Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Top Ten DOs for Writing Your Birth Plan: Tips from an L&D Nurse, PART 2 July 23, 2009

If you haven’t already, please check out PART 1 of this post:  Writing Your Birth Plan: Tips from an L&D Nurse.  Also, at the end of this post check out a birth plan written and sent to me by one of my blog’s readers who is due any day now!

  

#1    DO keep your birth plan short, simple, and easy to understand (1-2 pages max).

 

“Keep [your birth plan] short.  If you need to spell out a long list of points, you may not be with the right caregiver. If most of the things you want aren’t things your caregiver is used to doing (in which case you don’t need to put them in a birth plan!), you are unlikely to get them. For maximum effectiveness, keep your birth plan to a single page.”

Writing a Birth Plan by findadoula.com

 

#2    DO keep the language of your birth plan assertive and clear.

 

“Remember to keep your language assertive – polite but clearly stating what you want. Use phrases like “I am planning” and “I would like” rather than “if it is ok” or “I would prefer.

 

Be specific.  Avoid words and phrases such as “not unless necessary” or “keep to a minimum.” What one person thinks is “necessary” is not what another does. What one person defines as the minimum is not what the next person does. Instead, use numbers or specific situations, for example: “I am happy to have 20 minutes of electronic monitoring and if all is well then intermittent monitoring every hour for five minutes after that”  or  “I am happy to have a vaginal examination on arrival in hospital and after that every four hours or on my request.”

Writing a Birth Plan by findadoula.com

 

 

“Be sure to be assertive, but not aggressive when discussing your options. Do not allow your caregiver to brush off your decisions or suggest that this is unimportant. At the same time, don’t assume your caregiver [or nurses] will be hostile or uninterested in hearing what you have to say.”

How to write a Birth Plan by birthingnaturally.net

 

#3    DO use your birth plan as an impetus for doing your own personal research about your preferences for childbirth. 

 

One great place to start is at MothersAdvocate.com who, in partnership with Lamaze International and Lamaze’s Six Steps to A Healthy Birth, have created a website that offers FREE, evidenced-based, educational video clips and print materials to educate and inform childbearing families on how to have a safe and healthy birth for both you and your baby.  These extremely well reserached and produced materials are a MUST READ for all expecting moms!!!

 

The introduction handout for these video clips and print-outs entitled Introduction: Birth–As Safe and Healthy As It Can Be reads:

 

“While no one can promise you what kind of birth experience you will have, common sense tells us and research confirms that there are two tried-and-true ways to make birth as safe and healthy as possible:

 

• First, make choices that support and assist your natural ability to give birth.

 

• Second, avoid practices that work against your body’s natural ability, unless there is a good medical reason for them.

 

Lamaze International, the leading childbirth education and advocacy organization, has used recommendations from the World Health Organization to develop the Six Lamaze Healthy Birth Practices that support and assist a woman’s ability to give birth. Years of research have proven that each of these practices increases safety for mothers and babies.

 

The Six Lamaze Healthy Birth Practices are:

 1. Let labor begin on its own.

 

2. Walk, move around, and change positions throughout labor.

 

3. Bring a loved one, friend, or doula for continuous support.

 

4. Avoid interventions that are not medically necessary.

 

5. Avoid giving birth on your back, and follow your body’s urges to push.

 

6. Keep your baby with you—it’s best for you, your baby, and breastfeeding.”

 

The topics of the print materials include: 

Choosing a Care Provider,

Changing Your Care Provider,

If You Have Been Induced,

Maintaining Freedom of Movement,

Positions for Labor,

Finding a Doula,

Creating a Support Team,

Tips for Labor Support People

and even a Birth Planning Worksheet!!

 

 

“We cannot know the day or week labor will begin, how long it will last, exactly how it will feel, how we will react, or the health and sizes of our babies.  What we can do, however, is educate ourselves about the vast array of possibilities and learn which are more likely to occur. We can decide what is ideal and what we will strive for, what are the means to creating the most conducive environment for such a birth, and which people can best help us to attain those birth arrangements. Finally, we can prepare our own bodies and hearts for the process.”

Eyes-Open Childbirth: Writing a Meaningful Plan for a Gentle Birth

by Amy Scott

 

#4    DO include your fears, concerns, and helpful things for the nurse to know.

 

If appropriate, a birth plan can also include a few sentences regarding things you just want the nurse to know about and are important enough to make sure that every shift is aware of.  For example, I once had a patient who wrote the following in her birth plan:

 

“My husband is a type I diabetic and at times suffers from episodes of hypoglycemia where he does not have any warning signs or symptoms.  So if my husband starts to act inappropriate or seems ‘out of it’ or ‘drunk’ please offer him some juice!!  I am afraid that if I am in the throws of labor that I will not notice and this is something that I am very concerned about!”

 

Although this information wasn’t necessarily birth related, as a nurse taking care of this family I found this information EXTREMELY helpful to have in the birth plan!!  By putting it in her birth plan, this mother felt more at ease knowing that she did not have to waste any time worrying about forgetting to tell each new nurse that took care of her.  Having this in her birth plan also served as a reminder for me to pass along this important information when I was giving report to the next shift. 

 

#5    DO review your birth plan with your birth attendant and ask him/her to sign off that he/she read and understands it.

 

“Add a line at the bottom of your birth plan for your doctor or midwife, and other caregivers, to sign your plan under the statement ‘I have read this plan and understand it.’  When caregivers sign your plan, they are only acknowledging to you—on the record- that they have read and understood it.  They do not have to sign and say: ‘I agree.’  No matter what you tell them, they are always responsible for offering you their best judgment and skills as different circumstances arise, and then together you and your caregivers can agree on your care.  This benefits you.  Your birth plan will help you take responsibility for your decisions and ask to be fully informed.”

Creating Your Birth Plan, page 219

By Marsden Wagner & Stephanie Gunning

 

#6    DO make your birth plan personal (don’t just copy paste) and DO make sure that you understand and can elaborate on everything in the birth plan if asked.

 

In my humble opinion (regarding birth plans), there is nothing more frustrating for a nurse (and nothing more detrimental to a nurse’s overall attitude and view of birth plans) than to have a patient just copy and paste a general, “all-purpose” birth plan off the internet, check the boxes that “sound good”, and pass it in to a nurse with her name typed in at the top.  Why?  Because when a nurse (like myself) sits down to review the birth plan with the mother and her labor companions in order to start a dialogue about how the nursing staff can assist in adhering to the birth plan, it will most certainly become obvious to the nurse that the patient has done little to no research on any of her choices making it almost impossible to help the patient follow her birth plan when the birth attendant comes in and wants to do things differently.

 

Let me give you a few examples:

 

Example 1:  One time I had a patient who had the following statement on her birth plan:  “Regarding an episiotomy, I am hoping to protect the perineum. I am practicing ahead of time by squatting, doing Kegel exercises, and perineal massage.”  Now don’t get me wrong, this statement is great and it is one that I personally believe in and try to promote.  So while reviewing the patient’s birth plan with her and her husband I enthusiastically said the following, “Oh, I see here you have been doing perineal massage and Kegel exercises and wish to avoid an episiotomy.  That is great!  How many weeks have you been doing perineal massage for?”  The patient looked blankly at me and said, “What?  Oh I don’t even know what that is!  My sister just told me that I shouldn’t get an episiotomy so I checked that box.” 

 

Ladies, it is really hard for a nurse to advocate for you if you don’t even understand what you are asking for!

 

Example 2:  Almost all the birth plans I have seen make some statement about pain relief and pain medications.  Again, I think that this is a great thing, especially if the mother was inspired to research all of her pain relief options (both pharmacological and non-pharmacological) and make an informed pain relief plan during the writing of her birth plan.  One time I had a patient who had the following statement in her birth plan, “Regarding pain management, I have studied and understand the types of pain medications available. I will ask for them if I need them.”  Again, I was very enthusiastic when I read this and said to the mother, “I see here that you have done some research on pain management.  Wonderful!  Have you taken any childbirth preparation classes or read any books?”  The mother responded, “What do you mean?”  I replied, “Well you know, like any classes or books by Lamaze, Bradley, Birthing From Within, Hypnobabies, etc.”  The mother responded, “No.”  I then said, “Oh, did you do any research on the internet or talk to anyone?”  To which she replied, “No, not really.  I mean, it’s my first time so I don’t know what to expect.  My best friend just said she hated her epidural so I don’t really want one of those.  Unless , of course, I really need it.  We’re just going to wing it.” 

