The Ol’ Bait and Switch, OR Finding Out Your OB Has Been Leading You On October 21, 2009

Submitted on 2009/10/20 at 3:24pm

Comment under: Urgent Message from ICAN! Please Spread the Word!!

Dear Nursing Birth,

 

I’m a day short of 35 weeks pregnant today and went in for an OB appointment this morning. My doctor said that if I don’t go into labor on my own in my 39th week that (depending on how much and if my cervix is dilated) she might put me on pitocin- although she did say that “they don’t induce labor for VBAC patients”. But that they won’t let me go to 40 weeks, and that by 40 weeks they will have to schedule another c-section for me. (I live in Cedar Falls, IA)

 

I am shocked and angry! First of all- since when is 40 weeks, too late? My OB says it’s not wise to go to beyond 40 weeks due to increased risk of uterine rupture. But this just sounds like B.S. to me!

 

And how does the doc get away with not telling me something important like this until NOW? Unbelievable!!  My doctor and I have already gone through my birth plan, line by line, because I want as few interventions as possible and no drugs, seeking a natural vaginal childbirth. I’ve taken 12 weeks of Bradley method birth classes to help my husband and I be better prepared this time.  I also have a fantastic, knowledgeable, and supportive doula. But I can’t believe what a fight it is to have a VBAC!

 

If I had known sooner that this was the doctor/hospital policy for VBAC, I probably would have gone somewhere else. Since it’s so late in the game now, I’m probably going to stick it out. I don’t have to do anything they say, I can always stay at home and come in when I’m ready, and that will be after I am already in deep labor on my own.

 

I was just wondering if perhaps this reflects a change in my hospital’s policy for managing VBAC? One of the other OB’s I met with at the hospital said that after a high maintenance VBAC patient a few months ago (who also insisted on a natural vaginal childbirth, and did it, but most of the hospital staff were very unhappy dealing with this patient…?) that the hospital is reviewing whether to allow VBAC at all. I’m probably not helping the situation by openly trying to avoid their planned interventions. I KNOW I’m required to have continuous electronic fetal monitoring… but I’ve also been told that my labor has to be pretty much “text book” regarding continuous dilation of my cervix, and of course no tolerance for fetal distress…or else!

 

I just wish all women would know this before their first c-section. If you thought recovering from a c-section was bad, wait till you try to have a VBAC and deal with the red tape and lack of support from the medical community. It’s just so frustrating to have to be prepared to battle, and yet relax at the same time! 

 

Have you heard of this kind of change in management of VBAC? That VBAC isn’t even allowed to go to 40 weeks?? Thanks for writing such an informative, educational blog and for being so supportive of natural childbirth! I have enjoyed your tips and insight from the hospital perspective (about writing birth plans, and managing your OB, and also the many ways hospital staff really will be supportive- even if you barf!).

 

Sincerely,

Kelly

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Dear Kelly,

WOW!  I am so sorry that this is happening to you.  You story deeply saddens, frustrates, and angers me because unfortunately YOU ARE NOT ALONE!  Women all over this country have to fight everyday for their VBACs.  Too many are unsuccessful.

First off I want you to know that your gut is absolutely right; 40 weeks is NOT too late and the research does NOT support your obstetrician’s claims.

Second, if that hospital is actually considering revising their entire VBAC “policy” in response to one mother who, as it sounds to me, shook the boat a little bit by demanding better care as well as exercising her right to informed refusal, they are absolutely outrageous and ridiculous!  I would be skeptical of that story if I hadn’t recently read this about the sign placed at the entrance of the Aspen’s Women Center in Provo, Utah.

Third, sounds to me like you did everything right!  You found what you thought was a VBAC supportive care provider, you researched your options and decided you wanted to stack as many cards in your favor as you could for a successful VBAC by planning a drug-free/intervention-free childbirth, you wrote up a birth planthat you painstakingly went through “line by line” with your physician early on in your pregnancy, you have sought out and taken childbirth preparation classes that are geared towards not only providing knowledge about how to have a successful natural childbirth but also help in preparing mentally and emotionally for such an important journey (and on top of that you took those classes with your husband!), and you even hired a doula.  (Yup!  Just as I suspected…you did everything you could!)  So what happened?!?!…

Unfortunately you are a victim of the ol’ bait and switch.

It happens to women everyday around this country.  And its existence is further proof that our maternity system is broken, in shambles really.  There are some obstetricians, family practice physicians, and yes, even midwives that have become really friggin’ good at this awful game.  Women write in to me all the time with similar frustrations and complaints as yours, Kelly.  And I always find myself helpless and speechless.  I don’t know how to help women avoid it and I struggle everyday in my own professional life with how to fight it and stop it!

The worst part of the ol’ bait and switch is the feeling of betrayal that most women report experiencing after they have been victimized they this outrageous action.  (I want to note that I used the terms “betrayal” and “victimized” on purpose.  I understand that they are very strong words but I feel they are the best to describe this very serious phenomenon).  So why does it happen?  Both from what I have personally experienced as a labor and delivery nurse as well as what I have read (for example: Born in the U.S.A by Marsden Wagner and Pushed by Jennifer Block) there is not one simple answer for why some healthcare providers use this “technique.”  But there is no doubt in my mind that money, greed, fear of litigation, fear of losing patients, competition, superciliousness, willful ignorance, impatience, convenience, blatant disregard for evidenced based medicine, favoritism for the “because we’ve always done it this way” model of practice as well as favoritism for the paternalistic provider-patient model of practice (that is, the care provider only presents information on risks and benefits of a procedure/test etc. that he or she thinks will lead the patient to make the “right” decision (i.e. the provider supported decision) regarding health care) all have something to do with it.  Providers who practice the ol’ bait and switch fall somewhere on the, what I like to call “Asshole to Apathy,” spectrum.   Some may be bigger assholes than others, but in the end, they all fall somewhere on that spectrum in my experience.

[PHEW!  Okay, WOW!  Now I’m all worked up!  Sorry, sorry!  I don’t know where that rant just came from!  But this kind of thing really burns by britches!]

So Kelly, you must be thinking, “Where does this leave me?”  The good news is that Kristen, a philosophical doula blogger friend of mine over at BirthingBeautifulIdeas is author of an amazing series she calls “VBAC Scare Tactics” which I think is a resource that you, and other moms in your situation, might find very helpful.  What you are describing sounds to me like VBAC scare tactics (#3): An early eviction date (aka “I’ll let you attempt a ‘trial of labor’ just as long as you go into labor before your due date.  After that, we’re scheduling a repeat cesarean.”)

In each post she identifies one particular scare tactic, supplies a list of questions that a mother can ask her care provider in response to this scare tactic, and then provides an analysis and/or summary of the research that either challenges or even debunks the scare tactic and its insinuations.  In the introduction to the series she writes,

 

“Many women who want to have a vaginal birth after cesarean (or VBAC, pronounced “vee-back”) in this country have faced some sort of opposition from their care providers when they have expressed their desire to VBAC.

