Introduction to the “Injustice in Maternity Care” Series
Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?! Are you SERIOUS!? Oh come ON!”
What do I mean? If you have ever watched the amazing documentary The Business of Being Born and thought to yourself, “Oh no, that can’t be true? That must be an exaggeration,” I am here to tell you that it is NOT an exaggeration.
The fact is, the current state of maternity care in the United States is in a crisis and many times I find myself feeling defeated and helpless regarding it all. I mean don’t get me wrong, I take my job as a nurse and patient advocate very seriously and protecting the health, safety, and autonomy of my patients is very important to me. So seriously in fact that I have all but thrown a screaming fit at times when faced with particularly outrageous obstetricians and unjust circumstances. (Oh wait, I have thrown screaming fits before…Haha! J ) In the end I often find myself working with nurses that I feel are dedicated and fantastic, but who none the less have had to put up with this bullshit for so long that they sort of become complacent to it.
So where does that leave me? I feel my position as an L&D nurse really puts me at the end of the line when it comes to affecting change in how woman and families approach pregnancy and childbirth. One of the things that really inspired me to start this blog was that I realized I really only get my “hands” on families after they have already been sucked in to the medical model of maternity care. One particularly hard pill for me to swallow is this country’s epidemic of women undergoing unnecessary interventions, including but not limited to, the inappropriate use of labor induction and augmentation and unnecessary primary and repeat cesarean sections. But the more and more I have worked in this “culture” and talked with these women and families, the more and more I have realized that all too often these women are really lured in and duped into these interventions! That true informed consent is not really obtained and alternatives to the obstetrician’s (and even some “med-wives’ ”) proposed course of action are NOT provided. And a few days ago I took care of a patient that was really just the straw that broke the camel’s back.
Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series. If you are pregnant or planning on becoming pregnant, this series is dedicated to you! Since I prefer countdowns instead of count ups, I decided to start at a random number. I have no doubt I will be able to come up with 25 situations I have found myself or my patients in that could easily make the list. (Hmmm, maybe I should start at 1000! J )
Don’t Let This Happen To You #25: PART 1 of 2
Sarah & John’s Unnecessary Induction for “Oligohydramnios” and “Post-dates”
I came to work for 11:00 am as usual one cold and rainy Monday morning and despite the many obvious reasons to be in a bad mood, I was actually pleasantly optimistic about my upcoming shift. Things seemed to be going my way when I saw my assignment. I would be taking over a laboring patient of Dr. F’s in room 11 for a nurse who was only working a half shift. Since assisting women during labor is my favorite part of being an L&D nurse, I was happy.
So I went to the desk closest to the patient’s room and started to look over her chart until her current nurse was ready to give me report. Let’s see here…26 year old first time mom, first pregnancy (G1P0), no medical risks in her health history, no complications during this pregnancy. According to her LMP she is 40 weeks and 5 days (“aka” still 9 days away from 42 weeks or true “postdates”). A quick look at her most recent ultrasound report (performed 3 days earlier) showed a Grade II placenta (“aka” normal, healthy and well functioning), an amniotic fluid index (AFI) of 8.4 (“aka” normal, since at term a normal AFI is anywhere from 5-25), and an estimated fetal weight (EFW) of approximately 3628 grams (or 8 lbs 3oz). (Note: It is well documented in the medical literature that third trimester ultrasound scans can be off by as much as +/-2 pounds when estimating fetal weight!). Looking at the fetal heart rate pattern on the computer showed a reactive and reassuring strip with moderate variability, presence of great accelerations and absence of decelerations. Her vaginal exam on admission was 3cm, 70% effaced, minus 2 station. Hmm…she must have been admitted for labor….oh wait…what’s this in the doctor’s admission note?….
Indication for admission: Induction for oligohydramnios (low amniotic fluid) and post dates.
Plan: pitocin and early amniotomy.