 

Ummmm, huh?!?!  Now again, don’t get me wrong.  I feel that I am very supportive of mothers that are preparing for a natural, or physiological, childbirth and I often write about the risks and benefits of common obstetrical interventions, including pain medication and epidurals.  But ladies, your nurse can’t be the only one who is advocating for your natural childbirth.  YOU have to be on board too and YOU have to understand your reasons for not wanting pain medication or epidural.  Because if you don’t even know why you don’t want an epidural then the next person who walks into that room who feels differently, be it a nurse or your birth attendant, guess what’s going to happen?!  You’re probably going to agree to anything said nurse/birth attendant tells you you should get, because you don’t know any alternatives.

 

I am not trying to say that taking a certain childbirth preparation class or reading certain books is required for a positive and empowering birth experience.  But some type of research and preparation on the part of the mother and her labor companions/partner is EXTREMEMLY IMPORTANT!!   

 

Now here’s one more example to give you the full perspective.

 

Example 3:  One time I was taking care of a patient who had the following statement in her birth plan: “My husband and I have been preparing for and planning a natural childbirth.  I am very interested in using the Jacuzzi tub for pain relief in labor and have been reading about other drug-free ways to cope with pain.  I am not interested in pain medication or an epidural as I had both with my last baby and had a poor experience with both.   I respectfully request that they not be offered to me.  I have done research and feel that the risks outweigh the benefits.”  When I asked her about it we embarked on a really informative discussion about her last delivery, in which she had persistent numbness in her right leg for 2 months after the epidural as well as a debilitating spinal headache that took required two blood patches and made it difficult for her to nurse or care for her baby during her hospital stay.  She also told me that she did not like the way the IV narcotics made her feel, as she was “seeing things” and generally “very out of it.”  After our conversation I felt confident in advocating for her with her doctor (who often insisted his patients get epidurals) because I knew that if I said anything to the doctor that she would, in a sense, back me up and likewise I would back her up!! 

 

It is so hard when a patient has something in her birth plan like “I don’t want an epidural”, and hence I argue with the doctor about how the patient does not want an epidural, but then when he goes into the room to ask the patient himself, the patient says “Oh well, whatever you think is best doctor!”  It really just makes the nurse look like she is trying to “push her own agenda” when in reality the nurse was just trying to follow the patient’s birth plan!! 

 

One more thing…I don’t want anyone to feel like I am implying that a woman has to “prove” anything to me when I ask questions about her birth plan.  That is NOT the case.  I just know from personal experience how important it is for a woman to understand and agree with everything she herself puts in her birth plan!  Remember, mothers, labor companions, and nurses work best when they are all on the same page and work as a team to facilitate a positive and empowering birth experience!!

 

#7    DO look at examples of great birth plans online to get some ideas.

 

The following is a list of some good places to start. Remember, while these websites provide a wealth of ideas, they should not be simply copied and pasted!  The best and most effective birth plans are personal, NOT just a list of things with check marks next to them!!

 

a)      BirthingNaturally.net

b)      Sample Birth Plans from BirthingNaturally.net

c)      ChoicesinChildbirth.com

d)      American Pregnancy Association

e)      BabyCenter.com

f)      MothersAdvocate.com

 

#8    DO run through scenarios in your mind about how labor could unfold and actually talk these scenarios out with your labor companions and doula (or perhaps even your childbirth educator or birth attendant too!) 

 

Think about all the different ways labor could unfold and how you might react if labor was faster or slower than expected; harder or easier than expected. What would you need for comfort, support and information in each of these variations?  Thinking about “worst case scenario” doesn’t mean it’s going to happen.  But if it does, or if any variation does, it will make you more at ease to know that your team has already talked about it and knows your wishes. 

 

“If you knew that something would go wrong or would pose a difficult challenge during a portion of the labor and birth, what would your ideal strategy and scenario for handling that problem be?  How would you want your midwife or doctor to speak with you?  How would you like your spouse or another support system to help?  What alternatives would you like to try, and in what order?  Again, in your mind’s eye permit yourself to have the best.  What would help you relax and be able to continue labor under difficult conditions?”

Creating Your Birth Plan, page 219

By Marsden Wagner & Stephanie Gunning

 

 

#9        DO try to treat researching and birth plan writing as a fun and exciting experience, not a chore! 

 

Enjoy this time!  Don’t be afraid to be creative and fanaticize!  There are so many amazing thing that you can discover and learn about while doing research for your upcoming birth.  It is never too early to start so don’t put it off till the last minute!

 

And finally…

 

#10    DO remember to bring your birth plan to the hospital!! 

 

It won’t do much help to the nursing staff if you forget it at home on your coffee table!  I encounter this very often at work and I always feel so badly because I know that there is usually a lot of work put into writing a birth plan.  It might be best to make sure that you place a copy of your birth plan in the bag you have packed to take with you to the hospital.  I have even had a few mothers put an extra copy in their car’s glove box so that they wouldn’t forget it!

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

SAMPLE BIRTH PLAN

 

This birth plan was sent to me by a reader of NursingBirth who goes by the name “ContortingMom”.  Contortingmom’s guess date is 7/17/09 and she is still “cooking” with her first baby 🙂  I really like her birth plan for a variety of reasons.  #1 She was inspired to add some stuff to her birth plan after reading a couple posts of mine (which I think is pretty cool 🙂 and #2 I think it is a perfect example of a personalized birth plan!!  No check boxes here!  Thanks again to ContortingMom for allowing me to post her birth preferences for other moms to read and learn from!!

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~

Birth Preferences:

I understand that labor and birth are unpredictable and ultimately want the health and safety of both the baby and I to take precedence. In all non-emergency situations, all proposed procedures are to be discussed (benefits and risks) so I can direct the decision making with informed consent.    

Your help with these preferences is very much appreciated.

 

Labor:

• I intend to have as natural a labor as possible – including freedom of movement, intermittent monitoring, a saline lock instead of an on-going IV, and clear liquids as tolerated.

• Due to my GBS+ status, I request only very limited vaginal exams and do not want an amniotomy.

• Please accept my request that pain medication not be offered to me. For many reasons – personal and medical, I’m striving for an unmedicated labor and delivery. If I eventually want drugs or an epidural, I’ll be the first to ask for it and understand that options change as labor progresses.

• If augmentation is necessary, I would like to try non-pharmacological methods before resorting to meds. However, if my OB and I agree that pitocin is required, I request that the it be administered following the low dose protocol and increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each dose increase.

 

Birth:

• Please do not direct my pushing with counting or yelling. I will ask for help if needed.

• I strongly prefer a tear to an episiotomy and do not want a local anesthetic administered to the perineum.

• I plan to be as active during pushing & delivery as possible, including choosing productive positions. They will be probably anything except supine, lithotomy or “sitting squats” that put pressure on my tailbone. It’s been broken several times & currently inflamed. I also have restrictive pain from spinal injury & surgery, so please allow a position suited to my medical needs. I’ll make sure the OB has comfortable access.

• I would like to have the baby brought to my chest immediately for skin-to-skin contact & initial procedures – and to try nursing to see if it works to contract my uterus, delaying pitocin until we know.

 

If Cesarean Is Required:

• Please use double-layer sutures when repairing my uterus. If I have a second child, I hope to attempt a VBAC and understand this is a requirement for many doctors.

• As health permits, I would like to skin-to-skin contact with the baby, to stay together during repair and recovery, and to breastfeed during the initial recovery period.

• If my husband has to leave the operating room with the baby, I would like my doula to take his place.

 

Baby Care:

• We would like to spend as much time as possible with our baby after birth before being taken off for procedures and will be breastfeeding, so please refrain from giving bottles/pacifiers.

 

We Appreciate Your Support. Thank You!

