRD: Yeah.

MARLA HICKS: Well a midwife is an individual who is trained in normal birth in particular. As a midwife, my job is to watch, to make sure that things are staying within the normal limits and if they are moving outside the realm of normal to be able to get another opinion or to get a referral or consultation or to transfer care or whatever we need to do in order to ensure that we have a healthy momma and a healthy baby.

ANNIE LAIRD: So what’s the difference between what you do as a midwife and what I think a lot more people are familiar with just the OBGYN you know Oh that’s what’s covered by my insurance so just pick a doctor or you know so what the difference between what you do and what a typical obstetrician does as far as birth is concerned?

MARLA HICKS: I would say that it’s the model of care primarily. The midwifery model of care views pregnancy and birth as a normal event in a woman’s life unless proven otherwise. So when we see things moving out of the room of normal, we know that it’s time to refer to someone whose specialty is in dealing with complicated pregnancies and births and that’s what an obstetrician does.

ANNIE LAIRD: Right. I think sometimes also there’s a confusion between midwives and doulas and we had an episode already on hiring your birth doula but it is two different very different roles so can you clarify what the difference between those two is?

MARLA HICKS: Yes a midwife is trained and educated to assess the woman’s pregnancy and birth clinically and a doula is a support person who is there to support the woman in every way physically, emotionally but does not do anything clinical. So there are overlapping aspects sort of like a Venn diagram where you have some overlaps. Certainly a midwife can offer labour support and emotional support to the woman and generally does but the doula is not supposed to do anything clinical even taking a blood pressure or listen to heart tones much less doing any internal exam. Those things will be clinical and more importantly the assessment aspect of that even more important than the actual action of doing something clinical is the assessment part of it. Making that clinical judgement is outside the scope of practice for a doula.

ANNIE LAIRD: Oh okay. Now what type of woman would be appropriate to seek midwifery care?

MARLA HICKS: That’s pretty easy for my point of view to summarize.

ANNIE LAIRD: Yeah you mention you know you already said you know it’s for a low risk woman.

MARLA HICKS: Yes.

ANNIE LAIRD: So what’s the definition of low risk?

MARLA HICKS: Generally what defines low risk for pregnancy and birth is one baby head down with mother in vibrant good health. The baby is more than 37 weeks gestational age and less than 42 weeks gestational age. And there are no other complications that preclude having a birth in midwifery care.

ANNIE LAIRD: What are some of the other kind of complications that a woman would have?

MARLA HICKS: Well we could see problems with fetal heart tones occasionally during pregnancies certainly those are correct times during the birth or the labour. There might be problems with hypertension, high blood pressure, preeclampsia as an extension of that. There’s a host of things that can go wrong. Most of the times things can’t go wrong and that’s why for the majority of normal women, pregnancy can be assisted by a midwife.

ANNIE LAIRD: Now Katherine I know that you know Marla is your mother so wow.

KATHERINE BOTHWELL: Right.

ANNIE LAIRD: So I mean and you grew up around this you know…

KATHERINE BOTHWELL: Oh yeah.

ANNIE LAIRD: So I mean because your mom is a midwife from basically your birth right.

KATHERINE BOTHWELL: Before me.

ANNIE LAIRD: Yeah. Yeah.

KATHERINE BOTHWELL: I’m the last of all of them so she’s been around the block before.

ANNIE LAIRD: Yeah.

MARLA HICKS: Multiple times.

ANNIE LAIRD: Yeah.

KATHERINE BOTHWELL: Yeah no I definitely grew up around it as the normal you know it wasn’t, I never ever really knew of anybody that was going to the hospital to have a baby and my mom and I used to watch a baby story all the time together and we would laugh at it because it’s…

ANNIE LAIRD: As if it so likes watching like baseball like…

KATHERINE BOTHWELL: Yeah. That was pretty much our baseball season.

ANNIE LAIRD: Yeah.

KATHERINE BOTHWELL: Watch a baby story and would just laugh the whole time. Still that was kind of the normal for me. It was what I was aiming for. I am giving birth to a sumo wrestler working of the hulk. So…

ANNIE LAIRD: I give birth to a couple of sumo wrestler so yeah.

KATHERINE BOTHWELL: But since it’s my first baby and you know we, she’s a, she has very broad shoulder, she’s just wide. It’s not just about the weight and everything. She’s just really wide. We’re concerned about shoulder dystocia and things like that so…

ANNIE LAIRD: Are you being seen by a midwife at your hospital then or…

KATHERINE BOTHWELL: Yeah.

ANNIE LAIRD: Okay.