A double, triple, quadruple take proved to me that my eyes were not failing me. And to top it all off the patient had provided us with her birth plan. Now I don’t mean that to be sarcastic because I am not against birth plans. It’s that her birth plan was basically requesting things that because she was being induced with pitocin, were prohibited, discouraged, or generally made very difficult by our hospital’s policy and her physician’s orders/philosophy.
Here is an excerpt from her birth plan. Although I don’t have a copy of her actual birth plan, since almost every pregnant woman with a birth plan seems to find the same website (www.birthplan.com), I can confidently replicate it quite easily. My responses to why each of these reasonable requests were prohibited, discouraged, or generally made very difficult are provided in italics after each bullet:
§ I would like to be free to walk around during labor. (Although walking is not contraindicated during an induction, since the use of pitocin requires the use of continuous external fetal monitoring (EFM) and a good tracing of the fetal heart rate (FHR) and contractions, a portable telemetry monitor must be used. And since it is a machine with limitations, as the baby swish, swish, swishes in her amniotic fluid womb bath, more often than not adequately tracing the fetal heart rate is impossible or extremely difficult, especially if the woman has a lot of extra “cushion”.)
§ I wish to be able to move around and change position at will throughout labor. (Tracing the FHR with continuous EFM is virtually impossible sitting on a birthing ball or leaning forward, positions that many women find comforting, unless you hold the monitor constantly with your hands, something that is very difficult for even the most well intentioned nurse, especially if she has more than one patient. It is also often annoying for the patient.)
§ I do not want an IV unless I become dehydrated. (Since pitocin is a medication administered via an IV infusion, it necessitates an IV.)
§ I do not wish to have continuous fetal monitoring unless it is required by the condition of the baby. (Induction with pitocin requires continuous EFM, even in the most lenient of hospital policies.)
§ I do not wish to have the amniotic membrane ruptured artificially unless signs of fetal distress require internal monitoring. (Was the doctor’s plan even discussed with this patient?!)
§ I would prefer to be allowed to try changing position and other natural methods (walking, nipple stimulation) before pitocin is administered. (Ummm…hello!)
§ Unless absolutely necessary, I would like to avoid a Cesarean. (One of the best ways to avoid an unnecessary cesarean is to avoid an unnecessary labor induction!! See #8 in my post: Top 8 Ways to Have an Unnecessary Cesarean Section)
§ Even if I am fully dilated, and assuming the baby is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase. (We’ll get to this one later.)
So then came the nurse I was supposed to get report from. “Umm, why the hell is she being induced?!,” I said. “Oh brother, I know. Its bullshit isn’t it! We started the pit this morning at 8am but Dr. F couldn’t rupture her membranes at that time because the baby’s head was still high. He said he’d be back around 1:00 pm to do it.” she replied. “Like hell he will,” I thought to myself. And after a quick report I entered Sarah’s room to try to get some answers.
Upon entering the room Sarah was sitting up comfortably in bed while her husband, John, was typing on his laptop in a chair beside her. First I introduced myself and let them know that barring an emergency, I would be their nurse for the next 12 hours and probably for the birth of their baby! We engaged in some small talk for a bit, the typical “Where’re you from? What do you do? What’s the baby’s name going to be?” “How has this pregnancy been for you? yaddy yaddy yada. We then talked about their birth preparation. Turns out they had taken a childbirth preparation class and had read two of my favorite books: Ina May’s Guide to Childbirth and The Birth Partner. Good start! Next I pulled up a stool and with their birth plan in hand, went over all of their plans with the both of them before things started to rev up for Sarah.
Whenever a couple has a birth plan, whether it be a birth plan for as natural a birth as possible, as medicated a birth as possible, or anything in between, I like to actually sit down and review each point with them to let them know what is totally doable or what must be modified related to the patient’s condition or hospital policy. I let them know that my main jobs as a nurse are to provide support, assure the safety of the mother and baby, and be a patient advocate. That way everyone is on the same page and I think it helps build some trust between couple and nurse. Kind of like saying “Hey, I am going to take your birth plan seriously since this is your experience, but we might have to compromise on some things.”
