Friday, February 28, 2014

Cord Prolapse

This is another area I want to delve a little deeper into so people are more aware of this issue and know how to manage and what to expect if this occurs. I am thankful this does not happen frequently, but when it does it is a life or death situation for the baby.

What is umbilical cord prolapse?

An umbilical cord prolapse is when the umbilical cord comes out of the vaginal opening ahead of the baby. When this occurs, pressure is put on the cord cutting off oxygen to the baby, necessitating a quick delivery. 

What happens when this is found?

If the cord is in the vaginal cavity, you will immediately be laid as far back as possible and the bed put in the trendelenburg position (you will feel like you are standing on your head in the bed). A nurse or midwife will put her hand into your vagina and push the baby up into your uterus to take pressure off of the cord and you will be immediately rushed to an OR for a c-section.

What if I am not in the hospital when this happens?

If your water breaks and you can tell there is a cord coming out of your vagina find some way to get your hips in the air immediately! Then call 911 or have someone else to it if they are with you. Keep your hips in the air until you are positioned by the paramedics and they can help get the baby off the cord.

What are some risk factors?

Your water rupturing prematurely, having too much amniotic fluid, having a very long umbilical cord, the baby in an unfavorable position for delivery and having multiples

Do you have any experience with this type of emergency? 

Thursday, February 27, 2014

Placenta Problems

I want to go a little more in depth into some of the placental problems that can occur with pregnancy and can cause complication with childbirth. The placenta is formed early in pregnancy and supplies oxygen and nutrients to the baby and removes waste from the baby. Normally the umbilical cord is attached to it carrying the oxygen, nutrients and waste. It is usually attached to the front or side of the uterus. It is an amazing organ that God has designed, but like everything else in this world there are opportunities for things to go wrong.

Placenta Previa

This is the most common of the abnormalities that arise with the placenta. A complete previa covers all of the cervix. A partial previa covers part of the cervix. There is also a marginal previa where the placenta is touching part of the cervix. If any of these do not resolve a c-section will occur. Approximately 90% of the time a previa seen in the 20 week ultra sound will resolve before you are ready to give birth. There is nothing you can physically do to make it move. If you are desiring a vaginal birth, pray hard for God to move it.

Placental Abruption

A placental abruption occurs when the placenta pulls away from the uterine wall before the baby is born. There can be a partial or complete abruption. Both can cause serious problems for both mom and baby, however complete is more likely to cause death in one or both. Know the signs of abruption so you can seek medical help immediately.

Common signs are: vaginal bleeding, abdominal pain (usually sharp and very painful, but can be less severe), Uterine tenderness, back pain and contractions that are very close or a long contraction that will not let up.

If you have any of these signs contact your provider immediately. If you're in excruciating pain get to a hospital asap.

Placenta Accreta, Increta or Percreta

These occur when the placenta attaches too firmly and deeply into the uterine wall at different levels. An accreta is too deep into the placental wall and may not detach properly. An Increta is implanted even deeper into the wall keeping the placenta from being able to detach after birth. A percreta goes through the uterine wall and can attach to other organs, typically the bladder.

The most common symptom is vaginal bleeding and can cause premature labor and delivery of the baby. If they are suspected ultrasound or MRI might be done to check the severity. If known before delivery a c-section might be done to try to preserve the uterus or a hysterectomy may be necessary. Thankfully these are quite rare.

Retained Placenta

Sometimes after birth the placenta does not want to come out, which is called a retained placenta. If this happens a D&C will be required to remove the placenta before there is too much blood loss. A retained placental can cause severe blood loss for the mother and can be life threatening.

Have you had complications with your placenta? Share your experience.

Wednesday, February 26, 2014

Other Reasons for C-sections

There are other considerations for having a c-section than the reasons mentioned yesterday that may not be known until labor or you have more of an option as to whether or not you will have a c-section.