Advertisements
 

Writing Your Birth Plan: Tips from an L&D Nurse, PART 1 July 22, 2009

There have been many a time that I have written about the option of writing a birth plan, especially if one is planning a hospital birth.  And some of my readers have questioned me further, asking things like “I don’t know how to write a birth plan!  How do I begin?” or “There are so many websites about writing a birth plan, how do I know which one is best?”

 

Indeed when you type “birth plan” into Google you get 22,600,000 hits.  Yowzers!!  No wonder why so many expecting moms write to me and tell me how overwhelmed they are!!   And as we all know, not all websites are created equal as some are more helpful (and more accurate) than others. 

 

So since I suggest writing a birth plan so often in my posts and comments I feel that it is only proper that I write a post specifically about birth plans.  I will try to help you navigate through the sea of websites and direct you to the ones that I feel are the most accurate, truthful, easy to understand, and helpful.  I would like to make a disclaimer though:

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

Disclaimer:  This post is riddled with my own opinion as both a consumer of health care and an L&D nurse.  I feel that this post has something to offer to the world of birth planning articles because in all of my research I found very few birth plan guides written by L&D nurses.  I found them written by mothers, doulas, midwives, and even doctors…but very few, if any, written by L&D nurses.   This is very interesting to me because if you are planning a hospital birth the first person in the hospital that you present your birth plan to is the nurse.  Sure, your doctor or midwife might (wait, scratch that….SHOULD) go over it in the office with you and if you are hiring a doula, then she will most likely review it with you as well.  However when push comes to shove it is the L&D nurse who is your go-between and except for the actual “catching” part, it is going to be the L&D nurse who manages your care throughout your labor.  While I agree that there are probably many L&D nurses who feel differently than I do about how a birth plan should be written (if at all), I can say with confidence that there are surely just as many who do agree with my take on it.

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

Since the vast majority of women are planning a hospital birth and I am in fact a hospital based L&D nurse, this post is geared almost entirely towards women planning a hospital birth.  Although a birth plan isn’t a bad idea for a home or birth center birth, it is often less crucial.  Why?  As Leah Terhune, a certified nurse-midwife with Midwives Care, Inc. in Cincinnati is quoted in the article Eyes-Open Childbirth: Writing a Meaningful Plan for a Gentle Birth by Amy Scott says:

 

“A birth plan is not a must for out-of-hospital births because there is more self-education done by the mother, and most people come into the situation with the same philosophy: childbirth as a natural process.  In a really good relationship with a midwife, it should be understood by the end of the pregnancy what the expectations are.”

 

 

My goals for this post are the following:

 

1)      To assist you in writing the best birth plan you can by pointing you in the direction of the best resources out there, that I have found, on birth plan writing,

2)      To review the true purpose of a birth plan and to help you write a birth plan for the right reasons, and

3)      To help you navigate through a bureaucratic hospital system often perforated with outdated dogma and run by unofficial “policies” and help you and your labor companions facilitate a positive and empowering birth experience for your whole family!

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

 

What Exactly is a Birth Plan?

 

 

According to Penny Simkin, a physical therapist, doula, and author of The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions:

 

 

“The mother’s Birth Plan tells her caregiver and nurses in writing what options are important to her, what her priorities are, any specific concerns she has, and how she would like to be cared for.  The plan should reflect the mother’s awareness that medical needs could require a shift from her choices, and it should include her preferences in case labor stalls or there are problems with her or her baby.”

 

 

I like this definition of “birth plan” because no where in that definition does it state that a birth plan is the mother’s actual plan for her birth.  That is, it acknowledges what those of us who work with mothers in labor know to be absolutely true:  LABOR CANNOT BE PLANNED OR CONTROLLED.  (And likewise, when someone, including the mother, her labor coaches, or her birth attendant tries to control labor, it only spells trouble.)  Writer Lela Davidson quotes professional childbirth educator and doula, Kim Palena James in her article Create a Better Birth Plan: How to Write One and What It Can and Cannot Do For You:

 

 

“Too many parents create birth plans with the expectation that it will be the actual script of their baby’s birth. There is no way! Nature scripts how your child is born into this world: short, long, hard, easy, early, late, etc… The health care providers you choose, and the facility they practice in, will script how you and your labor are treated. The variations are vast. I wish every expectant parent spent less time writing birth plans and more time selectively choosing health care providers that align with their philosophy on health care, match their health status and their needs for bedside manner.”

 

 

In their article Writing a Birth Plan, findadoula.com writes:

 

“It is not possible to use a birth plan to “make” your caregivers agree to things they are not comfortable doing. For instance, if you don’t want an episiotomy but your doctor usually cuts them for most women, it is unlikely a birth plan will make your doctor change his practice.”

 

 

[For more information on choosing a care provider please check out my post: Must Read Blog: “It’s Your Birth Right!!”]

 

Also doula Kim Palena James warns that a birth plan CANNOT:

 

1. Change your health care provider’s style of practice, personality or protocols.

2. Script the nature of your labor.

3. Insure you have a satisfying labor. 

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

 

What Types of Birth Plans are UNHELPFUL to Mothers and Nurses?

 

 

Remember how I said that you cannot control labor?  Well you also cannot control your birth attendant or the medical system.  This is why author, certified nurse midwife, and childbirth educator Pam England, CNM, MA warns mothers about “The Birth Plan Trap.”  In her book Birthing From Within she writes:

 

“Writing birth plans is becoming a ritual of modern pregnancy.  This practice began with the positive intention of encouraging parents to take a more active role in birth.  Writing a birth plan motivates parents to learn about their hospital’s routines (usually with the intention of avoiding them).  A birth plan also can be a tool to open dialogue with doctors.  Telling a doctor what you want (and seeing his/her reactions) allows insight into the doctor’s philosophy of practice and willingness to share decision-making.

 

While gaining information is advantageous, the subtle implications of writing a birth plan are more complex than many people realize.  If you look below the surface, you’ll see that birth plans are like a hidden reef on which your efforts towards deeper birth preparations may run aground.

 

In my classes I discourage mothers and fathers from writing a birth plan.  I’ve changed my mind on this issue for several reasons.  I now believe that the need to write a birth plan invariably comes from:

 

  • Anxiety and/or mistrust of the people who will be attending you;
  • A natural fear of the unknown.  Some women attempt to ease that fear, and enhance their sense of control by writing a detailed script of how the birth should happen;
  • Lack of confidence in self and/or birth-partner’s ability to express and assert what is needed in the moment.  (Birth plans may be intended to substitute for face-to-face negotiations with authority figures.) 

 

In writing a birth plan, a woman focuses on fending off outside forces which she fears will shape her birth.  This effort distracts her from trusting herself, her body, and her spirituality.  Rather than planning her own hard work and surrender, her energy is diverted towards controlling the anticipated actions of others.”

(Birthing From Within, pages 96-97)

 

 

Indeed I have met and cared for couples as an L&D nurse where it seemed like they spent the majority of their time preparing for the birth by writing a birth plan that was intended to “ward off the enemy.”  Pam England calls this “fear-based externally directed preparation” (i.e. “I don’t want this,” “I don’t want that”).  And when I work with couples like this I, in turn, spend the majority of my shift trying to convince the couple (and sometimes their doula) that I am actually on their side.   And don’t get me wrong…I completely understand where their fear comes from (they probably experienced or heard about situations like in my “Don’t Let This Happen To You: Injustice in Maternity Care Series”)!  And there are plenty of stories of unsupportive nurses and crazy on-call doctors to where I don’t blame the couple for feeling like they have to gear up to fight me for everything they want.  But all that fear and worry does NOT facilitate an empowering and positive birth experience and sadly, it sometimes becomes a self-fulfilling prophecy; indeed a mother must almost let go of “control” in labor and surrender to the power of her body and of birth.   

 

So we’ve just learned that birth plans intended to control birth or ward off the enemy are not helpful to anyone.  However unlike Pam England, I don’t take the same drastic stance as she does by recommending that couples do not write a birth plan.  Why?  Because when a birth plan is written for the right reasons and contains the right information, it can really be a helpful tool that nurses can use to help facilitate the birth experience that you desire.  So what types of birth plans are helpful to childbearing families and nurses?  What should be included in a birth plan? and, How should a birth plan be written?  Well, I’m glad you asked!!