 

Sometimes this opposition is blatant.  Sometimes this opposition becomes obvious only at the end of the third trimester. (Many VBAC-ing moms refer to this tactic as a “bait-and-switch” since it involves a supposedly VBAC-supportive care provider rescinding this support once the actual VBAC is imminent.)  Sometimes even a care provider’s “support” of VBAC is instead a conditional, half-hearted, or perhaps sneakily-disguised opposition to VBAC.  These “scare tactics” are often misleading, exaggerated efforts by OBs (and yes, even midwives) to discourage women from VBAC and to encourage them to “choose” a repeat cesarean.  (Of course, it’s not really a choice if your provider won’t even “let” you VBAC, is it?)

 

If you do find yourself facing such scare tactics, and if you do want to have a VBAC, there are some questions that your care provider should be able to answer when s/he hurls those scary and/or outrageous comments and standards your way.  And if s/he refuses to or even cannot answer these questions, then you might want to consider finding an alternative care provider–one who is making medical decisions based on research, evidence, and even respect for your patient autonomy and not on fear, willful ignorance, or even convenience.”

Things I love about BirthingBeautifulIdeas’ VBAC scare tactic posts include:

#1    Her writing is organized and clear.  (You know how much I love organization and lists!)

#2    She respects research and understands the importance of evidenced based medicine. (In fact, the reason BirthingBeautifulIdeas is aware of much of the research she cites is because she actually used said research studies in weighing her own decision about whether to have an elective repeat cesarean section or instead prepare and plan for a VBAC.)

#3    She has personal experience with this subject.  (In fact she not only experienced a VBAC scare tactic and the “bait-and-switch” with her former OB, but also made the difficult decision to and successfully did transfer her care to a VBAC supportive care provider late in her pregnancy (at 37 weeks to be exact!) as well as experienced a subsequent and successful VBAC hospital water birth.  Check out her story “My very own VBAC waterbirth”.)

#4    She does not provide advice.  As she said herself, she is NOT anti-OB nor is she telling women to do anything.  Instead she provides tools that allow women to make their own decisions and stick up for their own decisions about the birth of their babies hoping that in doing so women come out of their birth experiences feeling positive and empowered, regardless of the outcome.

Kelly, please check out the post VBAC scare tactics (#3): An early eviction date.  I was going to write to you about the research and such on the topic but BirthingBeautifulIdeas has already done such a fantastic job herself that it wouldn’t even be worth it to summarize her article.

While I’m at it, here’s the entire VBAC scare tactics series:

VBAC scare tactics (#1): VBAC = uterine rupture = dead baby (aka “Why would you want to risk a VBAC only to have a ruptured uterus and a dead baby?”)

VBAC scare tactics (#2): When bad outcomes in the past affect patient options in the future (aka “I’ve seen a bad VBAC outcome, and it was terrible.  You really don’t want to choose a VBAC over a repeat cesarean.”)

VBAC scare tactics (#3): An early eviction date (aka “I’ll let you attempt a ‘trial of labor’ just as long as you go into labor before your due date.  After that, we’re scheduling a repeat cesarean.”)

VBAC scare tactics (#4): No pre-labor dilatation = no VBAC (aka “Since you are 39 weeks pregnant and your cervix isn’t dilated or effaced, it looks like you probably won’t go into labor on your own ‘in time.’   We need to schedule a repeat cesarean and forgo a VBAC attempt.”)

VBAC scare tactics (#5): VBACs aren’t as safe as we thought they were (aka “You know, VBACs aren’t as safe as we thought they were.  They are much more dangerous to you and your baby.  A repeat cesarean is the safer route.”)

A VBAC scare tactic interlude (Thoughts and resources on transferring your care to a VBAC supportive care provider, inducing labor when you have a history of a cesarean and weighing the pros and cons of pain medications and interventions if you are planning a VBAC.)

 

VBAC scare tactics (#6): CPD or FTP = no VBAC (aka“Here in your chart, it says that your cesarean was for failure to progress (FTP).  Oh, and there’s also a note here about cephalopelvic disproportion (CPD).  You’re not really an ideal VBAC candidate since your cesarean wasn’t for fetal distress or breech presentation, so we need to schedule a repeat cesarean.”)

 

VBAC scare tactics (#7): Playing the epidural card (aka “An epidural can mask the signs of uterine rupture, so I do not permit my VBAC patients to have an epidural during their labors.” OR “In case of an emergency cesarean, I require all of my VBAC patients to have an epidural in place in early labor.  That way, we will not have to wait for the anesthesiologist to get the epidural in place if a uterine rupture occurs.”)

VBAC Scare Tactics (#8): The MD trump card (aka “Look, I’m the one who has earned the medical degree and I am telling you that you cannot attempt a VBAC.  Your only choice is a repeat cesarean.  Period.”)

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Kelly you wrote, “Since it’s so late in the game now, I’m probably going to stick it out. I don’t have to do anything they say, I can always stay at home and come in when I’m ready, and that will be after I am already in deep labor on my own.”  You are right.  You don’t have to do anything they say.  You have the right as a patient to both informed consent as well as informed refusal.  However I want to say a few things.  (Here comes my cyber pep-talk, meant of course to be 100% supportive of whatever you chose and not at all meant to give you advice.  But I don’t think many women get a chance to hear from anyone what I am about to tell you.  To get the full intent of this pep talk just picture me standing behind you vigorously rubbing your shoulders as I squirt water into your mouth from a sports bottle and wipe the sweat off your face.  So here it goes…)

You deserve the opportunity to have the unmedicated, intervention-free birth that you have planned for.  Your desires for said unmedicated, intervention-free VBAC are well supported by the research.  You deserve to be cared for by a birth attendant who shares your philosophy regarding (among other things) childbirth and VBAC.  You deserve to NOT have to worry about fighting anyone to be given a fair chance at having the birth you have been planning…not the hospital, not the nursing staff, not your obstetrician, NOT ANYONE.  You deserve it for THIS birth.

I know that it is scary to even think about transferring care to a new care provider so late in the game.  But I encourage you to at least think about it.  Even if you think that there are many limitations in your options regarding availability, insurance, distance, etc. etc, it is worth it to you to at least check it out.  I also encourage you to get in touch with your local ICAN chapter (unless, of course, you have already done that.)  Some of the members might be able to give you some suggestions on VBAC friendly care providers that they know actually attend VBACs!  Sometimes even if a VBAC friendly midwife or doctor is booked they will make an exception for a late transfer of care if a doula friend or former patient calls and asks for a favor.  (I’ve seen it happen before with my local ICAN chapter).  Also ICAN’s website has a variety of helpful articlesfor moms planning a VBAC against hospital or provider resistance.

I can tell by your story that you are a very strong woman and my gut tells me that you will indeed fight for your rights even if you stay with your current obstetrician.  You just shouldn’t have to do that and it saddens me that any your energy is going to be dedicated to defending yourself during your birth.  Even one tiny little bit of energy devoted to that is too much!  You deserve more!  You deserve better!  I think you said it perfectly when you wrote, “It’s just so frustrating to have to be prepared to battle, and yet relax at the same time!”