KATHERINE BOTHWELL: We’re going to be meeting with somebody I just recently had. My last ultrasound and we’ve discovered how incredibly large she is. My mom being the wise woman that she is, she knows midwife and so I go talk to her and kind of figure out a birth plan from there so.

ANNIE LAIRD: Oh great.

KATHERINE BOTHWELL: Yeah. That would be good. I have someone that knows all the right questions to ask.

ANNIE LAIRD: Yeah. Jade how did you go about, did you have a midwife with your first child?

JADE KING: I did and then I went over 42 weeks and we passed out to a hospital so [inaudible] 42 and 2.

ANNIE LAIRD: Okay.

JADE KING: And it wasn’t a super great experience I mean I was wearing [inaudible] because my son is coming with some complications and needed to go into NICU but it was definitely not the ideal situation on you know I’m so type A. I you know had three birth plans. I had one from the birthing centre, I had one case I had to be transferred to a hospital and one case I needed a C-section and of course I still want it to happen all at home. You know everything that was on my birth plan went out the window and the only thing I did end up with that I didn’t want you know was a C-section but in the end you know everything else happened.

ANNIE LAIRD: Yeah.

JADE KING: I had what and was in our own house now and you know we have an almost two year old and I’d really like some to be a part of it if that’s what he chooses to do and you know what better place to give birth than your own house. It’s really comfortable and I know everything is and you know people come to me and I can labour how I want to and yeah..

ANNIE LAIRD: You can eat?

SAMANTHA EKLUND: It’s really exciting.

ANNIE LAIRD: Yeah. Now Jade were you when you transferred to the hospital to be induced, where you still under the care of midwives or did you transfer to your obstetrician on that point?

JADE KING: No they completely signed off.

ANNIE LAIRD: Okay. Now Marla I have to ask about that as well. When that happens because you mention that is you basically at 42 weeks, is that possible if you under the care of midwife you can have joint care with a midwife or with an obstetrician at that point?

MARLA HICKS: We have a brand new law here in California so I can only speak to the law of California.

ANNIE LAIRD: Okay.

MARLA HICKS: The law on California provides in cases of certain complications for the midwife to continue the care with an obstetrician and even if care has had to be handed over to the obstetrician because of complications.

ANNIE LAIRD: Okay.

MARLA HICKS: So…

JADE KING: My understanding is that finding an obstetrician to work with midwife is really-really hard.

MARLA HICKS: It’s getting better.

ANNIE LAIRD: Yeah.

MARLA HICKS: It’s getting better. It got better the day after the law was signed down here in San Diego and I know that’s true elsewhere so hope is coming for San Jose.

ANNIE LAIRD: Now Marla what are the, going on to a different topic here, what are the different types of midwives that practice here in the United States?

MARLA HICKS: There are essentially three different types of midwives. The first is the certified nurse midwife who is a registered nurse who has graduated from a Masters level program in nurse midwifery. These midwives are certified by the American College of Nurse Midwives and the programs that they attend are certified by the American Midwifery Certification Board.

The second type of midwife is a certified midwife. These midwives are legally recognized in five states. They’re programs are also certified through the American Midwifery Certification Board but because they are not nurses, they are certified midwives rather than certified nurse midwives.

The third type of midwife is a direct entry midwife. Many of these direct entry midwives are certified professional midwives that is a credential offered by the North American Registry of Midwives. It recognizes midwives who have trained by apprenticeship. It also recognizes a growing number of midwives who are trained through accredited programs that are accredited by the same that are accredited by the Midwifery Education Accreditation Council and both Midwifery Education Accreditation Council and the American Midwifery Certification Board receive their oversight from the same organization.

ANNIE LAIRD: Okay. And that’s the school that you are a Program Director at the Institute of Nizhoni here or a…

MARLA HICKS: It’s… I’m the Executive Director of Nizhoni Institute of Midwifery in San Diego.

ANNIE LAIRD: Oh okay, alright. Now as far as these midwives, which of them can work in a hospital?

MARLA HICKS: Well one of the things that I wanted to mention is that in many states, midwives are also licensed and so approximately half of the states in the US have licensure for direct entry midwives as well as for certified nurse midwives. And so in California, we have a rather unique situation in that licensed midwives are actually licensed to work in any setting. There are two licensed midwives in the state who have hospital privileges but the majority of California licensed midwives work either in free standing birth centres or they attend home births. There are many certified nurse midwives who also work in free standing birth centres and a small number of certified nurse midwives who attend births in home settings but most certified nurse midwives actually work in a hospital setting.