 

What Types of Birth Plans Are USEFUL and HELPFUL to Mothers and Staff?

 

In her article Lela Davidson writes:

 

“A birth plan is most useful when you use it to:

 

1. Discuss options and choices with your health care provider. Understanding how your care provider thinks and what her normal practices are will help eliminate confusion, debate, and disappointment during labor and birth. You’ll also increase the level of trust between yourself and your care provider: She’ll understand your priorities and you’ll understand her limitations and preferences.

 

2. Communicate your personality and unique physical, emotional, and environmental needs to your labor and delivery nurse. Let her know what works best for you: A quiet environment? Whispered voices? Do you have a fear of needles? Are you worried about too many people in your room? What do you want to do for pain relief? What helps you relax? What does your partner need? What are his or her fears? Do you like to be touched? What did you learn in your childbirth classes that you’d like to try?”

 

Up for Tommorow:  Top Ten DOs for Writing Your Birth Plan

 

Pitocin Protocol for Labor Induction/Augmentation Decoded July 9, 2009

Dear NursingBirth,

 

Just curious, since I’m not a nurse but AM looking into a future of nursing or midwifery… on the Pit pump, is the max number that is shown 20? Or is it 60? The reason I ask is because I had an unnecessary induction via my own decision (not that I truly wanted to, my husband was going to be out of town and first baby.. I was scared to possibly not have him around).  I was labored with pit for 12hours with 11of those hours having a broken amniotic sac. My doc said I would have my baby between 5-6pm and I believe they went above the max to make that happen (she was born at 5:47 pm). Months after I had my daughter (which was quite painful not having an epidural) I found pictures of me laboring in my husband’s phone. And the machine said 69… I was wondering if that is still a norm or what. I refuse to have pit administered ever again casually if there is not a dire need… Hell I might not ever deliver at the hospital ever again unless truly needed!

 

Sincerely,

Amanda

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Amanda,

This is a GREAT question.  Okay here it goes…

The way it works at the big city hospital that I used to work for (and many others for that matter) is that the bag of pitocin that is used is premixed by the drug company in the concentration of 20 Units of Pitocin per 1 Liter of Lactated Ringers or Normal Saline.  (Some do 10 Units of Pitocin per 1 Liter of fluid but I have never worked with this concentration so I’ll stick to what I have the most experience with).  This is in large part so that nurses do not have to mix their own, hence making less chance for medication errors. 

Most “low dose” pitocin protocols (as was the policy of the big city hospital I used to work for) is that pitocin is started at 2 milliunits per minute (mu/min) and increased by 1-2mu/min every 15-30 min to a maximum of 20mu/min.  The goal:  To obtain an effective and adequate contraction pattern of 3-5 contractions in 10 minutes (and no more) that cause cervical change.  However, IV pumps infuse in milliliters per hour NOT milliunits per minute and therefore there are conversion charts that nurses follow.  In this concentration, 2mu/min converts to 6 milliliters per hour (mL/hr) and therefore if you do the math 20mu/min converts to 60mL/hr.  So no, you are not going crazy!  The pump most likely did read 60!

[Addendum 3/30/2010:  In order to get a 1:1 ratio of milliunits/min to milliliters/hour the concentration of pitocin must be 30 units of Pitocin in 500mL of LR (or D5LR).  Hence when you do the math, 2 milliunits/min equals 2mL/hr and so on and so forth.  At a community hospital I worked at in the beginning of 2010 (which I not so affectionately refer to as “Bait & Switch Community Hospital”), the pitocin was hung in this particular concentration and the orders typically read: “Start pitocin at 2 milliunits per minute (mu/min) and increased by 2mu/min every 15-20 min to a maximum of 34mu/min.”  This was by far the scariest order for pitocin I was ever faced with and is one of the reasons that I am leaving this hospital!]

Okay, so if a doctor wants to go above “max pit” which, according to the “low dose pitocin protocol” that a big city hospital I used to work for follows, is anything above 20mu/min (60mL/hr), then they have to write out an entirely separate order.  At that hospital the “absolute max pit” is 30mu/min (90mL/hr).  Now, the higher the dose and the longer the infusion runs for the greater the risk for side effects and adverse reactions.

These potential adverse reactions include (source: RxList Drug Guide)

1) Potential adverse reactions in the mother:

  • Anaphylactic reaction
  • Postpartum hemorrhage
  • Cardiac arrhythmia
  • Fatal afibrinogenemia
  • Hypertensive episodes
  • Nausea
  • Vomiting
  • Premature ventricular contractions
  • Pelvic hematoma
  • Subarachnoid hemorrhage
  • Hypertensive episodes
  • Rupture of the uterus
  • Excessive dosage or hypersensitivity to the drug may result in uterine hypertonicity, spasm, tetanic contraction, or rupture of the uterus.
  • Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been reported.

 

2) Potential adverse reactions in the fetus or neonate related to hyperstimulation of uterus:

  • Bradycardia
  • Premature ventricular contractions and other arrhythmias
  • Permanent CNS or brain damage
  • Fetal death
  • Neonatal seizures have been reported with the use of Pitocin.

 

3) Potential adverse reactions in the fetus related to use of oxytocin in the mother:

  • Low Apgar scores at five minutes
  • Neonatal jaundice
  • Neonatal retinal hemorrhage

 

Remember the most serious of these adverse reactions occurs when pitocin is run at concentrations higher than 20mu/min for hours or even days of induction.  But unfortunately this abuse of pitocin does happen.

There is also something called a “high dose” pitocin protocol.  The way the big city hospital that I used to work for described it (right after it said that we were NOT allowed to order/follow it at our hospital) is the following:  Pitocin is started at 6 mu/min (18 mL/hr) and is increased by 1 to 6 mu/min (3 to 18 mL/hr) every 20 minutes until a maximum of 42 mu/min (126 mL/hr).  Now, I am sure that there a subtle variations on this, for example, some birth attendants/hospitals that follow this protocol will only do “high dose pit” on nulliparous women (first time moms).  However, again, the higher the dose and the longer it is infusing for, the greater chance of complications and adverse reactions. 

Now the other option could have been that the hospital that you went to uses bags of pitocin with a concentration of 10 units per liter instead of 20 units per liter.  If this is the case then everything would be doubled.  With a 10 unit/liter concentration, 2mu/min would actually be 12 mL/hr.  So that could be the case as well, although that is more unlikely.  

Now again, other nurses might report slight variations in this but I am confident that many hospital’s pitocin policy looks a lot like the ones I’ve worked at both in nursing school and as a nurse.

Last but not least please check out a great post from Jenn, a doula who blogs at Knitted in the Womb Notes.  She wrote a post a while back entitled My Rant On Pitocin and she actually copied the package insert from the pitocin bag that the nurse hung.  What saddens me most about that story is that at one point her client was considering just “going ahead” with a cesarean because the higher they put the pitocin the more the baby deceled.  However LABOR was not causing the baby distress…the ABUSE of PITOCIN was causing the baby distress!  That’s why when I hear things like “The pitocin was causing my baby’s heart rate to decel so they did an emergency c/s and Thank GOD because that OB saved my baby” I want to vomit.  Okay so if I STAB you and then bandage your wound so you don’t bleed to death….did I save your life???

Thanks again for your great question Amanda!

All My Best,

NursingBirth

 

“Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions

Yesterday in my post entitled “Pit to Distress: A Disturbing Reality” I wrote about a troubling way of administering the drug pitocin to augment or induce labor that some birth attendants are practicing in our country’s maternity wards.  Called “pit to distress”, the intention is to order a nurse (either verbal or written) to continue to turn up (or “crank” as is the current L&D slang) the pitocin in order to induce hyperstimulation/tachysystole of the uterus so that a women is experiencing more than 5 contractions in a 10 minute period.  This action, sooner or later, will cause fetal distress as research has shown that a baby needs AT LEAST a 1 minute break in between contractions where the uterus is AT REST in order for the baby to continue to receive adequate oxygenated blood flow from the placenta and not have to dip into his reserve. 