  1. Previous c-section- This one is tricky as the research goes "back and forth" as to the phrase "once a c-section, always a c-section" is really best. Having a previous c-section is something that must be considered, but does not mean you must have another c-section. Ask your provider where they stand.
  2. Multiple Pregnancy- When pregnant with more than one baby it may be recommended that you have a c-section, especially if one or more babies is not positioned ideally. Providers will consider allowing you to labor with twins, but typically if there are more than twins, they are unlikely to allow you to labor. 
  3. CPD- This is an abbreviation that means the baby's head does not fit in your pelvis. This is something that will likely not be known until you are actually in labor and may not discover until you have been laboring a while. Occasionally you may know if you have an oddly shaped pelvis ahead of time, giving you a heads up that this could be an issue, but many times this is not known until later. 
  4. Labor being too long- This, of course, you cannot know ahead of time. Having a long labor is not indicative of needing a c-section, but often times, especially if you are in a hospital laboring, this will give providers "concern" and you can end up with a c-section.
  5. Prolonged Rupture of Membranes- This, too, would not be known ahead of time. Once your water has broken you are "on the clock" in the hospital setting. They like the baby to be delivered by 24 hours after this happening. At the 24 hour mark it is likely they will begin talking about a c-section, especially if progress is slow. 
  6. Placenta accreta- This occurs when the placenta is implanted to deeply and firmly into the uterine wall. If it is caught ahead of time a c-section may be scheduled in the hopes of saving the uterus. 
There might be other reasons, but these are the common ones that happen fairly often. Have you had experience with these? Are there other reasons you can think of?

Tuesday, February 25, 2014

C-Section, No Question

Yesterday we talked about c-sections covering what they are. I concluded that they are great when they are needed. Today I want to share situations when a c-section would be absolutely necessary, no questions asked. Some of the information may be a little scary, but I believe it is important for us to be informed about these situations so if it arises during our pregnancies or births, we know that it is necessary for the baby's health and ours and not simply doctors attempting to control a situation.

  1. Placenta Previa- A previa is when the placenta is covering all or part of the cervix. A complete previa covers the cervix completely, a partial means it is over part of the cervix. Clearly if the previa is complete, there is no way for the baby to come out vaginally and a c-section is required. With a partial there is still a high bleeding risk involved and will still require a c-section. Often times previas will move. The placenta need to be at least 2 cm away from the cervix for a vaginal delivery. 
  2. Placental Abruption- This occurs when part of the placenta begins to tear away from the uterine wall before the delivery of a baby. Typically it comes on very suddenly and there is a lot of bleeding and pain. Due to the blood loss the baby needs to be delivered quickly for the health of both mom and baby.
  3. Prolapsed cord- This occurs when the umbilical cord comes down before the baby's head. This is an emergency and the baby needs to be delivered ASAP! 
  4. Non-reassuring heart tones- This includes prolonged decelerations or persistent late decelerations that do not stop with intervention. A prolonged deceleration in the baby's heart rate is an emergency and you will be running back for a c-section. Late decelerations (slight decrease in heart rate that occurs after the contraction) is not an immediate emergency, but are a sign that there is a problem with the oxygen supply to the baby. Other interventions would be attempted before a c-section, but if there is no improvement a c-section will be needed.
  5. Breech or Transverse Presentation- I mention these here because there are not many providers who will deliver a breech presentation vaginally and transverse presentation cannot be delivered vaginally. 
  6. Medical Conditions- There are certain medical conditions that will not allow for a vaginal delivery such as certain heart conditions, previous uterine surgery and active herpes legion. These will be discussed with your provider ahead of time.
These are the primary reasons I can think of for immediate c-sections. Have you had any experience with these? 

Monday, February 24, 2014

What Is A C-Section?

A c-section is a surgical procedure that is done to take the baby out of the uterus when a vaginal delivery may not be possible. The procedure is done by cutting a horizontal incision in the pelvic region of the skin and typically a horizontal incision in the uterus. The abdominal muscles are also cut during this procedure. On occasion, if there is an emergency a vertical incision may be done on the skin and/or uterus. The type of incision on the uterus will determine if you will be able to attempt a VBAC in the future. After the baby and placenta have been delivered the uterus, muscles and skin are then sewn back together with sutures that absorb. Sometime staples are used on the skin.

Typically they will use epidural anesthesia for a c-section unless it is a true emergency or you are unable to have an epidural for medical reasons. If you are unable to have an epidural, they will put you under general anesthesia. Typically those who have epidural anesthesia have a quicker recovery due to the nature of epidural vs general anesthesia, so if you know you are having a c-section then if at all possible you would want an epidural.