 

I couldn’t agree more!

So Kelly, I wish you the best of luck!  And like many of my readers, I really wish I was going to be your labor and delivery nurse!  CONGRATULATIONS on your pregnancy and on your upcoming birth!  I will keep you in my thoughts and I hope that you will one day come back and tell us how your birth went!  I hope that this post has helped you in some way.  Oh and please apologize to your friends and family for me since you probably will be wasting a lot more time in front of the computer now that I have provided so much reading material!  Haha!

Sincerely,

NursingBirth

The Good, The Bad, and The Icky on Vomiting in Labor October 19, 2009

 

Submitted on 2009/10/18 at 9:43pm

Comment left at: Top Ten Things Women Say/Do During Labor (And trust me… they are totally normal!)

 

 

Dear NursingBirth,

 

Hello, I know this is an old post, but I’ve been searching information on vomiting during labour for a few hours (lol!) and can’t quite find what I’m looking for.  So with the housework waiting I thought I should just come out with it and ask!  Your post is very informative and you seem lovely so I hope you are able to help me! (Or others who have been through it!)

 

I have emetophobia (fear of vomiting), and find I am able to calm myself about the potential of vomiting (because I have had to face that fact that I can’t just escape it!), if  I

 

#1: Know that “everything will be ok” if I do vomit. (i.e. Mainly that people won’t be disgusted, or freaked out and that someone will be able to deal with, well, the result, if I’m not able to.  Even though I’ve never vomited anywhere except in a toilet, it’s just the potential that terrifies me!  My husband is a wonder, and it’s only actually since being with him that I’ve begun to get over the phobia because he’s not scared about it, and not fazed by it).

 

And

 

#2: Remember that I can handle vomiting much better if it isn’t preceded by hours and hours of painful nausea.

 

 

SO, I find myself trying to prepare mentally for the possibility of throwing up during labour, and I have some questions stemming from this for you (I know it is an irrational fear, and these questions seem trivial but they are things that really stress me out – I actually lose sleep over them – so I appreciate your answers):

 

#1 Will the midwives be ok if I throw up all over the place? Will the staff get disgusted or freaked out?

 

#2 Will the staff clean it up or will I or my husband have to?

 

#3 What happens if it gets in my hair?

 

#4 Will I choke because I might be lying down?

 

#5 Will everything be okay if I do vomit?

 

And, finally

 

#6 Is it a different kind of vomiting – one that just kind of happens, rather than following hours of terrible nausea?

 

 

Anyway, I don’t mean to waste your time, and many thanks in anticipation of any answers – I’m just trying to mentally calm myself so I can focus more on the really important things about labour – like my baby!!

 

Sincerely,

 

NervousMumToBe

 

 

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Dear NervousMumToBe,

 

 

First of all I am sending you one MAJOR cyber *HUG* right now complete with back patting and me saying “You can do this!!”  🙂

 

 

Second, you are NOT wasting my time so don’t mention it!!  I have written before about worrying, that is that “WORRY is the WORK of pregnancy!”  In her book Birthing From Within, certified nurse midwife Pam England tells the story about a patient of hers (Hannah) that worried a lot about having a natural birth experience after having had a highly medicalized birth with her first baby.  She writes that Hannah longed to hear her say things like “Don’t worry” and “Everything will be alright” but instead England encouraged her to face her fears.  She instructed Hannah to write down all of her worries and explore each of them with questions like “What, if anything, can you do to prepare for what you are worrying about?” and “If there is nothing you can do to prevent it, how would you like to handle the situation?” 

 

 

 England lists the “Ten Common Worries” of Labor as:

 

1)      Not being able to stand the pain

 2)      Not being able to relax

 3)      Feeling rushed, or fear of taking too long

 4)      My pelvis not big enough

 5)      My cervix won’t open

 6)      Lack of privacy

 7)      Being judged for making noise

 8.)      Being separated from the baby

 9)      Having to fight for my wishes to be respected

10)  Having intervention and not knowing if it is necessary or what else to do

I would like to add #11:

           11) Fear of pooping in labor/Fear of embarrassment regarding bodily functions

 

 As you know I am a labor and delivery nurse and have estimated that I have been present at over 300 births during my career and still, I would have to say that when it is my time to give birth, #1 through #6 are top on my list of worries!!  And I witness the amazing power of women everyday!!  So NervousMumToBe, don’t *worry* about “worrying” about vomiting!  I am so happy that you are FACING YOUR FEARS!!  If vomiting is something that you are really concerned about, no matter how trivial it might seem to others, it is important to you and that is all that matters!  So I applaud you! 

  

Okay now that the most important thing is out of the way (i.e. the hug) lets get down and dirty about the #2 thing on every pregnant woman’s mind…VOMITING IN LABOR!!  (If you are wondering what the #1 thing on every pregnant woman’s mind is it is POOP.  Don’t believe me?  Check it out here.)  I want to preface the following post with a few things in the interest of full disclosure:

 

• I am drawing from both my experience as a labor and delivery nurse (as well as a medical/surgical nurse and nurse’s aide) and the research I have read on this subject to write this post as I do not have any personal experience with going through labor myself.  That being said…

 

•  I have thrown up a time or two myself (I did go to college after all 🙂 ) and know how it feels to do so.

 

• Some readers might have personal experiences that are different than what I describe.  However it is important to remember that if I make a statement like “In general I have found most women in labor to do x, y, or z” I do not mean to say that there isn’t anyone out there that had a different experience.  There are exceptions to every rule. 

 

• Although I have only been working as either a nurse or nurse’s aide for approximately 5 years (which I understand does not make me the most experienced nurse out there) I have certainly been working directly with patients for long enough to know a thing or two about bodily functions, including when they are likely to happen, how to make someone feel better, and how to clean them up.

  

• I cannot speak for every labor and delivery nurse and midwife out there.  After all, I have only worked in one labor and delivery ward (not counting nursing school clinical).  But since you asked me I will answer your questions as if I was your nurse or midwife.  I will also take into consideration what the other nurses and midwives I work with on a daily basis would do and how they too would react to the situations you present.   

 

 

Now to some answers!!  I will take your questions one at a time:

 

 

#1 Will the midwives be ok if I throw up all over the place? Will the staff get disgusted or freaked out?

Yes and No!!  YES!  The midwives and the labor and delivery nurses will be okay if you throw up all over the place and actually, they probably will not even bat an eye if you throw up!  And NO!  The staff will not get disgusted or freaked out if you throw up!  If bodily functions bothered us, we wouldn’t be working in healthcare!  I have been thrown up on before…more times than the average person for sure!  I have been splashed with blood, amniotic fluid, pee, spit, and mucus.  I have also cleaned up my fair share of explosive diarrhea.  And if I do get splashed with something I just kept on doing what I was doing until I have a break where I can go change.  (Remember L&D nurses usually have to wear hospital scrubs just in case they end up in the operating room.  The other bonus to this set up is that if you get splashed with something gross then you just go in the locker room and change into a new pair of hospital scrubs!)  I am sure over the course of time there has been some burnt out nurse that has said something really nasty or insensitive to a mother if she has thrown up but in reality, it’s all part of the job and the vast majority of nurses and midwives don’t get bothered by vomit!