 

Inspiration for my post came from two posts on the subject written by Keyboard Revolutionary and The Unnecesarean.  Since yesterday I have received many comments regarding this upsetting trend and one comment in particular has inspired me to address the topic again:

 

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

July 8, 2009

 

Dear NursingBirth,

 

I really enjoy your blog and I learn a lot from all your posts. I am wondering if there is a way (as the patient) to know if something like this is happening and refuse it? Is the patient always told how much pitocin she is getting and can she say at a certain point that she doesn’t want it any higher if she is making progress?

 

Sincerely,

Zoey

 

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

 

Dear Zoey,

 

This is a GREAT question.  I love hearing from women who desire to learn more about their choices in childbirth and become more proactive in the care they are receiving.  KUDOS to you for doing both!!  I have thought a lot about this and I have come up with a list that I hope you find helpful.  Please pass it along to all of your friends, both expecting and not, so that we can both work to inspire more women to do as you do….that is, DO their research and DEMAND better care!!!

 

 

 

TOP 7 WAYS TO PROTECT YOURSELF FROM UNNECESSARY AND HARMFUL OBSTETRICAL INTERVENTIONS (including “Pit to Distress”!)

 

 

#1  Interview different birth attendants/practices before or during early pregnancy and CHOOSE a birth attendant that practices in a way that aligns with your personal childbirth/postpartum philosophy, is appropriate for your health status, and (optimally) who practices a midwifery model of care!

 

I wish I could scream this from the roof tops!  Sometimes I feel like a broken record I say this so often but I say it so often because it is SO important!!  The bottom line here ladies is that if you think you can pick any care provider you want and then just write a birth plan that clearly states your philosophy and preferences and just get what you want…..THINK AGAIN!  Birth attendants are creatures of HABIT more than anything else.  If they cut an episiotomy on the majority of their patients then what makes you think that if you ask, they won’t cut one on you?  In fact, not only will they cut one on you but they will come up with some bogus reason why it was necessary.  Likewise, if your birth attendant induces most of their patients, what makes you think that he won’t start pressuring you to set up an induction date once you hit 37 weeks! 

 

Think of it this way, if the birth attendant has a high elective induction rate, they probably feel more comfortable managing pitocin induced or augmented labors as opposed to spontaneous labors and hence, they will probably try to do everything in their power [including persuasion (e.g. the “convenience” card and the “aren’t you sick of being pregnant” card) as well as scare tactics (e.g. the “big baby” card, the “I might not be there to deliver you if you don’t” card, or my favorite the “if you don’t your baby might be stillborn/dead baby” card)] to convince you that your labor needs to be induced or augmented with pitocin.  Why?  It probably is a mix between how they were taught (i.e. medical model of maternity care), what they are used to (a self fulfilling prophecy), and a desire to be the one in “control.” 

 

Writer Lela Davidson quotes professional childbirth educator and doula, Kim Palena James in her article Create a Better Birth Plan: How to Write One and What It Can and Cannot Do For You:

 

“Too many parents create birth plans with the expectation that it will be the actual script of their baby’s birth. There is no way! Nature scripts how your child is born into this world: short, long, hard, easy, early, late, etc… The health care providers you choose, and the facility they practice in, will script how you and your labor are treated. The variations are vast. I wish every expectant parent spent less time writing birth plans and more time selectively choosing health care providers that align with their philosophy on health care, match their health status and their needs for bedside manner.”  (Emphasis mine)

 

So PLEASE for the LOVE of all mothers and babies, PLEASE do your homework! 

 

Of course there is always the chance that you do interview a particular birth attendant and they act one way in the office with you and then, WHAM!, are a completely different person when you step foot on L&D.  I see it happen ALL THE TIME where I work.  Just because a doctor gives you his home phone number and is sweeter than sugar in the office, doesn’t mean he won’t section you just to get to the company Christmas party!  (This actually happened to a patient I took care of!  NO lie!)  So what can you do about that! 

 

Jill from Keyboard Revolutionary recently blogged about this:

 

“Ya know, sometimes I feel bad for the good physicians out there. I know they exist. We all do. We’ve all shaken our fists in righteous indignation at the rants of Marsden Wagner. We’ve listened intently to the poetic, thickly accented declarations of Michel Odent. We’ve swooned over the tender ministrations of “Dr. Wonderful,” a.k.a Dr. Robert M. Biter. God bless those diamonds in the rough, particularly in the obstetrical field. It must be twice as hard to shine when the lumps of coal around you are so horrifically ugly.

 

I was pondering just now in the shower how so many of us think we’ve got a real gem of an OB (or any other doctor, really) until show time, and suddenly we’re hit with the ol’ bait-and-switch. Sometimes there are warning flags along the way, sometimes not. Sometimes the flags don’t pop up until it’s too late. It sucks that for many women, we don’t realize what a crock we’ve been fed until we’ve already digested it. How do you know whether you’ve got a bad egg or your own Dr. Wonderful?”

 

This leads me to my second point…

 

 

#2  Ask the RIGHT QUESTIONS and the RIGHT PEOPLE when researching potential birth attendants.

 

Two of my favorite posts from Nicole at It’s Your Birth Right! are her posts about choosing the right birth attendant entitled Choose Wisely I and Choose Wisely II.  She writes:

 

“The decision about WHO is going to be your birth attendant should NOT be left to chance.  Where you deliver, how you choose to labor, what you chose to do while pregnant and in labor, while these things are definitely important, without the proper WHO, the plan will have difficulty coming together.

 

I get questions, all the time from friends, friends of friends and even strangers.  They want my thoughts about pregnancy, labor and childbirth. I have spent HOURS talking with women providing answers and information they should be able to get from their prenatal provider/birth attendant.  I think to myself at the end of those conversations, “Why isn’t she able to get this information from her?  If  he doesn’t make her feel special, does not answer her questions, and doesn’t agree with her philosophy on childbirth and labor, why on earth is she allowing him to be her birth attendant?!”

 

When I pose this question to the women themselves, the answers unfortunately never include “Because I did my research and I found him to be the best match for me and my desired childbirth experience.”  Most of the answers I receive fall into [one of] four categories, none of which are good enough reasons alone to choose a prenatal care provider/birth attendant.   They are: “She delivered my sister/girlfriend”, “She is my gynecologist,” “He is the best/most popular person in area,” and “Her office is so close and convenient to my office/house.”

 

Now I am not trying to say that you shouldn’t trust your sister, sister-in-law, or best friend’s opinion about her personal birth attendant but if you are going to ask such a person for advice please remember that she probably has only had limited experience with that birth attendant as compared to, say, an L&D nurse or doula, and it is important to ask her exactly why she loves her birth attendant so much.  Does she love him because he trusts in birth and strived to facilitate a positive and empowering birth experience for her or does she love him because he was the only OB in the area that would agree to induce her at 38 weeks because she was sick of being pregnant?  There is a difference!!

 

If you have done some research and found a birth attendant that you think you really like, I would recommend tapping into some community resources to get the “inside scoop” about your birth attendant.  Here are some ideas:

 

1)      Contact your local grassroots birth advocacy group like International Cesarean Awareness Network (ICAN) or BirthNetwork National and try to attend a meeting.  The women that attend these meetings are often in tune with the birth culture in their community and can be GREAT resources for which birth attendants are true and which are really wolves in sheep’s clothing!  Also, don’t count out ICAN as a resource even if you have never had a cesarean.  We have a quite a few moms currently in my local ICAN group that are first timers and decided to start attending because they said they were learning so much about birth in general from our meetings!

 

2) Sign up for a childbirth preparation class that is NOT funded/run by a hospital and ask the instructor for her opinion on different birth attendants.  It is the only way to guarantee that your instructor is not held back from speaking her true feelings since hospital based childbirth instructors are working for the interest and promotion of their hospital by the very nature of their job.  Independent childbirth instructors like Lamaze, Hypnobabies, Birthing From Within, Bradley etc. etc. can be GREAT resources as to which birth attendants follow which philosophies because often times their clients come back and tell them about their experiences.