So I started to go over the couple’s birth plan with them and basically tell them how induction with pitocin makes many of their requests impossible or very difficult but that I would do the best I could under the circumstances. And this is where things got interesting. The following is our conversation:
Sarah: “Oh yeah, I know. We had this big birth plan for a natural birth but that’s okay, I mean, when Dr. F told us two days ago that we needed to be induced, I realized that we couldn’t have everything we had planed for.”
Me: “Oh, what did he tell you was the reason you had to be induced today?”
Sarah: “Because the baby’s amniotic fluid was too low and I was overdue.”
John: “Yeah, umm, about that… Two days ago was the only appointment I had missed and it’s when they set her up for an induction. I didn’t even get a chance to ask the doctor what the normal levels for AFI were. I mean, he told us our level was 8. What is normal?”
Me: “5 to 25 is normal for a term baby,” (stated matter-of-factly)
John: “SEE! Then 8 is totally fine! And technically we still have a week left before we are considered really ‘overdue’, right?”
Sarah: “John, really, relax. It’s no big deal (awkward laugh). We’ll know better for next time. Really, it’s okay. Let’s not cause any trouble.”
John: “Melissa, what are some really important reasons for induction. Like, what are some real medical reasons where induction is necessary?”
Melissa: “Umm, do you truly want me to go into this? Because I can but…”
John: “Yes please.”
Melissa: “Well to name a few off the top of my head: If the baby is showing serious signs of distress on a non-stress test and biophysical profile, an AFI consistently less than 5 over multiple readings, worsening preeclampsia, signs of intrauterine growth restriction, a placenta that shows signs that it is getting too old too early in the pregnancy, etc.” (This is where things started to get awkward for me. I mean, I didn’t want to upset Sarah or make her feel self-conscious or distrustful of her physician because those feelings are certainly NOT going to facilitate a smooth labor. But then again, I secretly wanted to tell her, “You don’t have to be here!”)
John: “Well, the baby has had a great non-stress test every time we went to the doctor and he told us the placenta is healthy, and Sarah is healthy and her pregnancy has gone off without a hitch, she didn’t even really get morning sickness, and they said the baby is probably 8 lbs, which certainly isn’t too small! This is really frustrating!!”
Sarah: “John, it is okay. Dr. F must have thought it was important that I deliver. So we’ll just know better for next time. Next time we’ll be more prepared. But we’re here now and I am already being induced.”
I could see that there certainly was some tension between them regarding this issue and it seemed to me that although Sarah agreed with what John was saying, she was worried about causing any conflict or confrontation between her and Dr. F. But I have to admit that it really bothered me that she kept repeating “We’ll know better for next time,” because THIS time is important and THIS time could have negative affects on NEXT time.
Situations like this are one of the things that frustrate me the most about my job. Sarah and John were both intelligent people. (The were high school teachers with master’s degrees for goodness sake!). They read the right books. They attended childbirth classes. They wrote a birth plan and showed it to their obstetrician earlier in the pregnancy. (Of course I can almost guarantee that he briefly looked at it, gave them a blanket “okay” but didn’t really take the time to go over it piece by piece with them.) And yet they were still duped into an unnecessary induction. It is such a shame that there are so many women I care for that are more afraid of being considered a “difficult patient” for sticking up for themselves than the risks of unnecessary intervention. It’s like being afraid to tell your hair dresser you don’t like the hair cut she gave you TIMES A MILLION! In my opinion they were NOT provided with informed consent and NOT given the opportunity to give informed refusal. And in my opinion once they were told they “needed” to be induced, they felt trapped and didn’t want to “cause any trouble” with the doctor.
To be continued….
Up For Next Time: Don’t Let This Happen To You #25: PART 2 of 2
Read about Sarah’s labor, the birth of her baby, and how all three of us had to fight to fulfill her birth plan!