Continuation of 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!” 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! If haven’t already read it, I invite you to check out the first addition to the countdown: DLTHTY #25: Sarah & John’s Unnecessary Induction
There are so many things about the current state of maternity care in the United States that frustrate, infuriate, sadden, and annoy me but one particular thing that really gets my goat is the back door induction. As you might have already read, I am a labor & delivery nurse in a large urban hospital and we are BUSY! Although I know there are hospitals that way more deliveries a year than we do, for the capacity of our hospital, 4500 deliveries a year is almost more than we can handle with our current facility and staffing. (By the way, 4500 deliveries a year breaks down to about 375 deliveries a month and about 12 deliveries a DAY! (Jeeze, I am exhausted just looking at the statistics!)
One way to help organize all the chaos is to have an induction book in which doctors have to schedule all of their inductions at least 24 hours in advance. This way we have somewhat of an idea about appropriate staffing and room assignment for our patients for each day (in theory). (The exception to this rule is the induction in which there is a documented medical reason related to either mom or baby’s health that requires an urgent delivery of the baby. For example, severe intrauterine growth restriction (IUGR) with a non-reassuring nonstress test (NST) and biophysical profile (BPP) or worsening preeclampsia. We obviously don’t make these mom’s sign up for a spot. They are usually a direct admit from the office to the hospital.)
However, when a doctor is either lazy, anxious, rushed, or overall feels he is above the rules, he (or she) will send a patient in from the office as a direct admit to the hospital for labor when she actually is NOT in labor and will the proceed to INDUCE her under the guise of augmentation. When providers do this, it increases the amount and acuity of our patient census and puts an unnecessary strain on our staffing which compromises the amount of individualized care we can give to our patients. What these doctors don’t tell you is that inductions can take up to three days to complete! If you are truly in spontaneous natural labor, even a slow labor, you won’t be in the hospital for 3 days. Inductions take MORE time, MORE money, MORE staff, MORE resources and hence are MORE risky. Let’s digress for a moment so that I may clarify the difference between induction and augmentation:
Labor: Regular, noticeable, and painful contractions of the uterus that result in dilation (opening) and effacement (thinning) of the cervix. Therefore if you are having regular uterine contractions that are noticeable or even painful but are not making any change to your cervix, it is NOT labor. Likewise if your cervix is dilated and effaced but you are NOT having uterine contractions that are noticeable and painful then you are NOT in labor. (Note: I have had low intervention doctors and midwives send multips (a woman who has given birth at least once) home at 4 or 5 cm if they are not having any contractions or not changing their cervix. One particular patient I can remember was a G5P4 and was 5cm dilated when she came to the hospital. We kept her for 4 hours but she never changed her cervix…she couldn’t even feel her irregular contractions and she was comfortable. So she was sent home. Two weeks later she came back 8cm dilated in hard labor and I assisted with her very quick birth. She did amazing and the baby was happy and healthy! Clearly, even at 5cm, she wasn’t in labor.)
Induction: the use of medications or other methods to start (induce) labor before the woman’s body has spontaneously begun true labor on its own.
Augmentation: stimulating the uterus with medications or other methods during labor that has already begun naturally to increase the frequency, duration and strength of contractions, the goal of which is to establish a pattern where there are three to five contractions in 10 minutes, each lasting more than 40 seconds.
So just to be clear (and to adequately set up my story) if a woman is 4cm dilated but is not having regular, noticeable, and painful contractions that are causing cervical change she is NOT in labor. If said woman is sent into the hospital and any interventions to stimulate contractions are started, then it is by definition considered an induction NOT an augmentation. And if said patient was not scheduled to be admitted on such day, then it is considered a backdoor induction.