We are blessed that we have the ability to do these easily when they are needed, but c-sections are major surgery and should be considered very carefully in healthy women. Know your providers c-section rate. Know if they are quick to do c-sections for non-emergent reasons. Know what they are and when they are necessary. Ask a lot of questions, especially if you are hoping to avoid a c-section.

Friday, February 21, 2014


What is an episiotomy?

An episiotomy is when a cut is made in the perineum. There are 2 types: median and midline.
Midline is a cut made straight down the middle of the perineum.
Median is made at an angle to the right or left.

Are episiotomies necessary?

Generally speaking they are not necessary. Some providers use them as an alternative to tearing.
In the case of a emergent situation they can be necessary. For example, the baby is almost out at the vaginal opening, but the heart rate is dropping drastically. An episiotomy may be performed to help the baby get out quickly instead of doing a c-section.

Is an episiotomy better than tearing?

This question is clearly up for debate and you can find research supporting both views. From my personal understanding and experience I believe it is better to tear for healing purposes. The reason for this is it's a natural process and the tear fits back together upon repair like a puzzle. When there is a clean cut this does not happen. Also, with a cut it becomes easier to rip like when you cut a piece of paper.

Have you had an episiotomy? What are your thoughts on them?

Thursday, February 20, 2014

Pain Medication

What pain medications are available during labor?

There are a few that are used in labor and it depends on the provider what they generally use. It also depends on the stage of labor you are in what they might use.

If early in labor or being induced overnight, they are more likely to give you something longer lasting, while in active labor they are more likely to give you a short acting drug.

Some of the drugs that might be used include stadol, fentanyl, morphine, dilaudid, and demerol.

Are there risks involved with these drugs?

Like with all medication, there are risks. They give temporary relief, but they have the possibility of suppressing the baby's breathing upon birth. This can lead to needed interventions when they are born. Generally speaking this is not severe, but can be.

When can these be given?

Each provider and hospital have there different policies, but once you are dilated to about 7 cm or so, they will not give these for the risk above. Up until then they can be given every 2 to 6 hours depending on the drug.

Have you had any of these drugs during labor? What was your experience?

Wednesday, February 19, 2014


What is an epidural?

An epidural is placed in the epidural space in your back. I needle is used to place a catheter in this space and medicine is giving continuously through the catheter. What is put in the epidural depends on where you are and is typically a combination. Ask your provider what they use in their epidurals.

What are some pros of an epidural? 

  • If placed well there is complete pain relief with the ability to feel pressure when it's time to push
  • Ability to sleep/rest during your labor
  • If you have been in labor for a long time with out progressing it can help speed up dilation
  • If a c-section is needed you already have it in place
What are some cons of an epidural?
  • Can cause your blood pressure to drastically decrease- If too low can lead to distress with the baby
  • Unable to get out of bed in most places
  • Cannot eat or drink (ice chips only)
  • Can slow down labor process- (if this happens you may be given pitocin)
  • May not be able to feel to push
  • Catheter is needed to empty your bladder
When needed, epidurals are great tools to have. Again I encourage you to pray over whether or not this is the best option for you. 

What have been your experiences with epidurals?

Tuesday, February 18, 2014

Are There Ways to Induce Naturally?

You are past your due date and your provider is talking about induction and yet you do not want to induce if possible. The question that comes after this talk: is there anything I can do to start labor on my own? There is a lot of question about this as some things work well for some people while others have no success. With my first I tried a lot to make myself go into labor, but nothing worked. I have talked to others that the first thing they tried helped them go into labor.

With that being said, here are some things that may or may not help you go into labor.

First I suggest you pray, because ultimately God is the one who will make labor happen!

Walking- This one is completely up in the air as to whether or not it helps, hinders or has no effect at all on labor. Do not walk until exhaustion, but feel free to try walking as it will not hurt you.

Sex- Sex is one of the best options as long as you are healthy for several reasons. Semen has prostaglandins in it that help prepare the cervix for labor and can then kick you into labor. It also helps with intimacy and preparing you together for what's to come. There are other techniques I will mention that can be implemented during your time together.

Nipple stimulation- This can be very effective as it releases oxytocin, which is the natural form of pitocin, into your body. You must pay very close attention to your body so you do not over stimulate your uterus leading to contractions that are too long. This site has a good basic process to follow.

Acupressure- This can actually feel really nice as it is more of a massage technique. There are 2 primary places to use: 1) The webbing between the thumb and forefinger and 2) 4 fingers above the ankle on the inside of your leg. See this link to learn the process.