 

 

#2 Will the staff clean it up or will I or my husband have to?

This question is assuming two thing:  #1 That you are going to vomit (remember not all women vomit in labor) and #2 That if you do vomit that you will make a mess (remember not all women who vomit miss the bucket or don’t have a chance to throw up in a bucket).  That being said…

 

I know I can’t speak for every single nurse out there but I would NEVER EVER expect a husband (or any coach for that matter, including the mother herself) to clean up something like that.  After all it is the husband’s (or partner, coach) role to support the mother and if the mother did throw up, say, on the floor, I would ask the husband (partner, coach) to stay with the mother while I went to grab some towels to clean it up.  And then I would clean it up quickly.  And then it would be a non issue!  Done! 

 

One time I had a mother who was taken off guard by her need to vomit and accidentally threw up all over her bed.  She was very apologetic but apologies were not necessary.  I knew that she didn’t mean it!  With the help of her husband I walked her into the bathroom and had her sit down on the toilet to pee.  Her husband stayed in the bathroom with her.  Within 5 minutes I had the completely remade the bed with clean sheets.  Then I helped her into a fresh, new, warm gown and then back to bed.  It was like it never happened!  We all moved on and no one mentioned it again.  After all, who was thinking about a little vomit when there was a BABY about to be born! 

 

I learned from that experience and ever since then I always make sure that I give every mom a bath bucket when she is admitted and I put it right on her bedside table so that if she needs to throw up, it is right there for her.  Because I do this, I have rarely ever had a mother throw up in labor and not use the bucket.  Since you have a concern about vomiting, I would recommend that you ask your nurse for a bucket when you get to the hospital, just in case.  And when I say bucket I mean bath bucket (or wash basin), not those ridiculous kidney shaped “emesis basins” that wouldn’t even be helpful to catch ladybug vomit!

 

 

Remember, although it is not rare for a mother to throw up in labor, it is rare that she throws up all over the place, or has no idea that it is coming.  In my experience the vast majority of moms who vomit in labor do indeed make it into the bucket and therefore, there is nothing to clean up!  Also remember that labor vomit is different that “stomach flu” vomit.  That is, there is no risk to me as the nurse of getting sick from a laboring woman’s vomit because it is not caused by illness.  I’d rather clean up your labor vomit over my own stomach flu vomit any day!

 

 

#3 What happens if it gets in my hair?

If you were my patient and you started to vomit I would hold your hair back.  And I am sure that your husband would do the same for you too.  That way you wouldn’t get any vomit in your hair at all.  Have you considered putting your hair into a pony tail or clip while you are in labor?  If your hair was up it would be very unlikely that it would get any vomit in it.  Perhaps you can pack a few extra clips or elastics into your hospital bag just in case you need them.  If you don’t usually wear your hair back you may want to consider wearing a few hair elastics around your wrist so that they are readily available if you need them to tie your hair back if you feel nauseous.  I also have been known to cut the opening off a rubber glove and use it as a make-shift hair tie for just this type of circumstance! 

 

However if a little bit of throw up did get in your hair and if I was your nurse I would probably wet a warm washcloth and clean it out.  And then I would put your hair into a pony tail or clip for you to get it out of your face.  If it was really bad (I have never seen this but I suppose that technically it could happen) and if your midwife allowed, I would help you into the shower.  After all, many women find laboring in the shower to be extremely soothing and helpful!

 

 

#4 Will I choke because I might be lying down?

NO!  You will not choke, even if you are lying down.  Only people that are unconscious, have an impaired gag reflex, or are debilitated in some other way have a risk of choking on their own vomit.  I have never seen a conscious laboring mother choke on her own vomit…NEVER.  Why?  Because every single healthy, able-bodied, conscious person sits up or leans over automatically when they start to vomit.  I have never even seen a mother who was positioned flat on her back and numb from the breasts down for a cesarean choke on her own vomit.  Why?  Because every single healthy, able-bodied, conscious mother in that situation automatically turns their head to the side to vomit. 

 

If necessary every hospital room and operating room has (or at least should have) a suction canister in it with a yankauer suction set just in case a mother does lose consciousness and her mouth needs to be suctioned.  You might not have seen it when you toured your hospital because most birthing suites keep that kind of equipment behind pictures or in cabinets so that the room doesn’t look too “hospital like.”  But they are there.  I personally have only had to use the yankauer suction set ONE TIME as a labor and delivery nurse and I used it because my patient had an eclamptic seizure (a rare complication of preeclampsia) and when she came too she was really out of it (“post-ictal”) and her mouth needed to be suctioned because it was full of secretions.  That’s it, one time only.   

 

 

#5 Will everything be okay if I do vomit?

YES!  In fact, labor and delivery nurses get excited when they see a patient vomit because vomiting is usually a sign of transition which is the last stage of active labor (usually 7-10 centimeters) right before a women begins the pushing phase.  Remember whether or not she has been eating throughout early labor, a woman may still vomit when she enters transition so it is not necessary to starve yourself on purpose because you are afraid to vomit later on.  In fact, some women vomit because they have done just that!  (I know I personally get very nauseous as well as get a headache if I haven’t eaten anything all day).  I always think of it as a way the body is “making more room” for the baby! 

 

Also since vomiting, like holding your breath or making a bowel movement, is a vagal response, it inadvertently helps your cervix dilate and hence, is a great sign to a labor & delivery nurse!  The body does awesome things to help the process along!  So really it is not just okay if you vomit, it is GREAT if you vomit because it may help you cervix dilate!  I also want you to know that you will not hurt anything if you vomit, including the baby or your cervix.

 

 

 

#6 Is it a different kind of vomiting – one that just kind of happens, rather than following hours of terrible nausea?

 

In my experience as a labor and delivery nurse most women who have a natural, unmedicated, spontaneous labor do NOT have hours and hours of nausea before they vomit.  Instead, once there labor really starts to ramp up for the last few centimeters they get a feeling of nausea that gives everyone enough warning to grab the bucket and then they throw up.  After throwing up, the vast majority of women have told me that they feel better.  It is very rare that I have taken care of a woman who continues to throw up once they are 10 centimeters dilated and begin to push or is nauseous for hours and hours before they vomit.  That being said…

 

Nausea and vomiting are very common side effects of narcotic pain medications (e.g. stadol, nubain, demerol, morphine etc.) as well as ALL forms of anesthesia (including labor epidurals as well as spinal blocks often performed for cesarean sections).  Because of this, some physicians and midwives prescribe an anti-emetic (aka anti-nausea medication) like Phenergan, Zofran, or Reglan to be administered with the narcotic, epidural, or spinal to counter act this side-effect.  Sometimes it helps, sometimes it doesn’t.  Because you have such a fear of vomiting I want you to be aware of this fact.  