 

2)      Consider consulting or hiring a doula.  A doula is a great resource as to the true nature of a birth attendant because she is someone who is actually in the labor and delivery room with her clients and has as close to an “insider’s view” as you can get without actually working for the hospital.  If you hire a doula to be with you during your labor, they will also advocate for you, your needs, and your birth plan as well as provide essential labor support that (unfortunately) even the most well intentioned nurse might not have the time to do. 

 

 

#3  Do NOT agree to an induction of labor unless there is a legitimate obstetrical, maternal, or fetal reason for delivering the baby before natural spontaneous labor begins!!  PLEASE Do NOT agree to an unnecessary elective induction of labor. 

 

This might seem like a no brainier ladies but so many get sucked in!  They don’t call it “the seduction of induction” for nothing! 

 

Bottom line is if you want to protect yourself from such an asinine, unnecessary, and dangerous intervention as “Pit to Distress” then DON’T agree to be induced unless there is a very important medical reason!

 

BABIES AND MOTHERS HAVE THE BEST OUTCOMES WHEN THEY ARE ALLOWED TO BEGIN LABOR SPONTANEOUSLY AS WELL AS LABOR AND DELIVER WITH MINIMAL INTERVENTIONS!

 

In the Lamaze Institute for Normal Birth’s MUST READ patient education bulletin entitled Care Practice #1: Labor Begins on Its Own, author Debby Amis, RN, BSN,CD(DONA), LCCE, FACCE, and editor Amy M. Romano, MSN, CNM write:

 

“There is growing evidence that induction of labor is not risk-free. In 2007, Goer, Leslie, and Romano reviewed the entire body of literature on the risks of induction in healthy women with normal pregnancies and found that when labor was induced, the following problems may be more common:

  • vacuum or forceps-assisted vaginal birth;
  • cesarean surgery;
  • problems during labor such as fever, fetal heart rate changes, and shoulder dystocia;
  • babies born with low birth weight;
  • admission to the NICU;
  • jaundice;
  • increased length of hospital stay.”

 

Okay, enough said!

 

 

#4  If you have to be induced or augmented with pitocin for a true medical or obstetrical reason, be honest with your nurse about how you are feeling and have one of your labor companions keep track of how often your contractions are coming.

 

And this does NOT mean for your labor companion to “monitor watch”!!  It’s not a TV for goodness’ sake!

 

Research has shown that due to the risks of pitocin, continuous electronic fetal monitoring (CEFM) is a safety requirement for anyone being induced or augmented with it.  However, remember CEFM is a machine and machines have limitations.  The tocodynamometer or “toco” is “pressure transducer that is applied to the fundus of the uterus by means of a belt, which is connected to a machine that records the duration of the contractions and the interval between them on graph paper.”  However, depending on your body type, how “fluffy” your abdomen is, your position, and your gestational age, the toco might not be recording your contractions appropriately.  You might be having contractions every minute but the machine is not registering them.  This is why I always remind women that they have to tell me how they are feeling. 

 

If you are being augmented or induced with pitocin your nurse SHOULD:

 

1)      Be palpating (feeling) your fundus (top of your uterus above the belly button) before, during, and after contractions periodically throughout your labor to judge how strong they are (mild, moderate, or strong).  Palpation before and after contractions also assures the nurse that your uterus is actually coming to rest (is soft) between contractions, which assures that the baby (and mom!) are getting a break!  Remember, unless you have an IUPC (intrauterine pressure catheter) in, the toco can only tell the nurse how far apart and how long the contractions are NOT how strong they are!  That’s right!  Unless you have an IUPC in, the height of the contractions on the monitors is ABSOLUTELY MEANINGLESS!  So therefore the only way for the nurse to know how strong the contractions are is to TOUCH your belly and ASK you!

 

2) Ask you about your pain level (for example to “rate” your pain on a scale of 0 to 5 or 0 to 10) regularly during your labor unless you have specifically asked her not to ask you about your pain.

 

3) Give you periodic updates on your progress and the progress of the pitocin.

 

[Note: I can only speak for myself here but what I do when I have a patient on pitocin is first and foremost to explain the process of titrating the pitocin and what the desired outcome is (and according to our hospital’s policy the desired outcome is moderate to strong contractions that are coming every 2-3 minutes, or 3-5 in a 10 minute period), as well as keep her informed throughout the process when I am increasing or decreasing the pitocin and for what reason.  For example, I might say “It looks to me like you are contracting every 4 minutes.  What is your pain level?  Do you feel like you are getting an adequate break?  Would you like to change position?  I would like to increase to pitocin to achieve a more regular pattern.  What do you think?” or “It looks like the baby continues to have variable decelerations in his heart rate despite all of the position changes we have tried.  I am going to give you a small IV fluid bolus and turn the pitocin down some to see if it helps to resolve the decels.  The baby’s variability is still very reassuring and she is still having accelerations so she is doing well.  I just would like to keep her that way!”  Your nurse should be keeping you “in the loop” so to speak and if she is not, it is your right to ask questions!]

 

It is also important to remember that that running pitocin is much more of an art than a science.  Therefore you might think she is being “mean” if she is increasing your pitocin since you are only contracting every 6 minutes but remember, running the pitocin lower than is needed to cause cervical change isn’t going to help you either.  No nurse wants her patient to end up in the OR for “failure to progress” because she didn’t turn the pitocin up enough.  There is a happy medium somewhere that most nurses are trying to find.  So please, know that sometimes, even if you really feel like those “every 6 minute” contractions are strong enough already, it is important for the nurse to titrate the medication to achieve an effective labor pattern that promotes a vaginal delivery with a healthy baby. 

 

If your nurse is NOT doing these things then it is your right to ask questions!!!  However, please remember for your own sake that when asking questions, one attracts more flies with honey than vinegar.  Don’t start yelling at her or demanding a new nurse.  Give her a chance and ask questions first!  She might just be so busy that day that she is in the zone.  Most nurses are happy to teach when asked!

 

 

#5  Learn about and practice non-pharmacological methods of pain relief as part of your childbirth preparation and consider not getting or postponing an epidural until all other methods of non-pharmacological pain relief have been exhausted. 

 

Okay, I know that this one is a bit controversial but please here me out first. 

 

It is the truth that pitocin contractions, especially when the pitocin is being abused, are typically stronger and longer than spontaneous labor contractions.  Also, being that you have to be on continuous monitoring can also limit your movement and hence, one of your most effective and instinctual coping methods for the pain.  For this reason, many people feel that it is crazy for a woman to go though a pitocin labor without an epidural.  And when “Pit to Distress” is in play, it is truly unbearable to both experience and to witness.  However, if pitocin is administered compassionately and appropriately it is important to know that an epidural is NOT an absolute necessity.  I have seen many women do it without an epidural and many who have done it with an epidural.  So if you have to be induced with pitocin and you desire an “unmedicated” birth, your hands aren’t completely tied.  You CAN do it.  However, I have said time and time again, I would rather a woman have a vaginal delivery with an epidural than a cesarean section without.   That being said, the pitocin and epidural partnership has a dark side too. 

 

While an epidural can help the woman relax and allow the pitocin to work more effectively, most birth attendants that practice “Pit to Distress” persuade and even bully their patients into getting an epidural specifically so the nurse can “crank the pit” without the woman objecting.  But I would like to remind you that even if you can’t feel those contractions, your baby IS feeling them.  Also, epidurals themselves CAN and DO cause fetal distress and anyone who tells you that epidurals pose no risk to the baby is being dishonest!  At my work, we nickname this the “ten by ten”.  That is, almost without fail, many women who get an epidural are is likely to experience a whopping fetal heart rate deceleration lasting approximatly ten minutes about ten minutes after she is put back to bed, which of course throws everyone into a tizzy. 

 

All of a sudden mom finds herself with her face planted into the bed, her ass in the air, a mask of oxygen on her face, an anesthesiologist pushing adrenaline into her IV to increase her blood pressure and a doctor with his hands up her vagina screwing a monitor onto the baby’s head.  Most babies do recover from said decel and go on to deliver vaginally.  But it is NOT rare for the baby to NOT recover which lands mom…you know where….in the OR.  And guess what!  Since she already has that epidural in place, why they can just cut her open even faster! 