Food- There are some foods that may help you go into labor. Some that are out there include: pineapple, spicy food, eggplant parmesan, date fruit, curry, Chinese food and licorice. There is no definitive research to back up any of these, but it can't hurt to try.

Blue or Black Cohash- These are herbs and need to be handled with great care. Please consult your healthcare provider before trying one of these.

Castor Oil- This is another method that should be used with great care. You drink castor oil causing the bowels to be stimulated, which stimulates the uterus. I have talked to many women who have had success with this. It can cause severe diarrhea. Ask your care provider before using it.

These are just a few well known options. Again pray for wisdom and for God to bring out labor. If you are unsure of anything ask your health care provider.

Have you tried to induce labor naturally? What did you use? Was it successful?

Monday, February 17, 2014


What is induction of labor? 

This is when medical interventions are taken to cause a woman to go into labor.

When are inductions necessary?

There is certainly some subjectivity to this question, but some cases that may need an induction of labor would include developing pre-eclampsia or pregnancy induced hypertenstion (PIH), low or high amniotic fluid, the baby being too big or too small, and going far over your due date. This is not an exhaustive list but more of the common reasons why induction may be considered.

What medicines are used to induce labor?

Depending on the circumstances different medicines may be used.

Cervidil is used to help prepare the cervix for labor. It is put inside of the woman behind the cervix and left in for up to 12 hours.

Cytotec is also used to prepare the cervix for labor as well. It can be put behind the cervix and absorbed or taken orally. This can be given every 4 hours minimum, depending on contractions.

Pitocin is a synthetic form of the hormone secreted by women to cause labor. It is given through an IV and the dose depends on the provider and how labor is progressing.

Two of my births thus far have been inductions and were completely different experiences. I so desired not to be induced, but God taught me so much through them. From my personal experience I definitely would not recommend having an elective induction as my recoveries were a lot easier when I was not induced. Whether or not you should be induced should be a matter of prayer, seeking God's wisdom.

What is your experience with induction?

Friday, February 14, 2014

Non-Stress Test and Stress Test

A non-stress test is performed later in pregnancy, typically after 40 weeks to determine if the baby is doing well and if an induction might be needed. This is done in the doctor's office and a provider puts a fetal heart rate monitor and a toco (contraction) monitor to make sure that the baby is responding well to both normal state and to any contractions you might have. This is not necessary, but typically encouraged if going past your due date.

A stress test occurs when you are hooked up to the same machine but they put intentional stress on the baby by giving you oxytocin to see how the baby responds to contractions. It is done to make sure that the baby will be able to handle the stress of labor. This is usually done if a non-stress test is questionable and further evaluation needs to be done. Because they are giving you oxytocin there is a risk of labor beginning. This test is also not necessary, but usually there is other evidence to consider doing it.

Again pray for wisdom with these tests, especially the stress test since there is a chance of inducing labor.

Thursday, February 13, 2014

Glucose Tolerance Test

The Glucose Tolerance Test (GTT) is done around 24-28 weeks of gestation to check for gestational diabetes. You are given a very sweet drink to drink about an hour before your appointment. It varies on the provider if it needs to be fasting, but typically fasting will give you more accurate results. An hour after you finish the drink your blood is taken, either by needle stick in the arm or a finger stick to check your blood sugar. They like for your blood sugar level to be under 140 in most cases. Each provider has slightly different variations, so ask what they are expecting.

If you fail the 1 hour test, you will be required to return another time to have a 3 hour test, which is completely fasting for the full 3 hours.

This is a test I believe most OB/GYNs and CNMs require, though I have heard some midwives have stopped requiring this test. If you are not sure you want to do this test, ask up front if it's required. I have heard recently that there may be some question to how accurate this test is, though I have no current research to say for sure how accurate the GTT is. There is no direct harm to your baby or you with this test.

I have had this test with all of my pregnancies. With the 3rd and 4th I had to do the 3 hour test and I passed the 3 hour with flying colors. I tried to deny this with my providers (not strongly just to see what they would say) and they were not keen on the idea, so again if you have questions about doing this test, find out the requirements of your provider early on.