Let’s continue with the story…
It was a Friday morning before my weekend off and I came in to work at 11am as usual. I was looking forward to the weekend since it had been a really busy week and I was exhausted. For the first four hours of my shift, I triaged a few patients but ended up sending them all home for one reason or another. As I was finishing up some paperwork at the desk around 1:00pm, Dr. T came off the elevator and over to the nurses station. I overheard him telling the charge nurse that he was just at his office and was sending over a primip (a woman who has never given birth) for us to admit for labor who was 4cm dilated/50% effaced/-3 station by his exam in the office. He then slinked towards one of our second year residents who, in my opinion, will definitely be joining the ranks of the aggressive labor management elite, and uttered, “I’m sending over a patient from the office, 4cm. Could you break her water when she gets here and start her on pit. I know you’re the only one who will do it. The baby is still high.”
Situations like this one are exactly the reason why I shouldn’t eavesdrop! The reason why Dr. T was concerned that “no one else” would break her water was that when a baby is at a minus 3 station and is “too high,” if the membranes are ruptured artificially the umbilical cord could slip down before the baby’s head, getting pinched between the baby’s head and the cervix, cutting off all blood flow from the placenta to the baby. This is called a cord prolapse and it is a surgical emergency requiring an emergency cesarean section. This emergency is very unlikely if your water breaks naturally at term during labor because typically when it happens naturally the baby’s head is well applied to the cervix which puts pressure on the bag causing it to break. I wanted to turn around and shout at Dr. T, “If you are so concerned “no one else” will take the chance, why won’t you do it yourself?! Is it really so wise if it is so unsafe?” Furthermore, the thought of sending over a patient for “labor” and then immediately starting her on pitocin and breaking her water makes my head feel like its going to explode! If she is really in labor then she does NOT NEED pitocin! And if she “needs” pitocin, then she is NOT in labor! This is a BACK DOOR INDUCTION and ladies, it happens all the time. Think about it, it was a Friday and Dr. T happened to be on call that weekend. Looks like he didn’t want to get a page over Sunday brunch that one of his patients was in labor! AHHHHHHHHHHHHHHHHH!
Sorry, I lost it there for a minute J. But it is just these kinds of injustices that make my blood boil! Let’s continue…
Come change of shift at 3pm I was patient-less since I had sent all my triages home and hence was assigned to the patient in room 9. And guess whose patient it was! None other than Dr. T’s “labor” patient! Oh brother! This was going to be an interesting night!
From report I got most of the details: Jessica was a 25 year old first time mom (G2P0) just a few days past her “due” date (40 weeks and 3 days). Here health history was unexceptional: exercise induced asthma as a child that did not require any medications, tonsillectomy at age 7, and one miscarriage at 5 weeks two years ago. Her pregnancy was normal, healthy, and uncomplicated. The patient had arrived to the hospital at 1:30pm with her longtime boyfriend Jason. Jessica’s day shift nurse had completely admitted her and started her on pitocin but because the floor was crazy busy all day, she had only gotten the pitocin up to 4mu/min and the residents had only gotten the chance to write orders and not to rupture her membranes. (My thought = Yes!!) [Note: For a description of how pitocin is administered check out: Don’t Let This Happen To You #25 PART 2: Sarah & John’s Unnecessary Induction].
Next I went into the room to meet Jessica and Jason. Jessica was a bubbly young woman with big rosy cheeks. Her boyfriend Jason was living proof that you can’t judge a book by its cover. He was super funny and down to earth and very supportive of Jessica in every way, yet a bit intimidating at first because he was almost completely covered in tattoos and had multiple facial piercings J. They looked like total opposites and yet were so perfect for each other. We chit-chatted for awhile and really seemed to hit it off since we all had the same sense of humor. I took the opportunity to satisfy my curiosity about how Jessica had ended up in the hospital since she seemed very comfortable the whole time we were talking. The monitor strip revealed that she was having contractions about every 6-8 minutes but she was not even flinching as I saw them come and go on the monitor. To gain a bit more information I started to ask some questions. I kept the conversation light in tone, like “So tell me about your day today?” instead of “Why the heck are you here! Run! Run away!!” J Here’s our conversation:
Me: “So how did you end up at the office today? Did you have a scheduled appointment or were you having contractions?