 

 

So there you have it: the skinny on vomiting in labor!  I hope this has helped calm your fears and worries however if you have any more questions about this topic please feel free to leave a comment!! 

 

Thank you for writing in to me.  You are certainly not alone in your fears!!!  I know that your question will help other women out there who experience the same fears as you!  GOOD LUCK with your upcoming birth and CONGRATULATIONS to you!!!  And remember, although birth might be one of the messiest experiences of your life, no amount of fluids, cursing, farting, pooping, striping naked, howling, crying, peeing, bleeding, or vomiting will take away from how honestly empowering, mind blowing, and touching this experience can be for you and your family!!

 

 

Sincerely,

 

NursingBirth

Super Comment! Unexpected Guest Post from a Mother-Friendly L&D Nurse October 14, 2009

A couple days ago I posted this:  One Woman’s Journey To Her Own HBAC Water Birth and 360 Degree Career Change

 

Like always, I woke up this morning and sat down in front of my computer with my bowl of Cheerios to check the comments left on my blog.  I was pleased to see that I had a few comments about that post.  One in particular however, actually brought me to tears.  I was especially moved by her “garden” metaphor.  (I know, I am such a sap!)

 

Alethea is from Colorado and has been working with birthing families as a labor and delivery nurse for the past 8 years.  When she comments on my blog, she often writes about how she is truly inspired and amazed by the power of birthing mothers. She became a trained BIRTHING FROM WITHIN® mentor out of her desire to help guide more women along the path of empowerment through their birth experiences.  Alethea is also a co-founder of Colorado Conscious Birthing.

 

I think I was so moved by Alethea’s comment because I feel the same way about being an L&D nurse as she does.  Witnessing the miracle of life, the power, strength, and determination of women, and the overwhelming love of family and friends as your job is pretty amazing.  And I love it.  Even when I am having the worst day imaginable, I still love it. 

 

So I just couldn’t let this comment die, hidden away for only a few stragglers to read as they come across the old blog post.  I hope you enjoy it as much as I did!  It really brightened my day!!

 

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Dear NursingBirth,

 

This post spoke to me in ways that I can not express in written word, but I will try.  I also am all four of these women you write about. 

 

1) As a woman who has yet to give birth.  The power of a woman giving birth the way nature intended (regardless of the setting) takes my breathe away every time.  This was a beautiful, inspiring, empowering montage.  I hope to some day be empowered by my own strength and beautiful birth.

 

2) As a labor and delivery nurse.  My inspirational theme song is Ben Harper’s With my own two hands:

 

 …”I can change the world, with my own two hands.  Make a better place, with my own two hands…make a kinder place….I can make peace on earth…I can reach out to you….gonna make it a brighter place, gonna make it a safer place, gonna help the human race… with my own two hands…I can hold you…I can comfort you…but you got to use, use your own two hands…” 

 

Empowering women to search inside themselves and tap into their deep well of intuitive knowledge and strength is what keeps me coming back for more despite how tired, burned out, and sick of the politics I might be.  Forgetting the hustle and bustle outside in the hallways, my job is to delicately plant the seed that they can do this, they are strong, they are capable.  Bearing witness to the strength and power that women are capable of is an honor.  I am an advocate of normal birth, an advocate of women, an advocate babies and daddies and doulas and new families.  I am a labor and delivery nurse because I love supporting women with my own two hands, occasionally being lucky enough to be the first human to hold new life in my own two hands, but especially helping to break the cycle of doubt and fear in order to inspire women to understand that they can birth with their own two hands (or on their own two hands and knees).

 

3) As a labor and delivery nurse who has yet to experience birth.  It seems to me that because Lindsey is a home birth midwife she had the distinct advantage of seeing mostly normal, natural, beautiful births to inspire her.  And yet she still had that little seed of doubt threatening to take over her mind.  Like a weed in a garden, we have to pull up those seeds of doubt so they don’t take over our beautiful gardens.  We must lovingly attend to our gardens (growing baby, growing minds) nurturing the beauty, inspiration and trust.  Sometimes we pull up a weed, but we don’t get the entire root, and it comes back, even stronger and with a vengeance.  Threatening all the beauty and strength we have worked so hard to grow.  Pregnant and birthing women need to surround themselves with people who want to help tend to the garden, and avoid people whose defeatist attitudes are apparent in their neglected gardens (minds, attitudes) full of weeds (doubt).

 

Working in the hospital we do see a lot of “failure”.  Failure to progress, arrest of decent, fetal growth restriction etc, etc, etc.  The weeds (negative thoughts) in the hospital birth culture are rampant.  It takes even more hard work and dedication for those of us immersed in it to remember that the majority of birth could be normal and natural and beautiful if we nurtured and support physiologic birth and weeded out unnecessary intervention.  I am confident in my body, in my strength and in my capabilities.  I actually feel so blessed to have been a labor and delivery nurse for so many years before I have children.  I am well educated and well informed about my choices.  I have seen powerful births, and tragic births.  And through all I have seen I have learned so much.  I truly understand how my mindset, my choices and the people I choose to surround myself with when my time comes to give birth can impact how my birth plays out.  I am not denying the potential for an outcome I would love to avoid, or the potential need for medical interventions.  But I know what I need to do and what I need to avoid to put myself in the best possible position for an outcome that will make me proud to be a woman and confident in my capability to be a awesome mom.  I will not let the nurses who believe in the “The curse of the nurse” destroy my dream of an empowering birth.  We have the power to create magic with our words, I choose to surround myself with people who want to bless me not ones who wish to put a curse on me.

 

4) As a nurse with dreams of becoming a midwife.  When one has been called to something in life, you can only ignore that calling for so long.  I too feel that pull to empower women and touch their lives in an even deeper and more meaningful way.  As an LD nurse we often meet women for the first time when they walk in the door in active labor, and after they deliver, we may never see them again.  We don’t know if they felt empowered or deeply wounded by their birth experience.  I dream of working with women throughout pregnancy, birth and postpartum to help guide them to experience birth as the wonderful, life changing right of passage that it can be.  The time is not right now.  So I will give what I can and continue to pour love into my current role in birth, but not let go of that dream that someday I will be a midwife too.

 

Thank you NursingBirth for inspiring me to write about my experiences with birth and providing the forum for sharing my love of the work that I do.

 

Sincerely,

Alethea

http://www.coloradoconsciousbirthing.com

No Doula in the Name of Privacy? Oh Come On! September 26, 2009

This comment was recently left by a reader named Jessica under one of my older posts.  Since I read every comment that is posted on my blog I happened to stumble upon it this morning.  When I read it I couldn’t help but think “I Hear Ya Sister!!!”and felt that it was so well stated that it needed to be its own post!  I know that there are quite a few doulas out there that read my blog and I just wanted to take this opportunity and give a shout out to them all and say thank you for all you try to do to educate women before they get to me on L&D!  Unfortunately, they don’t all listen but I hope you know that there is at least one L&D nurse out there that appreciates your efforts, both before and during labor!!!