Wednesday, February 12, 2014


The majority of healthcare providers do an ultrasound around 20 weeks. The purpose of this ultrasound to so measure the baby to see that he/she is growing as expected. They also look at the placenta, blood flow, baby size and level of amniotic fluid. This is the time when they will also look to see what the gender is if you desire, but it is not the primary reason for the test and if the baby is uncooperative you are out of luck.

Later on in pregnancy ultrasounds are used to check size, fluid level and presentation if there is a question about which way the baby is facing. They do guesstimate the baby's weight with an ultrasound but it can be off up to a pound in either direction. If there has been a problem with the placenta they will check this also to see if the placenta is healthy or has moved.

Ultrasounds are not necessary for a healthy pregnancy, but I don't know how many providers will allow you to refuse it. If you do not want ultrasounds, you need to find out if that is acceptable for your provider. There are no risks that are known with ultrasounds, though many babies do not like them.

I have had ultrasounds with all of my babies and really like them. It's fun to see them and to see how the baby is doing as a whole.

Tuesday, February 11, 2014


Amniocentesis is not routine test, but I want to give it a brief mention in case someone may be needing to decide if it's a test they need to do. These are done after the triple screen and early ultrasound if something seems wrong. This test is very invasive and can pose a threat to both mom and baby.

Amniocentesis involves removing some of the amniotic fluid around the baby by inserting a needle in the woman's stomach under the guide of ultrasound. The fluid is then tested, typically looking for genetic disorders such as Down's Syndrome, Tay-sachs or Sickle Cell Anemia. If you are wanting to know if there is a genetic issue going on with your child, it is 99% accurate.

This is not a test to be taken lightly, however, because it is invasive. Though complications are rare it can cause pre-term labor, infection or miscarriage.

Again, amniocentesis is not routine and should be prayed over before performing. It can be a great tool if needed but also can be a great risk. We need wisdom in this.

Monday, February 10, 2014

Triple Screen and Early Ultrasound

The triple screen is offered to all women near the end of their first trimester or beginning of the second. This tests the mother's blood to look at the levels AFP, hCG and Estriol looking for indications of abnormalities in the baby. For this screening they prick your finger and take blood to be sent off for the screening. It usually takes around a week to process. This is only a screening and gives no diagnosis. If levels of any of the 3 substances comes back abnormal they may run further testing, however getting "false positives" is very common on this screen. To read more in depth on this screening check out this page.

The benefits of this type of screening is knowing if there is a problem early on that needs to be treated immediately after birth or possibly before birth in extreme cases. This is a screen that you can typically opt out of without any problem. I have not had this done, personally, so do not have any personal experience with it.

Along with this triple screen they will also do an early ultrasound to look at the neck folds of the baby, looking for indication of Downs Syndrome. They may also do an early ultrasound to check for dates, particularly if you have an irregular period or are very unsure of conception. Again you can usually opt out of this if you choose to. I had an early ultrasound with 4 of my pregnancies for dating purposes. This pregnancy is the first time I have not had one, and my pregnancy has been much like the others.

Do you have any experience with these? Would you recommend them?

Friday, February 7, 2014

Are Medical Tests and/or Interventions Necessary?

It is possible to be pregnant and give birth with out any medical tests or interventions, so no none of them are actually necessary generally speaking. There are many that have benefits, like ultrasounds, induction medications when needed, and c-sections when needed, and we are blessed to have access to these things.

Whether or not you personally need them will depend on your pregnancy and birth. There are some tests that are required by providers and you need to know what those are. Most of the time you can refuse screenings and vaccines as well as interventions in labor as long as the baby's and/or your life are not in danger. Remember to ask about these things in the beginning so you do not end up in a situation where you feel forced or coerced into doing something you are not comfortable with or do not know what it.

We will discuss specific tests and interventions in the future so you can have a better idea of what they are and know what you are OK with in your pregnancy and delivery.

Thursday, February 6, 2014

Is Having a Home Birth a Safe Option?

I touched on this a little in the post discussing where to have your baby, but I wanted to zero in on it a little as it is a much debated subject. Having been trained as a nurse in the medical realm, I use to think that having a home birth was a foolish option. However, in the past couple years as I have educated myself on home birth and met those who have had home births it is evident that having a home birth is as safe, in most cases, as giving birth in a hospital or birth center.