ANNIE LAIRD: Well when come back, we’re going to be discussing how you interview your midwife and make a choice of who is going to be attending your birth. We’ll be right back.

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ANNIE LAIRD: Welcome back. Today we are talking about how to hire your midwife. Marla so how is a pregnant woman how do they go about even finding a midwife to interview? Do they go to the Google or I mean Katherine you know you go down the hall…

KATHERIN BOTHWELL: Yeah.

ANNIE LAIRD: Hey mom you want to be my midwife so most women don’t have a that privilege of living with your midwife so yeah.

MARLA HICKS: I would say that the number one method for finding midwife happens to be the internet. Doctor Google is a great source of information and most people go to the internet nowadays.

ANNIE LAIRD: So as a midwife you got to have a good website then basically or at least have a child who can do it for you.

MARLA HICKS: Yes. It’s useful to have a web presence if you are a midwife these days.

ANNIE LAIRD: Are midwives covered by insurance as far as hospital versus home how does that all work?

MARLA HICKS: Many out of hospital midwives have their services at least partially reimbursed by insurance companies. I think that we will see more of that as time goes on because licensed midwives in particular are having greater recognition as members of the health care team.

ANNIE LAIRD: Well not to mention to with the passage of the affordable care act.

MARLA HICKS: Yes.

ANNIE LAIRD: You know their looking for…

MARLA HICKS: Affordable care.

ANNIE LAIRD: Affordable care, imagine that you know and midwifery care you know is a lot cheaper.

MARLA HICKS: Yes.

ANNIE LAIRD: So…

MARLA HICKS: Yes.

ANNIE LAIRD: A lot less you know you are stick to bringing to buy on, you’r just kind of…

MARLA HICKS: Yeah.

ANNIE LAIRD: You know.

MARLA HICKS: You can find a stick in the backyard…

ANNIE LAIRD: Exactly.

MARLA HICKS: It isn’t going to cost you anything. It really brings the cause down.

ANNIE LAIRD: It does. You can use your husband’s shoelace to tie off the umbilical cord. We’re all about economy.

MARLA HICKS: It is true thought that midwifery care does tends to be less expensive and there’s a lot of data that suggest that people are generally very satisfied with midwifery care whether it’s certified nurse midwifery care or care from licensed midwives.

ANNIE LAIRD: How important does experience obviously every midwife has to start somewhere. Somebody has you know birth number one birth number two…

MARLA HICKS: That’s right.

ANNIE LAIRD: But do you feel that that’s a primary factor that women should be looking for as experience? If not then what would be the primary factor that a woman should be looking for when hiring a midwife?

MARLA HICKS: When I first began my midwifery career, I’d had the benefit of some really great mentors and I felt very blessed in that respect. I was still very nervous about oh my goodness this is I’m it now, I’m the primary you know…

ANNIE LAIRD: Care provider.

MARLA HICKS: Care provider and I remember expressing this to one of the midwives who had been one of my primary mentors and she said Marla you’re going to be just fine if you remember three little words, transfer when necessary. So I think that experience is important absolutely. And I think education is important but I also think that a sense of your own limitations and an honest appraisal of that is very critical. That’s what will help make a new midwife a really good midwife if she can recognize when things are moving from normal to abnormal, you know we can’t always know what is going on because we don’t necessarily have the diagnostic tools to be able to assess that.

So we need to go to higher ground. And I’m not afraid to say that there is higher ground than for example home birth. I love home birth but there are times when home birth is not the appropriate choice any longer. And so we need to go to a setting in which you know there is higher level care available. If we can understand that then we can stop making this about us versus them, right versus wrong. We can understand that there’s a whole spectrum of care that is available and it’s important for the woman and for her care provider to be able to determine where she fits on that spectrum and to take an honest assessment. And so if you’re, even if you’re a less experience midwife, if you have a very good sense of your limitations and the limitations of your situation and also…

ANNIE LAIRD: And so I say it will be very different depending on how far you are from the hospital you know.

MARLA HICKS: Right.

ANNIE LAIRD: It’s very different if you are 3 miles down the road of if it’s an hour or so.

MARLA HICKS: Of course.

ANNIE LAIRD: Yeah.

MARLA HICKS: Of course so there’s a lot that goes into that decision making. And it’s important to have a good relationship with the health care providers who are hospital based.

ANNIE LAIRD: Jade what did you look for when you hired your midwife for your current pregnancy here? I mean how many interviews did you do?