 

For all you expecting moms out there please check out DONA’s website to learn a bit more about what a doula is, how you can find one, the effects a doula can have on your birth outcome and experience, and how a doula can advocate for you!

 

And just for the record, there is NOTHING private about a hospital birth experience.  Even in the most well meaning hospitals with the most well meaning birth attendant and the most well meaning nurse(s).  Albeit some women’s hospital births might be more private than others and I personally have had the priviledge to be a part of a few totally amazing hospital births.  But to not hire a doula for your hospital birth (especially at a university hospital!) because you want a “private” experience is a very VERY naive and misguided idea!  I am not saying that to hurt anyone’s feelings and I am certainly not judging anyone out there who decided not to hire a doula for one reason or another.  I am just telling it like it is.  Some food for thought…

 

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Hi NursingBirth!

I am a certifying doula and have recently had an interview with a perspective client. She is 36wks pregnant with her first. She was strongly considering a doula, but everyone else in her family was on the fence, and pushing a “private” birth experience. However, they are planning a delivery at a university hospital, she has yet to see the same health care provider throughout her prenatal care, she has no idea which one will be at the birth, or if it will even be someone she has met. They are planning a natural birth. She assured me that the hospital she is birthing at offers a multitude of birth options, including water birth, birth ball, position changes, etc… and the childbirth education from the hospital has given them confidence in their ability to get what they want from this birth. After much “deliberation” they decided that they were not going to hire a doula, based solely on their confidence in the hospital to give them what they want, and their desire for privacy. While I can completely respect their privacy request, I fail to see how birthing in a university hospital will give her much if any privacy…AND if she doesn’t even know who will be her health care provider at the birth…how is she confident that the hospital will give her what she needs? I wish there was some way to help open her naive eyes to the reality of birth in hospitals today. Her chances of getting to work with a mother friendly doc that understands and respects natural birth have got to be low! Reading your blog was comforting (because I know there are others who struggle with this) and depressing(because we have to struggle with this). I don’t want to have her hire me for her VBAC next time around. I want her to have the birth she desires now. I realize there isn’t much I can do for her at this point, which is why I am here, leaving my frustration with a bunch of like minded individuals. I am hoping things will go well for her and in the mean time, I’ve let her know that I am and will be available until the baby is born. just in case. Thanks for the space to rant.

  

Sincerely,

Jessica

  

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Jessica, you can rant here anytime!!!  I Hear Ya Sister!  Loud and clear!!

 

And now I leave you with one of my FAVORITE Monty Python skits of all time.  I have seen it a million times but it is still as hilarious (and eerily true) each time I see it.  Notice how the doctor invites in an army of people to watch.  It often feels like that where I work no matter what I do!!!

 

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

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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:

 

 

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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

 

 

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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

 

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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, evidenced–based, 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

Super Comment!: Maternal Death in the U.S., or TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth May 27, 2009

Dear NursingBirth,

I’m a huge fan of your blog! Please keep the awesome entries coming! I am learning so much. I am just a novice birth-junkie rather than a birth professional and so am anxious to eat up all the great information you’re giving out here.

Anyhow…. Our state treasurer’s wife (that’s here in Arizona) died today in childbirth, and their baby is said to be in grave condition. They’re not giving causes or reasons. Here’s the link:

http://www.azcentral.com/news/articles/2009/05/26/20090526treasurers-wife0526-ON.html

Can you think of occurrences in hospital-birth that would end up with a dead mother and a baby in really bad condition? I’d love to hear from someone who knows her stuff. The things that came to mind for me were amniotic fluid embolism, severe uterine rupture, and cesarean gone really wrong.

Keep up the amazing work!!!
Diana

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Dear Diana J.,

 

I just read the story you linked to and my heart goes out to that family.  Unfortunately the story you linked to did not go into any details, including the most important detail which is: Did the treasurer’s wife have a vaginal birth or a cesarean section, as the risks are significantly higher with a cesarean section.  I think your question is a good one and since this story has the potential to make national headlines, I think that it is an important enough question to put as its own post on my site.  I hope, however in posting about your question that moms out there who read my blog are not unnecessarily worried or upset that we are talking about maternal death as it is still a relatively RARE occurrence when you think about all the other causes of death in childbearing women. 

 

Let’s put it into perspective.  As the Arizona Central story stated, “In late 2007, the National Center for Health Statistics, part of the U.S. Centers for Disease Control and Prevention, released a report showing that there were 13 maternal deaths per 100,000 live births in 2004 in the United States.” And since in 2004 there were 4.1 million births in the United States, if you do the math that would make about 533 maternal deaths in 2004.  And don’t get me wrong…that’s 533 deaths to many for sure!  However take a look at this chart published by the Center for Disease Control (CDC) entitled: Leading Causes of Death by Age Group, All Females- United States, 2004.  It shows the following:

 

Leading Causes of Death for 15-19 year old Females, 2004:

1)      Unintentional Injury (51.7%), 2) Suicide (8.8%), 3) Homicide (7.5%), 4) Cancer (7.3%), 5) Heart Disease (3.1%), 6) Birth Defects (2.8%), 7) Pregnancy Complications (0.9%)

 

Leading Causes of Death for 20-24 year old Females, 2004:

1) Unintentional Injuries (40.5%), 2) Homicide (8.4%), 3) Cancer (8.0%), 4) Suicide (7.6%), 5) Heart Disease (4.6%), 5) Pregnancy Complications (2.7%), 6) Birth Defects (1.9%), 7) HIV disease/Stroke (1.4%).

 

Leading Causes of Death for 25-34 year old Females, 2004:

1) Unintentional Injuries (25.3%), 2) Cancer (15.1%), 3) Heart Disease (8.2%), 4) Suicide (7.5%), 5) Homicide (5.8%), 6) HIV disease (4.4%), 7) Pregnancy Complications (2.3%).

 

And for women ages 35-44 years old, pregnancy complications don’t even crack the top 10. 

 

Okay so if you are a pregnant mom please know that dying of pregnancy/childbirth related complications is rare and I don’t want to completely freak you out.  But there is something very disturbing about the United States maternal mortality statistics which shocks most people when they hear it….

 

The United States ranks 42^nd in the WORLD for maternal mortality rates, with 1 in 4,800 women dying from pregnancy complications in the U.S. in 2007.  That means that 41 countries other countries in the world have BETTER maternal mortality rates than the United States!

 

Many of our practices and current situations in this country, including our obsession with medically unnecessary labor induction, our over-medicalized maternity care system, the practice of defensive as opposed to evidenced-based medicine, the lack of a universal health care system, large differences in health disparities among different racial/socioeconomic groups, the obesity epidemic, and our skyrocketing cesarean section rate greatly contribute to our country’s maternal death rate. 