Not that long ago most women had their children at home and in many countries, women still have babies at home. A recent study, published recently in the Journal of Midwifery and Women's Health, showed that the outcomes are very good with minimal complication in the data they were able to collect between 2004 and 2009. To read the full research article click here. To read a review of the research click here.

If you would like to watch a document in home birth I would suggest checking out "The Business of Being Born." This really helped me in understanding those who took care of those laboring and delivering at home. These midwives are well trained in holistic care and are trained to know when extra help may be needed. They are very knowledgeable and desire to see women have good outcomes at home.

So the simple answer is it is as safe to have a baby at home as anywhere else. This is something that you must pray over and seek God's wisdom in where He is guiding you to have the baby.

What are your thoughts?

Wednesday, February 5, 2014

What Will My Insurance Cover?

This is an excellent question that I cannot completely answer. Different policies have different coverage so if you are pregnant or thinking of starting a family, find out what their policies are. Some cover everything without any stipulation, but that is not usually the case. There may be limitations on where you can have the baby or who you can have deliver you. There may be stipulations on when they will cover inductions. They may cover more things, but it may cost more to go out of network vs in network. These are all things you need to know. Most insurance companies have people who can help you answer these questions if you call the general number.

Tuesday, February 4, 2014

Where Should I Give Birth?

Many people do not believe they have options on where to give birth, but this is not the case. At times you can be limited by what is available around you, but most people have at least 2 choices. The 3 places to consider are a hospital, a birth center or your own home.

Hospitals are the primary places that women give birth in our country. In a hospital you would be under the care of an OB/GYN or CNM. Here you can expect to have birth treated very medically and interventions done as mild as external fetal monitoring and as serious as a c-section if they do not believe you are progressing as you should and others things in the middle. This is just the nature of the hospital. It is neither good nor bad, it is simply the way things are done in hospitals.

Birth centers are the in between from home and hospital, having a home like environment with much of the medical equipment available if needed. They are typically run by CNMs and are part of the healthcare system and therefore covered by some insurance companies. They tend to be more holistic in their approach and refrain from unnecessary intervention. Many find this a happy medium between a hospital and their own home. (For further general information and locations visit

A home birth means exactly what it sounds like, having your baby in your own home. These are on the rise again in the US. The challenge with home births is the legality issue of CPMs from state to state. It is technically legal for any woman to have an unassisted home birth anywhere they live, but most would prefer to have an attendant of some kind at their birth. To learn about the legislation issues for CPMs in each state please refer to this site and this site. To dispel any myths, for women who have had healthy pregnancies, it is as safe to have a baby at home as in a hospital or birth center. Many times there are better outcomes because of the woman being in a comfortable environment.

Again, you must be seeking God as you are deciding where to give birth. We will get more in depth with these as we go, but hope this brief overview helps. Feel free to give any basic information on the places above!

Monday, February 3, 2014

What Type of Provider Should I Have?

There are a lot of different types of healthcare providers in the labor and delivery department. There are OB/GYNs, CNMs, CPMs and CMs. Welcome to the alphabet soup of healthcare. What does this all mean? Here is a brief overview.

OB/GYN: A medical doctor who is trained in the care of women, including prenatal, labor and delivery and postnatal care. They are legal to practice in all 50 states and primarily practice in hospitals.

CNM (Certified Nurse Midwife): These are nurses who are also trained in midwifery. They are trained in the hospital setting and primarily practice in the hospital. They are legal to practice in all 50 states.

CPM (Certified Professional Midwife): These midwives are trained in providing safe, full-scope, out of hospital maternity care, and are certified by NARM. They specialize in home birth and currently on legal to practice in 28 states.

CM (Certified Midwife): These are trained in midwifery and are certified by the American College of Nurse-Midwives. They practice in the hospital setting and are only legal to practice in 3 states.

There is a lot to consider when choosing a provider, which is one reason we need to have an idea of what our expectations and desires are for labor and delivery. Anyone you think you may want to have taking care of you during your pregnancy, labor and delivery you need to ask good questions of. Check out the Interviewing Potential Providers page for questions to ask someone you may ask to care for you. Throughout the whole process pray for wisdom that you will have the best provider for your baby and you.

Where you desire to have your baby will also play a part in who you use. We will give an overview of places tomorrow.

(For more information on Midwives, their practice and some of the legal issues check out this site.)
(To learn where CPMs are legally able to practice and the current legislation in other states refer to this site.)