Jessica: “No I was feeling great! I had a scheduled appointment and when they put me on the monitor for a non-stress test, the nurses told me that I was having contractions! It was so crazy because I didn’t even know I was having them! So then Dr. T decided to check me since I was contracting and I was 4 centimeters!”
Me: “Can you feel any of your contractions now?”
Jessica: “I think so, well, am I having one now? Wait, no, maybe now? (Looks towards monitor) Yeah, I am having one now.
At this point I’m thinking: If you have to look at the monitor then the answer is no, no you are not feeling contractions! Sometimes I turn the monitor screen off so the patients or family members can’t “contraction watch.” J
Me: “So what happened next? Did Dr. T tell you to come right over or did he say you could go home first?”
Jessica: “He said we could go home first and get our stuff together but not to “dilly dally” because they were waiting for us here. So we rushed home and grabbed our bags. Good thing we packed last week!”
Me: “Yeah, it’s great you were prepared. What did Dr. T tell you the plan was for when you got here?”
Jessica: “He said that once we got here that he would break my water but they haven’t done that yet. I guess it’s really busy today, huh?”
Me: “Yeah, It’s a busy day. Did he say anything about starting you on pitocin?”
Jessica: “He mentioned that I might ‘need a little pitocin’ because my contractions weren’t in a regular pattern and were pretty far apart.”
Me: “I bet it was a big surprise to you to be induced today, huh!” (I couldn’t help myself!)
Jessica: (confused) “Well I didn’t expect to find out I was in labor today that’s for sure!”
Me: “Do you guys have a written birth plan or any thing I should know about regarding your labor and birth preferences?”
Jessica: “No nothing written. Well, I wanted to try to go as natural as possible. I don’t want any narcotics and I don’t think I want an epidural. I mean, I’m not ruling it out, but I really want to go as naturally as possible……………I mean, I guess that’s not totally going to happen now because I am on pitocin but, well, you know…”
(Yes! The “in” I’ve been waiting for! Sometimes I wish I could tape patients and then play back what they say to me to see if once they hear it back, they then realize how illogical their doctor is. I mean sometimes I feel like a mom who has to sneak spinach into her kids’ favorite foods to trick them into eating vegetables. I can never just come out and say my intentions, I have to play this “game” and hope they figure it out themselves. This is something of a daily internal struggle for me.)
Me: “Well that is not necessarily true because although we are limited by the fact that with the pitocin running I have to have you on the monitors, as long as I can trace the baby’s heartbeat I can help you into any position that makes you most comfortable. Unfortunately pitocin is not a good as the “real” thing you know? What I mean is it makes contractions artificially stronger and longer than natural contractions. But I will do my best to titrate the pitocin so that we get an effective labor pattern that both you and the baby can tolerate well. We can all work as a team, sound good? J”
Jessica & Jason: “Yeah sounds good!”
I’m sure, my savvy reader, you have already recognized why I started this post with the difference between induction and augmentation!! The TRUTH is: If you are at term and someone has to “tell” you that you are “in labor” then you are NOT in labor! I just feel so badly for these women! I truly don’t think it is their fault! I think that they put all their trust in their birth attendant and most of the time are just naïve and don’t know any better. And I don’t say that to be patronizing, I say it out of love and concern. And as I mentioned in the first post of this series, I don’t want to start off my first interaction with these patients by going off on a tangent about unnecessary induction because I don’t want to make them defensive, doubtful, untrusting, or upset because these emotions do not facilitate labor!
Up For Next Time: Don’t Let This Happen To You #24: PART 2 of 2
Read about Jessica’s labor, the birth of her baby, and Dr. T’s upsetting prediction about her birth too early in the game.
(Research for this post was aided by my trusty OB textbook from nursing school: Maternal-Child Nursing (Second Edition) by Emily McKinney, Susan James, & Sharon Murray Ó2005)