 

Please know that I am not condemning any woman who requests an epidural in labor, especially if she is on pitocin.  I just want all you women out there to know that sometimes that epidural that they keep waving in your face is just a way for them to shut you up so they can CRANK the pit.

 

 

#6  If you feel like you are contracting strongly at least every 2-3 minutes (3-5 in a 10 minute period) and the nurse or birth attendant desires to increase your pitocin, you might want to consider requesting a vaginal exam. 

 

Now, I know limiting vaginal exams is very important to many women as they are invasive and uncomfortable/painful.  I completely understand!  However, if your care provider wants to increase the pitocin and you feel it is unnecessary, asking for a vaginal exam is a way to reveal if you are making any cervical change.  If you ARE making cervical change then there is no real need to continue to go up on the pitocin!  Remember the TRUE goal of pitocin administration is to stimulate an effective labor pattern that causes cervical change.  It is NOT (despite how many birth attendants practice) just about getting a patient to “max pit.”  Every woman is different! 

 

Lastly,

 

 

#7  You could always try writing something about pitocin administration in your birth plan. 

 

For example: “If deemed necessary, I would like to try non-pharmacological methods of labor augmentation and induction including (blank) first before resorting to pharmacological methods.  However, if my birth attendant and I agree that pitocin will be administered to me, I request that the pitocin be administered following the “low dose” protocol and is increased in intervals no closer than every 30 minutes, allowing my body an appropriate amount of time to adjust and react to each dose increase.”

 

I will be very honest with you.  If your birth attendant or hospital does not practice in this way, it is doubtful that this request will be granted.  However, I suppose it can’t hurt and is worth a shot!  At least it can provide a sympathetic nurse with another platform on which to argue with the birth attendant if necessary (like, “But Doctor X, your patient has specifically requested a low dose pit protocol!”

 

This should be a last resort!  Remember, writing something in your birth plan does not guarantee you it is going to happen if your birth attendant doesn’t practice that way!  Please refer back to point #1 about choosing the RIGHT birth attendant for you!!! 

 

 

All My Best,

NursingBirth

 

“Pit to Distress”: A Disturbing Reality July 8, 2009

Dear NursingBirth,

 

I just saw a couple of posts about “pit to distress” on Unnecessarean and Keyboard Revolutionary’s blogs. Can you comment on that as an L&D nurse?! Is the intent really to distress the baby in order to “induce” a c-section?  I’m distressed that such things may actually happen, and am holding out a little hope that it’s a misunderstanding in terms….

 

Thanks!!!

Alev

 

 ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

Dear Alev,

 

I wish I could put your heart and mind at ease and tell you, from experience, that this type of outrageous activity (i.e. “pit to distress”) does not happen in our country’s maternity wards but unfortunately it does.  I know that it does because:

 

1) I have read and heard stories from other labor and delivery nurses who have worked with birth attendants who practice “pit to distress,”

 

2) I have read and heard stories from women (and their doulas!) who have personally experienced the consequences of “pit to distress,”

 

and, most importantly…

 

3) I personally have worked with attending obstetricians who subscribe to this philosophy. 

  

Before I start my discussion on this topic I would like to quote a blog post I wrote back in April entitled “Don’t Let This Happen To You #25 PART 2 of 2: Sarah & John’s Unnecessary Induction”.  This post is actually the first post I ever wrote for my Injustice in Maternity Care Series.  It is a TRUE story (although all identifying information has been changed to adhere to HIPPA regulations) about a first time mom who was scheduled for a completely unnecessary labor induction and the following excerpt is a good example of how “pit to distress” is ordered by physicians, EVEN IF they don’t actually write it out as an order (although some actually do!)

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

“…At 1:30pm, right on schedule, Dr. F came into the room.  After some quick small talk he asked Sarah to get into the bed so that he could perform a vaginal exam and break her water. 

 

Sarah: “Umm, I was hoping we could wait a little bit longer to do that, until I am in more active labor.”

 

Dr. F: “Well, if I break your water it is really going to rev things up and put you into active labor.”

  

Sarah: “I’d really rather wait.”

  

Dr. F: (visibly frustrated) “Well I at least have to check you!”

 

(Oh lord, I love the “have to”!)  Dr. F’s exam revealed that Sarah was 4 centimeters!  Yay!

 

After helping Sarah to the bathroom and back to her rocking chair, I stepped out the catch Dr. F at the desk.  “Thanks for holding off on the amniotomy, it was really important to her birth plan,” I said, trying to “smooth things over” and (gently) remind him that the patient was in charge!  “Yeah well I’ll be back around 4:00pm to check her again and if she hasn’t made any progress I am going to break her water,” he said, grudgingly. 

 

He started to walk towards the elevator but then turned around to me and said:

 

Dr. F: “You have the pit at 20 right?”

 

(Note: The way pitocin is administered for induction in my hospital (and many others) is that you start the pitocin at 2mu/min (or 6mL/hr) and increase by 2mu/min every 15-30 min (or more) to a maximum of 20mu/min (or 60mL/hr) until you obtain an adequate contraction pattern (or, 3-5 contractions in 10 minutes).  So what does that mean?  That means that you do NOT just crank the pitocin until you get to “max pit,” rather you TITRATE it until you get 3-5 contractions in 10 minutes that are palpable and are causing cervical change.  However, this is not what many physicians I work with ask you to do.   Bottom line is everyone is different.  I personally could take a whole box of Benadryl and not so much as yawn while my husband can take one tablet and all but hallucinate!  It is no different for pitocin.  Some people are extra sensitive and only need a little bit, and others tolerate “max pit” very well.  I seem to have this same “fight” with physicians all the time at work.  They insist you “keep cranking the pit” when all you are going to do is hyperstimulate the uterus and cause the baby to go into distress.  But I digress….)

 

Me: “No, I have her at 10mu/min.”

 

Dr. F: (sarcastically)  “What!?  What are you waiting for?! 

 

Me: (said while biting my lip so I didn’t say something I would regret)  “She is contracting every 2-3 min and they are palpating moderate to strong.  She has to breathe through them.  And the baby is looking good on the monitor.  I want to keep it that way!”

 

Dr. F:  “But she’s not going anywhere!  You have to keep going up if you want her to progress.”

 

Me: “But she has changed to 4 centimeters…”

 

Dr. F:  “I was being generous!”

 

Me: “So you lied…”

 

Dr. F:  (annoyed) “Listen, keep going up on the pit, even if she is contracting every 2-3 min.  They aren’t strong enough.  Keep going up.  If we hyperstimulate her, we can just turn the pit down.”  (Note: These were his exact words.  I know this because I was so flabbergasted that he said it, I wrote it down in my notebook that very moment!  The fact is sometimes the baby is in so much distress after hyperstimulating the uterus that just turning the pitocin down isn’t enough!  And it really bothers me when doctors start sentences off with “Listen…”  Grrrrr.)

 

Me:  (jaw dropped, completely dumfounded) If I turn the pit up anymore, I am GUARANTEED to hyperstim her.”

 

Dr. F: “We’ll cross that bridge when we get to it.  I’ll be back around 4:00pm.”

 

By this point I was more than annoyed with Dr. F.  I explained the situation to the charge nurse and told her that I would not be cranking the pit on room 11 unless Dr. F wrote me an order that read “Regardless of hyperstimulation or contraction pattern, continue to increase pitocin until the maximum dose is reached.”  (By the way, he wouldn’t’ write me that order).  She basically told me to do what I felt was right because it was my license at stake too.”

 

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

Ladies and gentleman the account that you have just read is called “Pit to Distress” whether the pitocin order was actually written that way or not.  What Dr. F gave me was a VERBAL ORDER to increase the pitocin, regardless of contraction or fetal heart rate pattern, until I reached “max pit,” which he acknowledged would hyperstimulate her uterus.  This goes against our hospital’s policy and the physical written order that this doctor signed his name under.  However, like some other doctors I work with, none of that mattered to him.  What he wanted was for me to “crank her pit” regardless and from my experience with this doctor, at the first sign of fetal distress we would have been crashing down the hallway for a stat cesarean!