 

So what exactly is defined as “maternal death.”  According to the World Health Organization, “A maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.”  Therefore a death of a woman that died from complications arising from a cesarean section a month after she had the baby would be counted in the maternal death statistics where a pregnant woman who died in a car accident or murdered during a domestic violence dispute would not. 

 

Okay, but you are probably thinking Why?  Why are so many women dying in childbirth in an industrialized, developed country like the United States at a much higher rate than other industrialized, developed countries like Japan, many countries in Europe, or Australia? 

 

Ina May Gaskin, midwife and founder of the Safe Motherhood Quilt Project, gives us some insight into the situation in her book Spiritual Midwifery, page 455, written in 2002:

 

“According to the CDC, there has been no improvement in the U.S. death rate (which is nearly twice as high as Canada’s) since 1982.  Sadly, the CDC estimates that the true death rate is as much as three times higher than that which is reported and that half of all the reported deaths could have been prevented through early diagnosis and good care.  Given the situation it makes sense for women to avoid unnecessary surgery while pregnant or in labor.  Women double or triple their risk of dying when they have an unnecessary cesarean.  Medical mistakes do happen, even to people who are well informed about their possibility.”

 

Also Ina May’s Safe Motherhood Quilt Project website also links to a Maternal Mortality in the USA Fact Sheet that is worth checking out!

 

The 2008 documentary Orgasmic Birth (which I highly recommend renting) has a 20- minute movie clip as part of the “special features” section of the DVD that provides some eye opening statistics about maternal and infant mortality rates in the United States as compared to other industrialized countries around the world.  In this short movie clip, entitled Birth By The Numbers, Eugene R. Declercq, PhD, Professor of Maternal and Child Health, Boston University School of Public Health, presents the sobering statistics of birth in the United States today.  It is a MUST WATCH CLIP for anyone who is or cares about a mother.

 

Also, here are some articles from mainstream news sources published in response to the 2007 maternal mortality rankings that provide some insight:

 

1) More U.S. women dying in childbirth: Death rate highest in decades; obesity and C-sections may be the cause  Associated Press, August 24, 2007

2) Maternal Mortality Shames Superpower U.S.  Inter Press Service, October 13, 2007

3) U.S. ranks 41st in maternal mortality  Seattle Post-Intelligencer, October 12, 2007 

 

A flyer published by the medical journal The Lancet in 2006 entitled Causes of Maternal Death: A Systematic Review ranks the top 9 causes of maternal death related to pregnancy/childbirth complications in DEVELOPED countries as the following:

1) Other Direct Causes (21.3%), complication of the pregnancy, delivery, or their management which includes (among other things):

            –Anesthesia Complications* (responsible for about 3% of all maternal deaths by itself and includes:    management of the difficult airway in obstetric patient, aspiration of gastric contents under general anesthesia, local anesthetic toxicity, and high spinal or epidural block which paralyzes the breathing muscles of mother).

2) Hypertensive Disorders (16.1%), includes (among other things):

            –Preeclampsia

            –Eclampsia*

            –HELLP Syndrome*

3) Embolism (14.9%), includes (among other things):

            –Pulmonary Embolism (typically a complication seen post-op surgery)

–Deep Vein Thrombosis (DVT) (more likely to develop for women on bed rest or post-op surgery

– Amniotic Fluid Embolism (rare and more appropriately known as Anaphylactic Syndrome of Pregnancy)*

4) Other Indirect Causes of Death (14.4%), pregnancy-related death in a patient with a preexisting or newly developed health problem like cardiovascular disease, seizure disorder, respiratory disorder, diabetes, kidney disorder, liver disorder, obesity, etc.

5) Hemorrhage (13.4%), includes (among other things):

  – Obstetrical Hemorrhage (most common causes being uterine atony, trauma, retained placenta, and coagulopathy)

  – Placenta Previa*

            – Placenta Accreta, Increta & Percreta

            – Placental Abruption*

            – True Uterine Rupture*

6) Abortion (8.2%)

7) Ectopic Pregnancy (4.9%)

8.) Unclassified Death (4.8%)

9) Sepsis Infection* (2.1%)  (most likely to occur post-operatively but can occur post-partum or antepartum)

 

*Comes to mind for me as having the potential to cause a critical illness or death for baby as well.

**Please note mothers undergoing cesarean surgery, especially repeat caesarean surgery are MORE at risk for anesthesia complications, pulmonary embolism, obstetrical hemorrhage, placenta previa, placenta accreta, and sepsis/infection than moms undergoing a vaginal birth.**

 

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You are probably thinking, “So what does all of this mean for me?” “How can I reduce my risk?”  Both are GREAT questions.  It is important to remember that I am not claiming that 100% of maternal deaths are preventable or even foreseeable.  No one is.  I also do not want anyone to get the impression that I am blaming mothers or putting unrealistic pressures on mothers to control things that are sometimes just happenings that are an unfortunate and very sad part of life.  For example, who could have predicted a fatal postpartum hemorrhage for a healthy mom after a normal uncomplicated unmedicated singleton vaginal birth?  No one could!  But what about a mom who experienced a fatal postpartum hemorrhage after elective cesarean surgery….well that one doesn’t sit so well with me!   And which do you think is more likely?  If you guessed the latter you are correct…by at least 4 times as much! 

 

So how does a mother reduce her risk of maternal morbidity and mortality related to pregnancy and childbirth complications?  The following is a short list you might want to keep in mind.  (Not surprisingly, many relate back to avoiding unnecessary surgery.)

 

TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth:

1)      Obtain good and thorough prenatal care, keeping all of your appointments, preferably beginning in your first trimester.

 

2)      Make a conscious effort to eat a well balanced diet during conception and pregnancy that includes adequate amounts of fresh fruits and vegetables, healthy fats, and protein.  There are a variety of prenatal nutrition books out there as well as many childbirth books that have a section on prenatal nutrition.  If you don’t have one buy one or borrow one from the library!!

 

3)      If you don’t exercise, start!  Many gyms, community centers, and YMCAs offer low-impact, pregnancy-friendly classes for expectant moms.  Even a 30 minute walk three times a week will do!

 

4)      If you suffer from a chronic disease or illness or are obese, it is important to know that making appointments with health care providers and specialists that can help you to manage your disease and lose weight in a healthy way before and during pregnancy can ultimately help you to reduce your risk of life threatening complications during pregnancy and childbirth.

 

5)      Consider hiring a birth attendant that practices a midwifery model of care.

 

6)      Do NOT agree to a medically unnecessary labor induction.

 

7)      Do NOT agree to a medically unnecessary or elective cesarean section.

 

8)      If you have a history of a cesarean section, seriously consider a vaginal birth after cesarean section (VBAC) if you have no reoccurring or new reasons or medical indications for a repeat cesarean.  If necessary switch to a birth attendant that supports VBAC and has the cesarean statistics to prove it.