JADE KING: Well I ended up hiring the first midwife that I interviewed just because she came highly recommended, had years of experience and is pretty well known in the Bay Area. And so I went to about two prenatal appointment and then when she told me that my son wasn’t welcome at the appointments, that was the deal breaker for me. You know I’m stay at home mom, my husband is in works full time and you know being new to the Bay Area, I’m not going to leave my son with anybody. You know that I don’t know so he needed to be with me and to be a part of this.

And so I just started over again. I hired a new midwife to I just really have a good connection with. I mean we could, our first appointment, it wasn’t even an appointment it was like an interview and we just sat and talk for over an hour and you know she also came highly recommended and you know it felt really comfortable with her and actually I messaged a couple of her past clients and they have really good things to say about her and I feel really-really good about my choice and they found to welcome that the appointments there’s actually a little play area behind where she sits.

ANNIE LAIRD: Sounds like a very family based care. Yeah. Marla how do midwives help women with pain and labour? Now I know when we joked about you know different you know coming in with a stick or you know if you don’t have an epidural you know in a birthing centre or a little more perhaps a woman don’t even want any kind of you know medical you know like IV drugs or something like that I mean what do midwives bring to the table for their clients as far as pain relief?

MARLA HICKS: I think that one of the things that midwives bring to the table as far as pain relief is a solid knowledge of bio mechanics. If you’re able to assess what’s going on for example the woman has a posterior baby and it’s creating back labour, that’s a fairly familiar scenario to a lot of people. Then a midwife should know what kinds of position will help not only to relieve pain but also facilitate the progress of labour and help the baby rotate. A lot of midwives are enthusiastic about the use of water during labour and even birth so water births had become popular and it is often very satisfying as a midwife to look you know at the woman who gets in to the pool of water and see the sense of relaxation that rolls over her.

Anyway that’s another tool that can be used and there were birth balls, and there were you know there’re lots of things that you can use. You can use your hands. You can use you know the kindness of you touch and your attention and a doula is certainly one of the most remarkable methods of pain relief that is available to women in labour. And we know from you know excellent studies that have been done in the past that doulas do a great deal of a good in terms of helping labours be normal just by their very presence.

ANNIE LAIRD: Do midwives work with moms who know they want an epidural? Obviously we’re talking about hospital birth here so…

MARLA HICKS: You bet. You bet.

ANNIE LAIRD: Yeah.

MARLA HICKS: Only certified nurse midwives worked with women who are planning to have an epidural you know many-many times. But licensed midwives you know provide care to women during the course of their pregnancy and you know sometimes I have women who come to me and say I don’t really want to sign up for a home birth but I understand that you know a lot about nutrition. You know about this or that and I would like to have the benefit of that so I would like to see you for a few prenatal visits and then I’m going to go to the hospital and have my epidural with my wonderful obstetrician. And that works out just as fine.

ANNIE LAIRD: Well thanks Marla for joining us today. For more information about Marla and her midwifery practice as well as information about any of our panellists, visit the episode page on our website. This conversation continues for members of our Preggie Pals club. After the show Marla will be discussing the top three questions that you should ask during the interview of your perspective midwife. To join our club visit our website www.preggiepals.com.

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ANNIE LAIRD: This is a Pregnancy Oops Story a funny story from one of our listeners. This is from Elizabeth from Oregon. She writes I was about fifteen weeks or so and I was sleeping at my boyfriend’s house. Well whatever I ate before bed must have not agreed with me to say the least because when I woke up my boyfriend was sleeping on the couch in the other side of the room instead in the bed with me. I ask him why he had moved in the couch and he said I was farting so much in my sleep that he can hardly breathe it was literally making him sick. He even opened up the window. Oops hey pregnant women get gas. I can’t help that. If you got your own pregnancy Oops or funny story you’d like to share, call our voicemail area code 619-866-4775 and leave us your story and we would play your story on air.

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ANNIE LAIRD: That wraps up our show for today. We appreciate you listening to Preggie Pals.
Don’t forget to check out our sister shows:
• Parent Savers for parents with newborns, infants and toddlers
• Twin Talks for parents of multiples.
• The Boob Group for moms who breastfeed their babies and

Next week we’ll be talking about planning your blessing way, the alternative to a baby shower.
This is Preggie Pals, your pregnancy, your way.

[Disclaimer]
This has been a New Mommy Media production. Information and material contained in this episode are presented for educational purposes only. Statements and opinions expressed in this episode are not necessarily those of New Mommy Media and should not be considered facts. Though information in which areas are related to be accurate, it is not intended to replace or substitute for professional, Medical or advisor care and should not be used for diagnosing or treating health care problem or disease or prescribing any medications. If you have questions or concerns regarding your physical or mental health or the health of your baby, please seek assistance from a qualified health care provider.

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