 

Hyperstimulation of the uterus (more appropriately called tachysystole) is harmful and dangerous for both mothers and babies: 

 

“If contractions are persistently more often than 5 contractions in 10 minutes, this is called “tachysystole.” Tachysystole poses a problem for the fetus because it allows very little time for re-supply of the fetus with oxygen and removal of waste products. For a normal fetus, tachysystole can usually be tolerated for a while, but if it goes on long enough, the fetus can be expected to become increasingly hypoxic and acidotic.

 

Tachysystole is most often caused by too much oxytocin stimulation. In these cases, the simplest solution is to reduce or stop the oxytocin to achieve a more normal and better tolerated labor pattern.”

Electronic Fetal Heart Monitoring” by Dr. M. J. Hughey

 

The truth, however, is that many times stopping tachysystole is not as easy as just shutting the pitocin off.  Although the plasma half-life of pitocin is about 6 minutes, it can take up to 1 hour for the effects of pitocin to completely wear off.  And for a baby in distress, one more hour in a hyperstimulated uterus is too much!  So guess what?!  The physician has two choices:

 

#1 Administer yet another drug (like terbutaline) to decrease contractions and wait and see (unlikely to happen), or

 

#2 Administer yet another drug (like terbutaline) to decrease contractions while heading to the OR for an emergency cesarean section (much more likely to happen.) 

 

Because in the end…who wants to “sit” on a compromised baby?!

 

 

What is also unsettling is that my encounter with Dr. F regarding the most appropriate administration of pitocin for that mother was downright pleasant as compared to some of the other encounters I have had with much more intimidating and hot-headed physicians.  Labor and delivery nurses all over this country (including myself) have been bullied, yelled at, cursed out, and down-right humiliated by birth attendants who want you to “keep cranking the pit” regardless of maternal contraction or fetal heart rate patterns or in general, refusing to be a part of or questioning other harmful obstetrical practices.

 

I once had an obstetrician, while in the patient’s room, call me “incompetent” in front of the patient and her entire family because I had not continuously increased the pitocin every 15 minutes until I reached “max pit” and instead, kept the pitocin at half the maximum dose because increasing it anymore caused my patient to scream and cry in pain and her uterus to contract every 1 minute without a break.  Who wants a nurse to take care of them that was just called “incompetent” by their doctor??!? 

 

Another time I had a physician (who via this program called “OBLink” can watch her patient’s monitor strips from her own home or office) call me on the phone from her house to chew me out about not having the pitocin higher.  When I explained that I had to shut the pitocin off an hour earlier and start back up at a slower rate because the baby started to have repetitive and deep variable decelerations despite position changes, IV fluid bolus, and 10 liters of oxygen via face mask, I was told that the decels “weren’t big enough” to warrant such a “drastic measure as shutting of the pitocin” and I was “wasting her time” because “at the rate [I] was going [her] patient wouldn’t deliver until after midnight.”

 

I had yet a third doctor tell me once that he wished that only the “older” nurses on the floor would take care of his patients because they aren’t “as timid” and “are not afraid to turn up the pitocin when a doctor orders them to.”  That younger nurses like me are “too idealistic” and don’t understand “how the world really works.” 

 

And yet another time I had a physician tell me that I needed to “crank the pit to make this baby prove himself either way” and that if I couldn’t do “what needed to be done” for his patient, then he would ask the charge nurse to “replace me with a nurse who could.”

 

And guess what, when I came in the next day and read the birth log, I discovered that 3 out of those 4 patients ended up with cesarean sections after I had left that night for “fetal distress.” 

 

AAAAAAHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH!!!

 

Although not one of these physicians actually wrote in black and white “Pit to Distress” and they didn’t have to; their words and actions speak to their true intentions.  These physicians are smart in the fact that they know that actually writing “pit to distress” like some practitioners do can land them with a law suit if an adverse outcome happens and they find themselves in court.  So while it is true that one’s medical record might not show “pit to distress” on the order form, it doesn’t mean that it didn’t happen to you!  What these doctors do instead are bully nurses into to doing their dirty work for them.  (And I would like to note that just like Dr. F, I have yet to encounter one physician who will actually physically put their hands on the IV pump and turn up the pitocin themselves when I refuse to do it!…..They know better!)

 

 

As a registered nurse my practice must adhere to the American Nurses Association Code of Ethics for Nurses.  Here is an excerpt:

 

“The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.  The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”

 

What these practitioners don’t realize is that when they work with nurses like me (and there are many out there!!), they are working with someone who values the health and safety of women and babies (as well as their nursing license) much more than a fake cordial kiss-ass relationship with some high-and-mighty doctor!  But let me tell you, its really frigging hard to work like that!  That is, to constantly battle with practitioners who have such a different philosophy about maternity care than you do!  I mean, even the best nurses will start to doubt themselves if they are constantly being bullied and told that they “can’t cut it” or are “incompetent” if they don’t follow the status quo!  Like many other nurses, sometimes I just don’t have the energy to argue and fight.  Sometimes I have down right lied to a doctor over the phone about how high the pitocin really is (telling them it’s running at a much higher rate than it actually is).  Other times I just “forget” to turn up the pitocin for hours at a time.  One time I actually disconnected the pitocin and discretely ran it into the floor!

 

Women of this earth…TAKE BACK YOUR BIRTH!!!  We need YOUR voice!  We need you to choose caregivers that practice evidenced based medicine, and BOYCOTT ones that don’t!  We need you to HIT THEM WHERE IT HURTS….in their WALLET!!  We need you to DEMAND better care!!  We nurses, birth advocates, doulas, childbirth educators, midwives, etc. etc. can’t make change without YOU!!

 

Thank you, Thank you, THANK YOU to Jill at Keyboard Revolutionary and Jill from The Unnecessarean for their blog posts on this issue!  I second their anger, outrage, and voice for change!!!

 

Are you an L&D nurse who has ever been ordered to “pit to distress?”  Are you a mother who has ever experienced the consequences of a birth attendant who followed a “pit to distress” philosophy?    Please share your story with us!! 

 

In closing I would like to say that I am NOT anti pitocin, but like ALL labor & delivery interventions, I speak out and advocate for the appropriate, evidencedbased, and safe use of them!

 

Please check out my next post!  “Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions

 

Coming Soon: Free Movie “Reducing Infant Mortality” July 1, 2009

 

Thanks to Maria at the Massachusetts Friends of Midwives Blog, I just stumbled across a a trailer for a new documentary that will be FREE to view on July 26, 2009.  The video is titled “Reducing Infant Mortality and Improving the Health of Babies” and is sponsored by the Santa Barbara Graduate Institute Center for Clinical Studies and Rearch. 

 

Watch the trailer here!

 

 

As stated on the website, “This free film will be a tool for everyone to use to draw attention to infant mortality and health issues as national health care policy is debated on Capitol Hill.”

 

The movie’s official website also reads:

The current US Health Care System is failing babies and families before, during and after birth. At this critical moment when the US government is re-envisioning our health care system, we are seizing the opportunity to make a 10-12 minute video not only to point out the flaws in the way we care for babies and families, but also to identify the keys to improved care. Our infant mortality ranking is 42nd on the world stage which means 41 countries have better statistics. This places us right in the middle of the following countries: Guam, Cuba, Croatia and Belarus, with over double the infant deaths compared to the top 10 countries of the world. (CIA World Factbook).

Our astronomically high African American infant mortality rate at 16 deaths per 1,000 is similar to countries such as Malaysia and the West Bank. Not only are babies dying needlessly, but the ones who survive this failing system are also often adversely affected by unnecessary procedures and separation from mother and family. Our intent with this video is to encourage policy makers to consider a health care system that holds prevention of these calamities as a high priority.  The midwifery model of care for healthy low-risk women is a simple solution which addresses many of these issues simultaneously.

We are advocating for a health care system in which it will be standard procedure for mothers and babies to thrive and not merely survive through birth and early life. The midwifery model of care will save our health care system millions of dollars each year.
 

To read about the credentials of the experts you see in the film’s trailer please visit  About the Film  and scroll to the bottom.

 

Spread the word!!