 

9)      Seriously consider avoiding interventions in labor that evidenced-based research have shown could increase your risk of a cesarean section, fetal distress, and infection including early amniotomy (breaking of waters), accepting pitocin to stimulate or augment contractions without trying other more natural methods for augmenting labor first, going to the hospital during very early labor, accepting continuous external fetal monitoring as opposed to intermittent auscultation for a normal healthy labor and a normal, reactive, and reassuring fetal heart rate pattern, and requesting an epidural or narcotic pain medication (especially in early labor) before trying all methods of non-pharmacological pain management techniques first.  (Check out my post: Top 8 Ways to Have an Unnecessary Cesarean Section)

 

10)   Empower yourself to make safe, healthy decisions regarding your pregnancy, your labor, your birth, and your baby by doing your own research!!  (Check out my post: Birth Resources EVERY Woman Should Know About).

Super Comment! Re: The Deal with Delayed Cord Cutting May 19, 2009

Many of you might not realize that I personally read every comment that is posted to my blog.  Why you ask?  Because I love reading what the people following my blog have to say!  I love when people engage in great discussions that have been stimulated by something I have written.  I love when women post comments seeking advice, information, or camaraderie and other readers respond!  And I love reading about other women’s birth experiences that they share via this forum.  Often, a reader will post a question to me under the comments section, a question so great that I take hours or days to research and write a response.  And I am such an information/research junkie that if I don’t know the answer, I’ve got to find out!!  Other times a reader will post a comment with some really great information or resources to share with other readers.  Unfortunately, many of these “super comments” often go unnoticed by readers who only read the posts and not each “comments” section.  So I have been inspired to create a new category for my blog entitled “Super Comments” to pay homage to all of the great super comments and questions that my readers post!

 

Today’s Super Comment is in response to May 17^th’s post entitled The Deal with Delayed Cord Cutting or “Hey! Doctor! Leave that Cord Alone!”

 

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Dear Nursing Birth,

 

I have a student nurse question. In nursing school we were taught that clamping/cutting the cord stimulates respirations. This comes from our textbook, Maternity, Newborn, and Women’s Health Nursing by Susan Orshan, specifically this quote “…clamping of the umbilical cord affects chemoreceptors sensitive to changes in arterial oxygen and carbon dioxide content, contributing to the onset of respirations.” This sentiment was echoed by our faculty to the tone of *this is why cords are clamped and cut immediately after the birth*.

I guess my question is this: Is the above quote enough to justify swift cord-clamping? Or not?
Thanks so much for this post. I’m enjoying the research you’ve done!

 

Sincerely,

BCB

 

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Dear BCB,

 

That is a really great question!  What you (and I) both learned in nursing school is right on one hand, but wrong on another.  Let me explain a bit further.  I would like to first address the statement you found in your textbook.

 

Your textbook reads “…clamping of the umbilical cord affects chemoreceptors sensitive to changes in arterial oxygen and carbon dioxide content, contributing to the onset of respirations.”  This is true in the fact that clamping the umbilical does stimulate the baby to breathe…BUT the act of clamping the umbilical cord is NOT necessary for the baby to take his first breath!  Clamping of the umbilical cord in a way actually forces the baby to take his first breath!  In the textbook Respiratory Physiology author John B. West writes:

 

“The emergency of a baby into the outside world is perhaps the most cataclysmic event of his or her life.  The baby is suddenly bombarded with a variety of external stimuli.  In addition, the process of birth interferes with placental gas exchange, with resulting hypoxemia and hypercapnia.  Finally, the sensitivity of the chemoreceptors apparently increases dramatically at birth, although the mechanism is unknown.  As a consequence of all these changes, the baby makes the first gasp.  

 

The fetal lung is not collapsed but is inflated with liquid to about 40% of total lung capacity.  This fluid is continuously secreted by alveolar cells during fetal life and has a low pH.  Some of it is squeezed out as the infant moves through the birth canal, but the remainder has an important role in the subsequent inflation of the lung.  As air enters the lung, large surface tension forces have to be overcome.  Because the larger the radius of curvature, the lower the pressures, this pre-inflation reduces the pressures required.”  (page 152, chapter 9)

 

Also (and this is a bit technical so bear with me!) an excerpt from the article “Cord Closure: Can Hasty Clamping Injure the Newborn?” by George M. Morley, MB published in OBG Management in July 1998 tell us:

 

“Very early clamping results in less than physiologic blood volume. The normal, term child routinely survives, but clamping the cord of a compromised child before ventilation is riskier. Initial aeration of the lungs causes reflex dilatation of pulmonary arterioles and a massive increase in pulmonary blood flow. Placental transfusion normally supplies this volume. Clamping the cord before the infant’s first breath results in blood being sacrificed from other organs to establish pulmonary perfusion. Fatality may result if the child is already hypovolemic.”  (Thanks to gentlebirth.org for the reference!)

 

And to answer your second question…

 

Homebirth midwife from Mountain View, CA and author of the website http://www.gentlebirth.org/ Ronnie Falcao, LM MS writes in a post entitled “Some comments about ‘Anatomy of A Fetus: Circulation and Breathing’” :

 

“It is not air hunger that causes the newborn to take a first breath, and it is certainly not necessary for the cord to be cut in order for the baby to start breathing.  …I am quite certain that nature didn’t assume that a birth attendant would be standing nearby, scissors in hand.  In reality, babies start to breathe right away even if the cord is left untouched.  It is not air hunger that stimulates a baby to take its first breath.  It is likely the stimulation that comes from the shock of cold air and the sudden exposure to light and noise.  Even dim lights and low noises seem very startling to a baby who’s only used to life in the womb.

 

Both Williams Obstetrics  and Varney’s Nurse-Midwifery concur: ‘The phenomenon that occurs to stimulate the neonate to take the first breath is still unknown.  It is believed to be a combination of biochemical changes and a number of physical stimuli to which the neonate is subjected, such as cold, gravity, pain, light and noise, which cause excitation of the respiratory center.’

 

Beyond the question of what stimulates the baby to take a first breath, we can look further at the triggers for the changes in the foramen ovale and ductus arteriosus. The delicate process of rerouting the circulatory system depends on the intricate interplay of blood gas levels that occurs naturally as there is a gradual shift from reliance on umbilical cord oxygen to reliance on air breathed into the lungs.  Sudden severing of the umbilical cord is an unnecessary and dangerous meddling with this process. Some people refer to this as premature amputation of the placenta because the baby is still using oxygen carried through the cord from the placenta.”

 

As an L&D nurse, I have witnessed births where the birth attendant practiced early cord clamping and some where the birth attendant practiced delayed cord clamping.  And guess what!?  These normal, healthy, uncompromised babies took their first breath and started to cry whether the cord was clamped early or late!  (When I first personally witnessed a few of the delayed cord clamped babies breathing just fine I started to wonder if the impression that I was given in nursing school (i.e. that babies needed their cord to be clamped to take their first breath) was really totally true.  Both experience and research have shown me otherwise!  Pretty cool huh! 

 

 

Thanks for your great question!

 

Best,

NursingBirth